Death, Ethics, And Education

Triaging has been a feature of medical care for a long time. It's a method for sorting patients so as to make the best use of limited resources. According to the usual pattern, patients are sorted according to the following plan:

           Those who are likely to live, regardless of what care they receive;

           Those who are unlikely to live, regardless of what care they receive;

           Those for whom immediate care might make a positive difference in outcome.

Medical attention is initially addressed to those in the third group. They're likely to be the most “productive” recipients of the limited resources.

Ethicists have discussed the proper husbanding of medical resources in view of the costs that have a significant effect on society. Sarah Palin, on her Facebook page, raised a sensitive issue, fearing that the Affordable Care Act would lead to “death panels” which would decide where limited funds would be used, and deny care to some elderly patients. Denials followed immediately, but the issue, once raised, concerned a lot of people. The patients, especially the grandmas, for whom most of the fear existed, were often those who would best fit into the third category: immediate care might make a positive difference. Whether true or not, it raises serious questions about our use of funds.

I'm 78. I have no school-aged children. But I pay school tax. Long ago I had such children and paid the Day School where they were educated. And I paid the school tax in addition to the tuition. And I've paid ever since although I've never had children in public schools. That allows schools to collect money from all of us for students it doesn't educate. (Actually, international statistics suggests that it doesn't do a very good job for those it does try to educate.) Attempts to get “vouchers” authorized, so those who wished to send their children to private schools would not have to pay twice to improve the quality of the learning in general, and in particular areas, were always opposed by teachers' unions, and always failed to get approval. It was maintained that they'd take funds away from public education. (As does the Department of Education – bureaucrats who supervise the states.) That's true, but vouchers would probably allow children to get a better education – rich and poor alike – if they could choose the school they attended. But besides acting as a prod for professional improvement, such a system would also cost the jobs of some union members, and this would be intolerable, despite the fact that some teachers were not up to the job.

The complaint was also made that vouchers would aid parochial schools and thus constituted a violation of the first amendment by destroying the separation of church. The Constitution, of course, has no such mandate – only against the establishment of a state religion. That, however, doesn't stop opponents of vouchers from protesting. And it doesn't stop them from bowing before the god of public education.

(The ante has been raised. Because those with college degrees earn more, and there is a history of free municipal colleges, there is a movement to once again offer free education for almost everyone. Who pays for that? And do we need more cabbies with college degrees? )

Suppose the ethics panel considered the use of public money for an educational system that was functioning poorly. Would they approve the use of limited resources for a failing system when other options existed? Would they pay for the education of all comers, irrespective of qualifications or interest?

Another question that comes to mind is based on the reality that there seems to be no limit on the resources used to save a preemie or an otherwise damaged newborn. No expense is spared and publicity is extensively lavished upon successes. Thousands, or even hundreds of thousands of dollars may be expended. An additional result may be the markedly increased expenses required to educate these children, which come from the costs of educating others – including the disabled. Do panels of ethicists ever ponder the morality and the wisdom of using limited medical and educational resources this way? I don't mean to suggest that we should withhold care from those who need it – preemies, the disabled, or grandmothers – only to raise the question of how we choose to use our limited resources.

It's basically a political issue. There are repeated and angry demands from all interest groups for the funding of their needs. Where do the funds come from? The treasury that contains our tax money. And the two opposing views of what funding should take place are those of ideologues.

Liberals: We are obliged as a society to care for our most vulnerable citizens, if that is possible. If it's not possible our ethicists will tell us what to do.

The costs should be born by the rich.

Conservatives: You get what you pay for.

They get what we pay for.

Perhaps we should reconsider, or even triage, taxpayer expenses with the aid of ethicists who consider all our problems, and all aspects of each of them.

Mom, Spinach, And The Supreme Court

                           

“Put on a sweater. I'm cold.”

I bet your mother said that to you. And she insisted that you eat your spinach because Popeye and other trained nutritionists said it was good for you.ⁱ And besides, there were children starving in Europe.ⁱⁱ That's what I was told, and I did as I was told, but I never really understood the ideas behind these pronouncements. I knew it was “for [my] own good,” but the details were a little hazy. And she also wanted me to get a good education. She wanted me to do better than herⁱⁱⁱ and my father.

Now I know it was a little like an insurance policy. If I paid the price^iv I might get the benefit. Might. There were no guarantees. It was gambling. Like the stock market. Or the lottery.

If you're going to gamble, though, the lottery's the way to go. The cost is low and the payoff could be humongous.^v But the chance of winning is infinitesimal.^vi Wishing won't make it so.^vii

Well, maybe it will. The issue may have more to do with intent and wish than with fact. At least that seems to be the Supreme Court's stand, and since they make the laws we have to take their decisions seriously.

Last June, when it rendered a judgment on the “Affordable Care Act,”^viii the Court ruled that, for the most part, the legislation passed muster.^ix Specifically the decision was made that the “individual mandate” was defensible, even if not the way Congress wanted the law. But to do so – to make the act Constitutional – it was necessary to “interpret” the law in a way contradictory to what Congress and the President expressly wanted. The Court decides what's legal, though, so they can do that, and substitute whatever suits their philosophy.^x

In this instance the bill was constructed in a manner which was expressly intended not to raise taxes. The individual mandate would result from Congress’s commerce clause powers^xi and the act contained a requirement that those who elected not to have health insurance, as was their right, would be subject to a “penalty” – a “shared responsibility payment.” But there would be no tax. This was specifically stated because raising taxes was viewed as unwise politically. According to the Huffington Post, “the actual text of the bill^xii uses the word 'penalty' – not 'tax.' Even Obama, while the law was still being debated in Congress, insisted in a September 2009 interview with ABC's George Stephanopoulos that his health care overhaul was 'absolutely not [emphasis added] a tax increase.'"^xiii But, as Derek Thompson, a senior editor of the Atlantic, noted in the publication's June 28, 2012 edition, “five Justices agreed that the penalty that someone must pay if he refuses to buy insurance is a kind of tax that Congress can impose^xiv using its taxing power. That is all that matters.” Consequently, in terms of legislation, the will of Congress – the Legislative Branch of government – is not relevant. Nor is that of the President. Congress could have legislated a tax if they wanted to, so even if they didn't want to do that, the Supreme Court has decided that what they view as Congress's intent trumps what it actually said and did.^xv Wishing can make it so. Congress wanted universal insurance and they could have legislated it. Therefore it's legal. It's also good for the individuals involved – whether they think so or not.

That was mom's view. She honestly believed that the sweater and the spinach were good for me and the children in Europe. They were a good insurance policy. Whether what she said made any sense, she could have made a logical case for her decision if she had chosen to. After all, she had the right to do so.^xvi And “That is all that matters.”

Which brings me to the lottery and my fortune. I'm sure the Supreme Court will support my contention that since I could have chosen the winning numbers – I was legally entitled to do so – I should be awarded all the prizes to date. My intent and my wish were to win. Wishing makes it so. Consequently I claim the $550 or so million up in the next^xvii “Power Ball” lottery. Even if I lack the luck to pick the right numbers, I'm certainly permitted to do so and “[t]hat is all that matters.”^xviii The Fourteenth Amendment, and all that's said about equal protection, make my claim as valid as those who favored the Affordable Care Act. At least according to the precedent set in deciding its validity. The Court will certainly see that my intent was to win, so even if I didn't choose the right numbers, I certainly could have chosen them, so it will be hard for the Justices to deny me the prizes without retracting their decision on Obamacare. They may not want to, but they've already decided that wishing, intent, and legal ability are what really count.

Oh. You have to buy a ticket? Well that shouldn't affect anything. I could have bought one.

Thanks mom. You were right about the sweater and the education. (I'm less sure about the spinach.) And some time soon I'll be able to buy a very expensive sweater. And one for you, too. There's no reason you should be cold.

Next episode: “Thank You Eve” – The Devil made me do it.

i      Spinach was believed to be very high in iron. As it turns out, the original calculations may not be accurate. In addition, the high oxalic acid content limits the absorption of iron. There are, however, high levels of vitamin A and antioxidants present, though the significance of their addition to a well rounded diet is not clear.

ii      Of course there were children starving elsewhere as well, but our focus was on the continent that had just gone through a world war, and we were Eurocentric – even though the word had not yet been coined. But we weren't self-conscious, nor were we guilt-ridden about our focus. Now you're more likely to hear a reference to somewhere in the “Third World” as we strive to prove that we are diverse, multicultural, sensitive, and inclusionary, in keeping with the modern vogue.

iii      Or is it “she?” I always have trouble with that construction.

iv      In these instances the price was directed at modifying my behavior (after all, how likely was it that my spinach would actually help the children in Europe, and who wants to get out of bed and go to school anyway – but mom's reassurance made it all worthwhile) rather than any fiscal layout, however to some even this seemed to be a little high in view of the negligible chance that there would be a specific payout. And if there were, we probably wouldn't recognize it.

v      Slang. It's not in my copy of the OED (Second Edition – 1991) but someday will Well not in mine, but in a new edition.

vi     Perhaps not. I think that it's possible to win every time. Legally. In fact, I could be a billionaire. And so could you. But more about that shortly.

vii    This, too, may need reevaluation.

viii   ACA and “Obamacare” are two ways that the more polite among us refer to this program. Others are not so generous, citing issues of individual liberty as the reasons for their concerns about the legislation.

ix    It was decided that the Federal Government could not withdraw existing Medicaid support from states that balked at significantly increasing the number of those eligible to receive this entitlement. Otherwise everything was copacetic.

x     The concepts of “checks and balances” and “separation of powers” no longer apply. The Supreme Court, like mom, is in charge, and there is no appeal from its decisions.

xi     Of course nothing in this clause (Article 1, Section 8, Clause 3 of the Constitution) that deals with this issue or even implies any connection to health care, but the Court has expanded its scope at will. According to Wikipedia, “During the post-1937 era, the use of the Commerce Clause by Congress to authorize federal control of economic matters became effectively unlimited.”

xii    I must admit that I never read the bill. It's far too long. In all likelihood, though, it wasn't read by most of the people who voted for it. They simply did what they were told.

xiii  June 26, 2009. Of course Congress's position, and that of the President, were well reported elsewhere as well, so that taxpayers would know that no one was raising their taxes.

xiv    If it wants to.

xv     What makes it a little harder for me to understand, however, is that the Court decided, when ruling on the legality of the individual mandate, that, despite Congress's wishes, which it ignored, this was a tax (intent was not relvant) and the commerce clause didn't apply, but, when dealing with the argument that the case should not then have been in court and decided, because taxes cannot be challenged until they have been paid (as per the Anti-Injunction Act of 1867) – and that has not happened yet – ruled on the case because, according to the Court, the act does not apply in this case since Congress used the word “penalty” instead of “tax,” signaling Congress’s intent that the Anti-Injunction Act should not apply in this case. The Court ignored Congress's wish that it not a tax, but after deciding it was a tax ruled that laws regarding taxes didn't apply to it because Congress didn't want a tax (intent was all that was relevant). I guess I don't understand because I have no legal education and lack the legal sophistication (sophistry?) to appreciate the nuances of the decision.

xvi     Some children's rights advocates might not accept this view. 

xvii    As well as the prizes in all previous lotteries.

xviii   Everyone else is equally entitled to win, so don't tell them my plan. At least not until I collect my fortune. After that I won't care and they can divide it all among themselves.

Paying The Bills

                                                                                

Percentage of United States budget for Health Care:ⁱ

Other health care costs:

Total cost of your health care:

I'm not a sophisticated economist. No. Change that. I'm not an economist. But my mind wandered a little this morning and I started wondering about health care costs. The presidential election's over now, and with it the rhetoric that usually clouds such issues with the complicated overlays of emotion and politics that make any real understanding difficult at best.

So I have the luxury of considering [selected] numbers without having to factor in such distractions [from the numbers] as guilt, responsibility, and the purpose of society. It's even easier since I've decided not to look up the numbers right now. I'll do that presently – after I've given some thought to the nature of the problem. Only then, when we both have a little more information, can we try to quantify it. I may be surprised and find out that no problem exists, but in the meantime I can give some thought to the way we manage money in our current society.

So let me get to some basic considerations, and they're really considerations of human nature. Because I spent most of my life in medicine (no, not taking, it but working as a physician) I'm focusing on health care. I noticed early on – in fact I noticed as a college student before I became a doctor – that there was a paradox in the cost of scientific glassware. It was both unconscionably expensive, and it was free. It was “free” because someone else was paying for it – usually the government or a granting foundation – but the price was inordinately high because the vendors knew that the people ordering it weren't paying for it themselves. And very often they didn't even need it. I also learned that there was a basic rule that you always spend all of the money given you, or you may get less the following year.

That's the way money management works. An individual may be very careful with his own budget, but will freely disburse what he doesn't see as his own. And he'll spare no effort to increase his intake – as income for himself or as money he can give away or spend on others. There's always an organization or some sucker with deep pockets who can be convinced to pick up the slack.

But that philosophy is one that involves not only people: governmentsⁱⁱ have little hesitation about spending our money on programs that sound good, and we don't care – especially since we don't recognize that in the end we'll wind up paying the tab. More likely our grandchildren or their grandchildren will wind up with the bill. We're paying for the generosity of those who preceded us. We're paying for their guilt and magnanimity, and our descendants will pay for ours. Actually we're only making the interest payments, but sooner or later our creditors will demand that we – really it will be those who follow us – start paying off the principle. That principle is the National Debt, which now amounts to … (I'll look that up later, too). We keep kicking the can down the road, but sooner or later someone will get it and have to open it – and it's a real can of worms. Greece knows that.

The needy, however, are everywhere, not just in our country. And they suffer not only from poverty but from disease and oppression.ⁱⁱⁱ The basic idea, and it is a beautiful one, is that we are all responsible for each other. In the Western tradition, the Bible tells us to help the poor, the widow, and the orphan. “Love thy neighbor.” And I have no doubt that there are similar injunctions in all other cultures. But religious teachings often place limits on the amount that one can give away, and realpolitik governs the extent of involvement we're permitted in the affairs of other countries. We're not always wise to try to care for all of humanity, nor are we always free to do so. We know about the tribulations of those around the world, but we can't afford to deal with all of them. And, many believe, it's not our place to do so.

That, however, is neither here nor there. At least it's not the subject of today's discourse. More to the point is our consideration of the cost of caring for the health of our own citizens. That used to be a family obligation but not any longer. Now it is a duty that has devolved onto society in general, even if we may disagree on what standards we should use to judge it^iv and those who receive it, we all pay for it.^{v vi} We consider it self-evident that those who can better afford it than we should pay more to support the kind of care that all our citizens deserve.^vii

Oh. I finally got around to checking. Health care makes up about 23% of the national budget. Apart what you pay for your own care, $230 of every $1,000 you pay in income taxes goes in that basket.^viii As well as 23% of what you pay in a variety of other taxes you pay – like tariffs for imported items – and the costs incorporated into the prices of whatever you buy. The latter reflect producer's and manufacturer's costs that are simply passed on to the consumer. Congratulations. The bottom line is that you're probably paying not only for your own medical costs but for those of others as well. I trust you feel magnanimous.

By the way, our National debt now is over $16 and a quarter trillion and rising rapidly with each new program. But who cares? There isn't any real problem (for me). It's only money, and soon enough it will be someone else's burden.

Next episode: “Growing Down” – It's a tall order.

i      By the way, the use of health care costs is only an example The same issues and calculations can be considered for all parts of our budget. I won't look up any numbers for you though.

ii     Or, more accurately, our elected representatives who are looking for votes in the next election.

iii    Sickness doesn't stop at the water's edge. Nor does guilt.

iv    We wish to raise our standards, but as more and more individuals become eligible for subsidized care, as payments for that care diminish, as medicine becomes more assembly-line, standards are more likely to diminish.

v      That includes Christian Scientists and others who may oppose the programs in general or some who oppose particular parts for religious reasons (like those who consider abortion to be murder). The First Amendment guarantee of religious freedom does not extend to health care.

vi      The reimbursement for some services can be lowered artificially, but that doesn't actually change the costs of performing or providing those services. If it leads to a lowering of salaries it will drive the best practitioners into other fields, diminishing both the number of providers and their quality. It may be necessary to enlarge the bureaucracy to supervise these services even if that will raise costs. The more people involved in regulating and minimizing the costs, the higher they'll be. But it will provide jobs.

vii    “From each according to his ability to each according to his needs.” It was good enough for Robin Hood and it's good enough for us (even if it's not clear who decides on ability and needs). The redistribution of resources makes a lot of sense in a society that prizes equality. Those who view Marx's words ("Jeder nach seinen Fähigkeiten, jedem nach seinen Bedürfnissen!") as a call for socialism are simply mean-spirited. And those who fear that this kind of redistribution will lessen the initiative of the capable are fear-mongers. We'll all work hard and work long hours to support those who don't.

As for those who contend that actions of this sort are contrary to the ideas of the Founders, they should be aware that the Declaration of Independence and the Constitution are outdated, and we now have the Supreme Court to make the laws.

viii   As you must certainly realize that is the amount expended by the government only. It covers Medicare and costs that cannot be paid by the poor and the disabled. It does not cover your costs to private insurers (I pay for long-term insurance to protect my children), deductibles, and out-of-pocket expenses for medications and the like.

The Court In Action

                                                                                                 

It's hard for me to determine if the Constitution is the best form of government possible, but it's what we have. I don't presume to be the best interpreter of it. That's not my area of expertise. I'm neither a historian nor a Constitutional scholar.

I can't comment on the validity of the Affordable Health Care Act that was given the green light by the Supreme Court. It's legal. They said so, and since they claimed the prerogative to make such decisions in Marbury v. Madison I have no standing to do question it. I'm not a lawyer and it's not my area of expertise.

But is it better to be healthy or sick? I can offer an informed opinion on that. I'm a doctor so I have the expertise. Even if I weren't, I suspect that I'd opt for good health if given the choice.

But I don't think that is the issue. Congress passed a statute that provided, under the Constitution's Commerce Clause, that everyone would be required to have health insurance or pay a penalty. It would not be a tax. Raising taxes is a dicey political issue and Congress made great efforts to avoid that pitfall.

Not only that, but when arguing for the validity of that law, the Executive Branch of our government emphasized the fact that this was not a tax and that its sanction lay within the Commerce Clause.

The Supreme Court, however, rejected that argument declaring that while it was not Constitutionally valid under that clause, it could still pass muster as a tax, since Congress had the right to pass such a levy.

The President declared victory since the Court left the Act standing, but he stated flatly that it was a penalty, not a tax. He denied the underpinning of the Supreme Court opinion while accepting the decision itself. He denied the appellation of a tax, which is toxic at any time, but even moreso in an election year.

Whether Congress has the power to assess a tax on those without insurance is not the subject of the debate. Clearly Congress did not want to do so. And the Executive didn't want to defend the statute on that basis. And that is a perfectly valid point of view and action, but the Supreme Court wasn't prepared to accept the will of Congress and the view of the President. The Court, which had assumed the responsibility of deciding what the law was, preferred to declare and legitimize what the Justices thought it should be.

One of the main concerns of many Americans is about what they consider “judicial overreach.” There is a view that the courts have usurped legislative power and made decisions regarding legislation based upon their views of societal needs rather than Congress's. Even without training in Constitutional Law, I doubt that this was the intent of the Founding Fathers.

This decision cannot be seen in any other light. Although the Court rejected the wishes both of Congress and the President, the majority found a way to approve the Act. Referring to a power of Congress which it had chosen to reject, the Court allowed the new law to remaining force even as the President rejected the Court's reasoning. The Court had based its view on a right that Congress had not claimed, because it existed – even if Madison meant something different when he wrote it. The majority found a way to achieve the desired goal of universal health care in spite of the other branches of government. It legislated what Congress had not wanted.

It is hard to argue against health and for the denial of care to everyone, but it is also unreasonable to insist that the State knows better than the citizens who created it. If the courts can justify whatever they consider appropriate, whether or not Congress wants to do so, there is no longer any real balance of powers – no checks and balances. The Court claims the right to decide on Constitutionality, but as such, its mandate is to judge the laws that have been passed, not to find a way to pass their own laws and then find them Constitutional. At that point, Congress, and the Executive, which is charged with the responsibility of enforcing the will of Congress, become irrelevant. If Congress acts in a way that the courts find to be wrong, but the goal is one of which the court approves, the judiciary can write its own law, irrespective of the wishes of Congress.

Our health is critical, but so is the health of our country. And it's our country and our Constitution that are the real victims of the Court's therapy.

Playing The Numbers

Employing modern jargon, I need my space. I'm a pacer. People get in my way.

It's not that I don't like people. At least it's not only that.ⁱ And I'm not claustrophobic – at least not in the usual sense. I don't have a phobia, only a need for breathing room. Things have gotten too big for me.

That's a shame. We live in an age of size and numbers. We're reminded of the size issue every time we open our e-mail and look at the spam and find products which I won't discuss. And there are plenty of plastic surgeons who specialize in changing the size of breasts and butts. And lips.

The obsession with numbers, however, seems to be the hallmark of our times. Not just lotto, but everything else as well. Movies and television shows, and the various social networks, are judged by the number of people they attract; sports broadcasting is so filled with statistics that there is no time for anything else – and some of the statistics are so bizarre as to be sillyⁱⁱ; and with modern technology, search engine results are in the tens or hundreds of millions. Numbers are big, and in part that reflects a change in the American (and world) culture, with a fascination for size and records. So all numbers seem to be big.

But the most striking numbers – and, in the end, the most significant – are those related to the “representative” democracy in which we live. When the American Constitution was written,ⁱⁱⁱ note was taken of the need for representatives to be familiar with the people they represented, but in order to limit the size of the House of Representatives they^iv wrote, “The number of representatives shall not exceed one for every 30,000, but each state shall have at least one representative ...”^v That was then. The population right now^vi is 313,397,468 with a net gain of one every fourteen seconds. With 435 member of the House, there are now an average of 720,453.949425287356321...^vii constituents for each congressman.^viii And each district has a variety of neighborhoods and professions. It's likely that the “representative” isn't able to represent much more than himself.^ix

To justify their positions our representatives (or their staffs) write bills, long bills. When the Supreme Court considered health care legislation recently, Justice Scalia commented “(W)hat happened to the Eighth Amendment?^x You really want us to go through these 2,700 pages?^xi And do you really expect the Court to do that? Or do you expect us to — to give this function to our law clerks?”^xii The laws themselves are too long,^xiii and they often are “fleshed out” by regulations whose elaboration by nameless bureaucrats may dwarf the legislation.^xiv

Speaking of “nameless bureaucrats,” as of February, 2010, according to the Employment Situation Summary published by the US Bureau of Labor Statistics, there were 21,292,000 government employees in the United States. That includes the President's eight speech writers.^xv It's likely that the Founding Fathers never anticipated all the complexities we'd create for ourselves.

It's not up to me to decide if a large governmental bureaucracy is good or bad. Both opinions have their adherents. And at a time of high unemployment there's a lot to be said for high government employment, especially in tenured Civil Service positions,^xvi but the risks of an unelected – and to a small degree elected, if unrepresentative – body that makes the rules for us, cannot be overlooked.

As for me, I have more important matters to ponder. Will we have a minyan^xvii tomorrow morning? But whether or not that that's the case – and I certainly hope we'll have enough – I'm sure I'll have enough room to pace. Large numbers are never a problem there.

Next episode: “All The News ... Addendum” -- Journalism. Take 2.

i     I would have made a great hermit. It's nice having someone to talk to, but only when I want to talk. I know it's a selfish attitude, but I like having someone around on my terms. I like to have plenty of room and not to have to pay any attention to anyone unless I feel like it. I realize that such an outlook is intolerable to others and I try to be sociable, but my heart isn't in it.

ii    Like doubles in the fourth inning on a Tuesday.

iii    1787

iv    Actually it was James Madison who wrote it.

v     Article 1, Section 2, Paragraph 3. Do you know that many? I don't know 30,000 people. Maybe they did but I don't. Nonetheless I can understand their view that this “limitation” would be sufficient to ensure proper representation.

vi    April 20, 2012 at 13:48 UTC – according to the US Census Bureau.

vii    The number just keeps going, but by now you've got the point. And parts of people are a little too difficult to conceive (of).

viii    The number just went up.

ix    But he probably does that admirably.

x     Dealing with cruel and unusual punishment.

xi    The Declaration of Independence, which outlined our ideals, and declared our independence and its justification, was about 1,330 words long and the Constitution about 4,500. The Constitution, of course, outlined our entire governmental system, listing the branches, their duties, and the details of our relations with other nations, among other things. The two together could fit in those 2,700 (plus however many thousand pages of pages are needed to clarify the shorthand of the original law) at 2.16 words per page. That's a lot of white space. It seems clear that the health care law is far more important than the Declaration of Independence and the Constitution.

xii    The Justices, though not elected, go through some form of review by the Senate; the clerks, however, are not in any way representative of the people.

xiii   And there are far too many of them, with the Federal government often taking over areas which the signers of the Constitution intended as the responsibility of the states.

xiv    “If you have ten thousand regulations you destroy all respect for the law.” – Winston Churchill

xv     I wonder how many George Washington had.

xvi    Whoever is elected, irrespective of which party, regulations will be written by these people, and will reflect their views and prejudices. To a degree this ensures stability, but the rules they write may not reflect the wishes of the legislators or their constituents.

xvii    The ten men needed for some parts of the Jewish religious service.

The Elephant And Insurance

So here's how it works. If I'm injured or killed in an attack by someoneⁱ riding an elephant, I'm entitled to full payment of medical or funeral costs – even if I'm merely stomped by the elephant. In fact, I get benefits even if I'm stomped by an elephant who isn't attacking. The benefits are lower, but I can count on them. There's a moderate deductible (larger if I'm not within twenty-five miles of my residence) and the insurance is only good in the United States. But it's solid insurance. The government stands behind the companies that issue it.

It has to. According to the new law I have to buy it. Perhaps it's of greater value to those who appear in Aida or work in zoos or circuses, but the cost for them alone would be too great, so everyone gets the insurance. And you never know. Anyway, that's the law.

And that's the way the new health care legislation works – at least to a degree. Everyone is required to buy the insurance or pay a penalty. It doesn't matter if they need or want the insurance. That's the law.

Actually it's contradictory to the concept of insurance, which is little more than gambling. The insurance company is betting on the insured, and the insured is betting against himself. But the payout, if there is one, is supposed to be large enough to cover the risk for which it is designed. As is the case with all betting, the house – the insurance company – will come out ahead. In this case, however, the individual who “wins” will be protected from a large loss. In reality, the government is forcing the individual to protect it from the lossⁱⁱ it would face if it had to pay for his health care. The program, however, forces those in good health, and who would prefer to take the risk of going uninsured, to buy in and, in effect, pay for those more likely to need help. There's a spreading of risks so that they're equalized among all participants. If there were similar equalization of salaries we'd call it socialism. But it's not that. It's more of a method for acquiring a national health service that is paid for without the risk of being accused of raising taxes. From the point of view of the taxpayer, however, it's a distinction without a difference.

Important features of the new health care system include the provision that no one can be excluded because of pre-existing condition, and the cost will be the same for men and women. Notwithstanding the evidence that it costs more to provide health care for women than men, there will be “gender”ⁱⁱⁱ equality.^iv Women will pay no more than men.^v And with programs like Medicare, we are already ensuring that those who don't smoke or drink will help underwrite the costs of those with lung cancer, emphysema, and cirrhosis. Those poor people are already suffering enough from their medical conditions and have had to deal with increased costs from the cigarettes and whiskey. They should have help from the rest of us. If they've worked some, and are eligible for Medicare, they'll get it.

Perhaps that will be viewed as reductio ad absurdum but it's hard not to conclude that obligatory participation is little more than a tax on the healthy and a method of shifting costs to the taxpayer in order to save the government money. Because the word “tax” is viewed negatively, a method has been found to change the label. And for those who elect not to participate, there is a “penalty,” not a “tax.” Well played. The government's done it again!

The case^vi has been argued in the Supreme Court and some time soon we'll learn where the Justices stand.^vii The law, however, seems to be in conflict with previous policy and with American thought. The Court decided that certain issues involved privacy and that individual decisions should be respected. Elective abortion is a matter of choice. It's difficult for a legal layman to understand why the decision to buy health insurance should not be a matter of choice, with that option having become a major factor in the country's thought. The termination of a pregnancy – what some view as the taking of another's life – can hardly be viewed as more private, and more a matter of choice, than the decision about payment for one's insurance policy.

I have health insurance, and there really is no mandate to have elephant-stomping insurance, so I'm in good shape. The principle, however, will have to be decided by the Court. More and more the extent of government intervention in our lives is likely to pop up in a variety of forms, and this is as good a time as any to decide on its propriety.

Next episode: “People Are No Damn Good” – Except me, of course.

i      Hannibal, for example.

ii     The government – or more accurately the governments, since it's usually paid for locally– is ultimately responsible through public hospitals.

iii    We don't say “sex” anymore.

iv    Other insurance is “rated.” Those with increased risks pay premiums proportional to the increased risk. That's business. And insurance companies usually have the option of declining to insure the really bad risks. “Assigned risk” is one answer to ensure coverage of drivers who are “accident prone” (some of whom, perhaps, shouldn't be driving for the protection of the rest of us), but their rates are certainly not the same as safe drivers. And drivers have the option of refusing to buy insurance. In some states this will mean that they don't get driver's licenses, but it's their option, and there is no monetary fine for the choice not to have coverage. Where uninsured driving is legal, the uncovered driver who is in an accident – he lost his bet that he could drive accident-free – will have to pay costs from his own resources.

v     The argument is made that an accident of birth should not affect the cost of insurance. It makes sense. But there are other “accidents of birth” that do affect an individual's standing and choices: intelligence, location of birth and subsequent citizenship and residence, and family income for example. Although we may wish it otherwise, a child born in Bangladesh is more likely to be hungry and poverty-stricken than an American. It may not be fair, but it's the case. Attempts to equalize situations like that and millions more will fail however much we wish their success. And despite what may seem unfair, most firms will not hire someone born blind to be a security guard.

vi     Regarding the new health care law.

vii    Actually, they usually sit.