Kidney donations occur every day, but most do not come out through the vagina. The case of a 48 year old woman whose donated kidney was retrieved through her vagina has made headlines, and rightly so. This is the future: natural orifice surgery.

So says NOSCAR (Natural Orifice Surgery Consortium for Assessment and Research) a collaborative of specialist surgeons. Conveniently, the acronym conveys the principle benefit of the surgery, no scar. In reality, there is a scar, but it is located internally. A kidney or appendix can be removed through the vagina. A gallbladder can be removed through the stomach and pulled out the esophagus. And that’s just the beginning. This represents a real paradigm shift in surgery.

Back in the Dark Ages, when I went to medical school, having surgery meant a substantial surgical incision. The kidney was removed through a large incision in the flank; the gallbladder came out through a large incision curving from the right upper abdomen toward the back; even the appendix, small as it is, required a 3-4 inch incision in the right lower abdomen. Since the skin incision is the most painful part of surgery, most surgical procedures required days or weeks of recovery, and substantial amounts of pain medication in the immediate post operative period.

All that changed with the introduction of the laparoscope, whose use was pioneered by gynecologists. The laparoscope was originally nothing more than a long tube with an eye piece and a light source. The laparoscope could be introduced into the abdominal cavity through a one inch incision located immediately below the navel. It provides a nearly complete view of the abdomen and pelvis. With the addition of a manipulating rod, introduced through a half inch incision in the lower abdomen, various types of simple surgery could be performed.

The laparoscope was a tremendous boon to gynecology patients. Many different gynecological problems present with similar symptoms. Sometimes symptoms made one diagnosis far more likely than the others, but all too often, the wrong treatment was implemented initially, or actual surgery was required to look into the pelvis and see what was going on. In the case of pelvic infection, the surgery turned out to be unnecessary in retrospect.

The laparoscope changed all that. Now if there was any doubt, the patient could have laparoscopy. The doctor could look into the pelvis directly to make the correct diagnosis and the woman was left with a tiny incision small enough to be covered by a bandaid. And they could do far more than look. With the advent of special instruments, a ruptured tubal pregnancy or an appendix could be removed. Fallopian tubes could be easily, and ovarian cysts, or an entire ovary could be removed using the scope. And in every case, the patient had far less pain and a very quick recovery. Patients went home the very same day as their surgery, with only one or more bandaids providing evidence that any surgery had occurred.

Gynecologists encouraged surgeons to embrace the technology. Now gallbladders and kidneys are routinely removed using the laparoscope. One thing did not change, however. Laparoscopy continued to require little incisions in the abdomen through which the scope and the instruments were inserted. And in the case where something large like a kidney was removed, a separate, larger incision was required to pull the organ out. That increased the pain and the recovery time.

Natural orifice surgery is a logical extension of laparoscopy. In natural orifice surgery, the laparoscope or the instruments are introduced through a tiny incision in a natural orifice. So, for example, in a “no scar” appendectomy, the scope is still inserted below the navel, but the instruments go in and the appendix comes out through an incision in the upper vagina. Now instead of 2 or 3 small abdominal scars, an appendectomy leaves one small abdominal scar, and one larger, unseen scar in the upper vagina.

An even greater benefit is that removal of organs like the kidney, that used to require a 2-3 inch incision to get the kidney out of the body, can be done with a similar incision in the upper vagina. A vaginal incision results in far less pain. The woman who donated her kidney declared that the donation was far easier than having a baby, and far less painful than when she had had her gallbladder removed through a traditional incision.

As natural orifice surgery is becoming more popular, surgeons are becoming more creative. How about removing the gall bladder through a small incision in the stomach? What about abdominal surgery done through a small incision in the rectum? Some surgeons are even exploring the possibility of urinary tract surgery done through a small incision in the bladder.

To be sure, there are technical difficulties that must be overcome. For example, in the case of the donated kidney, dragging it through the bacteria filled vagina before placing it in another person raises the risk of serious infection. Yet technical problems often lead to ingenious solutions. In the case of kidney donation, the first step is to enclose the kidney in a sterile plastic bag tied at the top. When the kidney is released from its attachments, it is removed through the vagina by simply pulling out the sterile bag, kidney enclosed.

Natural orifice surgery is not for everyone. Anyone who has internal adhesions (scarring) from previous surgery is often not a candidate for any kind of laparoscopic surgery. Natural orifice surgery is not appropriate for cancer surgery where it is critical to explore every corner of the abdomen and pelvis to make sure there is no cancer left behind.

“No scar” surgery represents a natural evolution in surgery. The operations have stayed the same, but the incisions have been shrinking and are now being placed in hidden areas. Pain and recovery time are dramatically reduced. It is still preferable to avoid surgery all together, but when that is not possible, natural orifice surgery can dramatically improve the experience.

Obstetrics, the saying goes, is 95% boredom punctuated by 5% terror. Most of the time childbirth is routine and the doctor shows up to catch the baby and make sure it doesn’t fall on the floor. Every now and then, though, someone tries to die; usually it’s the baby, but occasionally it can be the mother or both. Common obstetric emergencies include hemorrhage, fetal distress, and pregnancy induced high blood pressure (pre-eclampsia).

Only once in my career was there a weapons emergency.

That’s not because of a lack of weapons brought to labor and delivery. Hospitals don’t have metal detectors, so visitors (and probably patients, too) are free to conceal knives and guns in their clothing. Every now and then I would glimpse the handle of a father’s gun exposed at the top of a pocket, but no father ever drew a weapon in the hospital or threatened the staff. The same cannot be said of the visitors.

The key lesson to be drawn from the one weapons emergency is that the father should not bring his new girlfriend to the birth of his child by his old girlfriend. The participants in this particular drama were the teenage mother in labor, her sister who was her labor coach, the teenage father, and the father’s new girlfriend.

As near as the nurse could tell, the dispute started when the participants were speculating on what the new baby might look like. The dad was hoping the baby would look like him. The sister expressed her hunch that the baby would look like mom, and the new girlfriend weighed in with her opinion. She hoped that the baby would not look like mom, since “the bitch looks like a pig.”

As anyone knows, them’s fighting words. The sister pulled out the knife she kept in her pocket for just such events, and wrestled the new girlfriend to the ground where she attempted to stab her to death. The nurse stat paged … the chief resident. He arrived in a flurry, looking around for the medical emergency. The woman in the bed looked fine. The baby looked fine on the fetal monitor. He directed his gaze lower and took in the scene of the two women locked in mortal combat on the floor, and fled.

The nurse followed him out the door and he rounded on her. “Why did you page me?” he cried. “I’m a doctor, not a policeman. I’m not getting in between those two. Page security.”

Security was paged and duly arrived: two middle age men moving as fast as they could, breathing heavily and jangling keys. Somehow they managed to pry the women apart. I still don’t understand how no one was hurt in the melee. Although the sister was the one who pulled the knife, she was the labor coach, and it was agreed that she could stay if she handed over the knife, which she did reluctantly. The new girlfriend was banned from the room and left in a huff.

The baby was born 8 hours later. I don’t know whom she looked like.

There are several factors involved in vaccine rejectionism. Vaccine rejectionists lack even the most basic knowledge about science, immunology, and statistics. They don’t have even rudimentary tools with which to analyze the claims of charlatans. Just like the flat earthers, they are persuaded by what “seems” reasonable to them in their limited experience.

Another important cause of vaccine rejectionism is the inability of Americans to understand risk. In particular, Americans have great difficulty understanding health risks. We routinely panic about insignificant health risks (high tension wires, X-rays) and routinely ignore large health risks (driving without a seatbelt, tanning). This explains, in part, the fear bordering on panic generated by theoretical vaccine “risks”, and the fashion for “alternative” treatments.

David Ropeik, Director of Risk Communication at the Harvard Center for Risk Analysis, discusses the causes of misperception of risk in his article The Consequences of Fear. He mentions three main factors, control, choice and origin, that are especially relevant for understanding the misperception of risk among Americans.

Take the issue of choice, for example. It is widely accepted among scholars of risk analysis that risks over which we feel as though we exercise control are perceived to be smaller than risks that are imposed from outside. In other words, people not only tolerate the substantial risk of not wearing a seatbelt, but they perceive the risk to be relatively small, when, in fact, it is relatively large compared to risks that evoke more fear, like the risk of a plane crash or a terrorist attack.

many Americans sought a sense of control and safety after 9/11 by driving instead of flying. Air arrivals in Las Vegas were down 6.5% and motor vehicle arrivals were up 7.3% at the end of April 2002, compared with the same period in 2001, according to the Las Vegas Convention and Visitors Authority. Consider the public health ramifications of such a choice. Driving is far more likely to result in injury or death. A study by Michael Sivak and Michael Flannagan of the Human Factors Division at the University of Michigan Transportation Research Institute found that roughly 1,000 more Americans died in road accidents during October–December 2001 than would have been expected based on a comparison between figures from January–August 2000 and January–August 2001.

This leads vaccine rejectionists to take risks with their children’s lives by “choosing” to refuse vaccination. They labor under the misperception that making a “choice” to reject vaccination is safer than subjecting their children to the impersonal mandates of the government. Just as travellers imagined they were safer when driving, because they were not subject to the whims of terrorists, vaccine rejectionists imagine that their children are safer when rejecting vaccines, because they are not subject to the whims of the government. Even though the drivers felt safer, over 1,000 extra people died. Similarly, even though vaccine rejectionist parents think their children are “safer,” they actually face much greater danger.

A second factor that modifies perception of risk is a sense of control. There is a sense of control that comes from rejecting vaccines, as opposed to vaccinating children, which is mandated. The risk of death from NOT vaccinating a child is 1,000 times higher than the risk of death from vaccinating a child. Vaccine rejectionists appear to be entirely clueless on this point. In their minds, they cannot control the side effects of vaccines, but they can control the “health” of their children by feeding them “healthy” food and limiting their exposure to other people. They are more frightened by trivial or even imagined “risks” of vaccination which they cannot control, than the very real risks of infectious disease, which they think they can prevent.

The third factor is that risks of technology are widely perceived to be greater than risks from nature, even though in many cases they are not.

…many people fail to protect themselves adequately from the sun, in part because the sun is natural and because, for some of us, the benefit of a healthy glowing tan outweighs the risks of solar exposure. However, solar radiation is widely believed to be the leading cause of melanoma, which will kill an estimated 7,910 Americans this year.

It is axiomatic among “alternative” health advocates that “natural” choices are inherently safe just because they are natural. This is not and has never been true. Catching whooping cough or polio is entirely “natural,” and far more dangerous than any technological method of preventing or treating these diseases.

Many Americans are absolutely certain that the risks of not wearing a seatbelt are so small as to be trivial and are far outweighed by the risks of “toxins” in the environment. Similarly, vaccine rejectionists are absolutely certain that the risks of refusing vaccination are so small as to be trivial and are far outweighed by the risks of “toxins” in vaccination. This is a misperception of the risk. Because rejecting vaccination encourages a sense of control, is a risk that is freely chosen, and is perceived as natural the risk of vaccine rejection is misunderstood. The consequences of this misunderstanding are deadly.

There is a moral dimension to vaccine rejectionism that deserves attention. Vaccination is like many other aspects of living in a society: it has benefits and risks. Free-riders are people who elect to take the benefits, but refuse to accept the risks. The classic case of the free rider is a conservation water ban. People in a town are told not to water their lawns more than twice a week in order to conserve water. Most people, understanding the importance of water conservation, comply. However, there are always a few people who insists on secretly violating the ban. They believe that they will be protected from a water shortage because everyone else is conserving, and they don’t want to take the risk that their lawn will turn brown.

Vaccine rejectionism is similar, but far more serious. The greater the proportion of the population that is vaccinated, the greater the protection for all citizens. Vaccine rejectionists believe that they will be protected from contracting diseases because everyone else is getting vaccinated, and they don’t want to take the risk that their child will suffer a real (or a fabricated) risk of vaccination.

The vaccine rejectionists’ position is fundamentally unethical. They always and inevitably place more people at risk for disease than just the children who are not vaccinated. Indeed, those who are most at risk are the most vulnerable in the population, because they are too young or too sick to get vaccinated. It’s just like the free-riders who water their lawn during the water ban. They always and inevitably place other people at risk of a water shortage, not just themselves.

Vaccine rejectionism involves three all too human tendencies: fundamental misunderstanding of scientific principles, irrational risk perception, and selfishness. Vaccine rejectionists lack even the most basic understanding of immunology and epidemiology. Vaccine rejectionists have no concept of risk. They grossly overinflate the risk of vaccine complications and grossly underestimate the risks of vaccine preventable diseases. What is particularly ironic about vaccine rejectionism is that parents who are busily congratulating themselves on avoiding the risks associated with vaccines are doing so by being free-riders and taking advantage of everyone else.

Thomas May, a bioethicist, has written an excellent exposition of the free-rider problem in the article Public Communication, Risk Perception, and the Viability of Preventive Vaccination Against Communicable Diseases. The article appeared in the journal Bioethics in 2005. This article also includes one of the best explanations of vaccination I have read. On the results of vaccination programs:

Since its inception, the program of mandatory childhood vaccination for children entering the U.S. public school system has been remarkably successful – widely recognized as one of (if not the) most successful public health programs in history. The program has resulted in the eradication of smallpox, the elimination of polio, and a radical reduction in the number of cases of diphtheria, measles, pertussis (whooping cough), rubella, mumps, and a number of other serious diseases. For example, diphtheria has dropped from a peak of 206,939 cases in 1921 to only 4 cases in 1990, and similar drops in cases have occurred for measles, mumps, pertussis, and rubella. The success of the childhood vaccination program, however, faces threats from an increasingly visible anti-vaccination movement, and from visible (though extremely rare) cases of adverse reactions to vaccination. The DTP vaccine results in adverse events such as convulsions or shock for 1 in 1,750; acute encephalopathy for 0–10.5 in 1,000,000; and the MMR vaccine results in encephalitis or severe allergic reaction for 1 in 1,000,000. These risks are extremely low when compared to the adverse consequences from contracting vaccinepreventable disease (for pertussis, encephalitis for 1 in 20; death for 1 in 200; for measles, encephalitis for 1 in 2,000; death for 1 in 3,000) …

On how vaccines work:

No vaccine is 100% effective. The success of vaccination programs relies on a concept known as ‘herd immunity,’ wherein protection is achieved through attaining a high enough level of immunity to a disease so as to make exposure to the organism that causes the disease extremely unlikely. If a critical mass of people is immune, then, those who are not immune are protected through ‘herd immunity’… The actual level of vaccination necessary to maintain herd immunity is different for each potential disease (depending on the rate of effectiveness for the vaccine in question), but generally ranges from 83%–94%.So long as this level of vaccination is attained, those who refuse to be vaccinated are nonetheless protected through the unlikelihood that they will ever be exposed to the disease… If exemptions to vaccination should be great enough to threaten herd immunity, however, significant harms through exposure to vaccine-preventable disease could result not only for those exempted, but for those who are excluded from vaccination for medical reasons, and for those who are vaccinated yet remain susceptible to the disease (since, again, vaccination is not 100% effective).

This is precisely what has happened in the last year’s measles outbreak in Washington state. The level of vaccination had decreased to the point where herd immunity was compromised. As a result the children of vaccine rejectionists got measles, as predicted, and children who were too young to be vaccinated got measles as well, also as predicted.

On the logic of free-riding:

… [T]he action of any one individual will have a nearly imperceptible effect on the achievement of a collective goal, motivating free-riding behavior that seeks to garner the collective good at no cost to the individual in question. This will be true so long as an individual cannot be excluded from the collective good (as exemptors cannot be excluded from the protection provided when herd immunity is achieved), no matter how agreed upon the desirability of the collective good. However, widespread noncompliance with behavior necessary to achieve the collective good can result in loss of the good entirely – even for those who comply – a phenomenon often described as a ‘tragedy of the commons.’… [I]ncreases in exemption rates have occurred in several other states, most notably in Utah, where exemptions to mandatory vaccination rose high enough to threaten herd immunity and result in a measles outbreak where half of those contracting measles had been vaccinated but had not achieved immunity (not surprising, since the rate of exemption was roughly equal to the rate of vaccine ineffectiveness).

Vaccine rejectionism is more than a demonstration of ignorance on the part of vaccine rejectionists, and vaccine rejectionism harms others in addition to the children of vaccine rejectionists. Vaccine rejectionism is unethical because vaccine rejectionists implicitly or explicitly seek to enjoy the benefits of vaccination programs without sharing the risks. Vaccine rejectionism is unethical because it harms innocent others who have taken steps to protect themselves. Vaccine rejectionists need to take a closer look at their own behavior. Rather than congratulating themselves on their selfishness, they should be apologizing to the rest of us.

The flat-earthers are back!

Well, not exactly, but their descendants have come up with the flat-earth equivalent for the 21st century. They reject vaccination.

Vaccine rejectionists are all over the web promoting the “dangers” of vaccination. Vaccine rejectionism isn’t about vaccination, though. It’s all about parents and how they wish to view themselves.

It is important to understand that vaccine rejection is not based on science. There is no scientific data that supports vaccine rejection. Indeed vaccines are one of the greatest public health achievements of all time and virtually every accusation about vaccines by vaccine rejectionists is factually false.

Vaccines have been around for more than 200 years, and vaccine rejectionists have been around for almost as long. Over the years, they have made countless accusations about the “risks” of vaccines, and they have been wrong every single time. Despite the fact that vaccine rejectionists have been 100% wrong in their understanding of vaccines, statistics, risks and claims of specific dangers, they still have a large following. In large measure that is because the cultural claims of vaccine rejectionists resonate with prevailing cultural assumptions. Vaccine rejection is a social construct that has little if anything to do with objective reality or science.

‘Trusting blindly can be the biggest risk of all’: organised resistance to childhood vaccination in the UK (Hobson-West, Sociology of Health & Illness Vol. 29 No. 2 2007, pp. 198–215) explores these cultural attitudes. The first social construct is a re-imagining of the meaning of risk:

A primary way this is achieved … is to construct risk as unknowns… [This] serves as an example of how the realist image of risk as a representation of reality is undermined. In the realist account, uncertainty and unknowns may be recognised but are usually framed as temporary phases that are overcome by more research. For the [vaccine rejectionists], there is a more fundamental ignorance about the body and health and disease that will not necessarily be overcome by more research. Interestingly, this ignorance is constructed as a collective – ‘we’ as a society do not know the true impact of mass vaccination or the causes of health and disease.

The problem that vaccine rejectionism is based on false premises is elided by ignoring the actual scientific data and focusing instead on whether parents agree with health professionals or refuse to trust them. Agreement with doctors is constructed as a negative and refusal to trust is constructed as a positive cultural attribute:

Clear dichotomies are constructed between blind faith and active resistance and uncritical following and critical thinking. Non-vaccinators or those who question aspects of vaccination policy are not described in terms of class, gender, location or politics, but are ‘free thinkers’ who have escaped from the disempowerment that is seen to characterise vaccination…

This characterization of vaccine rejectionists can be unpacked even further; not surprisingly, vaccine rejectionists are portrayed as laudatory and other parents are denigrated.

… instead of good and bad parent categories being a function of compliance or non-compliance with vaccination advice … the good parent becomes one who spends the time to become informed and educated about vaccination…

… [vaccine rejectionists] construct trust in others as passive and the easy option. Rather than trust in experts, the alternative scenario is of a parent who becomes the expert themselves, through a difficult process of personal education and empowerment…

The ultimate goal is to become “empowered”:

Finally, the moral imperative to become informed is part of a broader shift, evident in the new public health, for which some kind of empowerment, personal responsibility and participation are expressed in highly positive terms.

So vaccine rejectionism is about the parents and how they would like to see themselves, not about vaccines and not about children. In the socially constructed world of vaccine rejectionists, risks can never be quantified and are always “unknown”. Parents are divided into those (inferior) people who are passive and blindly trust authority figures and (superior) rejectionists who are “educated” and “empowered” by taking “personal responsibility”.

This view depends on a deliberate re-definition of all the relevant terms, however, and that re-definition is unjustified and self aggrandizing. The risks of vaccination are not unknown. Believing that vaccines work is not a matter of “trust”; it is reality. Questioning authority is not the same as being “educated”; indeed, it isn’t even related. Lacking even basic knowledge of immunology and rejecting medical facts is not a sign of education, independent thinking or taking personal responsibility. It is a lack of education at best, and self serving, self aggrandizing ignorance at worst.

Part 2, the moral dimension: Vaccine rejectionism is unethical.

Part 3, misunderstanding risk: Panicking about small risks, oblivious to large risks.

I trained at the “House of God”. It was pretty much at Samuel Shem described it; its medical floors were filled with elderly victims of dementia, suffering from various medical problems which we should not have been treating as aggressively as we were. You could walk down the hall and see a neat row of elderly women posied (tied) into reclining chairs staring into space, or repeating meaningless sounds, or talking but making no sense. They were all named Ida or Rose.

Like most obstetricians, I did a rotating internship which included 6 months of general medicine. I absolutely abhorred it. Taking call was the worst of all. You ran around like a crazy person all night, treating chest pain and various complications, all the while hoping that you would not get another “hit”.

A “hit” was a new patient. Right away you can tell that we did not view a new patient as an opportunity to heal and learn. Far from it. In our sleep deprived, egocentric world, a new patient was admitted to the hospital to knock us down. The fact that she was actually sick just indicated her malevolence. Sure, she had been sick for days, but she had deviously chosen our night on call to show up at the hospital.

One winter evening, I was called to the ER with my resident to accept our latest “hit”. Ida (of course) was an 88 year old, unpleasantly demented resident of a local nursing home. She had a bleeding gastic ulcer and was sent to the hospital for transfusions because of a very low hematocrit. When I got to the ER I saw that Ida was unaware that her hematocrit was barely compatible with life, and was scratching and spitting at the nurses while issuing a stream of invective.

Our first mission was to get IV access. Everyone who had tried in the ER had been unsuccessful. My resident and I assessed the situation and handled it in a way that seemed perfectly logical to us at the time. We tied Ida to the stretcher with rolls of Kling gauze. While the resident tried to keep the patient from spitting on me, I put in the IV after a great deal of difficulty. The red blood cells started running in.

My resident cautioned me that I should accompany Ida to the floor and supervise her placement in bed. The IV was extremely precious, and I should do whatever I needed to do to preserve it. That also seemed perfectly logical to me. I trailed behind the stretcher on the way up to the medical floor, and after the patient was placed in bed, I personally tied each of her limbs to the bedrail TWICE. I was taking no chances. At the time, I saw absolutely nothing wrong with what I was doing. Indeed, it seemed merely prudent.

I did not hear anything more about Ida throughout that evening. At about 3 AM, after managing another patient’s chest pain, I happened to pass by Ida’s room on the way back to my bed. Two bright eyes peered at me from the gloom. As my eyes adjusted to the darkness, I saw that Ida, clearly a protegee of Houdini, had managed to remove all four of her double restraints. She had pulled off the bandages covering her IV site and was holding the IV tubing in her hand in preparation to pulling it out.

That is when I uttered the fateful words in a voice so loud that nurses came running from up and down the floor:

“Ida,” I shouted, “if you don’t let go of that IV, I will break your arm!”

Ida, of course, smiled sweetly, pulled out the IV and spit on me for good measure. I turned to find a circle of nurses staring at me with mouths agape. I burst into tears, the one any only time during my entire residency. The nurses figured that I was too distraught to manage the situation, and called the resident to restrain Ida yet again, and replace the IV. Although people tried to console me, I was inconsolable. I just kept saying over and over again,

“What has happened to me? I threatened to break a little old lady’s arm.”

I don’t remember what happened between then and morning rounds. I do recall that by the time of morning rounds, I was completely recovered and back to work again.

Either it’s a classic case of a psychopath, or it’s the worst possible case of mistaken identity.

Medical student Philip Markoff was arrested yesterday in the death of Julissa Brisman. The case had captured nationwide attention because Brisman was found dead in the hallway of a upscale Boston hotel, and her killer was thought to be connected to an armed robbery of a woman at another high end Boston hotel and the attempted armed robbery of an exotic dancer in nearby Rhode Island. Like Brisman, the other two women had also advertised their services on Craigslist.

This case challenges everything we know, or think we know, about people who kill. Yet it bears a striking similarity to classic descriptions of a psychopath. According to MSNBC, friends of Markoff, a 6 ft tall, “strapping,” blond medical student, easily recognized him from surveillance photos, but also expressed stunned disbelief:

James Kehoe, one of Markoff’s best friends … described the suspect as “a great guy.”

“He was one of my best friends in my dorm … I felt like he was smart, an intellectual, nice, friendly guy…”

Kehoe said when he saw images of the suspect in the attacks taken by hotel security cameras, there was no doubt in his mind that Markoff was the man pictured…

“I can’t even put it into words, the disbelief I’m feeling right now,” [a] neighbor … said. “This is a great guy, I met him a few times, saw him in the hall everyday, (he) always said, ‘Hey, how you doing Jon, what’s going on.’ Just a total disconnect from what we’re hearing in the news.”

One of the hallmarks of a psychopath is how easily and completely they can fool other people. Only a few days before, MSNBC explored the issue of pyschopathy in connection with the Columbine killings, in light of the tenth anniversary of the massacre:

Lack of conscience is the hallmark of psychopathy, which is estimated to occur in about 1 percent of the adult population, says psychopathy expert Robert Hare, a professor emeritus of psychology at the University of British Columbia and author of “Without Conscience: The Disturbing World of the Psychopaths Among Us.” Unlike psychosis, in which a person is out of touch with reality and experiencing delusions or hallucinations, for example, psychopaths know what they are doing. They just don’t care — and can’t really comprehend — how their actions hurt others. Psychopaths lack empathy, guilt and remorse, explains Hare.

Dave Cullen, in his new book about Columbine, offers an illuminating portrait of Eric Harris, the psychopath behind the killings:

Cullen walks us carefully through the definition of psychopathy, and how it differs from insanity, noting how perfectly Harris met the profile — particularly in his egomania, outsize contempt for humanity and talent for manipulation. (Just months before the attack, a teacher wrote on one of his essays, “I would trust you in a heartbeat.”)

It is a great irony and advantage of psychopathy that psychopaths are often the last people to be suspected as killers. The Boston Globe ran the above photo of Markoff captured at his “white coat” ceremony two years before, when the medical students in his class received their white coats in anticipation of venturing into the hospital for the first time. In an accompanying article, the Globe reporter points out that the charges conflict with portrait of clean cut student:

… He was engaged to be married in August to … a fellow SUNY student whom he met while volunteering in an emergency room in Albany in September 2005, according to the couple’s wedding website…

One Boston University medical school colleague yesterday recalled meeting Markoff at orientation in 2007 and studying anatomy with him more recently. She said “he seemed like a nice guy, and he was a helpful, smart kid.”

“I would assume they have the wrong person; that’s how shocked I am,” said the student … “He seemed to kind of get things… I kind of had him pegged as a surgeon because he was good at anatomy.”

The images of Markoff as a medical student and doting fiancé contrasted sharply with the grainy police surveillance photos released since the April 14 slaying of Julissa Brisman, allegedly showing a man walking calmly from the scene of the attacks, apparently sending a text message.

Markoff’s guilt remains to be determined, but his arrest has already challenged everything we think we know about people who kill.

The care of the elderly in this country is a national scandal, and it reflects the values and priorities of the nation as a whole, not the doctors who provide the care. The senile elderly are warehoused in nursing homes, sentenced to an existence that no one would want. When, as is appropriate for their age and condition, they try to die, they are shipped off to the hospital to be treated and then shipped back to the nursing home to be warehoused into the future. The lengths that we will go to continue this “care” are truly absurd. Consider the case of Ida for whom we convened court in the hospital in the middle of the night during my internship year.

Ida was 100 years old and suffering from a severe bed sore on her ankle so deep that her leg bone was exposed. The voluminous medical record revealed that Ida had led a wretched life. Throughout her 20s and 30s she had been repeatedly hospitalized for psychotic episodes. At age 40, her family had permanently committed her to one of the state’s mental hospitals, where she had remained until well into her 60s when she was transferred to the nursing home. Ida had never recovered from her psychosis, even as she slipped into senility. For the past 20 years, she had been completely incapacitated and had not been heard to speak a single word nor could she understand anything said to her. Beyond being able to experience pain, it appeared that Ida had no comprehension of the world around her.

They must have been taking fairly good care of Ida at the nursing home because she was in good shape for someone who could not care for herself in any way. They fed her and cleaned her, but they obviously did not move her around very much. Over the years she had permanently contracted into a fetal position. She could only be placed on one side or another. That was why she had developed the bedsore near her ankle. Now it was infected and threatening her life.

We treated her with antibiotics, pain medication, and supportive measures, but we could not gain control of the infection. If she were younger, the next treatment would be to amputate her leg below the knee, but that seemed to be far too aggressive for a woman who was 100 years old and completely unaware of her surroundings … or so I thought. Normally, Ida’s family would decide on the next step, but she had no surviving family. She had never married, and her closest relative, a niece, had died 15 years before. Therefore, we would have to ask the court.

The court appointed a legal guardian for Ida to represent her interests in the case. The guardian felt that it was very important for the judge to see Ida, and as Ida could not come to court, the court came to Ida. One evening, the judge and the guardian came to the hospital to hold a hearing. We explained the situation and recommended that Ida should not be subjected to the pain of an amputation, and simply be returned to the nursing home where should would die within a few weeks. The guardian, in keeping with his job, argued strenuously that the fact that Ida was 100 years old and uncomprehending should not be a reason to deny her the most aggressive care possible. The judge, to his credit, visited the bedside and insisted that we take off the dressing so he could see the extent of the bedsore and the infection.

It seemed to me that the judge was uncomfortable with the decision that he ultimately reached. He ruled that there was no reason to treat her any differently simply because she was 100 years old and uncomprehending. We were required to amputate her leg and to do it as soon as possible. Neither the chief resident nor I were happy with this decision, but the chief resident was philosophical.

“Look at it this way,” he said, trying to cheer me up. “It will be a great experience for you, because I’ll let you do the case. You can chop her leg off!”

We took her to the operating room that night. The chief resident carefully dissected the muscles away from the bone and tied off the blood vessels. He handed me the bone saw, and I did indeed saw her leg off below the knee. I was not appreciably cheered by the experience, however. I could not stop thinking that we had committed a great injustice.

It took almost a month for Ida’s leg to heal, but it did heal. It took several weeks more for me to arrange her transfer back to the state nursing home. When I got the call one morning that the nursing home finally had a space available, I completed the paperwork in record time and arranged for the ambulance to take her back. By lunchtime, we were celebrating Ida’s departure.

Later that afternoon, the chief resident came to find me. He looked grim.

“It’s Ida,” he said.

I was confused. How could we be having a problem with Ida; we had sent her back.

It turned out that Ida, no sooner having been returned to her bed at the nursing home, had promptly died. That was hardly surprising; she was 100 years old. However, Massachusetts state law mandates official investigation of any death that occurs within 24 hours of release from a hospital. Ida’s case was going to be referred to the Medical Examiner, and the chief resident and I were facing the possibility of a trial to determine whether we had played a role in Ida’s death. Fortunately, the Medical Examiner has discretion over which cases proceed to a full blown investigation and he ruled that she had died of natural causes and that no further investigation would be necessary.

To me, the entire episode seemed like a cruel farce from beginning to end. Why were we keeping Ida alive in a nursing home when she was completely unaware and had no hope of recovery? Why did Ida get transferred to the hospital for treatment of her infection? Why did we go to the trouble of convening the court at the hospital in order to decide Ida’s fate? Why did the judge insist that we amputate her leg to preserve her life?

At every step of the way, I did what I was told, because that was my job. Ida paid the price as we senselessly prolonged her life by amputating her leg, and subjecting her to the only thing she could perceive: discomfort. At no point during the proceedings did anyone, doctors, legal guardian or judge, stop to consider whether Ida, or anyone, would have wanted the “care” we were offering. Indeed, I have no doubt that none of us, doctors, guardian or judge, would ever have opted for the treatment that we forced Ida to undergo simply because she could not speak for herself and tell us to stop.

The National Women’s Law Center has just published a comprehensive report on individual health insurance. Nowhere to Turn: How the Individual Health Insurance Market Fails Women, that shows that women pay dramatically more than men of the same age.

… NWLC examined all “best-selling” plans (as identified by the online vendor) offered in the capital city in each state for a 40-year-old woman and man … For example, one insurer in Missouri charges 40-year-old women a whopping 140% more than men while another charges women 15% more than men. In Arkansas, all ten best-selling plans gender rate, and the difference in premiums ranged from 13% to 63% more for women. At the same time, not all plans use gender as a rating factor. For example, only some of South Carolina’s ten best- selling plans gender rate, but among those that do, NWLC found that 40-year-old women are charged between 15% and 54% more than men for the same plan.

How can that be? It happens because most states allow a practice known as “gender rating,” which allows insurers to set different health insurance rates for men and women. The National Women’s Law Center (NWLC) opposes this practice:

The wide range of differences in premiums charged women and men shows the arbitrary nature of gender rating in practice. Given the unfair and discriminatory nature of gender rating, and the financial barrier this practice creates for women to obtain necessary health care, the use of gender rating should be abandoned.

Is gender rating truly unfair or does it accurately reflect the differences in healthcare costs between men and women? Is gender rating discriminatory, or is it merely the flip side of an insurance system that routinely charges older men more for health insurance, and younger men much more for car insurance?

First of all, it is important to be clear that we are talking about only a small sector of the insurance market. Most people, including most women, obtain their health insurance through an employer. In fact, only 7% of non-elderly women purchase health insurance directly from the insurer in the individual market. However, the NWLC notes that individual health insurance may soon be a larger component of the health insurance market. Several proposals for healthcare reform involve giving people tax credits to buy insurance in the individual market. In addition, some employers have switched from providing employee healthcare insurance to giving workers a fixed sum to buy insurance in the individual market. Therefore, the phenomenon of gender rating may soon affect a larger proportion of women.

Why charge women more for health insurance than men? The answer is very simple; women under the age of 55 spend much more in hospital costs, physician costs and other health costs than men. There are three main reasons for this: maternity care, exclusively the province of young women; increased incidence of chronic conditions among women; and the fact that well women are more likely to access healthcare services than comparable age men. The fact is that providing healthcare to women under age 55 costs substantially more than providing healthcare to men of the same age.

Most insurance companies have decided to exclude maternity services from basic individual plans. In order to obtain coverage for maternity care, women buying insurance in the individual market must purchase a maternity care rider. A maternity care rider can cost more than the premium for health insurance itself. In addition, riders may be limited in scope, and may require a waiting period (10 months to 2 years) before they take effect. Even then, maternity care riders may leave women responsible for thousands of dollars in out of pocket expenses.

Is it discriminatory for women to pay more for the same healthcare coverage than men of comparable age? The NWLC thinks so. They advocate that states:

…should eliminate the discrimination that women face by banning gender rating, ensuring all health plans include maternity coverage as part of the basic benefits package, and eliminating the practices of rejecting applicants due to health history, excluding pre-existing conditions, and rating based on age and health history.

But is it really discriminatory to ask people to pay more for health insurance when it costs more to insure them? Consider that the majority of insurers who charge women younger than age 55 more for health insurance than comparable age men, charge women over 55 less for health insurance than men of the same age. The NWLC does not appear to view this discrepancy as discriminatory to men. Consider also that young men are routinely charged much more to purchase auto insurance than young women, simply because they are more likely to get into accidents that incur substantial costs. The NWLC has not spoken out on gender rating in that part of the insurance industry.

What would happen if gender rating were prohibited? The overall cost of insurance would not change; women would pay less, but men would pay more. An argument can be made, particularly in regard to maternity care, that men are every bit as responsible for a pregnancy as the woman who carries that pregnancy. Therefore, they should share the costs for pregnancy and related services. In that case, premiums for men would rise substantially, but women would not be forced to purchase expensive riders to cover maternity care.

The NWLC acknowledges that what is really needed is fundamental reform of the health insurance system, either by making employee sponsored health insurance easier to provide and easier to obtain, or by merging the individual insurance market with other markets to pool risk over a larger group of group of people to keep down costs. In the meantime, though, the NWLC recommends abolishing gender rating and mandating the inclusion of maternity care. Their recommendations would certainly make individual health insurance more affordable for women, but it not necessarily more equitable for all.

 Over the last two millennia, religion has opposed science on many different occasions. And every time religion has opposed science, regardless of the topic, religion has been spectacularly wrong, every single time. Evolution is no different.

There is no one who is more completely convinced of the validity of evolution than creationists. That’s why they argue against it passionately. That’s why they tie themselves into knots trying to come up with bizarre criticisms of evolution. They know two things beyond a shadow of a doubt. Evolution is assuredly true, and evolution is incompatible with a literal reading of the Bible. It doesn’t take a great logician to see where that leads you. If evolution is true, then the Bible is not.

For those of us who see the Bible as a founding religious document, no different from the Greek myths, the Bhagavad Gita or ancient Egyptian beliefs, it is difficult to understand what all the fuss is about. However, for those who believe that the Bible is a privileged document that represents the literal “word of God,” evolution is bound to cause serious psychic distress. For those people, religious belief is a first principle. They start with the premise that religion is true, particularly their own subset of religious belief, and that everything else must be evaluated with reference to the truth of religion.

Religion fills important psychological needs. It is a defense against the unpleasant reality that there is no meaning to life, no plan, no justification for our suffering. In the immortal words of folk wisdom, “Shit happens.” There’s no reason for it, no purpose to it, it is entirely random, and most importantly, there is nothing that can be done to prevent it. No amount of propitiating a “Creator” makes any difference, because there is no one running the universe and no one you can turn to for help. No one loves you, except your family (if you are lucky), and you are navigating this harsh world alone.

Simply put, religion isn’t truth. It is a made up story we tell ourselves to feel better in a lonely, dangerous world.

Evolution, on the other hand, is obviously true. We see the evidence all around us, and there is much more evidence buried in the ground. When we worry about drug resistant bacteria, we acknowledge evolution; when we perform scientific research on primates, we acknowledge evolution; when we search for genetic causes of disease, we acknowledge evolution.

Creationists are utterly convinced of the truth of evolution. That’s why they are trying so desperately to keep it out of the public schools and far away from children. It is so obviously true that anyone who learns about it will assuredly recognized that it is true. And if children will inevitably conclude that evolution is true, they might also conclude that religion is false. That must be prevented at all costs. The only way to do that is to prevent the teaching of evolution in school.

If evolution were “just a theory,” an equal among many competing theories, there wouldn’t be a desperate attempt to keep it secret from children. All the different “theories” could be presented and children (and older people) could judge for themselves. Creationists know that evolution is the only possible explanation for the world as it exists. No other “theory” can compete with it, and religious explanations sound foolish. Hence they fight strenuously to keep evolution out of school, and inevitably lose.

This is not the first time that this has happened. The “debate” over evolution is almost an exact recapitulation of the “debate” over Galileo’s demonstration that the sun is at the center of the solar system, not the earth. The Bible had located the earth as the center of the entire universe, to literally represent the role of man as the center of God’s concern. When it became apparent that the earth wasn’t even the central planet in our little solar system, religious authorities felt compelled to prevent anyone from learning the truth.

If it became widely known that the Bible was wrong about something as straightforward as the location of the earth within the universe, then it might be wrong about anything. Church leaders reacted as conservatives often do; they attempted to suppress knowledge. They tried to suppress Galileo (and Copernicus and others) not because they knew he was wrong, but specifically because they knew he was right.

Creationists have reacted in exactly the same way. They, too, are religious conservatives and they are attempting to suppress knowledge of evolution, not because they believe that Darwin was wrong, but specifically because they know he was right.

There have been many other, minor skirmishes between religion and science over the years. In every disagreement, religion has been wrong, usually spectacularly wrong. Every single time. Religion has never vanquished science and it isn’t about to start now. No one understands this better than creationists. Evolution is dangerous knowledge because it is true and that’s why they fight against it with all their strength. If evolution is true, then the Bible is false, and they will not, they cannot, acknowledge that.