Olbermann and his father have had conversations about end-of-life care. He's outraged at those who oppose this emotionally difficult but medically important event.

And as I left the hospital that night, the full impact of these last six months washed over me. What I had done, conferring with the resident in ICU, the conversation about my father's panicky, not-in-complete-control-of-his-faculties demand that all treatment now stop, about the options and the consequences and the compromise, the sedation, the help for a brave man who just needed a break. That conversation, that one, was what these ghouls ... decided to call "death panels."

Your right to have that conversation with a doctor, not the government, but a doctor and your right to have insurance pay for his expertise on what your options are when Dad says "kill me" or what your options are when Dad is in a coma and can't tell you a damn thing, or what your options are when everybody is healthy and happy and coherent and you're just planning ahead, your right to have the guidance and the reassurance of a professional who can lay that all out for you, that's a, quote, "death panel," unquote.

That, right now, is the legacy of the protests of these subhumans who get paid by the insurance companies, who say these things for their own political gain or like that one fiend for money. For money, Betsy McCaughey told people that this conversation about life and death and relief and release, and also about no, keep treating him no matter what happens, until the nation runs out of medicine, she told people that's a death panel and she did that for money.

It's a life panel, a life panel. It can save the pain of the patient and the family. It is the difference between you guessing what happens next, and you being informed about what probably will, and that's the difference between you sleeping at night or second-guessing and third-guessing and thirtieth-guessing yourself. And it can also be the place where the family says, "We want you to keep him alive no matter what, we believe in miracles," and the doctor says yes. Nobody gets to say no except the patient and the family. It's a life panel, and damn those who call it otherwise to hell!

For those who may have already forgotten Betsy McCaughey, she wrote a New York Post opinion piece that claimed Dr. Ezekiel Emanuel (brother of Obama's Chief of Staff Rahm Emanual) recommended health care rationing based on age and disability. McCaughey was the inspiration for Sarah Palin.

The truth was, Emanuel had commented on rationing, but his remarks were clearly limited to decisions involving scarce transplant organs or inadequate supplies of vaccine. Thanks to the hysteria of "death panels," however, we may not have any health care legislation at all.

According to Rolling Stone, Betsy McCaughey was paid to derail the Clinton health care plan back in 1994. If it's any comfort, McCaughey resigned her post as Director of Cantel Medical Corporation after being humiliated by Jon Stewart on The Daily Show.

Related posts:
Keith Olbermann & the Fight against Death
Were "death panels" a teachable moment for palliative care?
Health care: Reminding people of death triggers irrational emotions

In the Reagan/Thatcher years we saw an enthusiastic promotion of taking personal responsibility for one's health. Personal responsibility follows naturally from a neoliberal agenda: Deregulation, privatization, a free market economy. Neoliberalism champions the autonomous individual, whose responsible or irresponsible behavior relieves the state of any responsibility.

This theme is vigorously echoed today by Sarah Palin. You can even buy her "personal responsibility" bumper stickers, mugs, and t-shirts to promote the cause.

Personal responsibility is the conservative answer to public ownership of the structural inequities in society. As a political position, it has deep roots. Just as health inequalities are timeless, so is resistance to improving the health and welfare of the poor.

Opposition to health reform that would be of benefit to the poor takes two forms. One is the psychological/philosophical attitude that claims the poor have only themselves to blame for their situation in life and that they are unworthy of assistance.

The second form is the political position that justifies this attitude. The claim is that any coordinated action on the part of government would interfere with the autonomy of states, cities, and individuals. Individuals, cities, states, and whole nations should be able to take personal responsibility for their actions. Those who do not are undeserving of sympathy.

These two forms of opposition are closely intertwined. Here are some examples from the nineteenth century - before the age of political correctness - when politicians and editorialists did not hesitate to display their attitude towards the poor.

Cholera is the best of all sanitary reformers

The first British Public Health Act of 1848 established a central public-health authority that aimed to improve sanitation. (For a description of sanitary conditions in 19th century Britain, see my last post.) Any town with a death rate above 23 per 1000 was required to have such things as drinkable water and sewage removal.

There was considerable opposition to this. One newspaper wrote: "We prefer to take our chance with cholera and the rest rather than be bullied into health."

Dorothy Porter writes about the pushback:

Opposition ... came ... from outraged defenders of local government autonomy and those who opposed 'despotic interference' in the lives of individuals and the free relations of the economic market. The Tory [conservative] press raged against 'paternalistic' government. The Herald believed that 'A little dirt and freedom may after all be more desirable than no dirt at all and slavery,' and the Standard suggested that the country had 'heard enough of the effect of centralization in the New Poor Law.' Local ratepayers resented being dictated to by a 'clean party.'

The same newspaper that argued for taking its chances with cholera was not afraid to state its attitude towards the poor quite bluntly: "Cholera is the best of all sanitary reformers."

The poor -- a "race apart" -- are uncivilized

Here's an example of the political case for personal responsibility from early 19th century France:

The French philosopher and politician Constantine Volney (1757-1820) argued that it was the responsibility of all citizens to maintain their health for the benefit of the state. France, he argued, was a collective whole made up of political and economic units - the individual French citizens. Therefore, it was the duty of citizens, regardless of economic status, to be restrained in their consumption of pleasures, to control their display of passions, and to maintain high standards of cleanliness.

Another example from 19th century France that blames the poor for their own condition:

Louis Villermé (1782-1863), the French physician who discovered the relation between income and death rates in early 19th century Paris, believed that the poor were a "race apart." This, he asserted, accounted for their increased rate of death and disease.

When confronted with the argument that the industrialization of civilization was producing the conditions that created poverty, Villermé and his associates answered simply that the problem was not civilization. The problem was that the poor were uncivilized.

The cause of poverty was the poor themselves. They needed a program of moral regeneration -- religious indoctrination to improve their behavior. Through Christian example and education, the poor could be reformed into civilized citizens, leading respectable lives. Through religious education, the poor would cultivate social and hygienic habits worthy of civilization's moral standards.

Feeding stray animals: Condescension thrives in 2010

William Farr (1807-1883), a British epidemiologist, opposed financial assistance to the poor because it would be spent "indiscriminately upon the idle, reckless, vicious as well as the good but unfortunate."

For comparison, here's a statement from Andre Bauer, the Lieutenant Governor of South Carolina, made in January 2010. He makes an analogy between government assistance and feeding stray animals.

My grandmother was not a highly-educated woman, but she told me as a small child to quit feeding stray animals. You know why? Because they breed. You're facilitating the problem. If you give an animal or a person ample food supply, they will reproduce, especially ones that don't think too much further than that, and so what you gotta do is you gotta curtail that type of behavior. They don't know any better.

In defense of his statement, Bauer later remarked: "There's a big difference between being truly needy and truly lazy." Compare that to William Farr: Spending "indiscriminately upon the idle, reckless, vicious as well as the good but unfortunate."

Morally we appear to have made zero progress in 200 years. We should be outraged and ashamed.

Related posts:
Health inequities: An inhumane history
Health care inequality: The US vs. Europe
Health inequities, politics, and the public option
A reason for health care reform

The lack of universal coverage is perhaps the most disturbing difference. There are clearly economic advantages to universal health care: Diseases cost less in the long run when they're prevented or caught early; insurance costs less when it draws from a pool that includes both the healthy and the less healthy.

Universal coverage is an ethical issue. The US claims to be a country that values equal opportunity. If you lack adequate health care from the time you're conceived, however, your opportunities will never be equal.

All these recent discussions and comparisons have prompted Europeans to reflect on their own health care systems and to offer an explanation for the difference. According to Joseph Kutzin of the World Health Organization (WHO), the basic difference in European and American health care is that Europe has a well-managed system. whereas the US is hopelessly fragmented. The US has "no coherent regulatory framework for either universal coverage or cost control," according to Kutzin. European systems recognize the need for limits on health care spending. In America we call that "death panels."

Martin McKee, a London professor of European Public Health, comments on the role of inequality. Whether inequality is due to race, poverty, gender, unemployment, or age, the only way to increase equality is through state intervention. The way Europeans see it: "It's a rule of thumb that if you are rich, you are unlikely to need much health care, and if you are poor you are likely to need it. So there's redistribution from rich to poor, but also from people of working ages to those who are not, and in reproductive ages from males to females--health care inevitably involves redistribution."

Many Americans are adamantly opposed to the idea of redistribution. Some of this gets chalked up to our rugged individualism. But much of it is simply an unwillingness to recognize the structural causes of poverty. 71 percent of Americans believe the poor could escape poverty if they worked hard enough. That figure is only 40 percent in Europe. Only 30 percent of Americans believe luck determines income, versus 54 percent in Europe.

Is race the elephant in the room?

Some of the discrepancy between European and American health care systems can be explained by historical differences. Europeans not only have a longer history, but a more violent one. Antonio Duran, a consultant for WHO and an expert on Eastern Europe, comments:

Western Europeans are rich enough now, with their history of revolution, war and conflict behind them, to hear a clear message that either they protect the poor--or else... Europeans know that if you go too far one way or the other you pay a price, either in terms of social cohesion and unrest, or in terms of health indicators.

In the US, we had the Civil War, but what did we learn? We still have racism, and it's still a major determinant of health. Here's Martin McKee again (emphasis added):

There is an association in the US between low life expectancy and income inequality, but that is driven largely by the southern states. But there are correlations with other factors like race or class, so it's a complex issue. ... In Europe we had a post-war settlement with social welfare systems because the élite realised from their experiences in the war that they might have a schloss or chateau one day but nothing the next, so they organised things so that wherever they ended up it would be tolerable at least! But in the US, if you are rich you are likely to be white, and you know there's no chance that you'll wake up the next morning black! So I think race is the elephant in the room in the US. I find there is a real reluctance to discuss this in the US -- people don't want to get into it, on either side.

That's not quite a fair assessment. US medical journals are full of statistics on the negative health consequences of being black and/or poor. It's true, however, that the issue hasn't been adequately addressed in public discussions of health care, that is, in the popular media.

Due to the Massachusetts election - and the political nature of health care reform in the US - we're still having those discussions. So perhaps there's still time to point to the elephant and give it a name. It's a historical opportunity for Americans that we shouldn't miss.

Related posts:
Getting health care right: Paris and Amsterdam
How Australia does preventive health care
A reason for health care reform
Why is it so hard to reform health care? Rugged individualism
Why is it so hard to reform health care? The historical background
The health care debate: Seeing ourselves through the eyes of others
Robbing Peter to Pay Paul: The health care shell game
Universal health care: What would Socrates do?
Were "death panels" a teachable moment for palliative care?
The need for health and the right to health

Abigail Trafford, author and former Washington Post editor, has written an analysis of the failure that includes an historical perspective on the Clinton years.

It took too long and seemed too big

Although the Clinton and Obama strategies were polar opposites in many ways, one thing they had in common was how long it took to create legislation.

[B]oth strategies were undermined by fatal delays. Bill and Hillary Clinton waited almost a year to unveil their plan. With the Obama initiative, Congress has been the laggard. Administration lieutenants hoped to get something passed quickly; then they would sell the plan to the public. But the delay frittered away the public's post-election enthusiasm for reform while allowing opponents to mount a counterattack.

The Obama plan was much more limited. The highly visible public squabbling in Congress, however, made it seem overly complicated and considerably more comprehensive than it was.

No one seemed in charge of the narrative of why health reform matters, so the public viewed a daily soap opera of squabbling lawmakers. One day, a particular reform was in; another day, out. Public option a must? Or a bust. Deals for whom -- Nebraska? Unions? Big Pharma? What about home care? "Death panels"? Abortion restrictions -- in, out. Cost control -- out, with the special deals. The public became more confused about what was in the plan -- and more disgusted with Washington.

Of two minds

Polls show that Americans want health reform. They want the government to take care of them when they need help. But they also want to maintain their image as rugged individualists who distain government intervention.

This creates cognitive dissonance - believing in two contradictory ideas at the same time. It's a state of mind that generates anxiety, defensiveness, and anger. That's exactly what we saw last summer - and continue to see -- with the Tea Party. Obama - intelligent and articulate as he is - failed to explain how these two seemingly contradictory ideas could coexist.

Over the past year, there has been no grand communicator to help people reconcile these contradictory beliefs into a coherent philosophy of life that embraces personal freedom protected by a social safety net.

Continued in the next post.

Related posts:
Why did health care reform fail? Lack of empathy
Why did we shoot ourselves in the foot on health care?
Economic recovery and healthcare reform
Health care: Reminding people of death triggers irrational emotions
Health care reform: Navigating the maze
Why is it so hard to reform health care? Rugged individualism
Why is it so hard to reform health care? Political structure
Why is it so hard to reform health care? The historical background
Why is it so hard to reform health care? National identity
Why is it so hard to reform health care? The issues are complex

In support of such a good cause, a gentleman from Ohio (Jeff Ondash) raised money for heart health by giving away free hugs outside a Las Vegas casino. After 7,777 hugs in 24 hours, he had surpassed the previous Guinness record of 5,000. Mr. Ondash, who is 51, was motivated by the memory of his father and brother, who died prematurely of heart problems.

Advertising for love in Victorian times

Pam Epstein writes in the New York Times about personal ads in the Victorian age.

In the 19th century, as cities experienced enormous population growth, men and women invented new ways to find partners in an increasingly atomized world. Amorous advertisements abounded in newspapers around the country. ... Victorian critics derided the mostly male advertisers as wicked seducers, but the ads were a favorite among readers, who found them titillating glimpses into the hearts of strangers. ... [They] feel surprisingly familiar, reminding us, perhaps, that we are not so different from our 19th-century counterparts

An example from June of 1863:

A young lady of 18, wealthy, pretty and agreeable, wants a husband. Not finding any one of her acquaintance who suits her, she has concluded to take this method of discovering one. The happy gentleman must be wealthy, stylish, handsome and fascinating. None other need apply. Address within three days, giving name and full particulars, and enclosing carte de visite, Carrie Howard, Station D, New York.

Ms. Epstein, a graduate student at Rutgers, is writing a dissertation on the transformation of love and marriage between the mid-nineteenth and early-twentieth centuries in America. More samples of Victorian personals are available on her blog, Advertising for Love.

Sexually, I'm more of a Switzerland

Kate Harding writes in Salon about personal ads in The London Review of Books and its New York counterpart, The New York R of B. David Rose, the advertising director of LRB who started the personals section, has published two collections of ads (see Resources below). A sample:

Tall, handsome, well-built, articulate, intelligent, sensitive, yet often grossly inaccurate man, 21. Cynics (and some cheap Brentwood psychiatrists) may say 'pathological liar', but I like to use 'creative with reality'. Join me in my 36-bedroomed mansion on my Gloucestershire estate, set in 400 acres of wild-stag populated woodland. East Ham.12 Box no. 0620.

Harding's assessment:

Writing a self-deprecating personal may let potential partners know you're imperfect (gasp!), but it also tells them you know who you are and have the confidence to say, "Take it or leave it." And if you go far enough over the top ("Join me in my 36-bedroom mansion on my Gloucestershire estate ...) it can even invert the usual concern about how truthful a personal ad is. Instead of wondering how much worse this guy is than he claims, you're wondering how much better.

Harding gives an example of a personal ad that worked for her:

I smoke, I drink, I talk waaaay too much and think even more than that, I swear like a longshoreman, I'm usually covered in dog hair, I do not order salad as a full meal, I always want to Talk About It, I might be funnier than you, I want to be taken care of but hate feeling weak, I'm completely disorganized, I will keep cuddling until you pry me off you (and so will my dogs), I say "awesome" a lot, I don't lie even if it's easier, I tell my girlfriends everything, I expect to come, and I've been told repeatedly that I scare the crap out of men. If that sounds like your kind of girl, awesome.

Within two months of posting this ad, she'd met the man who became her husband.

Back to Hugs

While I may not be into Valentine's Day, or personals either, for that matter, I live in California, where hugs are de rigueur. So here's my favorite video on hugs. Happy Valentine's Day.

Related posts:
Couples who prefer to sleep alone: Your room or mine?
Happy Holidays!

The BBC has a new radio series that addresses the question: Why turkeys vote for Christmas. David Runciman writes the first installment, in which he asks: Why is it Americans who would benefit the most from health care reform are the most opposed? One third of Texas residents have no health insurance, for example, but 87% oppose reform.

There are many opinions on why Obama's reform didn't pass, and pundits will be arguing this issue for months, if not more. Texans, for example, are likely to oppose government involvement in any aspect of their lives, and that opposition can easily outweigh the value they place on health insurance.

If people vote against their own interests, it is not because they do not understand what is in their interest or have not yet had it properly explained to them.

They do it because they resent having their interests decided for them by politicians who think they know best.

There is nothing voters hate more than having things explained to them as though they were idiots.

Bush vs. Gore: Stories trump statistics

To make his case, Runciman draws on the ideas of Drew Westen, author of The Political Brain. Weston cites a presidential debate between Al Gore and George Bush in which Gore explained why voters would be worse off under Bush's plans for Medicare: "Under the [Texas] governor's plan, if you kept the same fee for service that you have now under Medicare, your premiums would go up by between 18% and 47%."

Bush's response: "Look, this is a man who has great numbers. He talks about numbers. I'm beginning to think not only did he invent the internet, but he invented the calculator. It's fuzzy math. It's trying to scare people in the voting booth."

Runciman writes:

Mr Gore was talking sense and Mr Bush nonsense - but Mr Bush won the debate. With statistics, the voters just hear a patronising policy wonk, and switch off.

For Mr Westen, stories always trump statistics, which means the politician with the best stories is going to win: "One of the fallacies that politicians often have on the Left is that things are obvious, when they are not obvious.

"Obama's administration made a tremendous mistake by not immediately branding the economic collapse that we had just had as the Republicans' Depression, caused by the Bush administration's ideology of unregulated greed. The result is that now people blame him."

More recently, Obama has been making an effort to B.I.O.B. ("Blame It On Bush"), as Senator McCain was eager to point out.

The French Revolution in reverse

Runciman also cites the ideas of Thomas Frank, author of the 2004 best-seller What's the Matter with Kansas?.

[Frank] believes that the voters' preference for emotional engagement over reasonable argument has allowed the Republican Party to blind them to their own real interests.

The Republicans have learnt how to stoke up resentment against the patronising liberal elite, all those do-gooders who assume they know what poor people ought to be thinking.

Right-wing politics has become a vehicle for channelling this popular anger against intellectual snobs. The result is that many of America's poorest citizens have a deep emotional attachment to a party that serves the interests of its richest.

Disadvantaged Americans think they are voting for one thing and end up getting the opposite. According to Frank:

"You vote to strike a blow against elitism and you receive a social order in which wealth is more concentrated than ever before in our life times, workers have been stripped of power, and CEOs are rewarded in a manner that is beyond imagining.

"It's like a French Revolution in reverse in which the workers come pouring down the street screaming more power to the aristocracy."

The triumph of truthiness

The preference for emotional engagement over reasonable argument is an example of The Colbert Report's concept of truthiness: Truth is what we know intuitively, from our gut. It doesn't matter if our beliefs are contradicted by evidence, facts, or logic.

Runciman: "The authentic politicians are the ones who sound like they are speaking from the gut, not the cerebral cortex. Of course, they might be faking it, but it is no joke to say that in contemporary politics, if you can fake sincerity, you have got it made."

Runciman concludes:

This is a culture war but it is not simply being driven by differences over abortion, or religion, or patriotism. And it is not simply Red states vs. Blue states any more. It is a war on the entire political culture, on the arrogance of politicians, on their slipperiness and lack of principle, on their endless deal making and compromises.

And when the politicians say to the people protesting: 'But we're doing this for you', that just makes it worse. In fact, that seems to be what makes them angriest of all.

Is this truly what we have become, a nation destined to shoot ourselves repeatedly in our collective feet? Unfortunately, it would seem so.

Frank's "French Revolution in reverse" alludes to a fairly comprehensive explanation for this mess we're in, including a majority of the changes we've seen in medicine and health care since the 1970s. Another name for what's happened is neoliberalism: "The policies and processes whereby a relative handful of private interests are permitted to control as much as possible of social life in order to maximize their personal profit." It's a complex story, and one I hope to return to many times in explaining the recent history of medicine.

David Runciman, as you may have guessed from his use of the word "learnt," is not American, but British. He teaches political theory at Cambridge University and is the author of Political Hypocrisy and The Politics of Good Intentions.

Related posts:
This mess we're in - Part 1
Why is it so hard to reform health care? Rugged individualism
Why is it so hard to reform health care? The historical background