Meeting of the Minds, April17, 2017

  On April 17, 2017 the Wise Guys met again for a more or less free wheeling discussion involving public policy. John B. suggested a subject that was unusual for the Wise Guys, i.e. what our parents taught us. Only one person elected to address the question directly and responded  that his father taught him about morality. This response led to a discussion of evil. The group talked about the nature of evil and how and why evil at times triumphs over good. A pertinent and eternally troubling question is why an all-knowing God would countenance such an outcome.  Although few in the group were admitted theists, they pursued the subject with vigor, particularly from the point of view of evil perpetrated by man, so-called moral evil.

  They brought up the issue as to whether evil disproves the existence of God. Why would an all-knowing and loving God allow for evil.  The answer to this question has been sought for thousands of years and is subsumed under the heading of theodicy. According to this theory, one cannot understand all of God’s plans or more pertinently, the presence of evil allows man to have free choice, the choice to be good or bad. An answer proposed by John B. was that Christians must identify the bad before they can define the good. The choice to pursue evil or good makes man a moral agent, a quality reserved for man and denied to animals.

   Earl H. continued the discussion of evil by referring to an article in the New York Times, entitled “U.S. Drops ‘Mother of all Bombs on ISIS Caves in Afghanistan” The NY times article dealt with the issue of collateral damage. The authors of the article were troubled by the fact that there was uncertainty about how many people were killed and the extent of involvement of innocent civilians. The article notes other incidents, specifically, those  in  Mosul and Syria  wherein innocent civilians were harmed.  Their conclusion was that our country has been inured to inflicting suffering on both the enemy and on innocent people. John B. responded that the NYT reignited his dismay over American values in peace and war and that humans seem to be moving towards a common fate as technology leaves no one safe from machine-induced massive, indiscriminant killing.

  

   Earl H. then discussed an article from the online newspaper the Seattle Intelligencer entitled A Man From the Holocaust.  It dealt with  Elie Wiesel who survived the Holocaust  to devote the remainder of his life to the memory  of the 6 million Jews killed by the Germans.  Though termed a survivor, he barely survived. He  dwelled in the past, reminding others about the potential evil existing in all men. The same article reported on a lecture, delivered by Wiesel at Seattle University entitled After Auschwitz, Can we believe?  Wiesel was concerned with both belief in God and belief in the goodness of man. In answer to the question where was God at Auschwitz, Wiesel responded with another question, where was man? Wiesel  found himself unable to believe in a God who  abandoned the Jewish people. Eventually he reconciled with God  but had not forgiven man and remained pessimistic about the future. . Wiesel retorted  “For the first time, we have weapons to destroy us totally and I doubt man’s wisdom not to eventually use them.” This conundrum led into a further discussion concerning the nature of evil.

  

  The group was  frustrated by the fact that they could not define evil. We were reminded that discussions of evil involve philosophy. In general, philosophy does not answer questions  directly and completely but uses arguments to clarify the issues. Socrates used discussion and argument to seek the truth.  This process has been termed dialectic.  Mary Wollstonecraft, a philosopher and writer, provided a simple answer as to why men are sometimes evil. She posited that the choice to pursue evil might be due to a mistaken  belief that evil may lead to happiness , the true good that all men seek.

   The session ended with the question  posed by John “do we expect the world to get better or worse?” Most thought that things would  get worse.  Karen N. attributed this attitude to her natural pessimism.  One cannot help but to be pessimistic after many of us witnessed the greatest evils of all time including world wars, the holocaust, and the killing of innocent people. Like Elie Wiesel, we mistrust man whom we cannot forgive for his persistent embrace of evil.  Apparently, we must await the Kingdom of God for it is surely not yet in our midst.

Posted by Arthur Banner

Meeting of the Minds- March 27,2017

   This is the first of a series of reports recalling the highlights of the meetings of the Wise Guys, which are held every third Monday in Edmonds.  The discussions are generally no holds barred but polite and consist of the collective wisdom of the group. I have termed these jottings a Meeting of the Minds. 

   On March 27, the Wise Guys met in downtown Edmonds to discuss, as usual, aspects of public policy.  The topics included existential issues such as access to health care, the danger from North Korea and the disturbing influence of Donald Trump on the body politic.  As is usual these days, the specter of Donald Trump hung over everything. Particularly upsetting was Trump’s approach to truth, which consists of alternative facts mixed with mindless blabber.  We   hunger for the eloquence of Michelle Obama whose praise of truth is a treasured memory:  “We learned about honesty and integrity - that the truth matters... that you don't take shortcuts or play by your own set of rules... and success doesn't count unless you earn it fair and square. “ 

   We began with RN’s careful analysis of the Affordable Care Act. (ACA) On this day, there was some bright news.  The GOP’s version of health care had just been defeated. In fact it was never even brought up for a vote.  One cannot help but be drawn to the notion of resurrection after death, i.e. the death of the GOP program and resurrection of the ACA.  A more appropriate word would be transfiguration, which has implications for anticipated miraculous change.

   

   S.A. suggested that the demise of the Republican health plan might have salutary effects on the entire system. He suggested that bipartisanship might be required to rescue the ACA and thereby rescue America. The change in climate in Washington might represent a dose of political reality, sorely missing in our present political infighting. Perhaps, we will follow the lead of the Founders, who encouraged compromise to achieve acceptable outcomes,

   While discussing Donald Trump, the issue arose as to his mental state, in particular whether he is mentally ill. Such a diagnosis might impact on the 25^th Amendment, wherein presidents may be removed when judged to be too ill to function.  However, there is no agreement within medical circles as to the precise nature of Trump’s illness. However, the search for a particular diagnostic category pertaining to Trump is a fool’s errand. Mental phenomenology includes character disorders, neurosis and psychosis.  In fact there may be a blending of all of these disorders in any particular individual. Persons who have character disorders may slip into neuroses or even psychosis under stress. Thus Trump, who clearly suffers from a character disorder characterized by narcissism and sociopathy, on occasion, exhibits delusional thinking. Ultimately, the decision to use the 25^th Amendment to remove Trump from office would be a political rather than a medical decision. After all is said and done, we are alarmed by Trump’s mental instability, but no more so than his incompetence. We all fear the long-term damage to the country as a consequence of his illness and inadequacies.  We recall the words of Anthony, as he as he spoke of the recently deceased Caesar: “The evil that men do lives after them”

     The discussion of the ACA led to the issue as to what determines access to medical care. A recent article in the New England Journal of Medicine  2017; 376, 1307-1309   suggests that in urban areas, the issue is insurance availability, whereas in under populated rural areas, it is the availability of physicians that is the determining factor. Physicians tend to practice in areas they find attractive. Often it is where they lived and where they trained.   JB reflected that this issue could best be addressed locally rather than nationally. He described WAMI; a health governance attempt run by a consortium of northwest states including Washington, Alaska, Montana, Idaho, wherein the education of physicians is shared between minimally populated states. The education of students during the first of the non-clinical years is reserved for the teaching institutions of the individual states. UW in Seattle then completed the clinical years. This education sharing is meant to encourage educated physicians to serve as primary care physicians in their respective states.  The point addressed is that access to medical care is a complicated issue and requires a multipronged approach.

   JB concluded the meeting with a discussion of how to react to and manage North Korea. This hermit country alarms everyone with aggressive actions with nuclear capability. The Wise Guys were unable to suggest an effective strategy. Interestingly, none favored going to war, although this alternative seemed the only effective way to stop North Korea. Interestingly, Time magazine (April 3,2017,p.41-44) dealt with the same issue by reporting the attitudes of 6 highly skilled diplomats. They were no better than the Wise Guys in seeing a way out of this situation.

   Although all of the above issues defied resolution, the meeting did provide for a thoughtful approach to these problems, reflecting wisdom of age and achievement, the treasured characteristics of the Wise Guys.

Posted by Arthur Banner

A Preventive Medicine Initiative, Stalled by Political Issues

        

   The rising costs of health care have alarmed the nation.  Measures to control excessive costs are warranted. That prevention is worth a pound of cure is a hackneyed phrase but does contain some truth and might define a path to cost containment.  However, solutions will not be easy since the problems are entangled with a variety of unanticipated costs.

   Preventive measures may lead to added costs attendant to testing procedures and for treating newly uncovered conditions, which in and of themselves may not require treatment.  Such eventualities might stymie preventive measures. Alternatively, the success of a preventive strategy may depend more on the astute handling of political forces, since it is these forces, which may present obstacles to health care reform.  The role of government in disentangling these issues is discussed in detail in The Perspective Section of the New England Journal of Medicine, 2016: 375: 1710-1712. In this article, the evolution of ideas leading to health care reform, with a strong component of prevention is discussed.

   The issue of preventive medicine has been a contentious issue for many years. The fact that it is has been difficult to document the success of disease prevention has inhibited physicians from a full-fledged endorsement of preventive strategies.  In an effort to prove beyond doubt the efficacy of disease prevention, the government established the US Preventive Services Taskforce in 1984. The agency was tasked with analyzing the data in a scientific fashion, free of cost concerns and political influence. This panel was proposed to serve as a consultant to practicing clinicians. In 2000, the Institute of Medicine suggested that congress should delegate Medicare preventive Services to the USPST, thus establishing a governmental agency, targeted with determining value of prevented medicine. Wary that the USPSTF’s credibility as an impartial determinant of efficacy might be undermined by political and cost considerations, a former task chief suggested that Medicare be allowed to govern insurance particulars. In 2008, it was suggested that the Secretary of Health and Human Services be empowered to add preventive measures if it was felt by the USPSTF that the benefit was substantial.   In 2009, a draft of the Affordable Care Act contained provisions that the USPSTF stipulate which preventive measures be covered.  However, this effort was felt to saddle the USPSTF with political and cost befit considerations, which was contrary to the original intention that this agency be free of such restrictions.  It called to attention the uproar in Congress when the USPTF suggested that mammography not be recommended for women under age 40, and later denigrated the value of PSA testing. At present, there is considerable controversy as to the role of the USPSTF in stipulating which services are to be covered.

   The effective implementation of preventive medicine measures holds promise for better patient outcomes with reduced cost. However, the solutions are not easy since the problems are entangled in cost issues, reimbursement for physician work, and political issues related to stakeholder expectations.  Medicare officials and those implementing the ACA subserve all these considerations under the sobriquet of public policy. The goals of the new administration muddy the waters a bit and an effective outcome is not yet evident.

Posted by Arthur Banner

Beyond the Cherry Tree

   After a recent meeting of the Wise Guys, Jim Hodges handed me a book he had written  entitled Beyond the Cherry Tree. The Leadership Wisdom of George Washington.. The cover consisted of a glorious painting of George Washington set against a pretty blue background.  The author’s wife Bonnie provided this illustration, as well as those throughout the book.

   My initial reaction was that this was a children’s book meant for our 7-year-old grandchild.  However, on more careful inspection, I realized that I was mistaken. The book represents an insightful analysis of what is meant by leadership. It is a multilayered examination of the moral and ethical values of George Washington, modern leaders of business and ultimately those of Mr. Hodges himself. It consists of multiple simultaneous narratives addressing each of these perspectives.

  

  This book was apparently a response to catastrophic business failures, in particular the debacle at Enron. The author attributes these failures to poor leadership, due mainly to ethical failings. The author chooses to center his analysis around George Washington since Washington was noted for his leadership, and moral principles, and qualities, which must resonate with the author’s own values. As the author points out, Washington’s leadership extended to business, agriculture and scientific farming. That he was ethically pristine is suggested by the story of the cherry tree, wherein Washington confessed to his father that he could not lie; it was he who cut down the cherry tree. The author realizes that the story is probably apocryphal and wishes to go” beyond the cherry tree" in his analysis of Washington’s ethical bonafides. The book is ostensibly a guidebook on how to conduct business based on ethical principles. In so doing, Hodges suggests that ethical behavior leads to improved profitability as well as improved human relationships.

   The book consists of 5 chapters each of which deals with a different aspect of leadership. The general strategy is to report the author’s ideas of leadership, intermixed with those of Washington and other individuals, generally representing CEO’s. . The ultimate conclusion is that those who follow ethical principles stand the best chance of success. The first chapter deals with leadership in general and highlights and embraces the views of Washington.  It begins with an actual letter of Washington, written at the beginning of the Revolutionary War to a Colonel   William Woodard, who solicited the General’s advice about how to lead men. In this first person letter he stresses the mechanics of good leadership. In other examples, Washington’s views are reported from secondary sources wherein he stresses the ideas of ethics, compassion and trust.

   The remaining chapters deal with character building, calculating risk, engendering loyalty, and planning for succession. In all cases, the views are essentially those of Mr. Hodges, but resonate with those of Washington. Frequently, the author describes those individuals who did not follow Washington’s leads, and were thus set on a course of failure and national derision.

    Contrary to initial impressions, the book is not really about George Washington but is actually about Jim Hodges and his notions concerning our national collective leadership.  That he chose to center the book on George Washington reflects his bond to the American leader.  He seems to favor male bonding as reflected in his participation in Jollies and the Wise Guys, where he is a valued member.

   As a conclusion, Mr. Hodges explains that his own leadership qualities were achieved by standing on the shoulders of a great mentor. This statement requires some thoughtful analysis. When one stands on the shoulders of others, he sees further than they did. Hodges never claims that his ethical principles were superior to those of Washington.  Rather what the statement does imply is that by standing on the General’s shoulders he was able to apply these principles to a modern world. It is these principles that enlarge one’s vision of leadership in a world crying out for guidance in matters of business, lest we go the way of Enron, and other failed companies consequent to failed leadership.

                                                             

Post by Arthur Banner