Something rotten in the state of Pennsylvania

For those of you who have missed the gruesome case of Kermit Gosnell and his victims, Slate has a grim article. It reads like something from an Eli Roth movie. [For the second time in a week, I feel moved to offer a disclaimer that the article details some horrifying crimes. It (and the remainder of this post) should be avoided if you're squeamish.] Gosnell, a Philadelphia doctor (I can barely bring myself to type that word, in this case), is accused of numerous things, the most grievous being the murder of newborns by severing their spinal cords.

The case throws into stark relief some of the more pressing ethical questions about abortion and murder, certainly late-term abortions. I intend to side-step that thorny issue, and to focus merely on the same question William Saletan appears to be asking in his series of articles on the subject -- how could this have been allowed to happen, and how did the politics of abortion contribute?

There are these disturbing images:
The grand jury's report, citing forensic evidence and testimony from clinic employees, accuses Gosnell of routinely delivering viable babies and severing their spinal cords. But it also details ill treatment of women. According to the report, Gosnell used unlicensed workers to administer anesthesia, failed to obtain patients' informed consent, gave them expired drugs; endangered their health with poor sanitation and broken equipment, and caused the deaths of at least two women.
Unless I am gravely mistaken, one of the central tenets of the pro-choice movement is that restrictions on abortion will lead to unsafe conditions just like this, except performed in back alleys. Apparently this clinic exists as some kind of horrible converse.
From 1993 on, Gosnell went completely uninspected. The grand jury says the health department "decided, for political reasons, to stop inspecting abortion clinics at all. … With the change of administration from Governor Casey to Governor Ridge, officials concluded that inspections would be 'putting a barrier up to women' seeking abortions." Casey was pro-life; Ridge was pro-choice.
I cannot understand this at all. In a world where our restaurants are inspected to confirm a basic level of sanitation, how can a "clinic" where invasive medical procedures are performed escape even the barest scrutiny? This seems like the worst effect of the worst kind of political cowardice.

This just sent me over the edge:
The other agency that could have stopped Gosnell was Pennsylvania's Department of State, which included the state Board of Medicine. According to the grand jury, the department ignored complaints about Gosnell for years. The complaints involved unlicensed administration of anesthesia; sexually transmitted infections (apparently spread by the clinic itself); perforated uteruses, cervixes, and bowels; hospitalizations of infected patients; and family members prevented from summoning emergency aid. The consequences allegedly included a hysterectomy and a patient's death.
This truly enrages me. A few years ago, a completely frivolous complaint was filed against me; it was absurd on its face. Despite its obvious lack of merit, I had to go through a lengthy response process, during which time the complaint and the records were reviewed by the Board (in a different state). The complaint was dismissed as soon as it could be, but even for a gripe as patently ridiculous as the one I faced, a very formal protocol was followed.

Seeing how grossly patient welfare can be affected by a break-down in the system meant to protect it, I am almost grateful for the seeming other extreme of my own experience. (I still think there should be a speedier process for dispensing with complaints that are clearly frivolous or abusive.) Given the gravity of the multiple complaints lodged against Gosnell, every single person involved in handling them is guilty of negligence, at the very least.

I understand that the abortion issue is immensely fraught. I can see how onerous regulations could be used to stymie access to legal, safe abortions. But using those issues as an excuse to abdicate regulatory responsibilities is partially to blame for the death of at least two women and many infants. Everyone involved deserves our collective anger, not merely the monster who perpetrated the acts themselves.


Still, it's better than Crash

A few disclaimers:

1) I am not a big fan of hip-hop music. This probably has much to do with the kinds of music I was raised with, which tended toward Nanci Griffith and classical. I do not consider my lack of appreciation a reflection on the inherent quality of the musical form.

2) I am not a big fan of Eminem in particular. I think he is a misogynistic, homophobic lout.

3) I did not watch the Grammy Awards last night. Acting awards shows I watch like a religion. Anything else, music awards shows especially, I skip.

All that said, I know with 100% transcendent certainty that the winner of a couple of last night's big awards was wrong. Deeply, deeply wrong. From the Times:
Asserting the power and versatility of the new Nashville, the country-pop trio Lady Antebellum was the big winner at the 53rd annual Grammy Awards, which were presented on Sunday night at the Staples Center arena here.

In a night of upsets, the band won five prizes, including the top two awards for a single track — record and song of the year — for “Need You Now,” besting Eminem and Jay-Z, as well as sweeping the country categories. It won in every category in which it was nominated except album of the year, which went to the indie-rock heroes Arcade Fire for “The Suburbs,” the first time a band solidly in the alt-rock world has taken that top category.
No. No, no, no.

I have heard "Need You Now" in various shopping centers, occasionally when flipping through channels, and maybe once on the radio before frantically spinning the knob to anything else. "Need You Now" is like Xanax-laced pudding being forced into one's brain through the ears. It makes "We've Only Just Begun" sound like "Darling Nikki." It could make Ambien obsolete.

It is inoffensive enough, I suppose. But there is no way it could possibly be considered the "Best" of anything.

Which cafe is to blame for Pol Pot?

I read a harrowing article in Slate (via Yglesias via Plain Blog) about Stalin and the enforced famine in the Ukraine in the early 1930s. It is, among other things, an exploration of the question about which was "worse," Communism or Fascism, Hitler or Stalin, or whether one can ever meaningfully answer such a question. The article itself hinges on the gruesome facts about cannibalism during the famine, and what it says about the depths to which humanity can plunge itself.

Anyone who clicks through the link should be aware that the article contains very graphic and unsettling descriptions of cannibalism. These details are not central to my point. Ron Rosenbaum, the author, believes it important to state open-eyed at what people are capable of doing to each other in the extremes of suffering and deprivation. I disagree somewhat, in that I think most of us know that unspeakable circumstances produce unspeakable horrors. However, knowing the truth about human history allows us to view the present more honestly, and I think it is important for us not to fool ourselves that human beings are innately incapable of ghastly crimes. (It is also important to remember that the same extremes of suffering and cruelty can also bring out remarkable heroism and charity.)

Having made my way through the article, though, I found myself started by this rather baffling conclusion:
Finally, the only other conclusion one can draw is that "European civilization" is an oxymoron. These horrors, Nazi and Communist, all arose out of European ideas, political and philosophical, being put into practice. Even the Cambodian genocide had its genesis in the cafes of Paris where Pol Pot got his ideas. Hitler got his ideas in the cafes of Vienna.
I don't think that this holds up under even cursory scrutiny.

First of all, it is absurd on its face to say that the killing fields of Cambodia or the horrors of the Great Leap Forward were "European." Their beginnings may have been in the cafes of foreign capitals, out of "European ideas," but they actually occurred far away at the hands of different people. Power-mad, depraved leaders can make the worst of any idea from anywhere, and one civilization is not responsible for the corrosion of another. Pol Pot and Mao did what they did where they did, to and with their own people. You can't blame that one Europe.

Further, even if the most heinous crimes of the 2oth century had their origins in European thought, the Holocaust was a wholesale failure of European civilization, not a negation. European civilization was and is not uniquely resistant to failure (as any passing student of history could tell you), but that doesn't mean that it hasn't existed. The worst that a society can do doesn't cancel out the best. Josef Mengele doesn't void Louis Pasteur, and Joseph Stalin doesn't nullify Immanuel Kant.

Finally, if we're going to blame Europe for the worst foreign iterations of its ideas, then it's only reasonable to credit it for the best. Which means Europe gets credit for American civilization, with its system of laws and civic virtues that herald back to their European roots. Unless one recognizes only the ugly and repellent as true, there is plenty to show that European civilization has inspired beauty and excellent.

Rosenbaum's larger points about the futility of comparing epic evils and trying to determine a system of ranking them stand up much better. When a figure blots out the lives of millions of people, that person defies our ability to categorize and parse, and deserves only the grimmest judgments of history.


If only they'd all boycotted

Oh, bother. I was really hoping that the presence of gays at CPAC would keep social conservatives away en masse. (Good luck infiltrating, guys! We'll squeak our agenda through yet!)

In all seriousness, it would be grand if the GOP would jettison the more obviously theocratic elements of the conservative movement. It would be a small first step toward making them sane again.

Sadly, this guy apparently showed up:
[Grand Hierophant Rick] Santorum also called social issues "the issues that bind us," and that when it comes to those issues, "just because it's not popular doesn't mean it's not true."

"The Judiciary cannot create life, and it did not create marriage, and it has no right to redefine either one," he continued.

"America belongs to God," Santorum said, "and we are the stewards of that great gift."

Who is this "us" that is bound by social issues? I feel a sneaking suspicion that I'm not included in that "us." I rather fear I fall into the "them" category. Further, I suspect that if it gives you pause to think that God owns America, you may also fall into the "them" category.

Between Santorum, Michele Bachmann and Donald Trump (Donald Trump? Really?), I don't think there's been a sane headliner at CPAC yet this year. As much as it chills my spine to think I might agree with Sarah Palin about anything, part of me understands why she never bothers to show up at this thing.


Internet Use 101

Every so often, someone uses a computer in such a flagrantly stupid way that it demonstrates how unfit they are for the job they have, even if the offense itself doesn't seem disqualifying per se. A little while ago it was those SEC officials using their work computers (which also happened to be government computers) to surf the Web for porn. Now it seems that an astounding lack of Internet savvy has cost former Rep. Christopher Lee (R - 1994) his job.

Mr. Lee, if you're reading, here are some tips to guide you as you enter the job market. I wouldn't have thought this was necessary in 2011, but apparently I was wrong.

1) If you're a married member of Congress, you should probably not be using Craigslist to troll for sex.

2) If you disregard tip #1, you should probably not troll for sex on Craigslist by sending out pictures of yourself sans shirt. It makes the fact that you are trolling for sex a wee bit more obvious than is seemly. (Nice guns, though.)

3) If you disregard tips #1 and #2, you should probably crop out your face. Should you find a woman who is interested in hooking up with you despite your rather blatant goals, I imagine you can find a less compromising way to get a picture of your face to her without making you seem quite so indiscreet.

I do feel a little bit sorry for ex-Rep. Lee. I don't really think being a complete nincompoop about Craigslist is disqualifying for elected office, and none of this was really anyone's business. (His wife being the obvious exception.) Perhaps a classier, more admirably live-and-let-live young woman wouldn't have sent the pictures on to Gawker, but that's the risk one runs when disregarding tips #1-3 above, and maybe she thought a married member of Congress had it coming.

Lessons learned too late for quondam MOC Lee. Hopefully his former colleagues are a bit wiser than he.



I am not at all excited about this:
The Huffington Post, which began in 2005 with a meager $1 million investment and has grown into one of the most heavily visited news Web sites in the country, is being acquired by AOL in a deal that creates an unlikely pairing of two online media giants.

The two companies completed the sale Sunday evening and announced the deal just after midnight on Monday. AOL will pay $315 million, $300 million of it in cash and the rest in stock. It will be the company’s largest acquisition since it was separated from Time Warner in 2009.


Arianna Huffington, the cable talk show pundit, author and doyenne of the political left, will take control of all of AOL’s editorial content as president and editor in chief of a newly created Huffington Post Media Group. The arrangement will give her oversight not only of AOL’s national, local and financial news operations, but also of the company’s other media enterprises like MapQuest and Moviefone.
I don't think anyone can argue that HuffPo isn't huge. It is an enormously successful site, and there's no question that it's managed to draw lots of eyeballs.

What it isn't is all that good. Its headlines often misrepresent the content of the articles to draw more attention to them. Its health and wellness section is rife with ridiculous pseudoscience and celebrity hooey. In less than twenty seconds I found this article about "doctors" of homeopathy, for whom I have roughly the same degree of collegial respect as your friendly neighborhood witch doctor. This kind of content needs less credibility and exposure, not more.

Further, I'm not sure I understand why Arianna is going to be in charge of content at AOL. HuffPo traffics largely in content generated elsewhere, and then tarted up with an inflammatory, eye-catching headline. True, she has lots of famous friends willing to write pieces of questionable quality for her, but being a well-connected self-promoter isn't necessarily a sign of editorial savvy.

Arianna Huffington is the left's Mitt Romney, pretty much willing to take whichever view is ascendant. While she is ambitious and well-spoken, I am skeptical that she is all that insightful or talented. On the other hand, this can't work out any worse than AOL's Time Warner fiasco.


Hopping off the Hopey-Changey Express

During my evening commute last night, I caught an excerpt of the President's speech at Penn State yesterday on the radio. In the brief bit I heard, he talked about increasing energy efficiency in buildings around the country as a way of helping both the environment and the economy.

The content of what he had to say seemed reasonable enough, and on its face appeared to be part of a sensible economic plan. What left me musing wasn't what little I heard him say, but rather my response to it.

I didn't find him annoying.

Sad to say, the last couple of times I've heard President Obama deliver major addresses, I've come away unimpressed. I'm still very much a supporter, but his much-vaunted oratorical skills have been leaving me cold. Both his speech in Tucson after the Giffords attack and his State of the Union sounded hackneyed and formulaic. Given that most of the reviews I read gave him positive marks, at least regarding the former, clearly it wasn't just that he had given lousy speeches. Why did I find him such a thrilling speaker as a candidate, only to watch the bloom come off the rose when he assumed office?

I think I figured it out. Both his Tucson speech and SOTU were heavy on broad themes. Lots of rhetoric about unity and America's character, lots of grandiloquent language and orotund prosody. In many ways, they were reminiscent of some of his more famous speeches, going back to his heralded (and, in my opinion, brilliant) speech at the 2004 Democratic National Convention.

The problem is that we all know what happened after all those fabulous speeches about changing the culture and tone of Washington, and Hope and Change and such. I remember 2008 fondly, but 2009 came immediately thereafter and blew any illusions about changing DC to smithereens. It was, if anything, even more rankly partisan than before. And while I place the blame for that almost entirely with the GOP, it was a bummer to see that part of my hope for the Obama administration was nothing more than idealistic hooey.

(Yes, yes. I should have known better. Shame on me. But it's not like that was the ONLY reason I voted for him. Hell, with Palin on the other ticket, I would probably have voted for Captain Kangaroo.)

Having now come back to my misanthropic, politically cynical senses, I no longer yearn to hear the POTUS wax poetic about American virtue or character or beauty. Heard it, thanks. Didn't take. Not sure it's his fault, but no longer interested in hearing any more about it. Even if the Tucson event called for such rhetoric, I'm no longer personally receptive to it. (And, sorry, but I still think all the audience whooping was inappropriate.) Any time I hear it now, it sounds hollow and devoid of much merit.

When he gets to specifics, on the other hand, I'm happy to hear him speak.


A question for our media overlords

If I just make crazy shit up, can I be a[n overpaid at any price] pundit, too?

On humility

Yesterday's Times Magazine has a harrowing article about shaken-baby syndrome. Its tragic and shocking subject matter makes it particularly challenging to read. I have (blessedly) never been directly involved in the care of a shaken infant. I remember a case being discussed at morning rounds once during my fellowship in New York City, but my subspecialty is unrelated and I heard nothing further about it. I hope I am lucky enough never to encounter this diagnosis again in the course of my career.

What I know about shaken-baby syndrome (on which I will not dwell in detail) is retained from residency, with a medical education conference or two on the subject since then. There is a constellation of findings that, viewed together, are pathognomonic for the syndrome. That is, if you find these things, they point conclusively toward shaken-baby syndrome. If these, then that, QED.

Except, maybe not?
A dozen years ago, the medical profession held that if the triad of subdural and retinal bleeding and brain swelling was present without a fracture or bruise that would indicate, for example, that a baby had accidently fallen, abuse must have occurred through shaking. In the past decade, that consensus has begun to come undone. In 2008, the Wisconsin Court of Appeals, after reviewing a shaken-baby case, wrote that there is “fierce disagreement” among doctors about the shaken-baby diagnosis, signaling “a shift in mainstream medical opinion.” In the same year, at the urging of the province’s chief forensic pathologist, the Ontario government began a review of 142 shaken-baby cases, because of “the scientific uncertainty that has come to characterize that diagnosis.” In Britain, after one mother’s shaken-baby conviction was overturned, Peter Goldsmith, then attorney general, reviewed 88 more cases. In 2006, he announced doubts about three of the convictions because they were based solely on the triad; in the other cases, Goldsmith said, there was additional evidence pointing to the defendant’s guilt.
I found this genuinely startling. There was such certainty in how I was taught regarding this diagnosis. If this, then that. If retinal hemorrhages and subdural hematomata are present, shaken-baby syndrome is the horrifying but clear diagnosis. Nothing left but to find the perpetrator. While this emerging information doesn't mean a baby with these findings wasn't shaken, it seems this diagnostic certainty is unfounded.

In my current position, I am not on staff in an emergency department. It is supremely unlikely that I will ever be called upon to make this diagnosis. The impact of this new controversy on my particular practice is likely to be minimal.

And yet, this was rather a dizzying article for me to read. It serves as an important reminder that, as a physician, there must always be humility in my approach to individual patients and accepted treatments. As a profession, we must always be willing to admit new information, and to question even the most seemingly unimpeachable evidence. It's good to be reminded of this now and then.

(As an addendum, this might lead regular readers to question if I would be willing to accept a link between vaccines and autism if evidence emerged to suggest it. My reply to this hypothetical question is that I have always been willing to accept a link between the two, were said evidence to meet the standards required of medical science. Given that the supposed link was first introduced through fraud [a fact his supporters are all too happy to blithely ignore] and no compelling science has actually supported a link despite vigorous and good-faith efforts to investigate it, I remain confident in my convictions. Should credible evidence emerge that causes me to question even this belief, I would give it my honest attention.)