Congress Considering Bill to Legalize Hypocrisy

Folks, this was reported on the news wires this morning:

WASHINGTON – In a move that has surprised observers, the U.S. House of Representatives is considering a measure that would legalize hypocrisy for all U.S. citizens. The proposed bill, H.R. 31345, would protect “any attack, public or private, in writing, speech, television, or any other media, in which the attacker is guilty of the same offense as the accused.” It also contains 782 items devoted to farm subsidies.

Co-author of the bill, Clinton Krumble (D, MO), says the new legislation should ease the partisan atmosphere in Washington. “We spend a lot of time around here charging each other with hypocrisy,” he told reporters at a press conference on Monday. “Legalizing hypocrisy will clear the air, and free up time for more constructive conversations.”

Republican co-sponsor Jeremiah Firebrand (KY), agreed. “Just because a guy is gay doesn’t mean he can’t be against gay marriage. This law would allow lawmakers to get citizens to do what we say, not what we do.”

Experts around the country seem equally enthusiastic. “There is ample evidence in the literature that banning behaviors only creates illegal markets,” said Markus Gay, president of the Society for Open Economies. “There is no question that legalizing hypocrisy will free up law enforcement to concentrate on other issues. Right now, there are a huge number of hypocrisy clubs in and around Washington. At night, you can see all kinds of Washington politicians and staffers coming and going from those places. And every time the police shut one down, two more will pop up in its place.”

Newt Gingrich, former Congressman from Georgia, read a statement in support of the bill. “Hypocrites are the most unfairly persecuted minority group in the United States. We have laws guaranteeing African-Americans the right to hold public office. But hypocrites are banned indiscriminately from public life. An old prejudice is being set aside and a new era of freedom is about to be born.” A tear rolled down Gingrich’s cheek as he spoke.

Although the bill has broad bipartisan support, a few groups promise stiff opposition. One of these is the pharmaceutical industry. According to industry spokesman and pharma representative Barbie Tightskirt, drug companies feel legalizing hypocrisy will only hurt patients. “We have new drugs in the pipeline to treat hypocrisy,” she said, referring to Virtua, a drug by Merck and Company that awaits FDA approval and is purported to treat hypocritical tendencies. “If patients think hypocrisy is permissible, many people suffering from this terrible mental disorder will not seek proper treatment.”

Another opponent, the Society of Native Americans, argues that the law would harm Indian tribes. Hypocrisy has been legal on most Indian reservations since the 1980s, Julian Roundtree, the group’s spokesman, explained. “Most reservations do heavy business in the hypocrisy trade, and if this law goes through, it will wipe out a lot of our profits. Without hypocrisy, all we’ll have is gambling , cheap booze, and cigarettes – that’s it. No one can expect a Native American tribe to survive on the scant millions a casino earns.”

Indian reservations began legalizing hypocrisy after market research showed that Christian conservative groups were avoiding reservation casinos. To appeal to this segment of the market, reservations started opening “hypocrisy villas,” complete with spiritual cleansing spas. Financial records are hard to come by, but it is estimated that on-reservation hypocrisy villas have brought in over $4.7 billion in revenue in 2004.

The bill has cleared committee hearings and will go to the House floor for a general vote this coming week.

History, New and Improved

An interesting story emerges from New Orleans. Google Earth has quietly replaced all satellite imagery of New Orleans with pre-Katrina photographs! On the internet, New Orleans has now been completely rebuilt, Chalmette and the Ninth Ward pumped dry, and the levees reconstituted. I salute the virtual White House and the cyber-Army Corp of Engineers. Their real counterparts could learn a thing or two from them.

You can see my old neighborhood as it was here. (Click on "satellite" to see the pictures.) Now picture many of the houses gone, with only a concrete slab remaining. There would also be a few roofs ripped off, cars on top of houses -- you know, the usual stuff. Note also that the copyright at the bottom says 2007. There is no indication that this photo is from 2005. A casual observer could be easily forgiven for thinking this photograph is current.

What I really want to know (not virtually) is who decided to do this. Why would someone at Google decide that erasing such a sad chapter from recent American history was the proper thing to do? Did they think they were protecting the public from unpleasantness? Perhaps the New Orleans photos were getting too many hits, and Google thought this was the internet version of rubbernecking.

My worry is that this is the handiwork of some politician who thought it advantageous to hide the slow pace of the recovery. Whatever the cause, this certainly shakes one's confidence in the internet. The internet theoretically democratizes information, allowing anyone access to the truth, no matter what the press and the government feed us. Unless internet companies choose to alter the facts. 

Sugar Daddy

He sat on the edge of my exam table, seemingly deep in thought. Clearly he was nervous. Typical of a middle-aged guy, I quickly posited, who up to now thought himself indestructible. All his life he had steamed along, no worries about his health; and then there it was, his first major medical diagnosis. Norman had felt perfectly fine until he caught a cold that would not go away. It got worse and worse, until one night he felt so bad he thought he was going to die. He had no doctor, so he went to the emergency room. In the ER, he got the good news: the headaches and hacking cough really were just a typical upper respiratory infection. Then came the bad: His blood sugar was 423.

The emergency department referred him to me for follow up. "New onset diabetes," the ER discharge note said. The note was dated was six weeks ago.

I naturally assumed Norman had delayed following up because he was nervous about seeing a doctor. He was afraid of facing the diabetes diagnosis, the pills, the diets, and possibly, the dreaded insulin injections. Or perhaps it was the great fear of all, the fear that this new disease could kill him. I could understand that. I was ready to empathize.

"Doc, I won't have to be on shots, will I?" he asked.

A carousel spun noisily in my mind, and a CD with the words "Standard Diabetes Speech" printed on it dropped down.

"Some people with diabetes can control their sugars with diet and exercise, some with oral medications alone, and some with insulin shots. Some need all three approaches. The most important thing is not how you control your sugar, just as long as you get it controlled. I . . . ."

"I drive a truck for a living."

I hit the pause button. He wasn't nervous about seeing me or about taking medicine. He wasn't even nervous about getting bloodwork or facing his diagnosis, let alone being concerned about something as existential as his own mortality. No, his concern was altogether earthy.

The state of Mississippi, like most other states, will not issue a commercial driver's license to someone taking insulin injections. Norman was worried about losing his job.

This always struck me as a very dumb law. At one time, perhaps it made sense, but not any longer. On the surface, it sounds sensible: A diabetic who takes insulin must have significant disease. Diabetes causes many medical problems one would not want to see in someone guiding an eighteen wheeler, including stroke, heart disease, kidney failure, and blindness. Further, insulin shots are a tricky business. They have to be taken every day, on time, and the dose has to be exactly right. A lot of room for error, and any mistake could leave a 10 ton hunk of crumpled metal on the side of the road at one of the Jackson I-55 interchanges. Case closed, right?

Well, no. There once was a time when it may not have been advisable to allow insulin users to drive. Not very long ago, there was only one type of insulin, short acting. Short acting, or regular insulin, came from the pancreases of slaughtered cows and pigs. It only lasted 3-6 hours and had an unpredictable release. This meant diabetics had to check their blood sugars often, and had to take four or more shots a a day. A trucker on that kind of regimen would have to stop every few hours to give himself another shot, and might have to pull off the road for periods of time to contend with low blood sugars in the event of accidental overdoses.

Those were the dark ages. Today there are several types of insulin, ranging from ultra-short acting (with onset in less than five minutes) to very long acting (lasting over 24 hours). There is even an insulin that is inhaled, rather than injected. With so many insulin types to choose from, and with the flexibility to combine insulin with the numerous new oral medications available, many diabetics can control their sugars with only a single injection a day. And since the introduction of human insulin derived via recombinant DNA, today's insulin is more reliable than its animal-derived predecessor.

I prefer to manage a patient's diabetes with insulin. Though pills seem more convenient at first, I find that pills deliver uneven results. Most oral diabetes medications can only be given twice a day at the most, which means a patient cannot take a little extra if his sugar is running high, as he can with insulin. Pills also have significant toxicities. Sulfonoureas can drive blood sugar low enough to kill if the patient takes too much. Metformin can damage the liver. Thiazolidinediones can cause fluid retention and sometimes heart failure. Insulin, on the other hand, is a naturally occurring hormone and thus has few side effects. Unlike pills it can be given in an almost infinite variety of doses, which means an insulin regimen can be adjusted to achieve very tight sugar control, a control that, in many diabetics, cannot be attained in any other way. The only danger with insulin is the low blood sugars a patient can get if he takes too much, and the risk of skin infections from the daily injections. This problem, however, has been largely alleviated with the modern insulin pens, which are very easy to use and have an extremely low error rate.

Simply put, I do not think insulin use, as it stands today, carries a greater risk for trucking accidents than oral therapy does. If anything, the risk is probably less because the sugar control is likely to be greater.

This does not mean I frown on the use of pills to control diabetes. But for many patients, insulin injections are by far the better option, and result in tighter glucose control. Insulin therapy is not the last resort; it should be the first option for many. Herein lies the problem. For truck drivers, the prohibition of insulin injections means that many patients who would be good candidates for insulin therapy will resist taking it for fear of losing their livelihood. By clinging to oral medications when they are not adequate, such patients are trading their long-term health for the short-term benefit of a paycheck. I don't blame them for making this choice. I blame an old, outdated law for encouraging patients to do the wrong thing.

This problem also underscores a real weakness of the healthcare system in the United States -- the association of health insurance with employment. Even if Norman decided to quit his job and find another career just so he could take insulin, he would lose his health insurance because he is insured through his employer. Worse, if Norman were to get a new job, his diabetes would qualify as a pre-existing condition, meaning his diabetes medications and doctors visits would not be covered for a while, or possibly for ever. Not a good situation to be in.

In the U.S., health insurance is seen as a personal privilege rather than a social good. This makes no sense. As a matter of public policy, we should want as many people working as possible. We should think of health care as a way to keep our workforce strong and competitive. To achieve this end, our laws should be designed to help people continue to work as long as they can. It is hard to see how a law that bars truck drivers from taking advantage of the best combination of medications available to them does that. Instead, it encourages drivers to hide their diabetes as long as possible, and to avoid insulin until the disease is so bad that they cannot avoid it. Then at last they pay the price for delaying appropriate treatment for so many years, and end up disabled from this terrible disease.

At the moment, Norman is on pills only, and his glucose control is excellent. But I know something Norman has not acknowledged yet, that diabetes tends to progress over time and that many, if not most, patients that start on oral medications end up requiring insulin injections in the end. As I see it, his best chance it to hope he will win the lottery by then. After all, the government seems to be better at promoting lotteries than organizing a cohesive health care plan.

The Latest Outrage

Anyone who has visited this site in the past knows I have little respect for the current presidential administration. But as bad as things have gotten, I do not think anything has gotten under my skin like this recent report in Salon. It alleges that the U.S. military has been sending injured soldiers back into active military units to artificially boost its numbers -- in effect, faking the troop surge we have been hearing so much about. According to the story, military officials have been altering medical records to make injured patients look like they can still serve.

Setting aside the point that this means the so-called troop surge may be a fiction, we are faced with the very serious possibility that the Bush administration is tampering with private medical records for political purposes. As a medical doctor, I cannot even begin to express how appalled I am at this possibility. A patient's medical record is considered scientific, and scientific data should never be altered for any non-scientific reason. Tainted data are useless data, and must be thrown out.

What is a soldier supposed to do if, twenty years from now, he is unable to work, and is claiming disability based on war injuries? If the records are inaccurate, the severity of injury cannot be proven. This leaves an ex-soldier without means of justifying need for long-term medical treatment.

I really don't care what side of the war on terrorism you are on. Falsifying medical information is completely out of bounds, even in when national security is an issue. You cannot win a war by cooking medical information. I would have thought even the current administration was not that stupid, but I guess I was wrong. 

The Ambulance Ride

Nora heard it coming into the parking lot. She rose from her seat at her son's bedside and walked over to the window. Through the blinds she could see it. An ambulance, and it was theirs. She knew at a hospital ambulances came and went at all hours, but she felt certain this one was her son's ride. It wasn't simply intuition. She had been through this three times before, and she had the timing down. About two hours ago the ER doctor had made the call, and she knew how long it took for a transfer team to make it from Children's Hospital to St. Tammany General -- two hours. The time had passed, and there was the ambulance. There was no coincidence.

In less than five minutes a team of paramedics appeared in the hallway outside her son's room. A doctor had come with them. The transport team. Nora, standing at the door of the ER exam room, watched them through a small glass window in the door. The window, crosshatched with wire to make it shatterproof, was usually used for the medical staff to look in and size up patients, Nora supposed. She was using it to size up the transport team. A few minutes of observed loitering was enough for her. She walked back to the bed. "Zachary," she said, "they are here to get us."

"Mom, are you coming with me this time?"

"Yes, Zachary, I promise."

She knew what she was promising. This was the fourth time Zachary had to be transferred to Children's  from St. Tammany General, and each previous time the paramedics had told her she couldn't ride. It was against policy, they had said. She would be in the way. Well, Zachary had been in the hospital over twenty times in his eight years of life, and one thing Nora had learned from all those admissions was that most hospital policies could be broken. Hospital policies were often thought up by the staff, and were in place for their convenience, not the patients' or the families'. This is perfectly fine when you are only in the hospital every so often for a C-section. But when you have been in the hospital as often as Zach has been, when hospitalization is not just an occasional thing but a way of life, rules have to bend.

She bent over and kissed her son on his sweaty forehead and then stepped through the door to plead her case. Only she had no intention of pleading. "I'm going with you," she said.

There was a lot of resistance. First the paramedics talked to her, explaining that this just isn't done. Nora permitted herself to fill up with the indignation of someone who had suffered more than the person she was talking to. She knew that until she talked to the doctor, nothing would change. So rather than fight the medics, she said, "I'm not talking to you. If the doctor says I can go, I can go."

After a time she was alone with the doctor, and she was emphatically telling her she could not go. "There is not enough room in the ambulance," she said. "We need space if your son gets into trouble."

"If I am not with him, he will get into trouble," she said.

The doctor tried again. "The ambulance insurance won't cover you if we get into an accident."

"If I am chasing after you in my car and get into an accident myself, I will make sure you answer for forcing me to drive 60 miles across the lake in the middle of the night. If he dies during the ride and I am not with him, you will answer for that also."

She could see her struggling with anger over that one. "You can't go with us and that's final."

"Then he's not going either."

"He will die if he stays here."

"At least he will die with me."

That clinched it. Zach was very ill. His temp had been 104. It had broken, and now he was covered with sweat. He had drips going in from four bags -- an antibiotic, IV fluids, and two drugs to keep his blood pressure up. Zach was in trouble and the doctor finally decided there was no point in putting up a big fight.

Nora went back to Zach's bed. She had to touch him. She silently hoped by touching him she would be forgiven for threatening to let him die if she was not allowed along. Zach had asked her to come, and she had not let him down.

They took Zach out of his room in the ER. She hadn't paid it much attention before now, but that was Nora's way -- seldom did she notice details until things were about to change. It was one of the two children's rooms in the ER, off in a quiet corner, every wall covered with bright colors and cartoon characters. Much like Children's, or Primary Color Medical Center, as she liked to call it.

Zach was on an adult gurney. It seemed that in all the world there was not a single child-sized one. Zach would have looked a lot better on a smaller stretcher. His tiny body, which looked like a five year-old's anyway, seemed all that much more insignificant on in an adult-length bed. After Zach got sick and wound up on dialysis, he had grown hardly ten inches and gained only fifteen pounds. A kid doesn't grow unless he stays well, and when has Zach been well? Not any time that she could remember.

It took some time for the medics to get the four IV bags unhooked from the hospital pumps and transferred to the portable pumps on the ambulance. Then there was paperwork, and the doctor had to write out some notes. After that they were ready to go. They rolled Zachary to the ambulance and pushed him in. One of the medics motioned Nora to get in first. There was a friendliness in his motion. It seemed that once Nora had won the fight and the decision to bring her along was made, everything was forgiven. That was one thing Nora respected about medical people. They were decision-oriented. They could argue and argue a question, but once the choice was made everyone was usually able to put matters behind them and go ahead in good humor. Sticking together and working from the same plan was more important to medical people than worrying about the past.

There was a long bench on one side of the ambulance, and Nora slid to the end of it. She was a few feet from Zach's head. He could see her if he looked up a little, but she needed only slide a few feet to her right to be well out of the way if the team needed room. The transport doctor was finishing a conversation with the ER doc. She collected a few final bits of information and stepped in last. The driver slammed the door.

The ambulance jerked forward. The ride would be fifty minutes long, the greatest part of it over the 24-mile Lake Ponchartrain bridge. It was night, and the traffic was light, allowing the driver to raise the siren only at red lights. In a moment and with a loud clank they shot through the toll plaza, and the ambulance was skimming across the lake on the bridge.

Nora could not clearly see the speedometer, balanced as it was from her perspective just barely above the driver's knee, but she thought they were going at least eighty. As they accelerated out of the toll plaza, the ambulance began to pulse as it hit the steel strips that separated the concrete slabs making up the length of the long bridge. At first the pulses were soft, but as the vehicle picked up speed they got louder and louder, drowning out most of the noise inside.

The regular beats could not have done more to lull her to sleep. She shifted around to say awake. Zach had dropped off. This was the third time she had taken this particular trip, but Zach had been in the hospital many more times than that -- twenty-six, twenty-eight? She couldn't remember.  Her ex-husband had moved out after hospitalization twelve, and the divorce was done at eighteen. After that, she lost count.

This poor child had suffered so much. And so much, she knew, on account of medicine, and on account of her. Zach had been three when he came home from preschool one day with a very bad cold. The cold itself was not so bad, but after a week Zach started to swell up. First in his face, then from head to toe. Over one weekend, he seemed to bloat more and more by the hour. Finally she and Tom brought him to the emergency room. In the blue-white fluorescent hospital light, Zach had looked so much paler than he did at home. She had felt intense remorse that they had waited so long, but neither she nor Tom wanted to be another one of those silly anxious parents bringing a kid with a cold into the ER at midnight, only to be sent home and with an instruction sheet on how to give fluids and Tylenol. That night, a couple of doctors had looked him over, then a couple more, and he was in intensive care. A few weeks later she and Tom were in a room with a nephrologist who was telling them that Zach would need to be on dialysis. They learned a new turn of phrase that night. Focal segmental glomerulosclerosis. It had been dialysis ever since.

Sometimes Nora would sit in the lobby at Children's Hospital and watch the parents of other sick children go in and out and wish Zach had someone else's disease. She knew it was silly to wish Zach could trade his kidney failure for leukemia or muscular dystrophy. It was just a mental trick. Every serious medical problem has its own specific challenges, but the problems of dialysing a child were so wearying that she just wanted to trade a new set of problems for the old ones. Maybe chemotherapy for a few months would be easier to bear, maybe not. But it would be a different set of worries. By now, it was not only worry, but the fatigue of worry, that was hurting so much.

The doctor sat at the end of the bench near the door, her head bent forward, trying to write. The pulsing from the bridge was so regular that she had gotten the timing of it, and could write three or four letters, pause to let the shock pass, then write three or four more before the next shock. She wrote by a dim white light screwed to the wall of the ambulance. Nora could not understand how she could see anything.

Outside it was completely dark. They were midway between the shores of the lake, and land was not visible in either direction. The amber streetlights blurred out the moonlight with their glare. She wondered if she were doing the right thing. Even this wondering only elicited fatigue. She had wondered this so many times before. Was it fair to him, to keep going, going? Zach never asked, and she was sure he was too young yet to even understand his options. Zach probably thought this was how life was, to suffer and suffer. He certainly didn't remember anything else. If there was anything that was unfair about this endless misery, it was that she had to face the possibility that it might be time to give up. It may be unnatural for a mother to bury her child, but for a mother to consider giving up the fight and allowing her child to die was unbearable.

She remembered when Tom had brought up the subject. It was during their last fight -- not a fiery, angry fight but one of the most soft-spoken arguments they had ever had. It was nonetheless the one that ended with him moving out. "Do we have to keep fighting for Zach?" he asked. "We could let him go." Tom had made many mistakes, had said so many awful things, but this was not one she held against him any more. She knew what he had meant, and she knew where it had come from. Zach was an eight year-old in a body the size of a child half his age. If he lived to adulthood, if he made it through the episodes of septic shock he seemed to get once a year, what kind of adult would he be? Four and a half feet tall, thin, sickly, little chance for a job or a spouse, forever tethered to a dialysis machine. What were they saving him for?

It is not as if Tom hadn't done everything he could have. When Zach turned six, Tom donated a kidney. They both thought this would be the end of all the hospitalizations, but instead it made things worse. Zach rejected the kidney after four months, and it was in and out of the hospital with kidney biopsies, switching and titrating medications in increasingly desperate efforts to save the transplant, and then finally back to dialysis. The return to dialysis had been so painful for her that she was not certain she could endure it again. She and Tom held out an entire year before they listened to the doctor and considered putting Zach back on the transplant list.

No, she did not hold it against Tom that he was willing to give up. Given all that had happened, it was logical, and for Zach, it might be merciful.  The doctor told her, and even her parish priest confirmed, that it is not morally wrong to stop medical treatment if the treatment is doing no good. She could see the dialysis was slowing destroying him. At eight, Zach could live another seventy years if he had even one good kidney, but Zach's nephrologist admitted to her that he had never seen a patient live thirty years on dialysis. Ten to twenty was more like it. Tom was not wrong, and she knew that he could love Zach very much and still say what he said.

Abruptly the pulsing stopped. They had reached the end of the bridge and were on dry land again. The driver resumed raising the siren each time they reached an intersection.

The problem for Nora was not the logic, or the mercy, or even the morality of it. Zach was her son, and she was his protector. It seemed to her, especially with Tom's doubts, that she was the only one defending his life without question. There had to be balance. Someone had to be arguing for keeping up the fight, for doing everything possible. She was terrified that if she gave up her determination no one else would have faith in Zach. The balance would tip against him. Somehow if both arguments, for and against fighting on, were not passionately argued she was afraid that some cosmic equilibrium would be lost and Zach would suddenly die. Logically this could not be true, but in her heart she thought that if a feeling were not passionately expressed that it would cease to be an argument. Like an old creed never prayed ceases to be religion.

And what mother ceases to be her son's avid advocate? What kind of a mother would she be if she did not praise even his most glaring weaknesses to the skies? It is the job of the rest of the world to objectively dissect her son. Not hers. Her job was to see him as perfect, even if he wasn't. Because if his mother did not see hope in his survival, no one would. If she did not feel unreserved hope for him, would even God?

One last bump and the ambulance was in the hospital parking lot. For the fifteenth or so time they would be admitted to this place, and usually when Zach was this sick it meant a month here. Provided he lived at all. A month of in and out of the ICU, drips, dialysis, maybe even a ventilator if things did not go well through the night. No one had to tell her this. She knew it. One month, minimum, sleeping on hospital floors and walking up to a coffee shop on Magazine Street each morning between ICU visiting hours to get a little daylight. A month in the hospital probably meant she would be fired from another job.

The driver backed the ambulance up to the ER bay. The medic at the foot of the bed pulled the latch on the back door and swung it open. The doctor and one of the medics climbed out, and Nora followed. The one man still in the ambulance raised the bedrails on both sides of the gurney and started pushing Zach forward. When they had the gurney almost completely out, they held it aloft for a moment, waiting for the wheels to drop down and lock in place.

For some reason, Nora stared at one of the wheels as it dropped to the asphalt. The paramedics pushed the gurney forward, and she watched the wheel as it started to turn.

Go, she thought.