Why don’t we throw people out of emergency rooms?

In discussions of market forces in health care, someone always points out that we don’t allow people to just die in the streets. Anyone who shows up in an emergency room must be treated (in the US this has been true since the Emergency Medical Treatment and Active Labor Act of 1986, I believe). Among the many other reasons why medical care does not respond to free market incentives, then, is the fact that the providers are not able to turn away customers who are unwilling or unable to pay.

But here’s what I’m wondering: This is always presented as an issue of basic humanity, or altruism. We can’t let the poor die of treatable injuries or illnesses because that seems too brutal. But is that the whole story, or even most of the story? My suspicion — and I’d have to go back to the debates on EMTALA to develop any clarity on this — is that the real reason we have a no-exceptions requirement that hospitals provide urgent care to the poor is that there’s a significant danger that the non-poor might be confused with the poor, particularly in times of medical emergency. Someone who has been hit by a car or has suffered a stroke and is disoriented is likely incapable of quickly identifying herself as an upstanding creditworthy citizen with health insurance. So the hospital is required to try to keep them alive long enough to allow them (or their relatives) to demonstrate that they are worth saving.

Which leads to a question: Supposing biometric databases become universal, and the hospitals are able to immediately ID anyone who comes through the door. Will we then relax the rules, and allow them to turn away the indigent, perhaps sending them off to some primitive alternative hospital for the poor?

Paradoxes of belief: Holocaust denial edition

(or, Vonnegut’s Mother Night reversed)

I’ve long thought it amazing how many odd, nearly unbelievable, individual stories are hidden in the corners of the grand ghastly narrative of the Holocaust; and no matter how many stories I read — Peter Wyden’s account of Stella Goldschlag, for instance, his Jewish schoolmate in 1930s Berlin who specialised in sniffing out undercover Jews for the Gestapo — there’s always another even stranger, such as the jewish graphic designer Cioma Schönhaus who survived the war, and saved many other lives, by learning to forge identity papers.

Holocaust denial seems to have its own bizarre corners. To wit, this new revelation:

[David Stein] a cerebral, fun-loving gadfly who hosted boozy gatherings for Hollywood’s political conservatives […] brought right-wing congressmen, celebrities, writers and entertainment industry figures together for shindigs, closed to outsiders, where they could scorn liberals and proclaim their true beliefs. That he made respected documentaries on the Holocaust added intellectual cachet and Jewish support to Stein’s cocktail of politics, irreverence and rock and roll.

[Under his original name David Cole he] was once a reviled Holocaust revisionist who questioned the existence of Nazi gas chambers. He changed identities in January 1998.

This reads like an April Fool’s prank, or a high-concept film plot from the fevered leftist imagination. The right-wing Jewish Holocaust documentary maker and fanatical Israel supporter is actually a secret neo-Nazi. Ha ha. Who would believe that? It’s not so easy to change your identity, particularly if you’ve just made yourself notorious on TV chat shows. And how would a man with no past be able to start a new career and become a political insider?

But what intrigues me most of all is when the Guardian article touches on the question of Stein/Cole’s true beliefs. One of the important lessons of modern cognitive psychology and philosophy of mind is that it is very difficult — perhaps impossible — to develop a coherent theory of beliefs, under which statements like “X believes Y” are statements of fact. (See, for example, the seminal book by Stephen Stich, that relegates beliefs — and other many other concepts — to the realm of “folk psychology”.)

Continue reading “Paradoxes of belief: Holocaust denial edition”

Freedom of religion in Britain and Germany

After the monarchy, state-sponsored religion is one of the strangest customs I’ve had to adapt to in the UK (and Germany, the other European country that I’ve lived in for a number of years). In the UK I’ve already written about the somewhat insidious role of state religion, such as the way it dictates which schools your children will be admitted to; that 26 bishops sit ex officio in the House of Lords (though it should be mentioned that the other state religion, Finance, has its own peculiar kind of special representation in the Commons); and that non-Anglican foreigners who wish to marry in the UK require permission of the Home Office, for which they must pay a substantial fee. (This Anglican exception may now have been rescinded; I know there was pressure from the European Court of Human Rights.) All UK state schools are required — following a Blair-era edict — to have daily Christian prayer (unless they are state-sponsored non-Christian religious schools, another Blair novum), though that law is not always followed, particularly in secondary schools — see par. 141 of this Ofsted report.

Germany is a federation in most respects, with wide variation in religion and religiosity, but a requirement for church-approved religious education (of two flavours, Catholic and Protestant) in the schools is anchored in the constitution. The federal government collects tax on behalf of the churches. And the churches, which control a significant portion of the hospitals, among other businesses and institutions — are allowed to discriminate against their employees in ways that would be forbidden, and indeed morally condemned, by any other employer. A recent court decision in Germany concerns a 60-year-old pediatric social worker, who worked for the Catholic organisation Caritas. Shocked and appalled by the extent of child-abuse perpetrated and covered up by the Church, he officially left the Church. (In other countries it’s not clear how you would officially stop being Catholic, other than by joining another church, but in Germany you just stop paying tax and you’re out. Reassignment of your soul’s eternal fate follows in 4 to 6 weeks.)

So the Church, which knows how to respond to a major breach of moral and ethical norms, clearly couldn’t stand for the scandal of a social worker in their employ taking a public stand against sexual abuse of children. And while being Catholic was apparently not a requirement of the job to begin, the courts agreed that being an ex-Catholic is forbidden, particularly one whose break with the Church was provoked by something so unseemly as individual conscience.

The Life of Julia: Another longitudinal fable

Picking up from my earlier discussion of the way cross-sectional data  get turned into (sometimes misleading) longitudinal stories, it’s been about a year since the Obama campaign unveiled The Life of Julia, a slide show that contrasted Obama’s and Romney’s policies with regard to their effects on women at different ages. Stated that way it would be pretty standard and uncontroversial, but in fact it turned into a flashpoint for the early part of the campaign. Why? Precisely because it was not a list of cross-sectional promises — What President Obama will do for children; What President Obama will do for seniors; etc. would be standard campaign web site headings — but was turned into a longitudinal story. These were not 12 different women, of different ages, who would putatively be helped by the president’s policies, but a single woman “Julia” who seems to be spending her whole life looking for government programs to scrounge from. Of course, it only seems this way because of the way this infographic interacts with our expectations of a biographical narrative, where we expect to be seeing the high points of her life, and every one of them involves government services. Creepy! It’s no wonder some critics were reminded of cradle-to-grave socialism.

Of course, the real story is cross-sectional. If Julia is 3 years old now, Obama is not really promising to provide a small business loan to her in the year 2040. And by the time she reaches retirement, she’ll probably be living on a Mars colony or hiding out from roving mutant bandits in subterranean bunkers after the nuclear climate catastrophe.

obama-julia-infographic julia full

Beware the Dijsselbomb!

Why are rich people so squeamish about the truth?

Some very smart people have taken to the Internet to ridicule Eurogroup president and Netherlands finance minister Jeroen Dijsselbloem for his inappropriate attack of clear speech. He said that “the Cyprus deal will serve as a template for future bank restructurings in the euro zone.” Sounds like something to cheer: Deposit insurance has been affirmed, but implicit taxpayer guarantees for wealthy bank creditors have been repudiated.

But instead we have Matt Yglesias saying “That’s the kind of remark that it would be very sensible for, say, a blogger to make. But Dijsselbloem is president of the Eurogroup of eurozone finance ministers, and a guy in his role is supposed to be reassuring people. Instead he caused them to panic.” And so Meneer Dijsselbloem issued another statement saying that of course the Cyprus bailout isn’t a template for anything, because every financial crisis is a unique special flower and no other European tax haven is an island and you can’t step into the same river twice… Continue reading “Beware the Dijsselbomb!”

World’s greatest healthcare (TM)

What does it mean when a US politician like Chris Christie tells the Republican National Convention the US has “the world’s greatest healthcare system”? Is it like when kids buy a “World’s Greatest Dad” mug for Father’s Day: An expression of affection for an ill-favoured thing, but mine own?

One of my formative political experiences was the summer during graduate school, when I listened on the radio to broadcasts of the US Senate debating the Clinton healthcare proposals. What struck me above all was how the senators universally (it seemed) invoked the unmatched excellence of American health care. “The envy of the world”, “best health care in the world”. The only difference of opinion was, of course, that opponents of the reform said that tinkering with this paragon of perfection would inevitably be disastrous, while supporters argued for making this blessing available to more people.*

So, the politicians certainly appear to believe it, and to believe that it should have policy implications; or to believe that a significant portion of the public believes it; or to believe that a significant portion of the public will respond favourably to the assertion, even if they suspect it is untrue. Is it cognitive dissonance? We’re America dammit, and being the sort of people we are, we certainly wouldn’t put up with a ramshackle healthcare system.

Continue reading “World’s greatest healthcare (TM)”

More reflections on 9/11 and the Iraq war

I left out a few points that I wanted to make in my post on the 10th anniversary of the Iraq War:

  1. About a week after, I wrote in my diary that I had the disturbing impression, reading the comments of journalists, politicians, and intellectuals, that a significant subset of them were in a certain way pleased: not that the country was attacked, certainly not at the tremendous loss of life, but that life had turned serious. The country had been wallowing in nostalgia for the “Greatest Generation” — Tom Brokaw’s book had been published just a few years earlier — while the current youth (a group which I was just growing out of, being then aged 33) had its culture defined by ironic detachment. So we had articles on “The Age of Irony Comes to an End“. It was mainly just another way to bash young people, which is always popular, but it also appealed to a deep-seated desire to be the protagonists of history, solving problems of historic dimensions. And there are no victory parades for conserving energy and stopping runaway global warming. This was confirmed for me when people started quoting incessantly W H Auden’s 1939 disdain for the “clever hopes” expiring “of a low dishonest decade”. Continue reading “More reflections on 9/11 and the Iraq war”

Evidence, WMD, and the Iraq War: Reflections on Tony Blair and Colin Powell

With the 10th anniversary of the Iraq War, it’s an appropriate time to comment on two elements of the public discussion of the war, in the US and the UK, that puzzle me.

  1. The insistence, particularly among lefties who supported the war then and have reconsidered the matter since then, that everyone thought Saddam Hussein had active nuclear and chemical programs. At the time, I strongly opposed the war — because I thought it was an inappropriate distraction from Afghanistan, I didn’t like the way it was being ginned up, the WMD argument didn’t seem to me sufficiently important relative to the trouble it was likely to stir up –but I had every anticipation that the US military would march in and would find the missing nuclear program, and that this would be waved in the face of everyone who was still legitimately skeptical. I assumed there was a lot of secret information that more or less proved to anyone entitled to see it that this work was going on. It seemed more likely than not, until… Until Colin Powell’s speech to the UN. I found that speech astonishing. My thought was, surely they are pulling out all of the most convincing bits from their secret dossier, and that’s it? Continue reading “Evidence, WMD, and the Iraq War: Reflections on Tony Blair and Colin Powell”

Statisticians of the World, Unite!

You have nothing to lose but your Markov chains!

From “A Brief History of Britain 1066-1485”, by Nicholas Vincent:

Finally, as in all modern debates from which statistics and the spirit of Karl Marx are never far distant, it has been argued that, by 1200, Philip of France was far richer than the King of England and therefore ideally placed to seize the Plantagenet lands.

Statisticians or Stakhanovites? You decide…

Fascism in America

Today we have conquered the health-care insurance exclusion for pre-existing conditions. Tomorrow, Poland!
Today we have conquered the health-care insurance exclusion for pre-existing conditions. Tomorrow, Poland!
Nuremberg rally
Die NRA sind unser Unglück!

I remember many years ago when I first saw a car bumper sticker saying “First round up the guns, then round up the Jews!”, which I assumed to be suggesting that the owner disapproved of both confiscations. Just now, the “Nazi gun control” trope is all over the place: for instance, here and here and even here.
It’s weird, because this story seems to have literally zero basis in fact. I’ve read quite a few books about the Weimar Republic, the rise of Nazism, and the Third Reich, and I’ve never come across any reference to a Nazi interest on the question of private gun ownership. Sure, Jews were forbidden to have guns, but they were also forbidden from owning cats. It’s not that the Nazis feared the wrath of the Hebrew feline defenders.

The only reference I’ve come across to a nexus between Nazi ideology and private guns (as opposed to military armaments, in which they obviously had an abiding interest) is a passage in Ian Kershaw’s masterful biography of Hitler. Discussing the extraordinary thoroughness of the campaign of “Gleichschaltung” — the “coordination” of all institutions, whether large or petty, with Nazi goals and ideology — in 1933, he quotes an “activity report” from the small town of Theisenort (population about 750) in Upper Franconia:

The Veterans’ association was coordinated on 6.8.33, on 7.8.33 the Singing Association in Theisenort. With the Shooting Club in Theisenort this was not necessary, since the board and committee are up to 80 per cent party members.

So there would have been no need to round up the weapons of regime opponents, because the shooting enthusiasts were all Nazis to begin with. That doesn’t really support the whole bulwark against fascism idea. Continue reading “Fascism in America”