Condom teletubbies?

From the people who gave us the Kama Sutra, comes a new video that leads the way in promoting safer sex. See this 6.58-minute clip produced by the International HIV/AIDS Alliance in India with help from artists from the Nrityanjali Academy. The dancing condoms sing in Telugu in an appeal aimed at the estimated 60,000-70,000 sex workers in the southern Indian state of Andhra Pradesh. (Wouldn't it be great to see people dressed up as condoms on American television?) Besides the Indian video, be sure to check out this hilarious commercial from France.

Our dumb world

The energy efficient flood light-bulb I ordered last week arrived today in a big box of styrofoam peanuts.

Life after death penalty

More on the death penalty, from today's NYT editorial:

"The United Nations General Assembly voted on Tuesday for a [non-binding] global moratorium on the death penalty. ... The resolution failed repeatedly in the 1990s, but this time the vote was 104 to 54, with 29 nations abstaining. Progress has come in Europe and Africa. ... The United States, as usual, lined up on the other side, with Iran, China, Pakistan, Sudan and Iraq. Together this blood brotherhood accounts for more than 90 percent of the world’s executions, according to Amnesty International."

I'm all for shame by association.

In other death penalty news: New Jersey abolished its death penalty on Monday - the first state in forty years to do so. To celebrate the New Jersey and UN votes, Rome "bathed the Colosseum, where Christians once were fed to lions, in golden light" (NYT). Back in the U.S., the Supreme Court is set to hear arguments on whether death by lethal injection is "cruel and unusual." The arguments come in the wake of a 2007 study that found that some executed inmates suffocated while still conscious, rather than first being sedated by the anesthetic. Lethal injection is legal in 37 states and was used in 52 of the U.S.’s 53 executions in 2006. The Supreme Court may not think that capital punishment is cruel (c'mon people!), but at least the UN vote shows that it's increasingly unusual.

Update: The Supreme Court ruled on April 16, 2008, in a splintered 3-2-1-1-2 decision, that ultimately reduced to a 7-2 decision, that Kentucky's practice of execution by lethal injection is by their account Constitutional. I'd recommend this summary of the arguments at DailyKos. I wish that the justices who decided in favor of Kentucky would attend and even participate in an execution themselves and then decide whether killing people can be deemed anything but cruel.

TB on the loose

The latest jail-break, from the AP:

JOHANNESBURG, South Africa (AP) -- Forty nine highly infectious tuberculosis patients cut through wire fencing and broke out of a hospital isolation unit, apparently because they wanted to spend Christmas with their families. The mass escape highlights the problems faced by South Africa as it struggles to cope with an epidemic of virtually incurable TB that feeds off the AIDS virus and kills most of its victims. South Africa has an estimated 5.4 million people living with the AIDS virus.

Confinement for XDR-TB is at least six months.

I wonder who would want to spend Christmas with them. I mean, for Christ's sake!

The sardonic factor aside, the ethical issue may be troubling. It seems that forcibly incarcerating people for being sick is a gross violation of their rights. How can it be illegal or wrong to get sick?

But I am totally for it. As incarcerating them may be a violation of their rights, not incarcerating them is a violation of their responsibilities. We have certain duties when living with others (not killing them seems like an important one). Hopefully such patients will understand the risk and submit voluntarily to confinement. But even if they do not, the protection of the public is paramount. Though treating people without their consent is anathema in medicine, the coercive arm of the state enjoys broad support (consider, for example, mandatory taxation or even traffic laws). Some may cry "unjust paternalism" about such incarceration, but that's not quite right. The state isn't saving these patients from themselves. It's saving the rest of us from XDR-TB.

Fired up, ready to go!

I'm coming out of the closet. I'm supporting Barack Obama for President.

First, policies:

Obama's health plan has been criticized for eschewing a mandate (at least at first) for people over age 17. From what I know about health insurance policy, I think I'd prefer a mandate. In the Netherlands, where residents are required to purchase insurance from one of several private companies (some for-profit, others non-profit), coverage extends to 98.5% of the population. But this mandate-or-no-mandate debate is overblown, despite what the Clinton campaign says. The quibble, says the NYT's Matt Bai, is "like watching a couple of homeless guys argue over which Ferrari they intend to buy." In fact, all the Democrats, except for Kucinich, have mediocre health plans. Only Kucinich would create universal, non-profit, single-payer health care by extending Medicare to everyone.

It's worth noting that the policy positions of the Democratic candidates are fairly similar. Differences are primarily matters of emphasis. Most would index the minimum wage to inflation, shift taxes to higher-income Americans, support workers' rights to organize, prohibit insurers from rejecting patients based on pre-existing conditions, and end the war in Iraq. (Yes, there are differences: Richardson would withdraw all troops, Edwards would withdraw combat troops, and Obama and Clinton would keep residual forces.) All would protect the legality of abortion (and I hope, fight to allow Medicaid to fund them). These policy positions are important. But the Democratic positions are not different enough, in my view, to crown one candidate over others (except perhaps Kucinich, but he wouldn't stand a chance in the general election).

So I look to the President's other role: To represent the U.S. to ourselves (speaking at the World Trade Center, the Minnesota bridge collapse, the California forest fires) and to the world (Iraq policy, G8, UN talks on climate change). The President serves as a rallying officer, a public face. And I think the next face of the United States should be Barack Obama's. I like several other candidates, especially John Edwards and Bill Richardson. I like Edwards' concern for the little guy and Bill Richardson's down-to-earth style. In the wake of Bush's failures - missing WMDs, climate change, Katrina, Walter Reed, Justice Dept. firings - I need a government I can trust, or at least one that doesn't fill me with cynicism. I don't think Hillary and Slick Willy can do that. I'd also worry about our democracy if Hillary wins the presidency. Counting from 1980, when George H.W. Bush was elected VP, to 2012, when Hillary would finish her first term as President, we would have 32 uninterpreted years of two families in the executive branch.

So, most of all, Barack Obama inspires me. Bill Clinton said he didn't inhale. Obama said of course he inhaled: "That was the point." It sometimes feels silly to evaluate a candidate by his character - after all, who cares if Bill Clinton enjoyed blow-jobs in the Oval Office - but I think Obama's public conduct and frankness sets a good example for government. Other candidates frame themselves in partisan terms. I see Obama as more conciliatory and thus more effective. I see him as a person who'd actually be able to convince people to get an HIV test by getting one himself on TV.

Below are photos from The Stumping Grounds, a photo blog maintained by four photographers who follow the Iowa political season voraciously. I picked out a few to tell a story:

Barack Obama, fired up and ready to go [© Scout Tufankjian 2007]:


Hillary Clinton, doomed by dynasty [© Allison Joyce 2007]:


John Edwards, reaching out [© Joshua Lott 2007]:


Bill Richardson, noteworthy [© Carey Wagner 2007]:


Obama's example, for America's future [© Allison Joyce 2007]:

Accident report

It's midnight on a Friday night (a week ago), and I'm sledding with friends. I'm feeling adventurous and jolly. The snow is a bit loose, flying everywhere as we fly south down the hills. I take off my glasses which keep fogging up during the fast descent. The visibility is awful, but I'm content to take in the world through my other senses: the unmistakable smell of winter, the cold against my face, the good-natured yelps of my fellow sledders, having fun. And then, in the delight of unrestrained youthfulness, I sled head-on - well, actually foot-on - into a tree.

I hobble back to the car, friends take me home, and my housemate Jake helps prepare a few bags of ice that I saran-up around my ankle. I sit mostly stationary through the weekend. On Monday, one of the med school professors I work for examines my ankle, and says: "Uh Eli, that's not good." She insists I go to the emergency room, and since all the local orthopedists seem to be booked (except the one who could only see me two days later), I said what the heck, this could be fun.

It turns out I broke my medial malleolus at the base of the tibia. Of course that wasn't obvious at first. I spent the downtime investigating ER culture: the EMS personnel rushing in with patients strapped to gurneys, the ER staff telling them to wait their turn, the secretaries too busy to look up when asked for a tissue, the elderly woman to my left pulling out her IV and yelling for attention... Over the course of the 4.5 hour visit, I spoke to four doctors, three nurses, a half-dozen x-ray technicians, and one very pretty resident who stopped by only to ask if it would hurt if she flicked my big toe. One or two asked about the book I was reading, Steinbeck's In Dubious Battle. I had arrived at 10 am. It was now 1 pm, and I had to leave by 2:30 to make a 3 pm opthalmology appointment. Time was running thin.

"Your particular fracture," says the doctor, "is commonly associated with a second fracture higher up on the tibia. So we'd like to take a second x-ray to rule out such a break."

"But doc," I say, "I've got no pain or tenderness higher up on the tibia."

"Well, you see," he says nervously, "it's a liability issue, standard of care."

"Ah, I understand.... I'll tell you what. I'll consent to it if you can get me out of here by 2:30."

It worked. A friend Nate drove me to the ophthalmologist with six minutes to spare.

It's been a week now. Probably 1-2 more on crutches, and another 3-5 with a cast.

Captive in Gaza

Digging through past bookmarks, I rediscovered this interview (10/29/07) with Alan Johnston, the former Gaza correspondent for the BBC. He was kidnapped by a Palestinian group called the Army of Islam (not associated with Hamas or Fatah) on March 12, 2007, near the end of his three-year tenure in Gaza. He was held hostage for 114 days, eventually gaining release on July 4. Here's an excerpt from the BBC interview. I think Johnston's right on.

Question:

You were forced to make a blatantly anti-Israel broadcast by your kidnappers. Assuming the words you stated were not yours, are there any amendments you would like to make?

Answer:

My view was anyway that any sensible person knows that video statements made by kidnap victims are always done under conditions of extraordinary duress. I do not imagine that many people take the words spoken very seriously.

On camera I talked of arrests and killings of Palestinians at the hands of Israeli forces. And of course during my time in Gaza I had indeed seen much suffering, including the shooting of children, the demolition of homes and the destruction of farmland. However I wasn't able, in my video, to set the conflict in any context. The Jihadis only wanted me to air their view.

For example, many Israeli army raids into Gaza are aimed at stopping the almost daily rocket fire. Palestinian militants launch crudely made devices that occasionally injure or kill people in Israeli towns and villages just across the border. This constitutes random bombardment of civilians, and it is clearly a war crime. The Israeli army's response often amounts to collective punishment - which is another kind of war crime.

But again, there is a wider context. The militants in Gaza often say that their attacks come in response to Israeli army actions in the West Bank. For more than 40 years the Israelis have sought to consolidate their occupation there and in East Jerusalem.

Pretty much every day there are Israeli army raids and arrests, and often militants and civilians are killed. The Palestinian camp often suggests that the conflict would stop if the occupation were to end. And it is the great hope of many neutral observers that such a deal can be struck and made to stick - and perhaps it can.

The Jihadis were not very interested in the wider context, but, unfortunately, neither are some Israelis.

Justice delayed, justice denied

Imagine being incarcerated for crime you didn't commit. Fancy the irony: the state stealing your time. Consider the torment: mental anguish, ruined career, and now-distant family. But suddenly, in the DNA age, you've been exonerated and released. What does the state owe you, if anything? How much should you be compensated for your time? What state services should you receive?

The question's been on my mind since I started tutoring at a prison. At least a half-dozen men, some more persistently than others, have insisted that they are innocent. I tend not to believe them. But I do believe that many of the guilty are being held for excessive amounts of time. These 20-, 30-year sentences span their entire adult lives and are more punitive than rehabilitative. At some point, we must be able to say that these prisoners have repaid their debt. Even if that debt can never be repaid, we should acknowledge that some are ready to become productive citizens. With regard to these extra years in prison - these years separated from their families and careers, opportunities flushed down the toilet - these men are not so different from prisoners who were wrongfully incarcerated to begin with.

The NYT (12/02/07) reports:

"With more than 140 exonerated prisoners released since 2000, 22 states and the District of Columbia now compensate them using formulas ranging from lump sums to calculations of lost wages. ... Wisconsin provides $5,000 a year up to a maximum of $25,000 total. California offers $100 a day [$36,000/year]. Tennessee provides up to $1 million total. Twenty-eight states offer nothing. ... Of the states with compensation laws, only three — Massachusetts, Louisiana and Vermont — provide for the costs of medical and psychological care."

I also think this piece of info is worth repeating: "Most of the exonerated who get money waited two to three years, forcing them to rely on family, friends, lawyers and even strangers for shelter, clothing, food and emotional support immediately after their release." In addition, prisoners can be "billed for the DNA testing that proves their guilt or innocence, for drug testing and even for the drug treatment they are supposed to receive as a condition of parole." Former inmates "can be dunned by four or five departments at once — and can be required to surrender 100 percent of his or her earnings. People caught in this impossible predicament are less likely to seek regular employment, making them even more susceptible to criminal relapse."

About half of the 137 exonerated prisoners tracked by the NYT were struggling, "drifting from job to job, dependent on others for housing or battling deep emotional scars. More than two dozen ended up back in prison or addicted to drugs or alcohol." Guilty prisoners don't fare any better after their release. From 1999-2003, the risk of death for former inmates in Washington state was 3.5 times that of other state residents and 12.7 times greater in the first two weeks (NEJM). The leading causes were drug overdose, cardiovascular disease, homicide, and suicide.

Path of least resistance

To social psychologists, it's obvious: decisions are not as cool and rational as sometimes portrayed by economists and philosophers. People are 'socialized' into the status quo, often failing to select a superior option that they themselves know to be better. They purchase fatty potato chips and microwave popcorn against their better judgment, simply because it's there, or because the benefits are immediate and the costs delayed. Such behavioral patterns are the subject of a recent solid article in the Journal of the American Medical Association: Loewenstein G, Brennan T, Volpp KG. Asymmetric Paternalism to Improve Health Behaviors. JAMA. 2007;298(20):2415-7. Here's one such behavioral pattern, sometimes called the default bias:

"[I]n New Jersey, the default on automobile insurance conferred a limited right to sue (with an option to pay extra to acquire a full right to sue), but only 20% of drivers chose to acquire this right. In contrast, in Pennsylvania, where the default was a full right to sue (with a discount if drivers switched to a limited right to sue), approximately 75% of drivers opted to retain the full right to sue. Likewise, employees save more when their employer automatically deposits a significant share of salary into a retirement plan than if the default is no contribution."

To direct people toward healthier behavior, we should exploit these behavioral biases to our advantage. Yes, that means being mildly paternalistic, in the sense of protecting people from themselves or at least their unprincipled actions. We should therefore strive to "make healthy behaviors more convenient (less immediately costly) and unhealthy behaviors less convenient (more immediately costly)." For example: "companies could offer free chilled bottles of water within easy access of employees or students, while soft drinks could be sold in less convenient locations farther away from employee work stations or offices." Other types of structural change would not be difficult to implement. Currently, patients have to remember (though they often don't) to schedule a colonoscopy every five years. Instead, colonoscopies would be automatically scheduled. The problem of missed colonoscopies is structural, not ideological.

What other biases are relevant? We tend to be biased toward the present, prioritizing immediate benefits over future costs. Unintended pregnancy and smoking cigarettes are obvious examples. Eating is another. We eat too much because the consequences (obesity, diabetes) come much later. Short of becoming time-travelers, there isn't much we can do, except...

"This aspect of present-biased preferences can be exploited by giving individuals choices between health-benefiting and health-harming behaviors before the time they will actually have to act on them. For example, individuals could choose to schedule gym visits and laboratory tests to monitor their cholesterol levels ahead of time and to voluntarily accept financial penalties for last-minute cancellation. Soft drink machines could be programmed with a personal identification code such that the machine cannot be accessed on the following day if an individual has not enabled his or her access or, conversely, if the individual has disabled his or her own access. An individual with a goal of losing weight is much more likely to be willing to deny himself or herself the pleasure of tomorrow's soft drink than today’s."

It's hardly radical, or even un-heard-of (ever work-out with a partner?), but it's brilliant.

Other policy changes are almost obvious: People are more likely to donate money to the Red Cross if collection bins are everywhere. Sex-crazed college students are more likely to use condoms if they're available in dormitories and not just at CVS. Citizens are more likely to have health insurance if people paid their premiums in their taxes and not as an additional expense on the side. And we could increase our organ supply if people had to opt-out instead of opt-in.

How about rising rates of obesity? We're moving in the wrong direction by making it less convenient to eat healthy. According to a hot-off-the-press study, nutritious foods now costs as much as $36.32 a day while junk foods cost just $3.52 a day (Monsivais P, Drewnowski A. The rising cost of low-energy-density foods. J Am Diet Assoc. 2007 Dec;107(12):2071-6). The authors conclude that these rising prices for healthier foods "may help explain why the highest rates of obesity continue to be observed among groups of limited economic means."

The lesson here? It's not about making bad decisions as much as having poor choices.

Tuesday, Saturday

I’ve been busy lately, though not very productive. My housemates and I (though mostly my housemates) have been re-tiling the shower. In the process, we unleashed an army of dust, which has exacerbated (and perhaps caused) a tormenting cough. I can feel the dust in my throat. It’s depressing to think that the air in the place I call home is somehow toxic to me.

It snowed last night so I commuted to work by foot. Shoulda taken the bike. The roads weren’t exactly clear, but they were better than the sidewalks. Feeling sorta crummy, I treated myself to a strawberry smoothie - a shameless attempt to boost the day’s languishing work ethic and to remind myself of the more palatable side of slush. It’ll be a few more months of this weather.

A book I read this fall is due back to the library, so today I shuffled through the pages to review a few passages I tagged. The book is Ian McEwan’s Saturday, which I enjoyed almost as much as his book Amsterdam. In fact, I’d recommend anything he’s written. Saturday follows a neurosurgeon named Henry Perowne through a rather tumultuous 24-hour period, which unfolds over 289 pages. At times, the book seemed a little forced, a little too clever, but McEwan's keen sense of the way people think made reading it entirely worthwhile.

An example: I try to be physically active, mainly through ultimate frisbee and biking (and recently, caving). I sometimes dread the upcoming games, fearful of that burning sensation in my calves and the desperation in my lungs. But I play anyway. It keeps me sociable, and I enjoy the camaraderie and even the self-scrutiny. Athletes have a way of seeing their athletic performance as a reflection of their larger personal aspirations and character. I posted a cartoon (here) about how people judge themselves in sports. We see our truer selves - anxieties, priorities, deficiencies, demeanor - when the going gets tough, and we judge others similarly, e.g., see the NYT's analysis of Barack Obama’s basketball game.

Well here's McEwan, describing Henry Perowne's thought-process during a game of squash:

"He twists back to life balls out of the rear corners, then dashes forwards at a stretch to connect with th drop shots. The constant change of direction tires him as much as his gathering self-hatred. Why has he volunteered for, even anticipated with pleasure, this humiliation, this torture? It's at moments like these in a game that the essentials of his character are exposed: narrow, ineffectual, stupid - and morally so. The game becomes an extended metaphor of character defect. Every error he makes is so profoundly, so irritatingly typical of himself, instantly familiar, like a signature, like a tissue scare or some deformation in a private place" (108).

I'm rarely pleased with my performance on the ultimate field. My body usually gives out
before my mind, and I start to imagine magnificent plays that I have no energy to do. I wonder now whether that's a symptom of inhabiting an academic universe these last six years.

Killing people to save lives

Does the death penalty deter potential murderers?

The NYT published a short, well-informed piece on the debate last week. I wrote a little about it in an earlier post. I don't respect the claim of deterrence. None of the prisoners I now tutor expected to end up in prison, much less put to death - and that applies even to the murderers. Everybody expects to beat the odds. And other evidence suggests deterrence doesn't work well. Besides, we could think of some pretty cruel things to do to people - crueler than death - indeed, so disgustingly cruel that people would shudder to think about breaking the law. But successful deference wouldn't make them right. Also, I don't think it's the responsibility of the individual prisoner to deter others.

But some people evaluate the case for the death penalty on consequentialist terms. Law professors Cass Sunstein and Adrian Vermeule write: "Capital punishment may well save lives."

But is saving lives all we care about?

Suppose the state's method for executing prisoners involved removing their organs for transplant. We could 'harvest' hearts, lungs, livers, kidneys, and pancreases - and save lives.

But why stop at criminals? Killing me could save lives, too.

Thanksgiving stem cells

Two nights ago, a friend and I discussed new findings on stem cells that "could ease ethical concerns" (NYT). I think "religious concerns" would be more accurate. In any case, scientists report that they can create the equivalent of embryonic stem cells without having to destroy a fertilized cell in the process. This new "breakthrough" seems unnecessary to me, at least on an ethical level. But it seems highly important in allowing stem cell research to go forward. The news meant more to this friend of mine (who approved this post, by the way). You see, he's a Christian. He was saying that cells 10-14 days after conception should be protected because they were, at the very least, life-on-its-way. I was saying, as I've written before, that something that could become life does not, by that very fact, have a right to it.

The conversation eventually moved on to other, more seasonal, topics.

"Hmm," said the friend, "I've got to pick up a turkey tomorrow."

"You know what the funny thing about all this is?" I asked. "That I believe that turkeys deserve life, and you don't."

* * *

Below are two cartoons on stem cells research. I love the first because I like to think that religious people don't always agree with their spokespeople. The second cartoon, which I don't like, illustrates the great struggle that some religious people face in deciding where they stand on stem cell research. For that, I think it's worth posting. But I should add: It's not actually true that embryonic stem cells destroyed in research would have become cute little kids had they not been used. As long as I'm on the topic, see this other cartoon about stem cells and this political video by Michael J. Fox from the 2006 elections.

17, going on 23

Tani Goodman would have been 23 today.

I marked the date last year in a post, "Happy birthday, friend," that was more a meditation about death's vacuum than about joyful Tani. You see, the truth is, I have known Tani longer in death than in life, having met him just eight months before he died in a tragic accident at age 17. I was also 17. Six years on, my memories now are memories of memories. Remember seeing his parents in January 2003? Remember when we marked the first yartzeit? Remember the ceremony at his grave? The way his friends, then soldiers in the Israeli army, clutched and leaned on their guns, blubbering and bawling? How I blubbered and bawled?

Tani's dad, Jerry, wrote that "Tani is 17 but he will be 23." I think that's how I feel.

Premature death is a terrible tragedy; it's just plain awful. I try to keep the potency of "it all" in mind (albeit in the back of it) as the newspapers fill with scenes of Darfur and Iraq. I try to remember how the death of a single person can affect friends, families, and others. It's tempting to be tough about death. But I don't think anybody really loses a friend and then shrugs it off with something banal like "blessed be the righteous judge." I think that's a deceiving attempt to impose order on a shockingly random and unruly world.

Of course Tani would have none of this melancholic talk. I remember a deep-thinking kid who stayed up late to discuss theological questions, who asked bold questions in front of big groups, and who kept his hair wild. I remember a fun, adventurous kid. See this picture at right, for example, from the memorial website his parents maintain. That's Tani on bottom and Ariel on top. I met the two of them over lunch on the first day of a summer program that brought Americans and Israelis together. I wanted to impress these two with some Hebrew I knew. So I said: "Na-la-ha-veir et ha-tapuz, b'vakashah," asking for the juice. Tani and Ariel roared with laughter.

"You just asked us to please, graciously, kindly, pleasantly, pass the juice," one said.

"Well how do you ask?"

"Like this." Ariel pointed a finger and snapped, and Tani tossed the item to him.

Oh, how we laughed!

Reading Rainbow: "Check it out!"

For library lovers everywhere:

$602 billion

That's the total cost (so far) of U.S. operations in Iraq, Afghanistan and elsewhere in the War on Terror, according to the Congressional Budget Office. That number covers Sept. 2001 through fiscal year 2007. Greg Mankiw made a handy chart (pictured below) to show the rising cost by year (in billions of dollars). National Priorities has the dollar-meter running, and an easy tool to compare opportunity costs. Also of note, health care for veterans could add another $650 billion dollars.


This money could have been spent on public housing, public education, pre-schools, , children's health, or college scholarships. It's a tragedy it's gone to war. There's a humor for this sort of tragedy, and political cartoons portray it best. Below are a few in reverse chronological order.

Nov. 15, 2007, Tom Toles:
Sept. 13, 2007, Jim Borgman:

Sept. 11, 2007, Jim Borgman:
Sept. 6, 2007, Tony Auth:
March 21, 2007, Ben Sargent:
Feb. 24, 2007, Ben Sargent:
Jan. 17, 2007, Tom Toles:
Oct. 10, 2006, Jim Borgman:
Sept. 13, 2006 , Pat Oliphant (related: Nothing to fear but fear itself):
Sept. 13, 2006, Tom Toles:
Aug. 2004 , Steve Benson:

More on Ashley X

I want to follow-up on an earlier post about Ashley X, the profoundly disabled girl whose parents had her breast buds removed, her growth attenuated, and a hysterectomy performed.

The case generated a lot of controversy in both the media and in the bioethics community. Last month in DC for the annual bioethics conference, I heard one of the pediatricians who treated Ashley, Dr. Doug Deikema, speak about the case (he wrote about it here). Deikema, who's also a medical ethicist, used his talk to reply to what he saw as the five most common objections to the growth attenuation component of the "Ashley Treatment," as it's been dubbed. I think his replies (paraphrased below) were excellent.

(1) It's not natural.
Reply: Neither are immunizations, antibiotics, or organ transplants.

(2) You're playing God.
Reply: Anytime you intervene medically (or decide not to intervene), you are playing God.

(3) It's a slippery slope.
Reply: Yes, there's potential for abuse. But ascending a slippery slope is sometimes worth the risk of slipping. The view atop a mountain, for example, is often worth the perils of the climb.

(4) Stunting Ashley's growth benefits the parents, not the child.
Reply: No, it benefits both. Their interests are intertwined.

(5) It violates her dignity.
Reply: That's an assertion without content.

Self-esteem boost

This cartoon reminds me of something I wrote over the summer but didn't post. I don't know who drew the cartoon or when; I saw it in the collection of a social psychology professor I work for.

Here's what I wrote:

At ultimate yesterday, the two-hour game, the final point. Seeing an opening, I run deep to the endzone. A teammate launches the frisbee over my head, as if to say "Go for it!" I watch the game-winner fly away; gosh it's far. But there I am, arms pumping, instinctively sprinting down the field. The frisbee sails over my shoulder in the last arc of its descent. As it nears its final plummet, I reach. I don't quite remember what happens next, but I imagine: the finger-tips of my left hand come into uncertain but lasting contact with the outer rim of the disc. I am horizontal. Heaving lungs are shoved up my throat. But I'm holding it, gripped firmly by two fingers and an opposing thumb, my body now planted in the dirt. A defender behind me mutters, "No way." Down the field, the players are shaking hands. Game over.

Caring for Ashley X

Two random questions: (1) what is 'personhood'? and (2) does it matter?

Consider the case of "Ashley X," a six-year-old girl from Washington State with profound mental impairment. She cannot think, speak, or form relationships. She cannot move on her own and lies still wherever she's put (say, on a pillow), hence her nickname, "pillow angel." Her parents faced a problem: As Ashley grew older, she grew bigger. In order to continue caring for Ashley at home, the parents ordered a hormonal treatment to attenuate her growth to 4'6''. Her parents also directed doctors to perform a hysterectomy so Ashley could avoid the discomfort of menstruating, and to remove her breast tissue to reduce the chance of abuse. The parents kept a blog and generously opened their case to media scrutiny. Ashley is now 10.

Some people have criticized the therapy. What, some ask, would Ashley herself have wanted?

Ordinarily in these situations, family and friends try to decide according to the patient's prior wishes. But Ashley never had capacity to begin with. As an alternate approach, decision-makers sometimes follow a "best interests standard." In that, we think about what any "reasonable" person would want. Mostly it works: Giving someone a blood transfusion even without consent is clearly in his or her "best interest." But this approach has been fraught with uncertainly: In our liberal tradition, we hesitate to make substantive claims about the good life. So instead of asking "what should be done?" we ask, "who should decide?" But the notion of "best interests" failed for Ashley X, as it did with Terri Schiavo, because people can't agree on what's best for someone with little or no mental capacity. It's also hard to say whether Ashley has any "interests" at all.

So what to do?

In a wonderful and reader-friendly essay on decision-making for children with severe neurological impairments, philosopher-doctor Carl Elliott sets up the problem this way:

"[I]n order to determine the moral status of severely damaged or limited human beings, we must ask ourselves whether or not they are persons. Why? Because we all know, more or less, what the moral status of a person is – that persons deserve a kind of respect, that they have rights, that we owe them duties that we do not owe animals or nonsentient life, and so on. If a neurologically damaged child (or for that matter, an anencephalic, a fetus, or an adult in a persistent vegetative state) is a person, then we must treat her morally as we treat other persons. But if she is not, then we are justified in treating her in other ways – say, as a being whose interests can be safely overridden for the interests of those who are persons."

--Attitudes, Souls, and Persons: Children with Severe Neurological Impairment. Mental Retardation & Developmental Disabilities Research Reviews. 9:16-20 (2003).

But having set up the debate, Elliott proceeds to point out the deficiencies in this line of reasoning. He thinks it’s futile and perhaps deceptive to delineate the elements of ‘personhood.” Simply describing the capacities of an animal, for example, is not sufficient to discern whether its life is "meaningful." Like "cruel" or "coward" or "bully," the word "person" contains both factual and evaluative elements. Personhood is an ethical evaluation, informed not only by what capacities we as humans exhibit, but by the meanings and societal attitudes associated with them. Elliott, writing four years before the Ashley story broke, doesn’t speak in the language of interests and rights. He thinks dignity and respect may be more helpful concepts (though he says they won’t suffice either). What I admire most about this essay is the inconclusiveness of the conclusion:

"We are the inheritors of a strong tradition of rights and equality that makes us reluctant to withhold treatment from a person on the grounds of her intelligence or disabilities. … [Yet] we recognize that these lives fail to meet the criteria by which we count our own lives as meaningful. We try to convince ourselves that we should protect vulnerable lives, but we cannot imagine this as a life we would want to continue living. We say all lives deserve respect, but our measure of the good life for ourselves does not include a life like this."

That divide speaks to me: the space being too judgmental and not being judgmental enough.

The literary problem of goodness

“I don’t like to use many photographs,” said Tracy Kidder. “They’re unfair to writers.”

Kidder, whose book Mountains Beyond Mountains I reviewed in April, spoke in Syracuse last week. Here’s my report. Be aware that all quotations are from memory. Kidder was subdued in all the ways Farmer is not. When asked about his current project, he said: “I can’t say, I just don’t know where it’s going, sorry.” He was a bit clumsy on stage, in an endearing way, uncomfortable in a suit and tie. I spoke to him briefly after his talk about opportunities for writers, especially those interested in public health issues. Again he apologized: “Your friends freelancing and starving,” he said, “know more than I do.”

In the lecture, Kidder ruminated on his trade as a journalist: “An author of non-fiction has to have justified belief,” he said. In his writing, he aspires to be “not flashy, but vivid.” He enjoys his work: “I can change my subject every few years without changing my job.” He also expressed his worries: “I’m terrified of wasting a year or two. When I start a new project, I feel like I’m jumping out a window, and I don’t know what floor I’m on,” he said, quoting Orwell. And of course, he said: “I think of myself as a storyteller. That’s how I understand the world.”

Writing about Paul Farmer troubled him. “I knew it would,” he said. “I waited six years after meeting Farmer before I pitched a story to him. I didn’t know how to make him believable. I just couldn’t find anything negative to say about him. I even called ex-girlfriends. Nothing. I worried that people would say, ‘this is a Hallmark card; this writer is fogging up the glass.’”

More Kidder: “A few people I interviewed said they didn’t like his style, but everyone praised him. Still, sometimes I’d hear, ‘Farmer is a good person, but I wouldn't want to be married to him.’ Sometimes I’d reply, ‘I didn't realize he had proposed.’ But that’s mean. As a writer, I struggled with the ‘literary problem of goodness,’ but it's also a personal problem. People feel uneasy around Farmer. They want to push away evidence of virtuousness because it makes them - us - suspicious. Such virtue? We like to believe that we have earned our privilege in the world, but we can’t avoid that inevitable question, ‘what if I had been born a Haitian peasant?’ In Haiti’s central plateau, the farmers' livelihoods were literally drowned by an international dam project. Farmer reminds us that our privileges are part of a global system that's built on the misery of others.”

One year anniversary

It's been more than a week since I've written here. A friend called yesterday to inform me "your readers are pissed." So I'm back, and not only back, but celebrating a whole year of blogging (!).

Some stats: In the last year, I've written 140 posts (or 1 per 2.6 days), for a total of 55,418 words. That's 121 pages, single-spaced. My favorite subjects have been: global responsibility (27), politics (20), health (16), feminism (16), and vegetarianism (11). I've sometimes succumbed to the narcissism of blogging, once rating my blog and another time listing my top 10 motivations.


I started this blog on Halloween last year. I didn't have many friends in Syracuse then, so I spent the evening at home, alone. Not one person rang my doorbell, and I ended up eating a whole bag of tootsie-pops myself. So, reaching out to the world, I wrote: "I wonder whether my life in suburbia is exciting enough to merit a blog.... I wonder if my standards will slide over time, or whether, like any good blogger, I'll fill this space with inchoate musings and witty chatter. I wonder whether I should disclose my love affairs and ideological battles, and whether my spicy secrets will lose their flavor if spread too thin. But, but, in my post-college anomie, I am driven by a need to record and an urge to connect." Yes, to record and to connect. I think, a year later, I've done that okay.

I have not disclosed my love affairs. I have disclosed some of my ideological battles, but not really. I rarely write about my uncertainties, say over apparent nobility of veganism or the justifications for war or my life plans - items for which I lack a steady argument. On this blog, I mostly assess the news, talk to myself (albeit a little more formally than I usually do), and try to get used to sharing my writing, of which I am sometimes quite protective. If this blog were a 'live journal,' perhaps I'd be more inclined to share personal anecdotes. Somehow I'm stuck in a formal tone: complete sentences, proper grammar, etc. I'm been trying to break out of it, but maybe it's not a indication of my novice blogging as much as a side-effect of my overall demeanor.

What else? It is one of the great luxuries of my life that I have time for fiction. I keep a book list - check it out here. A month ago, I went to a library booksale and bought a great mass of books. But now, paralyzed with choices, I just curl up with back issues of the New Yorker. I'd love your recommendations. For my part, I'll recommend J.M. Coetzee's Disgrace. A phenomenal book.

I do love keeping this blog, but I don't know if I'm going to write as regularly in the next year as I did in the last. Blogging takes time. There's an opportunity cost. For example, I recently called up a friend who's also a blogger to see if she'd like to go to a street carnival.

"Hold on," she says, "I'm finishing a blog post. I'll call you in a hour, k?"

I smiled: the life of a blogger. I do it, too. Indeed, we all need to remind ourselves that as much as we enjoy these forums (and I really do), blogging is not a substitute for human interaction.