The rabbit hole gets a little bit deeper
Whoa. According to this article, Filipino veterans of WWII are asking for VA benefits from the US department of Veteran’s affairs. According to the article, last year (2004) was the year that Filipino veterans were allowed into the US VA health care system.
That’s a surprise to me. In 1992, while I was an intern at the Long Beach VA Medical Center, which is partially administered by UC Irvine, one of my inpatients was a Filipino veteran who was never a member of the US regular armed services, but of the Filipino armed services. This man lived in the inpatient units of the VA for, to the best of my knowledge, months at a time, and had been a long term patient of the VA before I was hired, and continued to be a patient after I left. I asked about this at the time, and was told that President Roosevelt had authorized Filipino Vets to be treated in the US VA system, so it was legit.
On the other hand, according to the Sun-Times article linked above, the US Congress elected not to recognize Filipino veterans as "active veterans" in 1946. So, if my reading of the the Sun Times article is correct, from 1946 until 2004, barring unusual circumstances (and, based on the other irregularities I’ve described in the posts below this one, and the fact that no other unusual circumstances were described when I first asked about this back in 1992, my first guess as to the most likely set of operative "unusual circumstances" is fraud), Filipino veterans were not authorized for treatment at the VA medical centers. And yet, there he was. Makes me wonder about the other VA patients I met who were not US veterans. Also makes me wonder about the elderly woman whose records and ID had a man's name (her husband's name, according to her) on them, and who was also a long-term patient of the VA.
Anyone from the Long Beach VAMC or UC Irvine want to explain this? (bearing in mind that I’ve already gotten the "President Roosevelt gave them this, so it’s OK" explanation from the VA, which is apparently not true) I’m at pbanos[at]yahoo.com
Monday, April 11, 2005
Sunday, July 11, 2004
Since the time I wrote my last post below, describing my experiences at the University of California, people have asked me if I know of any other problems there. Indeed I do. So, over the next few postings, I will describe a few examples of what I believe to be large-scale insurance fraud that I saw, or otherwise know of, at the University of California medical system.
The largest case of which I am aware involved large scale ... umm ... mistaken billing for intern and resident services. I did my medical internship through the University of California, Irvine. I made $29,000 for one year of work, for which I worked approximately 80 to 100 hours / week. The University, however, apparently didn’t bill for my services as if I was making $29,000 / year. Instead, they allegedly billed for the services provided by the interns and residents, as if the services had been provided by attending physicians. (note: I don't know if services I personally performed were billed "incorrectly," just that large numbers of services around the time I was working for UC Irvine were "incorrectly" billed. I assume that some of what I did was billed "in error.") They even billed for attending physicians doing procedures at times when those attendings were documented to have not been in the hospital at all.
In February 2001, after years of appeals, but with new federal DA's on the way after the 2000 federal elections were eventually finalized, the University of California settled those
"erroneous" billing claims (referred to as "routine misbilling of medicare, medicaid, and other federal health care programs") for $22.5 million. (!) The last I read about this, in the LA Times, the whistleblower, from the University of California, Irvine billing department, was still wading through lawsuits and trying to get her life back on track.
The largest case of which I am aware involved large scale ... umm ... mistaken billing for intern and resident services. I did my medical internship through the University of California, Irvine. I made $29,000 for one year of work, for which I worked approximately 80 to 100 hours / week. The University, however, apparently didn’t bill for my services as if I was making $29,000 / year. Instead, they allegedly billed for the services provided by the interns and residents, as if the services had been provided by attending physicians. (note: I don't know if services I personally performed were billed "incorrectly," just that large numbers of services around the time I was working for UC Irvine were "incorrectly" billed. I assume that some of what I did was billed "in error.") They even billed for attending physicians doing procedures at times when those attendings were documented to have not been in the hospital at all.
In February 2001, after years of appeals, but with new federal DA's on the way after the 2000 federal elections were eventually finalized, the University of California settled those
"erroneous" billing claims (referred to as "routine misbilling of medicare, medicaid, and other federal health care programs") for $22.5 million. (!) The last I read about this, in the LA Times, the whistleblower, from the University of California, Irvine billing department, was still wading through lawsuits and trying to get her life back on track.
So, since I’m blogging today, I thought I’d describe one more apparent impropriety at the University of California. This one doesn’t involve the University of California directly, but is about the Long Beach VA Medical Center, which is partly staffed by UC Irvine. The content of this post comes in 2 parts:
PART 1:
As an intern, I rotated through the Long Beach VA Medical Center Emergency Room. After a while, it became obvious that the VAMC ER was admitting a lot of people who didn’t need to be admitted; people who weren’t really sick. I asked about that (made a stink is more like it), and eventually was summoned to the office of the director of Emergency Medicine at the Long Beach VA. She basically told me to shut up and do my job, but she also told me that the department of emergency medicine there was contracted (apparently in an unwritten contract) to admit at least 30% of their patients to inpatient units. It was implied that this was whether 30% of the ER patients were really all that sick or not.
OK, that’s possible fraud right there. But still, it was possible that 30% of the ER visits were legitimate admits. However, while working in the ER, and later while working in inpatient VA units, I noticed that some of the admits were not even close to being legitimate. I am not referring to old men with bronchitis who could have been treated as outpatients, but who were admitted for observation, or similar judgment calls. I am, instead, referring to the practice I observed of simply making up a serious diagnosis for ER patients, then using that diagnosis as an admitting diagnosis for inpatient admission.
PART 2:
For example, I had a patient, admitted by Dr. Queeda Draine of the VA, who was admitted for digoxin overdose. Digoxin is a medicine given to people for certain heart diseases; in overdose, it can cause arrhythmias and death. Admitting someone to the inpatient units for dig overdose is perfectly reasonable. However, this patient had no signs of digoxin overdose. His EKG was normal. He had no cardiac history which would have required digoxin therapy. He was not on digoxin. He claimed that he had never taken digoxin in his life. His serum dig level, which was available to me as the patient was being wheeled out of the ER to the ward, and which therefore should have been available to the ER attending Dr. Draine, was zero. To me the conclusion was inescapable: the admitting diagnosis of digoxin toxicity had been simply made up. Before admitting this patient, I called Dr. Draine to ask how the patient could have digoxin toxicity with a dig level of zero; Dr. Draine hung up on me.
Under orders from my attending, I admitted this patient for observation. The patient, as healthy in the morning as he had been on admission, was discharged at morning rounds, after I opined in morning report that this admission constituted pretty obvious fraud. I don't think it was the "fraud" part that caused the patient to be discharged; I think it was the "pretty obvious" part.
The patient never really knew why he'd been admitted; according to him, he spent the night in the hospital because 'that doctor in the ER thought I should.' As for why he had come to the ER in the first place, it is my recollection that he had come with complaints of "being tired." Being tired is a problem, but is generally not justification for an emergency admission.
Nevertheless, I have no doubt that the hospital billed for my services in admitting this patient for an apparently made-up diagnosis, and for observing him overnight for a disease which he did not have. In fact, based on the events referenced in the post immediately above this one, I have no doubt that the hospital overbilled for that work.
I observed a lot more examples like part 2, and was left with my own conclusions about inpatient admissions at that facility. I invite you to draw your own conclusions.
PART 1:
As an intern, I rotated through the Long Beach VA Medical Center Emergency Room. After a while, it became obvious that the VAMC ER was admitting a lot of people who didn’t need to be admitted; people who weren’t really sick. I asked about that (made a stink is more like it), and eventually was summoned to the office of the director of Emergency Medicine at the Long Beach VA. She basically told me to shut up and do my job, but she also told me that the department of emergency medicine there was contracted (apparently in an unwritten contract) to admit at least 30% of their patients to inpatient units. It was implied that this was whether 30% of the ER patients were really all that sick or not.
OK, that’s possible fraud right there. But still, it was possible that 30% of the ER visits were legitimate admits. However, while working in the ER, and later while working in inpatient VA units, I noticed that some of the admits were not even close to being legitimate. I am not referring to old men with bronchitis who could have been treated as outpatients, but who were admitted for observation, or similar judgment calls. I am, instead, referring to the practice I observed of simply making up a serious diagnosis for ER patients, then using that diagnosis as an admitting diagnosis for inpatient admission.
PART 2:
For example, I had a patient, admitted by Dr. Queeda Draine of the VA, who was admitted for digoxin overdose. Digoxin is a medicine given to people for certain heart diseases; in overdose, it can cause arrhythmias and death. Admitting someone to the inpatient units for dig overdose is perfectly reasonable. However, this patient had no signs of digoxin overdose. His EKG was normal. He had no cardiac history which would have required digoxin therapy. He was not on digoxin. He claimed that he had never taken digoxin in his life. His serum dig level, which was available to me as the patient was being wheeled out of the ER to the ward, and which therefore should have been available to the ER attending Dr. Draine, was zero. To me the conclusion was inescapable: the admitting diagnosis of digoxin toxicity had been simply made up. Before admitting this patient, I called Dr. Draine to ask how the patient could have digoxin toxicity with a dig level of zero; Dr. Draine hung up on me.
Under orders from my attending, I admitted this patient for observation. The patient, as healthy in the morning as he had been on admission, was discharged at morning rounds, after I opined in morning report that this admission constituted pretty obvious fraud. I don't think it was the "fraud" part that caused the patient to be discharged; I think it was the "pretty obvious" part.
The patient never really knew why he'd been admitted; according to him, he spent the night in the hospital because 'that doctor in the ER thought I should.' As for why he had come to the ER in the first place, it is my recollection that he had come with complaints of "being tired." Being tired is a problem, but is generally not justification for an emergency admission.
Nevertheless, I have no doubt that the hospital billed for my services in admitting this patient for an apparently made-up diagnosis, and for observing him overnight for a disease which he did not have. In fact, based on the events referenced in the post immediately above this one, I have no doubt that the hospital overbilled for that work.
I observed a lot more examples like part 2, and was left with my own conclusions about inpatient admissions at that facility. I invite you to draw your own conclusions.
Sunday, June 16, 2002
Bill Quick and Megan McArdle seem to have an interesting debate about resident work hours going on on their blogs. I personally believe that resident work hours are often onerous beyond any need for patient care, but I don’t think that’s necessarily a disaster in and of itself. I believe that the long work hours are, in fact, not a problem, but a symptom of the real problem, which is the total control residency programs have over medical licensure and board certification. This control can be misused in many ways, like making residents work long hours for cheap; to me, however, the greater misuse of that control is the ability of residency program directors to demand unethical and arguably criminal behavior from their residents.
Yeah, I bet that got your attention. What am I talking about? Well, here’s my story.
While in medical school, I was the second author of a national presentation on the law and ethics of informed consent in emergency situations (Prehospital use of Tissue Plasminogen Activator, Pamela Grim et al, presented at the 1988 meeting of the University Association for Emergency Medicine). In order to help create that presentation, I studied the law of informed consent from many perspectives. As such, I feel that I was, and to a lesser extent still am, well versed in the legal and ethical requirements of obtaining informed consent for medical procedures.
One of the main tenets of obtaining informed consent is the requirement that the patient, or the patient’s guardian be informed about all significant risks to a procedure. There are some exceptions for emergencies, and a few other situations, under the “doctrine of implied consent,” but, in general, patients rely on their doctors to inform them, and doctors have an obligation to do so. Contrary to some opinions, it is not the job of a physician to talk the patients into whatever cockamamie procedure happens to generate the highest reimbursements.
For anesthesiologists, for example, what constitutes a “significant risk” is often a matter of disagreement but it’s very hard to make the argument that THE most common cause of lawsuits against anesthesiologists should not be considered a “significant risk.” On the other end of the spectrum, it’s very hard to argue that death, which, though rare, is a particularly horrible consequence of general and spinal anesthesia, is not a significant risk.
After graduating from medical school, I took a residency spot at the UCLA department of Anesthesia. I made an effort to meet my responsibilities regarding informed consent, and it was there that I eventually realized that there was a problem. After obtaining consent for various procedures, I was often told that I could not tell patients the risks I had just told them. There seemed to be no set of risks that I was allowed to tell patients. In particular, Dr. Michael Sopher, the residency program head, specifically told me that I could not tell patients about the risks of dental damage (the number one source of lawsuits against anesthesiologists) because dental damage “wasn’t a significant risk.” He told me that I could not inform patients about the risk of death because “it was too rare.”
A quick aside: although I believe that death is a significant risk even if the chance of death is rare, the sad fact is that death from anesthetic misadventure was all too common at UCLA. I am aware of two children who died prematurely while under anesthesia at UCLA during the less-than-a-year that I was there. One child was not my patient, but I understand it was a healthy child who suffered an arrest while under, and simply died for “no reason.”
The other child was one of my patients, assigned to me when I had been a resident for about two months. This two year old child had a congenital heart defect, and essential tachycardia, with baseline hypoxia. Because of that tachycardia, my attending elected not to give the child pre-induction atropine. When the child was induced, he had an apparently vagal response to intubation, had a short period of bradycardia, and got even more hypoxic. This was followed by asystole. He was coded, and his heart came back, but the child never woke up. An EEG two days later was flat. If the child had been atropinized, I believe he might have survived the procedure (a hernia repair, for anyone who is interested).
It was bad enough that these children died. What was completely mind-boggling was that there was no M&M (morbidity and mortality conference) related to those deaths. In the case of "my" patient who died: once it became obvious that the resident (me) could not be blamed for the death, it was as if the death never happened. (It was the attending's plan that had gone wrong, and the attending never had a chance to leave the OR after induction since the plan went wrong so quickly.) In neither case was there a serious investigation into the cause of death, nor any attempt to generate lessons learned. Yes, I learned something – always atropinize children before induction of general anesthesia – but my attending and I should have presented that mismanaged case to the rest of the department, in an effort to prevent future mishaps. I probably should have learned something from the death of the healthy child who died for "no reason," but that death was also never presented at M&M. Draw your own conclusions. That sort of pretending that bad things didn't really happen had echoes in other cases, such as the "intentional, despicable and unprofessional" actions surrounding damage to Ms. Denise DeSoto. (last link added 03/26/2011)
Back to the main story. Dr. Sopher told me that I would bear no legal responsibility for failure to inform of the risks of anesthesia because “I guarantee you, no one has ever been sued for that.” Another attending, Dr. Blockmaans, told me “you can’t tell old people the risks of anesthesia …. old people just can’t handle it.” Finally, I was asked by the residency program director that if a patient refused a surgery based on what I had told him, “don’t you realize that you would be responsible?” The implication was clear to me then, and I trust it is clear to you now.
Of course, every one of the quoted statements above is mistaken, and was mistaken at the time. It is relevant to note that, since I left UCLA, UCLA, UCI, UCSD, and UCSF have all had suspension or cancellation of programs after medical research or practice was done without proper informed consent. In UCLA’s case, the Westwood VA (partially administered by UCLA, with physicians who work at both UCLA and at the Westwood VA) had it’s human research approval suspended because they had conducted research on people not only without their consent, but allegedly over the express refusal of at least one patient (I can't find a reference for that last part, but I believe that's what led the VA to suspend human research).
Due to my expressed difference of opinion about what constituted proper informed consent, I made multiple appointments with my residency program director to watch him obtain informed consent. He missed every appointment, and I never saw him obtain any consents.
It is also relevant to note, that, before I left UCLA, I encountered a patient who had apparently been advised by her surgeon, Dr. Susan Love, to bring a tape recorder with her to her preoperative meeting with the anesthesia department. I never spoke to Dr. Love about this, so I don’t know her motivation behind that recommendation, but it is my guess that Dr. Love also understood that the consent obtained by the department of anesthesia was not truly informed.
I also encountered what I eventually realized was “Hollywood-style” medicine. In one case, I personally witnessed the director of the pain management program, Dr. Anthony Nyurges, berate one of my postoperative patients to the point of tears when she requested Demerol (as opposed to other narcotics) for her pain (this patient was a former drug abuser, and knew her narcotics). I don’t believe in Demerol, but this same physician, on the same service, in the same hospital, in the same month, authorized very large doses of Demerol, on an ongoing basis (i.e. not immediately post-op) for a “powerful” Los Angeles figure when that patient had no objective signs of pain. Demerol is generally considered to have one of the greatest euphorogenic to analgesic ratio of any common narcotic (i.e. it makes people feel “happy” out of proportion to it’s pain-killing properties), and is therefore a drug generally favored by people who want to get high, and disfavored by people who are in actual pain.
I admit, and am glad, that I did not fit into the UCLA anesthesia residency program. I resigned from that program.
Unbeknownst to me at the time, federal agencies were also finding fault with University of California informed consent procedures while I was struggling to convince my superiors at UCLA of the importance of informed consent. Here is a list of publicized scandals revolving around informed consent in the University of California System:
UCLA: From the LA times:
• 1993: UCLA informed consent procedures had already been criticized by federal regulators, and had been changed in response to federal requirements. Even so, a 1993 law review article by Dr. Jay Katz of Yale, “tore into the new [informed consent] form that UCLA created in response to the government's [earlier] requirements, still finding it misleading, vague and inadequate.”
• March 1994: Dr. Michael Gitlin and Dr. Keith Nuechterlein of UCLA were officially reprimanded by the NIH in March of 1994 for issues with the procedure used to obtain informed consent. Procedures used to obtain informed consent, presumably approved by the UCLA IRB, were described as “immoral from the perspective of informed consent, because (they) were deceiving subjects” in an article about this in the LA times. The research for which Drs Gitlin and Neuchterlien apparently did not obtain informed consent may have been responsible for the suicide of Tony Lamadrid, one of the research subjects.
(addendum: Mr. LaMadrid, apparently unknown to him, was a research subject in an experimental protocol designed to assay the pharmacokinetics of drugs for schitzophrenia. According to the father of one of the surviving members of the Nuechterliein-Gitlin study, Mr. Lamadrid, a previously well-compensated adult, and apparently unaware that he was in the study, drifted into decompensated schitzophrenia as his meds were replaced with placebos. Mr. Lamadrid then told his "counsellor," who apparently was, in reality, a research monitor, that he was planning to kill himself. Nothing was done, Mr. Lamadrid's meds were not restarted, and Mr. Lamadrid went home and killed himself.
Further, according to this same source, the existence of a federally-required advocate whose presence might have prevented such an outcome had been fraudulently certified by someone in the office of the Chancellor of UCLA. In other words, a ghost UCLA employee had been created and certified to exist, but was later found out never to have been real.
You may wish to keep those items in mind as you read the next sentence)
• September 1994: According to the LA times, “from all appearances, the controversy over the Nuechterlein-Gitlin study hasn't caused any deep soul-searching at UCLA.”
• March 1999: The West Los Angeles Veterans Affairs Medical Center (which shares physicians, staff, research, etc with UCLA) had it’s authorization to conduct human research suspended after continuing allegations of failure to obtain informed consent for studies. I can’t find documentation for the following assertion, but I believe that, in this case, at least one person was alleged to have been the subject of medical experimentation even after expressly refusing to be part of a research protocol.
UCI (From the Orange County Register):
• May 1995: Three doctors at UCI Center for Reproductive Health accused of stealing eggs from an Orange County patient without her consent and transferring them to another woman, who delivered a baby boy. Eventually, doctors resign from university, two flee country and clinic closes. More than 100 women are victims.
Years later, (the rest of this paragraph is not from the OC register) I worked with a former trustee of the University of California who told me why he had resigned his trusteeship. According to him, up until the time the reproductive endocrinology staff fled the country, the trustees had been planning to back them to the hilt, not because of contractual obligations, a sense that they had been unfairly accused, or a commitment to their employees, but because of the money brought in by the reproductive endocrinology clinic. When the department fled the country to avoid federal prosecution, the point was moot, but this trustee resigned anyway.
• 1996: Researcher Dr. John Hiserodt treated cancer patients with unapproved doses of experimental vaccine, grew human tissues without required federal and university approval, and injected experimental compound not approved for human use into brain of Miami girl dying from cancer.
• June 1997: UCI Medical Center tissue and organ bank closed after finding employee has personal relationship with president of company that does business with the bank. Hundreds of human-tissue specimens had to be destroyed because of poor record-keeping and storage.
• December 1998: UCI officials say 27 dying cancer patients in clinical trials may have been improperly charged thousands of dollars. At least nine others were encouraged to make donations to get loved ones into trials. UCI offers refunds of $1,450 to $4,000.
• September 1998: Associate clinical professor Dr. Darryl See resigns after university inquiry concludes he used patients' blood samples in two unapproved research projects on AIDS and chronic fatigue syndrome. He later publishes a study, purportedly based on his UCI research, that is used to sell nutritional supplements.
• August 1999: UCI suspends the director of the medical school's Willed Body Program, Christopher S. Brown, after finding evidence that he sold donated bodies. UCI fires him in September.
UC San Diego:
• 1995: Dr. Ricardo Asch, as well as Drs. Jose Balmaceda and Sergio Stone, and their employee, Dr. Jane Frederick, of UCSD, are sued by three different parties alleging unapproved use of human eggs for zoology research, and transfer to other childless couples without the consent or knowledge of the egg “donor.” I don’t have the results of those lawsuits.
Again, the above cases are simply the ones that made the papers. I know of more.
My point? Residency programs have far too much power over their residents, and can generally act with impunity towards them. This causes problems. Just this month, I became aware of a woman who came to UCLA with chest pain in late May 2002, was sedated for the pain, and WHILE SEDATED AND ALONE was then induced to give consent for entry into a cardiology research protocol.
This wasn't a resuscitation situation, or apparently even much of an urgent situation. This woman's caretaker had simply gone out to the car to get a few things, and, in the interim, the sedated woman "gave consent" to be entered into a research protocol. This same woman eventually sustained so much heart damage that she wound up getting a heart transplant. It’s my bet that the resident or fellow who got the "consent" for research felt that he was under pressure to enroll people in the study, and that it wasn’t such a great idea to wait for family members or for the patient to no longer be sedated. Long work hours aren’t the worst effect of the control training programs have over their trainees. Not by a long shot.
Oh yeah ... since I'm naming names, I might as well put up my own name. For those who don't want to deal with the challenge of figuring out who I am ... my name is Peter T. Banos, MD, MBA. I got the MBA a few years after leaving UCLA; graduated from the University of Chicago in 1999, with concentrations in entrepreneurship and finance. And yes, I have met Megan McArdle.
Yeah, I bet that got your attention. What am I talking about? Well, here’s my story.
While in medical school, I was the second author of a national presentation on the law and ethics of informed consent in emergency situations (Prehospital use of Tissue Plasminogen Activator, Pamela Grim et al, presented at the 1988 meeting of the University Association for Emergency Medicine). In order to help create that presentation, I studied the law of informed consent from many perspectives. As such, I feel that I was, and to a lesser extent still am, well versed in the legal and ethical requirements of obtaining informed consent for medical procedures.
One of the main tenets of obtaining informed consent is the requirement that the patient, or the patient’s guardian be informed about all significant risks to a procedure. There are some exceptions for emergencies, and a few other situations, under the “doctrine of implied consent,” but, in general, patients rely on their doctors to inform them, and doctors have an obligation to do so. Contrary to some opinions, it is not the job of a physician to talk the patients into whatever cockamamie procedure happens to generate the highest reimbursements.
For anesthesiologists, for example, what constitutes a “significant risk” is often a matter of disagreement but it’s very hard to make the argument that THE most common cause of lawsuits against anesthesiologists should not be considered a “significant risk.” On the other end of the spectrum, it’s very hard to argue that death, which, though rare, is a particularly horrible consequence of general and spinal anesthesia, is not a significant risk.
After graduating from medical school, I took a residency spot at the UCLA department of Anesthesia. I made an effort to meet my responsibilities regarding informed consent, and it was there that I eventually realized that there was a problem. After obtaining consent for various procedures, I was often told that I could not tell patients the risks I had just told them. There seemed to be no set of risks that I was allowed to tell patients. In particular, Dr. Michael Sopher, the residency program head, specifically told me that I could not tell patients about the risks of dental damage (the number one source of lawsuits against anesthesiologists) because dental damage “wasn’t a significant risk.” He told me that I could not inform patients about the risk of death because “it was too rare.”
A quick aside: although I believe that death is a significant risk even if the chance of death is rare, the sad fact is that death from anesthetic misadventure was all too common at UCLA. I am aware of two children who died prematurely while under anesthesia at UCLA during the less-than-a-year that I was there. One child was not my patient, but I understand it was a healthy child who suffered an arrest while under, and simply died for “no reason.”
The other child was one of my patients, assigned to me when I had been a resident for about two months. This two year old child had a congenital heart defect, and essential tachycardia, with baseline hypoxia. Because of that tachycardia, my attending elected not to give the child pre-induction atropine. When the child was induced, he had an apparently vagal response to intubation, had a short period of bradycardia, and got even more hypoxic. This was followed by asystole. He was coded, and his heart came back, but the child never woke up. An EEG two days later was flat. If the child had been atropinized, I believe he might have survived the procedure (a hernia repair, for anyone who is interested).
It was bad enough that these children died. What was completely mind-boggling was that there was no M&M (morbidity and mortality conference) related to those deaths. In the case of "my" patient who died: once it became obvious that the resident (me) could not be blamed for the death, it was as if the death never happened. (It was the attending's plan that had gone wrong, and the attending never had a chance to leave the OR after induction since the plan went wrong so quickly.) In neither case was there a serious investigation into the cause of death, nor any attempt to generate lessons learned. Yes, I learned something – always atropinize children before induction of general anesthesia – but my attending and I should have presented that mismanaged case to the rest of the department, in an effort to prevent future mishaps. I probably should have learned something from the death of the healthy child who died for "no reason," but that death was also never presented at M&M. Draw your own conclusions. That sort of pretending that bad things didn't really happen had echoes in other cases, such as the "intentional, despicable and unprofessional" actions surrounding damage to Ms. Denise DeSoto. (last link added 03/26/2011)
Back to the main story. Dr. Sopher told me that I would bear no legal responsibility for failure to inform of the risks of anesthesia because “I guarantee you, no one has ever been sued for that.” Another attending, Dr. Blockmaans, told me “you can’t tell old people the risks of anesthesia …. old people just can’t handle it.” Finally, I was asked by the residency program director that if a patient refused a surgery based on what I had told him, “don’t you realize that you would be responsible?” The implication was clear to me then, and I trust it is clear to you now.
Of course, every one of the quoted statements above is mistaken, and was mistaken at the time. It is relevant to note that, since I left UCLA, UCLA, UCI, UCSD, and UCSF have all had suspension or cancellation of programs after medical research or practice was done without proper informed consent. In UCLA’s case, the Westwood VA (partially administered by UCLA, with physicians who work at both UCLA and at the Westwood VA) had it’s human research approval suspended because they had conducted research on people not only without their consent, but allegedly over the express refusal of at least one patient (I can't find a reference for that last part, but I believe that's what led the VA to suspend human research).
Due to my expressed difference of opinion about what constituted proper informed consent, I made multiple appointments with my residency program director to watch him obtain informed consent. He missed every appointment, and I never saw him obtain any consents.
It is also relevant to note, that, before I left UCLA, I encountered a patient who had apparently been advised by her surgeon, Dr. Susan Love, to bring a tape recorder with her to her preoperative meeting with the anesthesia department. I never spoke to Dr. Love about this, so I don’t know her motivation behind that recommendation, but it is my guess that Dr. Love also understood that the consent obtained by the department of anesthesia was not truly informed.
I also encountered what I eventually realized was “Hollywood-style” medicine. In one case, I personally witnessed the director of the pain management program, Dr. Anthony Nyurges, berate one of my postoperative patients to the point of tears when she requested Demerol (as opposed to other narcotics) for her pain (this patient was a former drug abuser, and knew her narcotics). I don’t believe in Demerol, but this same physician, on the same service, in the same hospital, in the same month, authorized very large doses of Demerol, on an ongoing basis (i.e. not immediately post-op) for a “powerful” Los Angeles figure when that patient had no objective signs of pain. Demerol is generally considered to have one of the greatest euphorogenic to analgesic ratio of any common narcotic (i.e. it makes people feel “happy” out of proportion to it’s pain-killing properties), and is therefore a drug generally favored by people who want to get high, and disfavored by people who are in actual pain.
I admit, and am glad, that I did not fit into the UCLA anesthesia residency program. I resigned from that program.
Unbeknownst to me at the time, federal agencies were also finding fault with University of California informed consent procedures while I was struggling to convince my superiors at UCLA of the importance of informed consent. Here is a list of publicized scandals revolving around informed consent in the University of California System:
UCLA: From the LA times:
• 1993: UCLA informed consent procedures had already been criticized by federal regulators, and had been changed in response to federal requirements. Even so, a 1993 law review article by Dr. Jay Katz of Yale, “tore into the new [informed consent] form that UCLA created in response to the government's [earlier] requirements, still finding it misleading, vague and inadequate.”
• March 1994: Dr. Michael Gitlin and Dr. Keith Nuechterlein of UCLA were officially reprimanded by the NIH in March of 1994 for issues with the procedure used to obtain informed consent. Procedures used to obtain informed consent, presumably approved by the UCLA IRB, were described as “immoral from the perspective of informed consent, because (they) were deceiving subjects” in an article about this in the LA times. The research for which Drs Gitlin and Neuchterlien apparently did not obtain informed consent may have been responsible for the suicide of Tony Lamadrid, one of the research subjects.
(addendum: Mr. LaMadrid, apparently unknown to him, was a research subject in an experimental protocol designed to assay the pharmacokinetics of drugs for schitzophrenia. According to the father of one of the surviving members of the Nuechterliein-Gitlin study, Mr. Lamadrid, a previously well-compensated adult, and apparently unaware that he was in the study, drifted into decompensated schitzophrenia as his meds were replaced with placebos. Mr. Lamadrid then told his "counsellor," who apparently was, in reality, a research monitor, that he was planning to kill himself. Nothing was done, Mr. Lamadrid's meds were not restarted, and Mr. Lamadrid went home and killed himself.
Further, according to this same source, the existence of a federally-required advocate whose presence might have prevented such an outcome had been fraudulently certified by someone in the office of the Chancellor of UCLA. In other words, a ghost UCLA employee had been created and certified to exist, but was later found out never to have been real.
You may wish to keep those items in mind as you read the next sentence)
• September 1994: According to the LA times, “from all appearances, the controversy over the Nuechterlein-Gitlin study hasn't caused any deep soul-searching at UCLA.”
• March 1999: The West Los Angeles Veterans Affairs Medical Center (which shares physicians, staff, research, etc with UCLA) had it’s authorization to conduct human research suspended after continuing allegations of failure to obtain informed consent for studies. I can’t find documentation for the following assertion, but I believe that, in this case, at least one person was alleged to have been the subject of medical experimentation even after expressly refusing to be part of a research protocol.
UCI (From the Orange County Register):
• May 1995: Three doctors at UCI Center for Reproductive Health accused of stealing eggs from an Orange County patient without her consent and transferring them to another woman, who delivered a baby boy. Eventually, doctors resign from university, two flee country and clinic closes. More than 100 women are victims.
Years later, (the rest of this paragraph is not from the OC register) I worked with a former trustee of the University of California who told me why he had resigned his trusteeship. According to him, up until the time the reproductive endocrinology staff fled the country, the trustees had been planning to back them to the hilt, not because of contractual obligations, a sense that they had been unfairly accused, or a commitment to their employees, but because of the money brought in by the reproductive endocrinology clinic. When the department fled the country to avoid federal prosecution, the point was moot, but this trustee resigned anyway.
• 1996: Researcher Dr. John Hiserodt treated cancer patients with unapproved doses of experimental vaccine, grew human tissues without required federal and university approval, and injected experimental compound not approved for human use into brain of Miami girl dying from cancer.
• June 1997: UCI Medical Center tissue and organ bank closed after finding employee has personal relationship with president of company that does business with the bank. Hundreds of human-tissue specimens had to be destroyed because of poor record-keeping and storage.
• December 1998: UCI officials say 27 dying cancer patients in clinical trials may have been improperly charged thousands of dollars. At least nine others were encouraged to make donations to get loved ones into trials. UCI offers refunds of $1,450 to $4,000.
• September 1998: Associate clinical professor Dr. Darryl See resigns after university inquiry concludes he used patients' blood samples in two unapproved research projects on AIDS and chronic fatigue syndrome. He later publishes a study, purportedly based on his UCI research, that is used to sell nutritional supplements.
• August 1999: UCI suspends the director of the medical school's Willed Body Program, Christopher S. Brown, after finding evidence that he sold donated bodies. UCI fires him in September.
UC San Diego:
• 1995: Dr. Ricardo Asch, as well as Drs. Jose Balmaceda and Sergio Stone, and their employee, Dr. Jane Frederick, of UCSD, are sued by three different parties alleging unapproved use of human eggs for zoology research, and transfer to other childless couples without the consent or knowledge of the egg “donor.” I don’t have the results of those lawsuits.
Again, the above cases are simply the ones that made the papers. I know of more.
My point? Residency programs have far too much power over their residents, and can generally act with impunity towards them. This causes problems. Just this month, I became aware of a woman who came to UCLA with chest pain in late May 2002, was sedated for the pain, and WHILE SEDATED AND ALONE was then induced to give consent for entry into a cardiology research protocol.
This wasn't a resuscitation situation, or apparently even much of an urgent situation. This woman's caretaker had simply gone out to the car to get a few things, and, in the interim, the sedated woman "gave consent" to be entered into a research protocol. This same woman eventually sustained so much heart damage that she wound up getting a heart transplant. It’s my bet that the resident or fellow who got the "consent" for research felt that he was under pressure to enroll people in the study, and that it wasn’t such a great idea to wait for family members or for the patient to no longer be sedated. Long work hours aren’t the worst effect of the control training programs have over their trainees. Not by a long shot.
Oh yeah ... since I'm naming names, I might as well put up my own name. For those who don't want to deal with the challenge of figuring out who I am ... my name is Peter T. Banos, MD, MBA. I got the MBA a few years after leaving UCLA; graduated from the University of Chicago in 1999, with concentrations in entrepreneurship and finance. And yes, I have met Megan McArdle.
Saturday, May 04, 2002
Via email, I just got a request to sign this petition opposing a new INS rule allowing the INS to issue 30-day tourist visas (instead of the usual 6-month tourist visas).
Personally, I think that restricting tourist visas from foreign countries is completely reasonable during this time of crisis. Yes, I know that many people find it convenient to come to the US for six months, and, ordinarily, I think that’s great. In general, I am all for unrestricted tourism; there’s plenty of room, and, as long as visitors don’t become a public charge, I think it’s great that they come and spend money.
This isn’t, however, a time for “in general.” In February 1993, and again on September 11, 2001, it became blindingly obvious that there is a well-organized, dangerous group of people out there who are TRYING TO KILL US. All of us. Any of us. Whichever of us they can get. Letting almost everyone in on a six-month visa makes it easier for terrorists to come here, plan an attack, and carry it out.
Some would say that there is a case to be made for the complete elimination of tourist visas until the threat from foreign terrorists continues. Limiting tourist visa durations to one month is a compromise. If tourist visa durations are shortened, and enforcement procedures are improved to make visitors check in every month, then perhaps it will be harder for the next batch of terrorists to successfully organize the next terrorist attack. People who want to stay longer will probably have to check in with the INS every month. In a worst-likely-case-scenario, potential tourists will have to visit Canada or Mexico once a month. The INS will still be able to grant 6-month or longer tourist visas, if necessary. And, of course, this new 30-day rule will have no effect on student, work or business visas, or on legal immigration.
The petition organizers point out that the 30-day rule may invite retaliation from other governments. To me, that putative willingness of other governments to restrict US citizens is a feedback mechanism that will reduce the chance that the INS will apply the 30-day rule to everyone or in an unreasonable manner. The existence of such a feedback mechanism is another argument to adopt the 30-day rule.
Maybe it’ll work. Maybe it won’t. If it has a reasonable chance of preventing another terrorist attack, then it’s worth a try.
Should INS officials have the discretion to decide who gets a 1-month visa and who gets a 6-month visa? Given the abysmal record of the INS in keeping terrorists out, the answer seems to be a clear “no.” There’s just one problem: there’s nobody else to do it. So, by default, the INS gets the job.
The petition for the repeal of the 30-day rule points out that the new rule affects tourists from all over the world. The September 11 terrorists did not come to the US directly from Saudi Arabia, but from various countries in Europe. Lest someone think that there are no longer any potential terrorists in Europe, I present this picture FROM BERLIN:
Someone IN BERLIN dressed up the little girl as a weapon. Someone IN BERLIN thought it was a good idea to portray that child as nothing more than an expendable dynamite holder, destined to be reduced to little shreds of cooling meat after completing her terrorist mission. Allowing that person into the US for six full months is madness, even though that person is in Europe.
There are no rights, constitutional or otherwise, diminished by this new rule. Based on my review of the petition website, and a scan of some of the comments, the organizers and signatories make no argument that the 30-day rule would hinder or would not affect the war on terrorism. The tradeoff opposed by the petition organizers seems to be simply this: the US government is demanding that some non-citizens on pleasure trips get less bang for their travel buck, so that thousands of US citizens are less likely to be horribly slaughtered. I am shocked and saddened that so many people are unwilling to at least give that tradeoff a try.
UPDATE:
Holy smokes. According to this LA Times article, the INS has cited airlines 6,000 times for not ensuring that people who entered the US with NO visa actually left the country. Seems that the INS has a lot of fronts to cover.
Personally, I think that restricting tourist visas from foreign countries is completely reasonable during this time of crisis. Yes, I know that many people find it convenient to come to the US for six months, and, ordinarily, I think that’s great. In general, I am all for unrestricted tourism; there’s plenty of room, and, as long as visitors don’t become a public charge, I think it’s great that they come and spend money.
This isn’t, however, a time for “in general.” In February 1993, and again on September 11, 2001, it became blindingly obvious that there is a well-organized, dangerous group of people out there who are TRYING TO KILL US. All of us. Any of us. Whichever of us they can get. Letting almost everyone in on a six-month visa makes it easier for terrorists to come here, plan an attack, and carry it out.
Some would say that there is a case to be made for the complete elimination of tourist visas until the threat from foreign terrorists continues. Limiting tourist visa durations to one month is a compromise. If tourist visa durations are shortened, and enforcement procedures are improved to make visitors check in every month, then perhaps it will be harder for the next batch of terrorists to successfully organize the next terrorist attack. People who want to stay longer will probably have to check in with the INS every month. In a worst-likely-case-scenario, potential tourists will have to visit Canada or Mexico once a month. The INS will still be able to grant 6-month or longer tourist visas, if necessary. And, of course, this new 30-day rule will have no effect on student, work or business visas, or on legal immigration.
The petition organizers point out that the 30-day rule may invite retaliation from other governments. To me, that putative willingness of other governments to restrict US citizens is a feedback mechanism that will reduce the chance that the INS will apply the 30-day rule to everyone or in an unreasonable manner. The existence of such a feedback mechanism is another argument to adopt the 30-day rule.
Maybe it’ll work. Maybe it won’t. If it has a reasonable chance of preventing another terrorist attack, then it’s worth a try.
Should INS officials have the discretion to decide who gets a 1-month visa and who gets a 6-month visa? Given the abysmal record of the INS in keeping terrorists out, the answer seems to be a clear “no.” There’s just one problem: there’s nobody else to do it. So, by default, the INS gets the job.
The petition for the repeal of the 30-day rule points out that the new rule affects tourists from all over the world. The September 11 terrorists did not come to the US directly from Saudi Arabia, but from various countries in Europe. Lest someone think that there are no longer any potential terrorists in Europe, I present this picture FROM BERLIN:
Someone IN BERLIN dressed up the little girl as a weapon. Someone IN BERLIN thought it was a good idea to portray that child as nothing more than an expendable dynamite holder, destined to be reduced to little shreds of cooling meat after completing her terrorist mission. Allowing that person into the US for six full months is madness, even though that person is in Europe.
There are no rights, constitutional or otherwise, diminished by this new rule. Based on my review of the petition website, and a scan of some of the comments, the organizers and signatories make no argument that the 30-day rule would hinder or would not affect the war on terrorism. The tradeoff opposed by the petition organizers seems to be simply this: the US government is demanding that some non-citizens on pleasure trips get less bang for their travel buck, so that thousands of US citizens are less likely to be horribly slaughtered. I am shocked and saddened that so many people are unwilling to at least give that tradeoff a try.
UPDATE:
Holy smokes. According to this LA Times article, the INS has cited airlines 6,000 times for not ensuring that people who entered the US with NO visa actually left the country. Seems that the INS has a lot of fronts to cover.
Sunday, March 24, 2002
Via the perfesser, I just read something that upset me just a little bit here. In particular, I disagree with the combination of this line:
"I don't think the United States should allow dual-citizenship at all. Not ever. Not with Australia, not with Canada, not with Israel, not with Mexico. Not with anyone."
With the absence, even of acknowledgement, of this line:
"All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the state wherein they reside." (US constitution, Amendment XIV, 1868)
And this one:
"The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people." (Amendment X 1791)
Don’t get me wrong. I think it’s perfectly valid to think that the United States should not allow dual citizenship. It’s just that such a concept breaks into two parts: (1) not allowing native-born citizens, or those already citizens, to pick up another citizenship, and (2) requiring foreign-born persons who seek naturalization to give up their birth citizenship.
Any argument regarding not allowing native-born citizens, or those already citizens, to pick up another citizenship should, in my mind, address the right of the government to remove the citizenship of one who is already a citizen. The constitution does not authorize this; hence, the government cannot do this. The Supreme Court is on my side on this one; check out Afroyim v. Rusk, 387 U.S. 253 (1967). Another interesting, relevant case is Mandoli v. Acheson, 344 U.S. 133 (1952).
It is clear to me that the government does not have the right to remove a person’s citizenship, and certainly not for obtaining another citizenship. The US government is created by the people, aka "We the people of the United States ...." (preamble, US constitution). What the people choose to believe, and particularly to whom the people choose to bear allegiance, is not for the federal government to decide or punish. I was born with US citizenship, and that citizenship is mine to do with as I will. It wasn’t given to me by the government; it is part of who I am, simply because I was born in the United States and subject to the jurisdiction thereof. If I choose to obtain another citizenship, there is nothing the government can do about it; the power to remove my citizenship is not delegated to the United States by the Constitution. If the government could simply remove American citizenship, then it would be much easier to quash dissent or disagreement.
That said, I perceive that there may be a good argument to be made regarding requiring foreign-born persons who seek naturalization to give up their birth citizenship. It seems that some people , including myself, believe that there is a brewing problem with some people who have American citizenship, but who never really became “Americans.”
I believe that there is one attribute that differentiates Americans from the population of every other country on earth: the love of freedom over all else. Though many have colonized this continent, the norms of our nation were established by people who, in their own minds at least, were willing to risk their lives for the freedom to worship as they pleased. Our independence of Kings was established by a decade of slow, tortuous, uncertain battles, before the advent of antibiotics or nylon, by people who preferred to fight in freezing, wet, deadly conditions rather than consign their children to subjecthood. One of our great national quotes, aimed at the American population that didn’t wish to fight, and that would soon become Canadian or English, speaks to that very concept:
“If ye love wealth greater than liberty, the tranquillity of servitude greater than the animating contest for freedom, go home from us in peace. We seek not your counsel, nor your arms. Crouch down and lick the hand that feeds you; May your chains set lightly upon you, and may posterity forget that ye were our countrymen." (Samuel Adams, August 1, 1776)
If you don’t have that love of freedom, you are not what I would call an American. If you are willing to trade your freedom for money, or security, or anything else, you are not an American. If you already have American citizenship, there’s nothing to be done about that, but, like Sam Adams, I sincerely wish that you would go away.
Fortunately, however, at least a plurality who are raised here do believe in freedom. I think that there is a cultural meme here that is passed down from generation to generation, regardless of one's ancestry. It is likely that there are also genetic components to the desire for freedom, but the culture itself seems to be enough to ensure that there is a plurality of Americans who believe in freedom. I wish it were more, but, again, there’s nothing I, or anyone else, can do about it. And that’s as it should be.
It’s clear to me, however, that the people of other nations, raised in different cultures, don’t feel the same way as often as do native-born-and-raised Americans. Canadians, similar to Americans in so many other ways, have traditionally been much less likely to riot, protest, fight, or kill for their freedom. I think it’s because their country was descended from the forbears to whom Samuel Adams spoke. Throughout their history, Mexicans have tolerated repressive, thuggish governments that are exactly what Americans have not tolerated. Yes, I know that there’s an uprising in Chiapas, and I believe that the Zapatistas are trying, in their own way, to fight for freedom, but they get precious little support from the general population of Mexicans. I mention Canada and Mexico simply because they are so close to the US; to the best of my knowledge, there is not one other country on earth in which ordinary people have so often been willing to lay down their work, pick up weapons, and fight, kill, and risk death for what they (sometimes incorrectly) perceive as freedom. Rather than an appeal to king, country, rodina, or god, a (sometimes bogus) appeal to freedom is what motivates us to fight. From the American Revolution to both sides of the American Civil war, from the Lincoln Brigades to today’s militia movement, Americans fight for perceived freedom far more frequently than the people of any other land. Unfortunately, another way to say exactly the same thing is that the people of other countries are generally less interested in fighting for freedom than are Americans. And therein lies the reason to ask newly naturalized citizens to give up their citizenship to the mother country.
In a perfect world, I would like citizenship to be available only to those who believe in freedom. I think that’s the motivation underlying the offering of political asylum in the US; if you’ve fought for freedom hard enough to attract the unwelcome attention of the authorities, then you’re our kind of person. However, I think that asking people to give up their allegiance to their homeland in exchange for American citizenship is another reasonable sorting mechanism. If your home is less free than the US, and you are not willing to renounce that less-free country, then you really shouldn’t be a citizen here. You obviously value something more than freedom. If you come from a country that is more free than the United States (I don’t believe such a country exists; if I thought it did, I would go there tomorrow), then you clearly are willing to give up freedom to come here, and, again, you are the kind of person who really should not be a citizen here.
As opposed to the situation of taking away the citizenship of native-born Americans, putting conditions on naturalization is perfectly constitutional. The US Constitution, article 1, section 8, states that “The Congress shall have power to establish a uniform rule of naturalization,” and that pretty much gives Congress the right to do whatever it wants in this area.
Just a few other quick points: while I would like to see citizenship more tightly restricted than it is now, I also believe in open borders with no welfare. I believe anyone should be able to come here, participate in our economy, and succeed or fail based on their own efforts. They just shouldn’t be allowed to vote without evidence that they love liberty greater than wealth. And, for me, having open borders does not imply that we keep them open to everyone in times of conflict, i.e. I think it would be perfectly rational to evict all non-citizen male muslim arabs between the ages of 18 to 34, until the end of the current war on terror. But those are blogs for another day.
"I don't think the United States should allow dual-citizenship at all. Not ever. Not with Australia, not with Canada, not with Israel, not with Mexico. Not with anyone."
With the absence, even of acknowledgement, of this line:
"All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the state wherein they reside." (US constitution, Amendment XIV, 1868)
And this one:
"The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people." (Amendment X 1791)
Don’t get me wrong. I think it’s perfectly valid to think that the United States should not allow dual citizenship. It’s just that such a concept breaks into two parts: (1) not allowing native-born citizens, or those already citizens, to pick up another citizenship, and (2) requiring foreign-born persons who seek naturalization to give up their birth citizenship.
Any argument regarding not allowing native-born citizens, or those already citizens, to pick up another citizenship should, in my mind, address the right of the government to remove the citizenship of one who is already a citizen. The constitution does not authorize this; hence, the government cannot do this. The Supreme Court is on my side on this one; check out Afroyim v. Rusk, 387 U.S. 253 (1967). Another interesting, relevant case is Mandoli v. Acheson, 344 U.S. 133 (1952).
It is clear to me that the government does not have the right to remove a person’s citizenship, and certainly not for obtaining another citizenship. The US government is created by the people, aka "We the people of the United States ...." (preamble, US constitution). What the people choose to believe, and particularly to whom the people choose to bear allegiance, is not for the federal government to decide or punish. I was born with US citizenship, and that citizenship is mine to do with as I will. It wasn’t given to me by the government; it is part of who I am, simply because I was born in the United States and subject to the jurisdiction thereof. If I choose to obtain another citizenship, there is nothing the government can do about it; the power to remove my citizenship is not delegated to the United States by the Constitution. If the government could simply remove American citizenship, then it would be much easier to quash dissent or disagreement.
That said, I perceive that there may be a good argument to be made regarding requiring foreign-born persons who seek naturalization to give up their birth citizenship. It seems that some people , including myself, believe that there is a brewing problem with some people who have American citizenship, but who never really became “Americans.”
I believe that there is one attribute that differentiates Americans from the population of every other country on earth: the love of freedom over all else. Though many have colonized this continent, the norms of our nation were established by people who, in their own minds at least, were willing to risk their lives for the freedom to worship as they pleased. Our independence of Kings was established by a decade of slow, tortuous, uncertain battles, before the advent of antibiotics or nylon, by people who preferred to fight in freezing, wet, deadly conditions rather than consign their children to subjecthood. One of our great national quotes, aimed at the American population that didn’t wish to fight, and that would soon become Canadian or English, speaks to that very concept:
“If ye love wealth greater than liberty, the tranquillity of servitude greater than the animating contest for freedom, go home from us in peace. We seek not your counsel, nor your arms. Crouch down and lick the hand that feeds you; May your chains set lightly upon you, and may posterity forget that ye were our countrymen." (Samuel Adams, August 1, 1776)
If you don’t have that love of freedom, you are not what I would call an American. If you are willing to trade your freedom for money, or security, or anything else, you are not an American. If you already have American citizenship, there’s nothing to be done about that, but, like Sam Adams, I sincerely wish that you would go away.
Fortunately, however, at least a plurality who are raised here do believe in freedom. I think that there is a cultural meme here that is passed down from generation to generation, regardless of one's ancestry. It is likely that there are also genetic components to the desire for freedom, but the culture itself seems to be enough to ensure that there is a plurality of Americans who believe in freedom. I wish it were more, but, again, there’s nothing I, or anyone else, can do about it. And that’s as it should be.
It’s clear to me, however, that the people of other nations, raised in different cultures, don’t feel the same way as often as do native-born-and-raised Americans. Canadians, similar to Americans in so many other ways, have traditionally been much less likely to riot, protest, fight, or kill for their freedom. I think it’s because their country was descended from the forbears to whom Samuel Adams spoke. Throughout their history, Mexicans have tolerated repressive, thuggish governments that are exactly what Americans have not tolerated. Yes, I know that there’s an uprising in Chiapas, and I believe that the Zapatistas are trying, in their own way, to fight for freedom, but they get precious little support from the general population of Mexicans. I mention Canada and Mexico simply because they are so close to the US; to the best of my knowledge, there is not one other country on earth in which ordinary people have so often been willing to lay down their work, pick up weapons, and fight, kill, and risk death for what they (sometimes incorrectly) perceive as freedom. Rather than an appeal to king, country, rodina, or god, a (sometimes bogus) appeal to freedom is what motivates us to fight. From the American Revolution to both sides of the American Civil war, from the Lincoln Brigades to today’s militia movement, Americans fight for perceived freedom far more frequently than the people of any other land. Unfortunately, another way to say exactly the same thing is that the people of other countries are generally less interested in fighting for freedom than are Americans. And therein lies the reason to ask newly naturalized citizens to give up their citizenship to the mother country.
In a perfect world, I would like citizenship to be available only to those who believe in freedom. I think that’s the motivation underlying the offering of political asylum in the US; if you’ve fought for freedom hard enough to attract the unwelcome attention of the authorities, then you’re our kind of person. However, I think that asking people to give up their allegiance to their homeland in exchange for American citizenship is another reasonable sorting mechanism. If your home is less free than the US, and you are not willing to renounce that less-free country, then you really shouldn’t be a citizen here. You obviously value something more than freedom. If you come from a country that is more free than the United States (I don’t believe such a country exists; if I thought it did, I would go there tomorrow), then you clearly are willing to give up freedom to come here, and, again, you are the kind of person who really should not be a citizen here.
As opposed to the situation of taking away the citizenship of native-born Americans, putting conditions on naturalization is perfectly constitutional. The US Constitution, article 1, section 8, states that “The Congress shall have power to establish a uniform rule of naturalization,” and that pretty much gives Congress the right to do whatever it wants in this area.
Just a few other quick points: while I would like to see citizenship more tightly restricted than it is now, I also believe in open borders with no welfare. I believe anyone should be able to come here, participate in our economy, and succeed or fail based on their own efforts. They just shouldn’t be allowed to vote without evidence that they love liberty greater than wealth. And, for me, having open borders does not imply that we keep them open to everyone in times of conflict, i.e. I think it would be perfectly rational to evict all non-citizen male muslim arabs between the ages of 18 to 34, until the end of the current war on terror. But those are blogs for another day.
Saturday, March 16, 2002
Yeah, so maybe some officers and employees of Andersen shredded some documents. Maybe they did engage in some criminal activity. But to indict the entire company? Did congress indict the entire Marine Corps after Ollie North lied to them and authorized document shredding? Was anyone indicted after Hillary Clinton ordered the shredding of Vince Foster's documents in the Rose Law Firm, and of Health Care Task Force documents that were the target of a court probe? If obstuction of justice is the issue, was the FBI indicted after the Branch Davidian's door "disappeared?" It's pretty clear that the Justice Department is applying a different standard to private organizations than the one they have applied to govenmental organizations.
The market, all by itself, has already punished all of Andersen Accounting. There is already an incentive for officers of private organizations to be their "brother's keepers." Why add criminal prosecution of people who were't connected to the shredding? Particularly when government officials in similar circumstances face neither market retaliation nor criminal charges?
Because they can, that's why.
Friday, March 15, 2002
OK, I’ve had it for now with writing about the police state. Don’t think that I didn’t notice the fact that the feds are too concerned with exerting their authority over us to bother pulling the visas of foreigners who (1) are dead and (2) have flown planes into the WTC. That story has been covered to death; I really don’t have anything to add.
So, today’s blog is about a cool aircraft concept: the zero-roll gyrocopter. There are two companies that have been working on this concept: CarterCopters and the Groen Brothers. The CarterCopter achieves zero-roll liftoff by (1) spinning up the main rotor on the ground, while cancelling out the tortsional forces with the landing gear of the grounded aircraft, (2) storing the rotational energy in the rotor with the aid of rotor weights which turn the rotor into a gyroscopic energy storage device and (3) lifting off and achieving autorotation before the energy stored in the rotor dissipates. The Groen Brothers plan to achieve zero-roll takeoff by (1) turning the rotor with ramjets at takeoff then (2) lifting off and achieving autorotation before turning off the ramjets.
From what I can tell, the CarterCopter seems like a much more elegant design. No ramjets on the rotor means no fuel supply to pump into the spinning rotor, no need for ramjet maintenance, and no ramjet noise. Further, the CarterCopter team has already achieved reproducible zero-roll takeoff.
The other cool concept of the CarterCopter team, which the Groen Brothers don’t seem to be replicating, is the concept of slowing rotor speed in flight and generating lift with fixed wings. Current rotor wing aircraft have a limit on forward speed because the spinning rotor tip travels through the air faster on one side (the advancing edge) than on the other side (the retreating edge). At relatively low speeds, this leads to asymmetrical lift; the faster part of the rotor generates more lift than the slower part of the rotor, and steps must be taken to prevent the craft from tipping over. At high speeds, the advancing tip speed relative to the fuselage, plus the airspeed of the entire craft relative to the air, add up to a rotor tip speed that is much faster than the craft is traveling through the air. This exposes the advancing tip to more turbulence, even, in the extreme case, to mach buffeting. If the CarterCopter team can slow the rotor rotational speed enough, then this problem shouldn’t show up until much higher speeds, and so the aircraft can travel faster.
So all this adds up to a zero-roll, fast, efficient aircraft. Think you’d want one of those? I know I would. And I bet a lot of other people would too. I therefore nominate the improved gyrocopter, from whatever source, as my pick for the technology most likely to get us the Jetson’s-style flying car.
Next (probably tomorrow): the cheap, high-capacity AN2. Costs $50,000 to buy and $160/hour to run, holds up to 14 passengers and 2 crew, needs 492 feet to take off, and is barred by the FAA from any useful task in the US (damn, my hatred of the feds slips in again).
So, today’s blog is about a cool aircraft concept: the zero-roll gyrocopter. There are two companies that have been working on this concept: CarterCopters and the Groen Brothers. The CarterCopter achieves zero-roll liftoff by (1) spinning up the main rotor on the ground, while cancelling out the tortsional forces with the landing gear of the grounded aircraft, (2) storing the rotational energy in the rotor with the aid of rotor weights which turn the rotor into a gyroscopic energy storage device and (3) lifting off and achieving autorotation before the energy stored in the rotor dissipates. The Groen Brothers plan to achieve zero-roll takeoff by (1) turning the rotor with ramjets at takeoff then (2) lifting off and achieving autorotation before turning off the ramjets.
From what I can tell, the CarterCopter seems like a much more elegant design. No ramjets on the rotor means no fuel supply to pump into the spinning rotor, no need for ramjet maintenance, and no ramjet noise. Further, the CarterCopter team has already achieved reproducible zero-roll takeoff.
The other cool concept of the CarterCopter team, which the Groen Brothers don’t seem to be replicating, is the concept of slowing rotor speed in flight and generating lift with fixed wings. Current rotor wing aircraft have a limit on forward speed because the spinning rotor tip travels through the air faster on one side (the advancing edge) than on the other side (the retreating edge). At relatively low speeds, this leads to asymmetrical lift; the faster part of the rotor generates more lift than the slower part of the rotor, and steps must be taken to prevent the craft from tipping over. At high speeds, the advancing tip speed relative to the fuselage, plus the airspeed of the entire craft relative to the air, add up to a rotor tip speed that is much faster than the craft is traveling through the air. This exposes the advancing tip to more turbulence, even, in the extreme case, to mach buffeting. If the CarterCopter team can slow the rotor rotational speed enough, then this problem shouldn’t show up until much higher speeds, and so the aircraft can travel faster.
So all this adds up to a zero-roll, fast, efficient aircraft. Think you’d want one of those? I know I would. And I bet a lot of other people would too. I therefore nominate the improved gyrocopter, from whatever source, as my pick for the technology most likely to get us the Jetson’s-style flying car.
Next (probably tomorrow): the cheap, high-capacity AN2. Costs $50,000 to buy and $160/hour to run, holds up to 14 passengers and 2 crew, needs 492 feet to take off, and is barred by the FAA from any useful task in the US (damn, my hatred of the feds slips in again).
Wednesday, March 13, 2002
Tuesday, March 12, 2002
Yes, I know that this blog has a predictable side. You can rely on me to come down on the anti-police-state side of any police state story. And I was going to write about something different today, namely Cartercopters and innovative aircraft in general. You can still check out cartercopters by looking at the link on the left.
And then I read this website: man arrested for “public drunkenness.” He was at home drinking a beer; police knocked on his door, he answered the door, and then was arrested for being drunk in public. Read the web site. I have no idea what is true and what is false on that web site, but, if true, it’s pretty damning.
And then I read this website: man arrested for “public drunkenness.” He was at home drinking a beer; police knocked on his door, he answered the door, and then was arrested for being drunk in public. Read the web site. I have no idea what is true and what is false on that web site, but, if true, it’s pretty damning.
Monday, March 11, 2002
Megan McArdle still doesn’t have any multivariate regressions on her site, but she does have a clear description of how moral hazard can lead to economically inefficient investment decisions. She relates this to the social security privatization debate.
For me, the bottom line is that current social security goes to fund government, which is just about the least economically efficient use possible. Even so, I am willing to grant, for the sake of argument, that the government can offer a “return” of 1.25% on social security money. That’s 25% of the lowball estimate of US equity returns. Moral hazard would have to decrease average equity returns by 75% before a privatized social security system became a worse deal than the current system.
For me, the bottom line is that current social security goes to fund government, which is just about the least economically efficient use possible. Even so, I am willing to grant, for the sake of argument, that the government can offer a “return” of 1.25% on social security money. That’s 25% of the lowball estimate of US equity returns. Moral hazard would have to decrease average equity returns by 75% before a privatized social security system became a worse deal than the current system.
Sunday, March 10, 2002
Apropos of a discussion I had with a cousin of mine this afternoon, I want to pose the question: when does an organization go bad? It seems to me that there is a continuum between organizations that are so bad that just joining makes you morally suspect, and those that are so good that one is compelled to give its members the benefit of the doubt beyond what you would give others.
The Nazi party, al-Qaeda, and the KKK would be organizations on one end of the continuum. If you know that someone has joined those organizations, you are justified in surmising that the person is more evil than average.
Contrawise, joining any fire department implies that one is, if not actually on a higher moral plane, at least entitled to more of the benefit of the doubt than average. I personally feel the same way about Salvation Army officers. Those organizations have a reputation of doing good, for few rewards, and (especially for firemen) at great personal risk. Therefore, it’s a safe bet that anyone who joins is likely to be more selfless and giving, and perhaps even good, than the general public.
So this is what I’m thinking about: where are the borders between one type of organization and another? In particular, when does an organization stop being morally neutral and become so bad that joining it implies some sort of moral failing? It seems that there are two influential and important organizations which are drifting into just such immorality as we watch. Ironically, membership in both those organizations has been thought of as “good” in the past, but is rapidly becoming an indication of evil.
Those two groups are the Catholic Bishopric and the FBI. I’m going to write about the FBI first, because I might not have time to address both, and I’m more concerned with the FBI, since I have to pay for it even as it degenerates into a modern version of the SS.
In recent years, the FBI has been responsible for almost every type of crime which past generations might have expected it to fight:
Mass murder. Try mass incineration of men, women and children, live on international TV, at Waco, followed by a multi-year coverup of same.
Home assault. Look at Ruby Ridge. (An aside: While I'm on the topic of home assault and incineration, I also suggest that you look up the death of James Beck, who was burned to death in his home as homes on either side of him were doused with water. The embers were bulldozed within 48 hours. The ATF, but not the FBI, was involved).
Espionage on behalf of the Russians (before and after the fall of the evil empire). Done by FBI special agent Robert Hansen.
Perjury, false imprisonment, and knowing protection of murderers. All done in the case of Joseph Salvati, set up by the FBI, and imprisoned for 30 years for a murder he didn’t commit, so that the FBI could protect Joseph "the Animal" Barboza. Barboza, now thought to be the real killer, was one of the FBI’s informants, and Salvati spent 30 years in jail to cover up the FBI’s connection with him.
Random street violence. There’s an example of that on this very blog, just a few posts down.
False imprisonment and perjury (if Wen Ho Lee was innocent) or setting free communist spies (if Wen Ho Lee was guilty). Check.
The FBI was too busy committing all these crimes to stop terrorists, even those they knew about, from getting into the United States. The FBI was even too busy to pay attention to pleas from a Minnesota flight school to check out Zacarias Moussaoui, one of the flight school’s students.
It is perfectly clear that the FBI has already sullied its reputation to the point that honest citizens should question anything they say. When, however, is the organization bad enough to sully the reputation of everyone who joins it? This goes back to the conversation I was having with my cousin, described at the top of this post. The cousin is thinking about joining the FBI.
While I love my cousin, and I know he is a decent, honest, gentle young man, I would loose respect for him if he was to knowingly join an evil organization. Again, I refer to the top of this post: if my cousin joined the Nazi party, I would know that there was something wrong with him. If he joined any fire department (something he’s talked about as an alternative to the FBI), I would know that he was a better person than I give him credit for, and certainly a better person than I am. So what about the FBI?
My cousin says, perfectly reasonably, that he thinks the FBI has made mistakes, but that it’s basically committed to good, and that he wants to make it better from the inside. I know that he believes what he is saying, and that makes me think that most of the young people who join the FBI this year can also believe the same thing. However, at some point, it must become clear to any observer that the FBI is beyond redemption, and making it “better” from the inside is likely to be as effective as trying to make a traveling minstrel show out of the 1940’s einsatzgruppen. When it’s that obvious, then anyone who joins can safely be said to be evil.
So when does that time come? How many crimes and coverups does an organization have to commit before it’s obvious that there’s a problem? More difficult to answer: how many crimes have to be committed before it must be obvious to the 22 year old young people who make up the junior ranks, and hence an indictment of the character of those who do join? I know from personal experience that 22 year old men are pretty clueless; I look back on my 22nd year, and count myself lucky to have survived at all. A lot of the kids who join any organization, honest or corrupt, don’t really know what they are getting into. But, again, at some point, it must become obvious, even to 22 year olds, that there’s a problem. Mustn’t it?
I suggested to my cousin that, if he wants to become a peace officer (note that I did NOT say law enforcement officer) that he move to Texas, join a Texas agency, and work on becoming a Texas Ranger. They seem squeaky-clean.
Well, if you have any thoughts on this topic, please comment. Like the blog says, I’m trying to make sense, and maybe others are as well.
The Nazi party, al-Qaeda, and the KKK would be organizations on one end of the continuum. If you know that someone has joined those organizations, you are justified in surmising that the person is more evil than average.
Contrawise, joining any fire department implies that one is, if not actually on a higher moral plane, at least entitled to more of the benefit of the doubt than average. I personally feel the same way about Salvation Army officers. Those organizations have a reputation of doing good, for few rewards, and (especially for firemen) at great personal risk. Therefore, it’s a safe bet that anyone who joins is likely to be more selfless and giving, and perhaps even good, than the general public.
So this is what I’m thinking about: where are the borders between one type of organization and another? In particular, when does an organization stop being morally neutral and become so bad that joining it implies some sort of moral failing? It seems that there are two influential and important organizations which are drifting into just such immorality as we watch. Ironically, membership in both those organizations has been thought of as “good” in the past, but is rapidly becoming an indication of evil.
Those two groups are the Catholic Bishopric and the FBI. I’m going to write about the FBI first, because I might not have time to address both, and I’m more concerned with the FBI, since I have to pay for it even as it degenerates into a modern version of the SS.
In recent years, the FBI has been responsible for almost every type of crime which past generations might have expected it to fight:
Mass murder. Try mass incineration of men, women and children, live on international TV, at Waco, followed by a multi-year coverup of same.
Home assault. Look at Ruby Ridge. (An aside: While I'm on the topic of home assault and incineration, I also suggest that you look up the death of James Beck, who was burned to death in his home as homes on either side of him were doused with water. The embers were bulldozed within 48 hours. The ATF, but not the FBI, was involved).
Espionage on behalf of the Russians (before and after the fall of the evil empire). Done by FBI special agent Robert Hansen.
Perjury, false imprisonment, and knowing protection of murderers. All done in the case of Joseph Salvati, set up by the FBI, and imprisoned for 30 years for a murder he didn’t commit, so that the FBI could protect Joseph "the Animal" Barboza. Barboza, now thought to be the real killer, was one of the FBI’s informants, and Salvati spent 30 years in jail to cover up the FBI’s connection with him.
Random street violence. There’s an example of that on this very blog, just a few posts down.
False imprisonment and perjury (if Wen Ho Lee was innocent) or setting free communist spies (if Wen Ho Lee was guilty). Check.
The FBI was too busy committing all these crimes to stop terrorists, even those they knew about, from getting into the United States. The FBI was even too busy to pay attention to pleas from a Minnesota flight school to check out Zacarias Moussaoui, one of the flight school’s students.
It is perfectly clear that the FBI has already sullied its reputation to the point that honest citizens should question anything they say. When, however, is the organization bad enough to sully the reputation of everyone who joins it? This goes back to the conversation I was having with my cousin, described at the top of this post. The cousin is thinking about joining the FBI.
While I love my cousin, and I know he is a decent, honest, gentle young man, I would loose respect for him if he was to knowingly join an evil organization. Again, I refer to the top of this post: if my cousin joined the Nazi party, I would know that there was something wrong with him. If he joined any fire department (something he’s talked about as an alternative to the FBI), I would know that he was a better person than I give him credit for, and certainly a better person than I am. So what about the FBI?
My cousin says, perfectly reasonably, that he thinks the FBI has made mistakes, but that it’s basically committed to good, and that he wants to make it better from the inside. I know that he believes what he is saying, and that makes me think that most of the young people who join the FBI this year can also believe the same thing. However, at some point, it must become clear to any observer that the FBI is beyond redemption, and making it “better” from the inside is likely to be as effective as trying to make a traveling minstrel show out of the 1940’s einsatzgruppen. When it’s that obvious, then anyone who joins can safely be said to be evil.
So when does that time come? How many crimes and coverups does an organization have to commit before it’s obvious that there’s a problem? More difficult to answer: how many crimes have to be committed before it must be obvious to the 22 year old young people who make up the junior ranks, and hence an indictment of the character of those who do join? I know from personal experience that 22 year old men are pretty clueless; I look back on my 22nd year, and count myself lucky to have survived at all. A lot of the kids who join any organization, honest or corrupt, don’t really know what they are getting into. But, again, at some point, it must become obvious, even to 22 year olds, that there’s a problem. Mustn’t it?
I suggested to my cousin that, if he wants to become a peace officer (note that I did NOT say law enforcement officer) that he move to Texas, join a Texas agency, and work on becoming a Texas Ranger. They seem squeaky-clean.
Well, if you have any thoughts on this topic, please comment. Like the blog says, I’m trying to make sense, and maybe others are as well.
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