Ethics of the Arpaio Pardon

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After seeing what a professional dominatrix had to say about Trump pardoning former Mericopa County Sheriff Joe Arpaio, I decided to see what professional ethicist Jack Marshall had to say. I shouldn’t have been surprised.

Is the balance between profiling, which in such situations is a valuable law-enforcement tool, and the importance of equal treatment under the law a difficult one legally and ethically? Yes. Does a sheriff have the right and authority to ignore the way this balance is decided once legal authorities define it?

No.

Is the determination of this balance often polluted by ideological biases, in this case, against enforcement of immigration laws?

Yes.

“Ideological biases.” That’s what you call someone else’s principles when you don’t like them. Jack is fond of accusing people of bias.

Do Donald Trump, and his supporters, and those Americans who may not be his supporters but who agree that allowing foreign citizens to breach our borders at will without legal penalties is certifiably insane, believe that Arpaio’s position on illegal immigration is essentially correct and just?

Yes.

Does that have anything to do with the results of the trial that found him guilty of contempt of court?

No.

Nonetheless, did his ham-handed methods give ammunition to open-borders, pro-illegal immigration, race-baiting activists […]

Yes.

Is sending Arpaio to jail a political imprisonment?

Yes, although he made it easy to justify on non-political grounds.

Are political prisoners the ideal objects of Presidential pardons?

Yes.

Good God, it’s crazy to call Arpaio a political prisoner. A judge ordered him to stop doing something, and he went ahead and did it anyway, which bought him a contempt charge. It was pretty straightforward. Sure, there are people who didn’t like him for political reasons (I’m one of them), but that’s true of every elected official.  This is nonsense.

Also, just for the record, it’s misleading to call someone a “political prisoner” when they’re not, you know, in prison.

Would pardoning him send dangerous messages (it’s OK to violate judicial orders you think are wrong; the ends justifies the means; Presidents should meddle in local law enforcement, “extremism in defense of liberty is no vice”) as well as defensible ones (judges and elected official enabling illegal immigration are a threat to the rule of law; Joe is an old man with a long record of public service who deserves mercy even though he was wrong…)

Yes.

Invoking Arpaio’s record of public service is kind of laughable when it’s his failure to follow the rules of that service that got him his conviction. And it’s unreal that Jack would mention the rule of law without mentioning the awful damage that Arpaio’s pardon does to the rule of law. Arpaio is a thug, and Trump’s pardon sends a message to law enforcement thugs everywhere that the federal government is going to give them a pass. This is not even the first time Trump has sent that message, and it doesn’t get better with repetition.

 

Will such a pardon, especially as the news media is again spinning to make the case that Trump is sympathetic with xenophobes and white nationalists, further inflame an overly emotional debate that needs to be calmed, not exacerbated?

God, yes.

Or to put that a different way: Evidence that Trump is sympathetic to xenophobes and white nationalists tends to help make the case that Trump is sympathetic to xenophobes and white nationalists.

Sure enough, Democrats, Trump-haters like Senator John McCain and my echo-chamber Facebook friends are denouncing the pardon as if the President had loosed Hannibal Lector on the world.

The books area little vague, but I’m pretty sure Hannibal Lector didn’t kill anywhere near as many people as have died in Arpaio’s jails.

In doing so, they really look ridiculous, and might as well be wearing  “I hate Donald Trump and will scream bloody murder no matter what he does” in neon on their heads.

I don’t just hate Trump, I hate Arpaio too, and have for a long time. That Trump thinks Arpaio is a great example of American law enforcement is more than a little worrisome. Ditto for Arpaio’s brother-from-another-mother, Sheriff David Clarke.

Especially for Democrats, who have argued that non-violent criminals shouldn’t be imprisoned at all when they are young and black, the argument that an 85 year old man’s under-two year maximum sentence is an outrageous object of Presidential mercy and grace—that’s what a pardon is, you know–is the height of partisan hypocrisy.

Trump didn’t pardon Arpaio out of mercy for an old man. He as much as said he thinks Arpaio was convicted for “doing his job.” Trump pardoned Arpaio because he has no problem with a Sheriff who people’s rights and a court order to harass immigrants. Trump pardoned Arpaio because he likes “tough” cops.

The fact that Arpaio is 85 alone justifies a pardon by the standards Presidents have used since the beginning of the office.

Presidents don’t pardon every elderly prison inmate. They exercise discretion, and we can judge them on that discretion. Besides, if Trump was really concerned about Arpaio’s ability to survive prison, he could have commuted the sentence rather than granting a pardon.

Furthermore, the Federal Bureau of Prisons already has a compassionate release program to address situations like this. Prisoners who develop serious health problems are eligible, and prisoners over the age of 65 may request compassionate release after serving 50% of their sentence.

For that matter, we don’t even know what Arpaio’s sentence would have been. Judges take circumstances into account. He might not have gone to prison at all. But he would still have the conviction for contempt.

That his sentence is relatively short—many, many prisoners with far longer sentences have been pardoned by Trump’s predecessors–makes the pardon, if ill-considered, also de minimus, especially since there is no chance, literally none, that the old man, now out of office and retired, will have an opportunity to repeat the crime he was convicted of committing.

This is disingenuous. One of the purposes of punishment is to deter other people from committing the same crime. Pardoning Arpaio undermines this deterrence because it suggests to other people, including other chief law enforcement officers, that they can defy federal judges and federal law if President Trump likes them.

A pardon is an act of grace by which an offender is released from the consequences of his offense, according to the U.S. Justice Department’s website. It does not say that the offender was not guilty, or that the law that was violated can be breached at will.

But doesn’t it? If the President has stoked anti-immigrant fervor, and if he has championed Arpaio-style “tough” policing, then doesn’t pardoning Arpaio imply that Trump thinks it’s okay to break the law to do that?

They want him to be metaphorically hung up by his heels to appease their open-border, pro-illegal immigration base, making the fervor to punish him purely political, and having little to do with respect for the rule of law, which their own position on illegal immigration proves that they don’t respect themselves.

Rule of law is usually presented as being in contrast to rule by arbitrary exercise of power. Whether the government helps you or punishes you should depend on whether you follow a set of explicit rules, not on how much you are liked or disliked by the people wielding power. Thus the rule of law is undermined by the fact that Trump’s first and only Presidential pardon went to one of his most prominent campaign supporters.

(Jack used to talk a lot about the importance of avoiding the appearance of impropriety, even when there’s no actual impropriety, yet there’s no mention of that in anything he’s written about the pardon.)

It seems clear that Jack is getting hung up in immigration issues, but there’s a lot more wrong with Sheriff Joe Arpaio than the immigration-related activities involved in the contempt charge.

  • Arpaio’s office has botched a lot of sex crime investigations, either doing a sloppy job or not working them at all.
  • Arpaio proudly treated his prisoners terribly, sometimes serving them spoiled food and offering substandard medical care.
  • Arpaio setup a temporary “tent city” outdoor jail that operated for something like 20 years in the sweltering Arizona sun, subjecting prisoners to unsafe temperatures, sometimes with lethal results.
  • Arpaio did very little to discipline guards who mistreated prisoners in his jails, which he himself referred to as “concentration camps.”
  • Arpaio used his police force to intimidate his enemies. He jailed reporters who were critical of him, and launched a corruption investigation against a judge who ruled against him.
  • Then there’s the whole fake assassination plot against him, which put an innocent man in jail for 4 years.
  • Or the puppy-burning incident.

That’s the guy Trump pardoned. That’s the guy Jack is defending.

Let me be clear. This isn’t a Rationalization #22 “it isn’t the worst thing” defense of the pardon. It is a “the attacks on this pardon are wildly disproportionate to its reality, and thus transparent political theater” indictment of the pardon’s critics. Almost every pardon can be called a rejection of the “rule of law,” if you don’t understand what the pardon power is, and politicians who have been undermining respect for the very laws that Arpaio went over-board enforcing are the last people on earth who should make that argument. They are ridiculous in their hypocrisy.

I’m not sure what that is, but if it isn’t “it isn’t the worst thing” or “everybody does it” then it’s an ad hominem attack. Whether Trump’s critics are right or wrong about the pardon has nothing to do with whether they are hypocrites. A murderer who declares that “murder is bad” is not wrong.

Joe Arpaio was an arrogant, grandstanding bully and thug, and unworthy of his badge. I wouldn’t have pardoned him despite his age, but there were some good reasons for Trump to do so. It was almost worth doing just to prompt Trump’s foes and pro illegal immigration hypocrites into embarrassing themselves.

That’s a terrible reason for pardoning someone.

The Dominatrix and the Sheriff

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I’ve been watching the reaction on Twitter to President Trump’s pardoning of former Maricopa County Sheriff Joe Arpaio. Arpaio is a despicable authoritarian bigot, who I’ve written about several times previously. He is famous, and famously proud, of how tough he was on the prisoners in his custody. He liked seeing them mistreated and humiliated, often in very unpleasant ways. I don’t know if he actually enjoyed it when his prisoners died, but a bunch of them have died, often under questionable circumstances, and Arpaio has never shown an ounce of human sorrow.

I was most struck by the reaction from Mistress Matisse:

Now, this next part is probably the sort of thing that only seems profound at 3:00 in the morning (when I started writing this), but bear with me… What really got me thinking is that Mistress Matisse and Joe Arpaio have something in common: They both like to hurt people.

As you might have guessed from the name, Mistress Matisse is a professional dominatrix. She literally hurts people for a living. And if you follow her Twitter feed (@mistressmatisse), you’ll see she enjoys her work. Oh, I’m sure there are days where she’s like “Oh God, I can’t wait to veg out in front of the TV once I finish sticking needles into this guy’s penis…”, but for the most part, she seems to have found satisfying employment. She hurts people, and she’s good at it.

Nevertheless, Mistress Matisse is pissed about Joe Arpaio, because of course, the difference between Mistress Matisse hurting people and Joe Arpaio hurting people is consent. And consent makes all the difference in the world.

Mistress Matisse posts descriptions and photos of the some of the things she does to her clients and, honestly, I couldn’t take that. If she tried to do some of those things to me without my consent, I would resist, violently if necessary. But her clients not only give their consent, they actually pay her to do those things.

Yet if I’m ever in Seattle and I happen to run into Mistress Matisse, I wouldn’t be the least bit concerned about her pain-causing skills. I don’t pretend to know or understand her very well, but I’ve read enough of her writings to know that she thinks very carefully about issues of consent. She doesn’t want to hurt people against their will.

Sheriff Joe Arpaio, on the other hand, doesn’t give a shit about consent. He’s a thug, and he had an army of deputy thugs working for him. I would be very nervous running into him in a situation he controlled. If he could find a way, he wouldn’t hesitate to have a critic like me thrown in a cage in the 110 degree heat of the Arizona sun.

I don’t have any profound point here. And I certainly hope this is not coming across as “Joe Arpaio is even worse person than a professional dominatrix,” because that would be insulting to the pro dom community. The juxtaposition between Mistress Matisse and Joe Arpaio just struck me as a stark illustration of the importance of consent.

As a someone who leans libertarian, I place a lot of importance in the concept of consent. And I regard the absence of consent as a defining requirement for legitimately designating something as a crime: Sex without consent is rape, commerce without consent is theft, and inflicting pain without consent is torture.

Lack of consent alone is not enough to make something a crime, but if there is full consent, then it should never be a crime. As far as I’m concerned, Mistress Matisse is a successful and valued practitioner of an unusual art. Nothing to worry about.

Joe Arpaio, on the other hand, hurt a lot of people without their consent. Obviously, detaining and punishing criminals without their consent is a necessary part of criminal justice, but the lack of consent also makes it especially important that the criminal justice system is subject to strict requirements and oversight. Arpaio had little of that, and he and his deputies went way beyond what was necessary to keep the peace.

It’s particularly relevant to the contrast with Mistress Matisse that Arpaio jailed consensual sex workers and subjected them to harsh conditions, including one particularly gruesome case in which his guards tortured and killed a sex worker. Yet that’s just one of many deaths and many more prisoners subject to torturous conditions. Arpaio was one of the most monstrous figures in modern American law enforcement.

There’s something very wrong, some kind of complete inversion of the meaning of consent, when we have governments that want to throw people like Mistress Matisse in jails that are run by people like Joe Arpaio.

How Not to Change Your Employer’s Culture

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I told myself I wouldn’t write about the Google memo. The situation followed a drearily predictable script — guy writes something arguably sexist, it goes public, outrage erupts, company fires him, he becomes a martyr for the MRA cause, etc. — and I didn’t want to have anything to do with it.

There’s something that bothered me though… As I understand it, the (now former) Google employee criticized the company’s diversity policy regarding women, using an argument based on statistical differences between the sexes. At least that’s what I’m hearing from people I consider reliable. I still haven’t read the whole memo, and I hope I don’t have to.

Honestly, I tried reading it, but I didn’t have the stamina to go on once I got to the part where he invokes evolutionary psychology. I’ve seen this before, and it’s never pretty. Evolutionary psychology is a branch of biology that tries to link psychological traits back to the conditions under which they evolved. It’s a legitimate science, but one in which firm conclusions are difficult to come by. Unfortunately, that hasn’t stopped a lot of people from invoking it to make some very questionable pronouncements about race and gender.

I haven’t read enough of the Google memo to know how far the author goes down that road, but here’s the thing: Given his stated purpose, evolutionary psychology is completely unnecessary. The author justifies his proposals based on supposedly innate differences between men and women. But if the evolutionary basis for those differences is backed by science, that science must necessarily make use of contemporary studies of men and women which demonstrate those differences, and those studies alone should be sufficient to support his proposals.

When your purpose is to propose changing the work environment to make it more accommodating to the differing preferences of women, all you need to know is what those preferences are. How women came to have those preferences may well be an interesting area of scientific inquiry, but it has nothing to do with workplace policy.

For example, suppose evolutionary psychologists conclude that women like the color pink because ancestral women were the primary caregivers of infants and attention to pink tones in skin coloration was important to maintaining infant health. If this was real science (instead of something I just made up), then the body of research supporting feminine color preferences must necessarily include studies that establish the statistical observation that women like the color pink. So if you want to propose painting Google meeting rooms pink to make women more comfortable, you need only refer to the studies showing that women like pink. There’s no need to bring up evolution.

More generally, for the ostensible purposes of the memo’s author, the reasons for differing preferences are beside the point. Perhaps they arise because of evolutionary pressures, or perhaps they are instilled in men and women by the expectations and restrictions of society, but when it comes to setting personnel policy, it just doesn’t matter. By the time men and women walk through the doors at Google for their first interview, they have whatever preferences they have, for whatever reasons they have them, and Google can’t do a thing about it. Google has to take its job applicants as it finds them.

The point I’m trying to make here is that this should have been obvious to the memo’s author. If he was sincerely trying to propose ways to accommodate women’s preferences, all he had to do was cite the research that backs up his arguments about differences between men and women. Bringing in evolutionary psychology was unnecessary, divisive, and distracting. If this was a sincere attempt to influence company culture, it was a stupid way to go about it.

The author’s other major mistake was to be disrespectful to the powers that be. The title alone, “Google’s Ideological Echo Chamber,” implies that Google managers are closed-minded and therefore foolish. Even if the author is right and Google is managed by people with absurd liberal biases, this is not the way to make them see the light. In fact, if you begin your letter to your employer with the rhetorical equivalent of “Hey, dumb-asses!” you should not be surprised when they construe it as your resignation.

A Professional Ethicist Responds to Trump’s Remarks About Charlottesville

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Over the weekend there were some public gatherings of white nationalists in Charlottesville, Virginia. These were met by counter-protesters, and some of the encounters between the groups got violent.  The worst violence came on Saturday, when someone identified with the white nationalist movement deliberately drove their car into a crowd of protesters, killing one and injuring many others.

Everyone was kind of wondering what, if anything, President Trump would say about this. As it turns out, he had something to say, and it was…telling. You can read the whole thing here, but this is arguably the key sentence:

We condemn in the strongest possible terms this egregious display of hatred, bigotry and violence on many sides, on many sides.

It was the “many sides” phrase that got people’s attention. Trump may not exactly have been wrong — given that some of the counter-protesters were antifa activists, it seems likely that both sides got violent — but it’s the seemingly deliberate obscuring of the fact that one of the sides consisted of virulent racists that’s so revealing. We’re talking about a guy who famously denounces anyone who angers him, from his own appointed Attorney General to a department store that stops carrying his daughter’s line of fashion accessories. Yet he had nothing bad to say about any of the white supremacists, not even when asked directly about it. Twice.

For more insight into this matter, let’s see what one of my most frequent sources of blogging material has to say about it. Here’s professional ethicist Jack Marshall writing about the president’s remarks:

In contrast to the President’s correct restraint, we have Virginia’s governor Terry McAuliffe, who used the power and influence of his office to declare that people holding views he does not approve of are not welcome in the Old Dominion. In the midst of some patriotic grandstanding, he said…

“You are not wanted in this great commonwealth. Shame on you….There is no place for you here. There is no place for you in America.”

This is leftist fascism, by definition. Who is Terry McAuliffe, or Virginia, or anyone, to say who can or should have a “place” in the United States of America? How is this statement applied to white nationalists any different legally or ethically from applying it to Muslims, or lesbians, or abortion advocates, or Catholics, Jews or libertarians?

I wasn’t expecting that. Damn, being a professional ethicist must be really hard. I never would have guessed that was the correct answer.

I Guess Racism Isn’t Quite Over…

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Almost nine years ago, right after Barack Obama was elected President, I wrote:

[W]e now know how the story of American racism ends: The racists get their asses kicked. Racism won’t vanish in a week or a year or even a decade, but it will vanish. Barack Obama’s victory is a clear message to all the hardcore racists out there—the KKK, the Nazis, Stormfront: It’s over. You’ve lost. You are no longer important. There’s no place for you here in the future.

It appears I may have been mistaken.

This was going on at the University of Virginia in Charlotte tonight:

These people are basically white nationalists, or maybe white supremacists. Although given that stiff-armed salute and the reports of swastikas and their chants of “blood and soil,” I think we can probably call them straight-up Nazis without triggering Godwin’s law.

(They’re really more like Nazi Lite though: Those are Tiki torches.)

Obviously, this is not the first sign that something has gone wrong with our pluralistic society. The alt-right has been growing for years and developing into a movement, we’re seeing a rise in anti-Muslim and anti-immigrant sentiment, and now Britain is exiting the European Union and Donald Trump is in the White House.

Yet this rally somehow brought it home for me. I think it’s because many of them are so young. These aren’t just the bigots of the old society clinging to the past. These are newly-minted bigots. That’s not a good sign. I had kind of hoped we wouldn’t see much more of that.

Cabbage Day [Updated]

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So the other day my friend Leo got a call from his cardiologist confirming an appointment. As I’ve mentioned before (post 1, post 2), Leo and his father are staying with us while Leo recovers from heart problems and a stroke. We had set up an appointment with his cardiologist for last Friday in preparation for heart surgery, but according to the call he received, the appointment was not on the day I had in my calendar. I called the cardiologist to find out what was going on, and the office staff had no idea what I was talking about. They had the same date for the appointment that I did.

So maybe Leo misunderstood the message. He has aphasia from the stroke, so he has trouble communicating with people, and it didn’t help that the message was one of those robo-call appointment reminders, which left him unable to ask for clarification. This was really not a good way to communicate with a stroke victim.

Eventually, I figured out what was going on. This call was actually from his cardiac surgeon rather than his cardiologist. Apparently, the surgeon had visited him while he was in the hospital, and somebody had set up a followup appointment, and not bothered to tell us about it.

Actually, we’re pretty sure they told Leo about the appointment, but this would have been a few days after his stroke. I’ve mentioned that his mental abilities are improving every day. The corollary is that his mental abilities were much worse when all this started. He remembers very little that happened during that first week after the stroke.

(This sort of thing was a common occurrence when dealing with Leo’s healthcare providers. A few days after this call we got another call about a cardiology appointment we had never heard of. This time it turned out to be a cardiologist who saw him at the second hospital and wanted to do a followup. We agreed there was no reason to see two cardiologists and cancelled the second one.)

Anyway, since the cardiologist and the surgeon are located a few minutes apart but about 50 miles away from my home, we got the surgeon’s office to reschedule their appointment to the same day as the cardiology appointment we already had, with a tentative surgery date of the following Wednesday. However, when Friday came, the cardiologist’s office called to cancel the appointment and asked if we could reschedule for the following Monday or next Friday. Suppressing my annoyance at the scheduling issue and the fact that these people clearly do not talk to each other, I explained that our surgery date meant next Friday was too late, so we’d be there on Monday.

It was still a busy day. We met with the surgeon’s office nurse, and she asked us a lot of questions and explained the process to us. The whole staff seemed very efficient. Then we were off to the neighboring hospital for pre-operative lab tests and a chest X-ray. Before I even got the car started, however, we got a call from the surgeon’s office. After we had left, the surgeon decided he needed a CT scan of Leo’s head, and in the time it took us to walk out to the car, his staff had called the radiology department to set it up. All we needed to do was tell the receptionist.

That all went relatively quick, and with the afternoon off because of the cardiologist’s rescheduling, we decided to drive over to Leo’s house just to make sure everything was okay.

Leo is something of an amateur naturalist, and last year he killed off all the grass in his yard so he could replant it with wildflower seeds native to the Illinois prairie. When I last saw the place, the prairie flowers had grown in a few feet high and looked pretty thick, but when we got there on Friday afternoon, almost a month later, Leo’s yard had turned into a spectacular explosion of dozens of different types of plants towering over my head and teaming with tiny wildlife.

Leo also likes to feed the local critters — birds, deer, raccoons, skunks, cats, etc. — so he can take pictures of them, but it looked like the feed bags he keeps in his house were starting to attract bugs, so we dumped them out at the back of his property so the local fauna could chow down.

(In my neighborhood, uncontrolled plant growth and feeding wildlife would piss off my neighbors and probably get me cited and fined, but it’s amazing what you can get away with when you live in an unincorporated area far from the prying busybodies in town government.)

While we were there, we started Leo’s car and moved it a bit so the tires wouldn’t develop a flat spot. (I don’t know if that’s really still a thing with modern tires.) We also rebooted the home network, which was behaving a little weird, and tidied up a bit.

On Monday, I stayed home to work while my wife took Leo to the cardiologist’s office. While they were there, the surgeon’s office called to say they needed some kind of approval from his primary care doctor. After a bit of a pissing match between the two offices, Leo’s doctor managed to get them in late that afternoon, which pretty much killed the whole day.

On Tuesday night, Leo ate his last meal before surgery. He then took a shower using special soap. This morning we got up at 4am, and he took another shower with the same stuff. I guess the idea is to minimize the chance that the surgical team will pick up contamination from a non-sterilized part of Leo’s body.

We were ready early, so we left early, just in case we ran into unexpected delays during the drive. We didn’t, so we got to the hospital an hour ahead of time. Eventually they brought us into some kind of prep room where Leo changed out of his street clothes. The anesthesiologist visited. The surgeon visited. They explained what would happen. They started an IV. And then we sat around and both dozed off until they came to take him an hour and a half later.

I’m in the waiting room now, trying to keep calm and keep occupied.

Leo is having open-heart surgery. It’s a cardiac artery bypass graft, abbreviated to CABG, which all the cool kids apparently call “cabbage.” Basically, as I understand it, they will knock him out and then open up his chest and cut through his chest bones to get at his heart. Then they hook him up to a heart-lung bypass machine that oxygenates and circulates his blood. This allows them to stop his heart. With the heart immobile, the surgeon can splice grafts into the cardiac arteries using relatively unused blood vessels from Leo’s leg. He’ll try to add as many grafts as he can, to maximize blood flow to the heart muscle. When he’s done, they will restart Leo’s heart, wire his chest back together, and then close him up. He’ll recover in the ICU for a day or two, and then they’ll move him to a regular room

As you might guess, this is not a sure thing. The heart-lung bypass lines can come loose, or he can start bleeding where they’re connected, or the machine can cause his blood to form clots which will enter his blood stream. The surgeon could make a mistake. A blood vessel could tear. His heart might not restart. Leo could start bleeding internally after the surgery. And there’s always the risk of infection.

Leo’s surgeon is apparently one of the best. The hospital staff speaks highly of him. Leo’s doctor says he’s the guy she’d want if she was having the surgery. From what they’re saying about him, I get the feeling he’s the kind of surgeon from whom medical students learn how to behave in the operating room.

And yet… there’s a small chance — but not small enough to be negligible — that my friend Leo will die. I can’t really grasp that. I can’t imagine what it would mean to me if Leo were gone. What haunts me now is thought of making that hour-long drive home to tell Leo’s wonderful father that his son is dead.

Really, though, I’m mostly OK. The surgery will in all likelihood go just fine. It usually does. There aren’t a lot of complications in Leo’s case, and everybody seems real confident. So the odds of failure are probably pretty small. Less than 1-in-100. Maybe less than 1-in-1000. In one sense, that’s terrific. But it’s still probably hundreds or thousands of times greater risk of death than on an ordinary day.

Well, an ordinary day for an ordinary person. With Leo’s heart problems, he’d be very likely to die soon without the surgery. So he has to have the surgery, and there’s no point worrying about it because neither of us can do anything to change the outcome. Leo has made the only decision he can, and we’re just going to have to see what happens.

Leo has been totally cool about that. As for me, as I sit here waiting for the surgeon to finish his work and come out and tell me how it went, I’m wavering between somewhat cool and somewhat freaked out.

So, I’ve got my laptop plugged in, I’m on the hospital we-fi, and I’m waiting.

Update:

Surgery is over. Everything went well. He’s just been moved to the ICU. I’ll drop in on him there — because for some reason everyone expects me to want to see him unconscious and on a respirator — and then I’m outta here. There may be drinking in my future.

(I’ve changed names, places, and other details to protect my friends’ privacy.)

Fun and Games With the Sick and Elderly

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It’s been a little over a month since my friend Leo had heart failure and a stroke, and things have been very busy around here. As I mentioned, Leo had been planning to go into the hospital for heart surgery for a while, and since he was the sole caregiver for his 87-year old father, we had been planning that I would help take care of him by visiting him every other day.

At least that was the original plan, when Leo found out he needed heart surgery two years ago. For various reasons, some medical, some logistical, he kept having to put off the surgery, until last month his heart gave out and he had a stroke. And during that period, it turns out that things had changed. Things my wife and I were unaware of.

For about a week and a half, we tried to follow the original plan of making the 100-mile round trip to visit his father every day or so. Gradually, we realized that Leo’s father was not as independent as we thought. For one thing, his dementia is a little worse than we expected. He’s not totally out of it, and he’s able to live by himself surprisingly well — microwaving his own meals, taking his own medicine from pre-filled pill containers, and even doing his own laundry — and that fooled us for a while.

Eventually we realized that he was more forgetful than we realized, and that we would need to monitor him more closely. We decided the only thing that made sense was to bring him to live with us. It was already the weekend, and we knew we weren’t ready for him over yet, so we hired a home care service to help him out for three hours every day during the next week, with us still coming over most evenings as well. This would get us through until the following weekend, which would give us time to prepare the place.

Meanwhile, we were dealing with a medical mystery. Leo’s father was a diabetic, and his blood sugar levels had started rising since his son went into the hospital. We had a list of his medications, and there was no insulin, so it looked like he managed his diabetes with pills and diet, as evidenced by the supply of healthy low-calorie frozen dinners in his freezer. Our best guess was that he was eating too many of his favorite meals rather than a mix of healthy ones, so we began to shop for increasingly low-sugar/low-carb foods, and that seemed to help.

What neither of us knew is that Leo’s father was taking insulin. Or rather, he was supposed to be taking insulin. It turns out that the list of medications we had was only for filling Leo’s father’s pill boxes. Leo managed the insulin separately, since he didn’t want his father taking it by himself.

(I had asked Leo in the hospital if he managed his father’s diabetes with pills and diet, and he confirmed that he did. I knew not to entirely trust that answer, because Leo was often confused, but we had also asked Leo’s father if he took insulin injections, and he said no, so I felt pretty confident. In retrospect he must have misunderstood the question.)

We started to figure all of this out when I finally got Leo’s father’s primary care doctor’s office to send me a list of his medications, conditions, etc. I called his doctor immediately, and he told us that given the glucose levels we were seeing, the amount of time he had gone untreated, and the lack of any symptoms, we shouldn’t be too concerned. Just get him back on insulin again.

We went over that evening to get him started on the insulin. You’re supposed to take daily insulin in the morning, but we felt that giving it to him in the evening was better than nothing. Now that we knew what to look for, we immediately found a couple of boxes of insulin pens in the refrigerator. Then we had him test his glucose levels. They were perfectly normal.

There was no way we were going to dose him up with insulin and then just leave, because he could start to crash and we wouldn’t know it. So we just left things the way they were. The next day, a visiting nurse from the VA came to see him, and — thanks to a home care worker who gave him some high-sugar soft drinks she found in the refrigerator — his insulin was sky-high again. So the nurse dosed him up good and, with the help of someone at the VA, helped us figure out a proper insulin schedule.

The following Saturday, in an operation that went much smoother than it should have, we brought Leo’s father to live with us, along with his clothes, toiletries, meds (with insulin cold-packed for the trip), pillow, blankets, easy chair, iPad (for movies), bathroom scale, and binoculars (for bird watching).

Fortunately, this coincided with the beginning of our planned two-week stay-at-home vacation, so we had plenty of time to get Leo’s dad integrated into our household. It also gave me time to go back to his house for his microwave oven, so that he wouldn’t have to learn to use ours, which was also awkwardly located for him. I also prepped Leo’s house for vacancy by taking or discarding all perishable foods, emptying and shutting off the refrigerator, turning the air conditioning up to 87, setting some lights on timers, and installing an alarm system and security cameras. I also let the neighbor know we had moved him out and notified the Sheriff’s office so they could check the house periodically.

Meanwhile, while we were trying to take care of Leo’s father without putting him into a diabetic coma, Leo himself was working his way through the recovery process. He was transferred from the hospital where he was initially admitted to another hospital that had a good rehab program, and he immediately began receiving physical therapy, speech therapy, and occupational therapy. This was about 20 minutes closer to where I live, so I had little trouble continuing to visit him every other day or so, and he continued to get a little better every time.

After maybe a week, the discharge planning nurse called me to tell me they were ready to move him to a nursing home for rehab. They sent me a list of facilities that were covered by Leo’s insurance and asked me if I wanted to pick one. I wanted to find one that was close to me so I could visit more often, but after doing some research on the Medicare website and Yelp, I decided to go with one of two nursing homes that were near the hospital. I took a quick tour and was impressed by the cleanliness and preparedness of the staff of both, so I went with the one that was closest to the hospital, on the theory that they were used to working together.

Leo continued to improve at the rehab facility, and after a week or so they contacted me to let me know they were thinking of discharging him, if we could take him in. That had been our plan all along, but this call came the week after we took in his dad, just as we were getting settled down.

That touched off a whole planning session for how to arrange the spare bedroom to hold a second bed. The bed that was in there was queen size, and we could fit another bed in next to it, but there wouldn’t be enough room between them for someone with a walker. Eventually, I got the idea of putting in a twin bed at a right angle, which would leave enough space for both of them to use walkers, but that idea was blown up when the home care service announced they were sending us a hospital bed for Leo. We considered not taking it, but they pointed out that he still had heart surgery coming up and would probably need it then. So we ordered another twin bed to go with the hospital bed and took out the queen size bed, which is now leaning against the fireplace into our family room/library.

Part of the discharge process from the nursing home was for me to receive caregiver instructions. So made a special trip over during the day, and the physical therapist explained to me the proper procedure for Leo to stand up from a chair and sit down safely, and which foot Leo should move first when climbing up and down the stairs. He also had me bring my car around so he could show us how Leo could get in and out of a car.

Leo and I agreed later that this training was mostly useless. I’ve taken care of someone more disabled than Leo before, and we’re both overweight, so we’re both used to moving carefully. For better or worse, pushing off the arms of a chair when standing up is not a novel idea for either of us.

On the other hand, you know what would have been nice to receive training on? The ZOLL LifeVest wearable defibrillator that Leo has to wear everywhere. Basically, it’s a cloth vest with EKG sensors and defibrillator shock paddles that snap into interior pockets, connected by a cord to a portable control box which is expected to sense dangerous fibrillation in Leo’s heart and if necessary, administer a shock.

I learned how it works by visiting the company website and watching their training video, which explains how to change the batteries and how swap the sensors between vests when it’s time to change to a new one. It also explains the alert sequence that occurs when it detects a problem with the patient’s heart: First the vest vibrates, then it emits a series of increasingly loud warbling tones, then it announces that bystanders should stand clear and not touch the wearer, and finally it extrudes conductive gel from the shock paddles and administers a defibrillation jolt. Rather annoyingly, all the LifeVest documentation refers to this as “treatment,” presumably to avoid alarming patients by admitting that it will electrocute the crap out of them.

In some sense, I guess I didn’t need training in how the vest works because Leo had been taught to take care of it himself, but it would have been nice to have been told what the LifeVest did and how it works. In particular, the control box has two buttons on it that the patient can press to stop the shock. In engineering terms, this step implements the condition that only a person who has lost consciousness is in need of defibrillation. For that reason it’s really important that only the patient operates the buttons.

So anyway, the rehab place sends Leo home to us on Saturday, and he and his dad have a reunion. Without the nursing home staff looking over his shoulder, Leo abandons his walker and quickly discovers that he can walk well enough without it. Everything is going fine.

And then later that evening the warbling alert tone starts on Leo’s life vest. Leo is standing up at the time, so he presses the buttons that prevent the vest from shocking him. He says he feels fine. And then the alarm goes off again. This happens several times in a row. He tells me it does this all the time and it’s nothing to worry about.

I’m not entirely convinced, but what really has me freaked out is that even if there’s nothing serious going on with his heart — and we’re pretty sure there isn’t because he’s still conscious — every single time that alarm goes off, it means that he’s within about 30 seconds of getting a painful electrical shock to the heart. Every single time. A few weeks of dealing with that and I’d be a nervous wreck.

Anyway, as I’d hoped, having Leo around makes our lives easier rather than harder. He’s still pretty messed up from the stroke, but he’s got it together enough that he can help take care of his father, which is a big load off our minds, because we knew we’d have a lot less free time once our vacation was over.

It’s a little weird, though. Leo has aphasia, which means he has trouble expressing himself, but that doesn’t necessarily mean his thinking is impaired. For example, one evening he told us that his father’s blood sugar was too low, “About 150.” That’s actually pretty normal, but when I checked the glucose meter myself, it was actually around 50, which is much too low. Leo had read the meter correctly and diagnosed the problem, but he was unable to say the number accurately. Similarly, he has trouble saying the numbers on his father’s insulin injection pen, but he can still do the math to figure out how much insulin to give his father and then set the pen correctly by counting clicks.

And of course, Leo has far more experience taking care of his father than we do, so he can spot subtle clues about his father’s health, such as the sluggishness that indicated low blood sugar. Leo also understands his father’s needs better than we do, and can point them out to us, even when his father is too polite to mention it.

For example… You remember when I mentioned that his father was only eating very healthy low-calorie meals? Leo had something to say about that. At first, all he could say is that his father needed “big food” not “small food.” After some back-and-forth, we eventually realized Leo was talking about low- and high-calories meals. He was telling us that the low-calorie meals were his meals, which he had been eating to lose weight. His father, on the other hand, had been eating normal nutritious foods. What must have happened is that by the time we showed up to do grocery shopping, his father had finished most of his food, so all we saw in the freezer was Leo’s low-calorie diet meals. We assumed that’s what his father normally ate, and so that’s what we bought for him. And he was far too polite to ask for better food.

In other words, over the past few weeks we managed to run a 78-year-old diabetic man’s blood sugar way up…and then starve him with a weight-loss diet.

No harm done, apparently, but…Yeah, it’s a good thing Leo’s here.

(I’ve changed names, places, and other details to protect my friends’ privacy.)

 

 

Trump Wants Obamacare to Fail

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This tweet of President Trump’s yesterday illustrates what a clueless dick he is when it comes to healthcare policy:

Let me quote the key part:

…let ObamaCare fail and then come together and do a great healthcare plan.

People who talk like that — including some of the people who demand that Congress should “repeal Obamacare” —  have no idea what Obamacare is or how it works. Obamacare is not just bolt-on legislation (like a subsidy or a tax) that can easily be removed. The Affordable Care Act was a complex, multi-phase restructuring of the healthcare insurance market that ran to 2000 pages. It created standards, regulatory bodies, organizational structures, mandates, taxes, waivers, funding channels, and a schedule for implementing all of it.

Obamacare is not something added to healthcare, it’s a transformation of healthcare. If you want to undo it, you can’t just remove it — not without throwing the healthcare market into chaos. You have to specify the transformation process that will produce the market structure you want. Consequently, the people who talk about “repealing Obamacare” are talking about a transformation of the healthcare insurance market that is every bit as fraught with risk as Obamacare itself.

I’m pretty sure that Trump has no idea what market structure he wants for healthcare. I doubt he’s thought about it much beyond a few aspirational slogans about how great it will be. And in the tweet I quoted, he isn’t even talking about something as vague as repealing Obamacare. He wants to let Obamacare fail.

In an insurance market, failure means that the insurance companies and their customers are unable to reach an agreement on price. It usually happens when premium prices start going up and policy holders who are least in need of insurance — those who have few claims — refuse to pay the higher prices and don’t buy insurance. That leaves behind only policy holders who have a lot of claims, so insurance companies have to raise premium prices to avoid losing money. That encourages even more policy holders to quit their insurance plans, and the cycle continues until the insurance companies give up and leaves the market, leaving everybody uninsured. This industry term for this is a “death spiral.”

It’s an open question whether ACA healthcare plans are in a death spiral. The ACA has features which are intended to prevent a death spiral, most prominently the individual mandate penalizing people for not buying insurance, which is supposed to keep policy holders from leaving when prices go up. However, there have been signs that a death spiral is in progress, such as rising prices and health insurance companies abandoning some markets. On the other hand, the market could just be shaking out — weaker players quitting because they can’t figure out how to operate profitably — which happens in a lot of new markets. It’s clear the Obamacare markets aren’t healthy, but it’s not clear if they’re actually failing.

Under the Obama administration, insurance companies had good reason to believe that the government would try to prevent a death spiral: This was Obama’s namesake legacy achievement, after all, and he would try to protect it. Since they were unable to get the cooperation of congressional Republicans, the administration was limited to making changes that were within the authority of the executive branch (although some argue they exceeded that authority). Nevertheless, the Obama administration kept a close eye on what was happening in the healthcare insurance market, and they kept tweaking the implementation of the ACA to keep things going.

Things are different now. With control of Congress and the White House, Republicans are in charge of healthcare policy and can do pretty much whatever they want. Yet so far, the various Republican healthcare plans haven’t addressed the “death spiral” issue at all. In fact, some of their proposals weaken the individual mandate without strengthening other aspects of the healthcare exchanges, which seems likely to increase the risk of a death spiral.

And as this tweet makes clear, Trump has no personal interest at all in keeping the exchanges going. But rather than dismantling them in an orderly fashion, Trump sees no problem with letting them fail. This is deeply callous. It’s the healthcare equivalent of owning a run-down apartment building and deciding that rather than repairing it, or even demolishing and rebuilding it, you’ll just let it collapse on its own before you try to rebuild.

Trump doesn’t seem to care that the failure of the Obamacare markets will have real harmful effects on people. It was a running joke that what Republicans didn’t like about “Obamacare” was the “Obama.” That struck me as unfair, but I think it’s accurate for Trump. Not in a racist way, as was implied by the joke, but in a personal way. Trump doesn’t care what happens to people who lose coverage if Obamacare fails because he sees this as a personal fight: He sees himself as the greatest President, a winner, and for that to be the case, all challengers must lose. He wants to see Obamacare fail because that will show the world he’s better than Obama.

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