EJ Dionne’s Friday op-ed piece in the Washington Post describes how difficult it is to be a moderate Republican under the current hegemony:

“The 74-year-old Specter’s victory is thus a last hurrah, not the next new thing. Those conservatives gathered around the Club for Growth, a political action committee devoted to pushing moderate Republicans either to the right or out of office, can claim a tactical triumph for the nearly $2 million the group directed toward helping Toomey.

Stephen Moore, the Club for Growth’s president, always saw the effort as having a double purpose: to replace Specter with a conservative if possible, but also to demonstrate how much anguish conservatives could create for Republican moderates who did not fall into line. “

Lincoln Chafee, Olympia Snow, George Voinovich are other choice targets. Dionne suggests that the moderates will either be pushed toward retirement or, even if they hold on, succeeded by a new generation far to their right. If they choose to seek reelection they will inexorably be pushed rightward in their ideology. Dionne cites a roster of liberal Republicans who have been knocked off in primaries as the Republican Party has gotten more conservative. There is another option, however, Vermont Sen. Jim Jefford’s way — to defect from the GOP. Dionne suggests that the Club for Growth is trying to push the moderates to do just that and recreate the Republican Party in their image. Let us hope the moderates realize they should make such a choice far in advance of their retirement, which could result in incumbents shifting to the Democratic side of the aisle or a significant splintering of the Republican Party. A third party challenge that would siphon votes from the Republicans as the right wing analogue to the Nader Effect would surely be welcome, possibly even in the ‘Red States’. It is an open question how broad or sustained an appeal Rabid-Right Republicanism would have, especially as disaffection with the Bush League may be reaching a tipping point and especially if the Boy King is defeated in November. Here’s to the Club for Growth’s ideological wish fulfillment fantasies clouding their political realism. [And where is Ross Perot when we need him most?]

“We had no training whatsoever”. In the BBC’s coverage of the Abu Graib torture appears the following fascinating passage:

“…(O)ne of the six soldiers charged, Sergeant Chip Frederick — a reservist whose full-time job is as a prison officer in the US state of Virginia — …said he and his fellow reservists had never been told how to deal with prisoners, or what lines should not be crossed. ‘We had no training whatsoever,’ he said.

‘I kept asking my chain of command for certain things… like rules and regulations. And it just wasn’t happening,’ he said.

He said he never saw a copy of the Geneva Conventions – which govern the treatment of prisoners – until after he was charged. The Army investigation confirmed that reservists at Abu Ghraib had not been trained in Geneva Convention rules.”

The comanding officer of these military police, Brigadier General Janice Karpinski, has been suspended and is among military personnel being investigated since publicity about the torture practices emerged. Army investigators have apparently determined that her leadership failures were to blame for the abuses.

It strikes me we have come a long way from Nuremberg, when “only following orders” was offered as a defense. These barbarous sons of bitches are claiming that they would have needed to be instructed in how to take care of their prisoners humanely? And that, in the absence of guidance, their natural fallback was bestial torture? (Oh, wait, the MP interviewed is a correctional officer in his domestic life…) If the cause for concern about their commanding officer was her “lack of leadership and clear standards”, by the by, should the buck stop there? IMHO, it should proceed up the chain of command to the buffoon-in-chief in the White House himself.

Rafe Colburn on Republican smear tactics:

“Karen Hughes was busy on CNN yesterday attacking John Kerry for things he said 30 years ago. This from the loyal retainer of a man who dismisses everything he did before age 40 as ‘youthful indiscretion,’ and who was probably saying things like, ‘Should we go out and buy a couple more six packs before the convenience stores close?’ back then. Politics is politics, but I quake at the temerity of Republicans who want to compare their candidate’s lifestyle in his early twenties to that of Kerry.”

The only thing I have to add is — he’s talking about Dubya, isn’t he? Because ‘convenience store’ doesn’t really ring true — too many syllables to trip lightly over his tongue…

And Rafe on a security issue that has bothered me for a long while:

“One popular security question used to confirm the identity of a person making a request is, “What is your mother’s maiden name?” Well Brad Graham points out that using Google, you can find that information for many people on genealogy sites. He discusses this in the context of retrieving other people’s passwords to their Gmail accounts, but it’s just as true for your credit card or anything else. The Gmail case is particularly egregious because you generally don’t tell other people your credit card numbers, but you do tell them your email address.”

Note to identity thieves: I long ago invented a different answer to the ‘mother’s maiden name’ question, which I use consistently (it doesn’t have to be accurate, just memorable…). Even if I did use my mother’s real maiden name, you wouldn’t find geneological information of my ilk anywhere on the web anyway. Not that there would be much reason to steal my identity; there’s little of consequence either in my email account or my bank account.

From the null device:

Life imitates Christopher Brookmyre novels: a nurse in Britain is on trial for being somewhat overzealous in tackling the bed-blocker problem, to the extent of attempting to hasten several patients’ journey through death’s door. In her efficiency drive, Barbara Salisbury is alleged to have given patients overdoses of diamorphine and withdrawn their oxygen supplies.

Salisbury, who was described by the prosecution as an experienced, capable and efficient nurse, is accused of attempting to murder Frances May Taylor, 88, in March 2002 in that she inappropriately administered diamorphine using the syringe pump, telling a colleague: “Why prolong the inevitable.”

She is accused of attempting, 10 days later, to murder Frank Owen, 92, by instructing another member of nursing staff to lay Mr Owen on his back, allegedly adding: “With any luck his lungs will fill with fluid and he will die.”

I wonder whether (assuming that the charges are true, of course) she was acting out of a personal cruel streak, or whether this is merely the most extreme manifestation of an institutional focus on patient turnover in the Thatcherite/Blairite health system in Britain (as was the plot of Brookmyre’s Quite Ugly One Morning; though, granted, Brookmyre seems to write from a Scottish-socialist point of view).

My thoughts as a physician — I don’t think it is, probably, either of the possibilities he suggests in his last paragraph. Taking the latter first, there are easier ways to free up beds if you buy into the pressure for “efficiency” (which, by the way, most patient-care health professionals, as opposed to management, do not, in my experience). In the US, it is not NHS iof course but the third-party payors and their indentured servants, the hospital administrators, who press us doctors for shorter lengths of stay. The ‘utilization review managers’ come to morning rounds to press us on patients whose continued stay the insurance company is threatening not to pay for — to dump them back on their families sooner, refer them to horrendous but less expensive rehab or nursing facilities, transfer them to public institutions where they will be on the taxpayers’ nickels, or just to street ’em.

What the insurance companies don’t realize is that holding down length-of-stay for a given patient does not save them money in the long run, for at least two reasons — (1) premature discharge before a patient is stabilized leads to inflated costs for her/his care, including potential rehospitalization, in the future; (2) more importantly, an empty hospital bed is like a black hole down which overhead is being poured without generating any revenue, so another patient will just be admitted to fill it in short order. Managed care does not overall affect bed occupancy, especially because decreasing reimbursement has made many hospitals fail and close their doors, increasing the pressure on the remaining facilities. Since bed supply in a region’s hospitals is less elastic than management options for many patients (of cours, not all; every patient presenting to the ER undergoing an acute MI has to be admitted immediately, for instance), my guess is that in most medical specialties, the insurance companies end up paying out largely the same amount overall whether they are paying for many shorter admissions or fewer longer ones.

It is particularly bad in my field, psychiatry, where beds are filled not just from the emergency room downstairs but any emergency room in the region, far and wide, searching for the first vacancy within reach of an ambulance ride. Psychiatric units usually run at >90% occupancy all the time, at least in New England. If the ER team were unable to find an open bed, they would usually scramble harder to find a solution (the one they should have found in the first place??) to allow the patient to be sent home without hospitalization, at least for the moment.

There is a sense, though, in which I am noticing that ‘legitimate’ decisions to withhold medical care and hasten the end of life, i.e. those made via the patient’s wishes not to have extraordinary measures taken to prolong their life, expressed in their advanced directives (also referred to as living wills or DNR orders), are increasingly being made on an economic rather than quality-of-life basis. The influence of a persuasive health care professional over a patient, especially in extremis, or her family to sign opt out of life-extending measures is substantial (just watch the way it is depicted on ER, one of the things the scriptwriters get right on that show, IMHO) , as is their discretion about how scrupulously to adhere to those expressed wishes in the act. Increasingly, it seems to me that health care professionals are buying into the idea that medical care is a limited resource and should be expended where it will do the most good — as if they had the crystal ball that could predict infallibly how much good an intervention will do — and that how costly a life will be to prolong should factor into whether it should be extended. This attitude is anathema to me and contrasts with a — perhaps old-fashioned and outmoded? — notion that life extension decisions and health resource allocation decisions in general should be made on the basis only of the clinical circumstances, quality-of-life, values and principles, and expressed preferences of this patient, in this bed, in front of you now.

With respect to the alternative, that it is an extreme expression of the nurse’s mean streak, these “Angel of Death” health practitioners usually rather have a misguided sense that they are being merciful, IMHO, not expressing any sadistic urges. Control and domination, playing God, presuming to know better, etc. but I don’t think sadistic.

But then again I haven’t read Brookmyre; perhaps I ought to? […do like that Scottish-socialist viewpoint…]

I finally get to see what my online friend Mark Wood looks like. Thanks, Mark. [Scroll down to the bottom of the 4-28-04 entries.]

Mac iLife runs down the changes in Apple’s just-released ver. 4.5 upgrade to iTunes. Many are incensed that Apple used the upgrade as an opportunity to tighten up on the DRM rights they extend to their users —

In iTunes 4.5, you can authorize up to five Macs or Windows computers to play your purchased music — up from three. But Apple giveth and Apple taketh away: you can now burn a playlist containing purchased music up to seven times (down from ten). And the old workaround of simply changing the playlist slightly does not work.

What is not being discussed as much is that Apple seems to have found a way to defeat the widely available de-DRM hacks developed under earlier iTunes versions by changing their protection scheme. After buying music from the iTunes Store, it is reasonable to convert the protected .m4p’s in which form they arrive to .mp3’s with m4p2mp4 (which strips off the copy protection and writes plain .mp4’s — as I understand it, m4p2mp4.exe is just a Win-executable wrapper around the much-publicized QTFairUse DRM-busting code) and dbPowerAmp (which takes the .mp4’s to .mp3’s). Many have no compunctions about doing this for their own “fair use”. Having bought these songs (or the rights to them) for $0.99 apiece, the feeling is that one ought to be able to play them on a non-iPod .mp3 player or continue to listen to them after going through the fifth ‘authorized’ computer. But since iTunes’ upgrade this week, m4p2mp4.exe doesn’t work anymore; the .mp4 file it writes from an .m4p song is the right size, and it has the song’s ‘tags’, but it is empty of musical content. Anyone know of a source where the Windows installation package of the previous iTunes version is still available for download, and if deinstalling the new iTunes and reinstalling the old one will work? It doesn’t work. The fallback is to burn the purchased music playlist to audio CDs (a person ought to have a hard backup of the music they have purchased anyway, right?) and then rip the CDs into iTunes. But how long do you suppose it will be before Apple finds a way to close this ‘hole’ in their DRM?