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Set in the Present

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She referenced Billie Eilish, so this must be getting pretty close to the pandemic. But we've seen the last two years in-universe, so if it's set in the future, they must be in at least 2023 by now. [*adds thumbtacks and string to wall*]
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jonathaneidsness
20 days ago
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Westminster, Colorado
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jgbishop
20 days ago
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We totally do this analysis now when watching TV.
Durham, NC
alexanglin
20 days ago
Agreed, though I'm not looking forward to the next decade of COVID-related media that addresses it.
alt_text_bot
20 days ago
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She referenced Billie Eilish, so this must be getting pretty close to the pandemic. But we've seen the last two years in-universe, so if it's set in the future, they must be in at least 2023 by now. [*adds thumbtacks and string to wall*]

Book Review: House of God

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I’m not a big fan of war movies. I liked the first few I watched. It was all downhill from there. They all seem so similar. The Part Where You Bond With Your Squadmates. The Part Where Your Gruff Sergeant Turns Out To Have A Heart After All. The Part Where Your Friend Dies But You Have To Keep Going Anyway. The Part That Consists Of A Stirring Speech.

The problem is that war is very different from everything else, but very much like itself.

When I lived in Japan, I had a black neighbor who would always get told that she looked like Condoleezza Rice. She looked nothing like Condoleezza Rice. But if you’re Japanese, and the set of people you recognize includes ten million other Japanese people plus Condoleezza, then maybe all black women blur together into a vague Condoleezza-shaped blob. That’s how I am with war movies. War is so far from my usual experience that the differences among war movies don’t even register.

Medical internship is also very different from everything else but very much like itself. I already had two examples of it: Scrubs and my own experience as a medical intern (I preferred Scrubs). So when every single personin the medical field told me to read Samuel Shem’s House of God, I deferred. I deferred throughout my own internship, I deferred for another two years of residency afterwards. And then for some reason I finally picked it up a couple of days ago.

This was a heck of a book.

On some level it was I can’t really explain it. It was exactly as predictable as I expected. It hit all of the Important Internship Tropes, like The Part Where Your Attendings Are Cruel, The Part Where Your Patient Dies Because Of Something You Did, Did And It’s Traumatizing, The Part Where You Get Camaraderie With Other Interns, The Part Where You First Realize You Are Actually Slightly Competent At Like One Thing And It Is The Best Feeling In The Universe, The Part Where You Realize How Byzantine And Pointless 99% Of The Medical System Is, The Part Where You Have Sex With Hot Nurses, et cetera.

All I can say is that it was really well done. The whole thing had a touch of magical realism, which turns out to be exactly the right genre for a story about medicine. Real medicine is absolutely magical realist. It’s a series of bizarre occurrences just on the edge of plausibility happening to incredibly strange people for life-and-death stakes, day after day after day, all within the context of the weirdest and most byzantine bureaucracy known to humankind.

Just in the past week, for example, I had to deal with an aboulomaniac patient – one with a pathological inability to make up his mind. He came to my clinic for treatment, but as soon as he saw me, he decided he didn’t want treatment after all and left. The next day, he was back on my calendar – he’d decided he needed treatment after all – but when his appointment came around, he chanegd his mind and left again. This happened five times in five days. Every day he would phone in asking for an appointment. Every day I would give it to him. Every day he would leave a minute or two before it began. Unsure how to proceed, I sought seek out my attending. He ignored my questions, pulled ignores my questions, pulls me into a side office, took takes out his cell phone, and started starts playing me a video. It’s a scene from his musical, The Phantom Of The Psychiatric Unit, which he’s been forcing his interns to rehearse after rounds. I watched, horrified. It was watch, horrified. It’s weirdly good.

If I were to write a book about this kind of thing, people would criticize me for being unrealistic. The only way to get away with it is to pass it off as “a touch of magical realism”, and this The House of God does to excellent effect.

The story revolves around an obvious author-insert character, Roy Basch MD, who starts his internship year at a hospital called the House of God (apparently a fictionalized version of Beth Israel Hospital in Boston). He goes in with expectations to provide useful medical care to people with serious diseases. Instead, he finds gomers:


“Gomer

Gomer
is an acronym: Get Out of My Emergency Room. It’s what you want to say when one’s sent in from the nursing home at three A.M.”

“I think that’s kind of crass,” said Potts. “Some of us don’t feel that way about old people.”

“You think I don’t have a grandmother?” asked Fats indignantly. “I do, and she’s the cutest dearest, most wonderful old lady. Her matzoh balls float – you have to pin them down to eat them up. Under their force the soup levitates. We eat on ladders, scraping the food off the ceiling. I love…” The Fat Man had to stop, and dabbed the tears from his eyes, and then went on in a soft voice, “I love her very much.”

I thought of my grandfather. I loved him too.

“But gomers are not just dear old people,” said Fats. “Gomers are human beings who have lost what goes into being human beings. They want to die, and we will not let them. We’re cruel to the gomers, by saving them, and they’re cruel to us, by fighting tooth and nail against our trying to save them. They hurt us, we hurt them.”

This is where the magical realism starts to come in:

Rokitansky was an old bassett. He’d been a college professor and had suffered a severe stroke. He lay on his bed, strapped down, IV’s going in, catheter coming out. Motionless, paralyzed, eyes closed, breathing comfortably, perhaps dreaming of a bone, or a boy, or of a boy throwing a bone.

“Mr. Rokitansky, how are you doing?” I asked.

Without opening his eyes, after fifteen seconds, in a husky slurred growl from deep down in his smushed brain he said: PURRTY GUD.

Pleased, I asked, “Mr. Rokitansky, what date is it today?”

PURRTY GUD. .

To all my questions, his answer was always the same. I felt sad. A professor, now a vegetable. Again I thought of my grandfather, and got a lump in my throat. Turning to Fats, I said, “This is too sad. He’s going to die.”

“No, he’s not,” said Fats. “He wants to, but he won’t.”

“He can’t go on like this.”

“Sure he can. Listen, Basch, there are a number of LAWS OF THE HOUSE OF GOD. LAW NUMBER ONE: GOMERS DON’T DIE.”

“That’s ridiculous. Of course they die.”

“I’ve never seen it, in a whole year here,” said Fats.

“They have to.”

“They don’t. They go on and on. Young people – like you and me – die, but not the gomers. Never seen it. Not once.”

“Why not?”

“I don’t know. Nobody knows. It’s amazing. Maybe they get past it. It’s pitiful. The worst.”

Potts came in, looking puzzled and concerned. He wanted the Fat Man’s help with Ina Goober. They left, and I turned back to Rokitansky. In the dim half-light I thought I saw tears trickling down the old man’s cheeks. Shame swept over me. My stomach churned. Had he heard what we’d said?

“Mr. Rokitansky, are you crying?” I asked, and I waited, as the long seconds ticked away, my guilt moaning inside me.

PURRTY GUD.

“But did you hear what we said about gomers?”

PURRTY GUD.

Someone once said that the point of art is to be more real than reality. The House Of God is way more real than reality. Reality wishes it could be anywhere close to as real as The House of God. This is a world where young people – the kid just out of school, the blushing new mother – die. Even normal old people – your grandmother, your grandpa – can die. But the most decrepit, demented people, the ones for whom every moment of artificially-prolonged life is a gratuitous misery and you pray at every moment that God will just let them find some peace – somehow they never die. They come into the hospital, they go back out to nursing homes, a few weeks later they’re back in the hospital, a few weeks later they’re back in their nursing homes, but they never die. This can’t be literally true. But it’s the subjective truth of working in a hospital. The Fat Man is right. I’ve been working in medicine for three years now, and I have seen my share of young people tragically cut off in the prime of life, and yet as far as I can remember I have never seen a gomer die. The magical realism of House of God describes the reality of medical professionals infinitely better than the rational world of hospital mortality statistics.

In the world of The House of God, the primary form of medical treatment is the TURF – the excuse to get a patient out of your care and on to somebody else’s. If the psychiatrist can’t stand a certain patient any longer, she finds some trivial abnormality in their bloodwork and TURFs to the medical floor. But she knows that if the medical doctor doesn’t want one of his patients, then he can interpret a trivial patient comment like “Being sick is so depressing” as suicidal ideation and TURF to psychiatry. At 3 AM on a Friday night, every patient is terrible, the urge to TURF is overwhelming, and a hospital starts to seem like a giant wheel uncoupled from the rest of the world, Psychiatry TURFING to Medicine TURFING to Surgery TURFING to Neurosurgery TURFING to Neurology TURFING back to Psychiatry again. Surely some treatment must get done somewhere? But where? It becomes a legend, The Place Where Treatment Happens, hidden in some far-off hospital wing accessible only to the pure-hearted. This sort of Kafkaesque picture is how medical care feels, and the genius of The House of God is that it accentuates the reality just a little bit until its fictional world is almost as magical-realist as the real one.

In And in the world of The House of God, medical intervention can only make patients worse: worse.

Anna O. had started out on Jo’s service in perfect electrolyte balance, with each organ system working as perfectly as an 1878 model could. This, to my mind, included the brain, for wasn’t dementia a fail-safe and soothing oblivion of the machine to its own decay?

From being on the verge of a TURF back to the Hebrew House for the Incurables, as Anna knocked around the House of God in the steaming weeks of August, getting a skull film here and an LP there, she got worse, much worse. Given the stress of the dementia work-up, every organ system crumpled: in a domino progression the injection of radioactive dye for her brain scan shut down her kidneys, and the dye study of her kidneys overloaded her heart, and the medication for her heart made her vomit, which altered her electrolyte balance in a life-threatening way, which increased her dementia and shut down her bowel, which made her eligible for the bowel run, the cleanout for which dehydrated her and really shut down her tormented kidneys, which led to infection, the need for dialysis, and big-time complications of these big-time diseases. She and I both became exhausted, and she became very sick. Like the Yellow Man, she went through a phase of convulsing like a hooked tuna, and then went through a phase that was even more awesome, lying in bed deathly still, perhaps dying. I felt sad, for by this time, I liked her. I didn’t know what to do. I began to spend a good deal of time sitting with Anna, thinking.

The Fat Man was on call with me every third night as backup resident, and one night, searching for me to go to the ten o’clock meal, he found me with Anna, watching her trying to die.

“What the hell are you doing?” he asked.

I told him.

“Anna was on her way back to the Hebrew House, what happened – wait, don’t tell me. Jo decided to go all-out on her dementia, right?”

“Right. She looks like she’s going to die.”

“The only way she’ll die is if you murder her by doing what Jo says.”

“Yeah, but how can I do otherwise, with Jo breathing down my neck?”

“Easy. Do nothing with Anna, and hide it from Jo.”

“Hide it from Jo?”

“Sure. Continue the work-up in purely imaginary terms, buff the chart with the imaginary results of the imaginary tests, Anna will recover to her demented state, the work-up will show no treatable cause for it, and everybody’s happy. Nothing to it.”

“I’m not sure it’s ethical.”

“Is it ethical to murder this sweet gomere with your work-up?”

There was nothing I could say.”

After learning these medical secrets, Dr. Basch uses hook and crook to prevent his patients from getting any treatment. They end up healthier than anyone anything else in the hospital, and Basch becomes a contender for “Most Valuable Intern” – in typical House of God style, nobody knows if this award really exists or is just a rumor. His colleagues compete for another award, the “Black Crow”, which goes to the intern who gets the most autopsy consents from grieving families – and which the administration doesn’t realize incentivizes doctors to kill their patients. This is so reminiscent of the bizarre incentive systems in real hospitals that it hurts.

But as the year goes on, everyone gets more and more frazzled. One intern has a mental breakdown. Another commits suicide by jumping out of a hospital window (this isn’t dramatic exaggeration by the way; three junior doctors have committed suicide by jumping out of windows in the past three years in New York City alone). Dr. Basch runs through all sorts of interesting forms of neurosis. Finally, the end of the year approaches, the original crop of interns thinned-out but triumphant – and then they realize they have to do the whole thing again next year as residents, which is maybe a little less grueling but still in the same ballpark.

So they decide, en masse, to go into psychiatry, well-known to be a rare non-terrible residency. The author of House of God is a psychiatrist, so I guess this is only a spoiler insofar as you aren’t logically omniscient. When the Chief of Medicine learns that every single one of his hospital’s interns are going into psychiatry and there aren’t going to be any non-psychiatry residents in the whole hospital…

…okay, fine, I won’t spoil the ending. But suffice it to say I’m feeling pretty good about my career path right now.

II.

House of God does a weird form of figure-ground inversion.

An example of what I mean, taken from politics: some people think of government as another name for the things we do together, like providing food to the hungry, or ensuring that old people have the health care they need. These people know that some politicians are corrupt, and sometimes the money actually goes to whoever’s best at demanding pork, and the regulations sometimes favor whichever giant corporation has the best lobbyists. But this is viewed as a weird disease of the body politic, something that can be abstracted away as noise in the system.

And then there are other people who think of government as a giant pork-distribution system, where obviously representatives and bureaucrats, bureaucrats who are incentivized in every way to support the forces that provide them with allow them more campaign funding and personal prestige, prestige will take those incentives. Obviously they’ll incentives and use the government to crush their enemies. Sometimes this system also involves the hungry getting food and the elderly getting medical care, as an epiphenomenon of its pork-distribution role, but this isn’t particularly important and can be abstracted away as noise.

I think I can go back and forth between these two models when I need to, but it’s a weird switch of perspective, where the parts you view as noise in one model resolve into the essence of the other and vice versa.

And House of God does this to medicine.

Doctors use share certain assumptions, like:

1. The patient wants to get better, but there are scientific limits that usually make this impossible
2. Medical treatment makes people healthier
3. Treatment is determined by medical need and expertise

But in House of God, the assumptions get inverted:

1. The patient wants to just die peacefully, but there are bureaucratic limits that usually make this impossible
2. Medical treatment makes people sicker
3. Treatment is determined by what will make doctors look good without having to do much work

Everybody knows that those first three assumptions aren’t always true. Yes, sometimes we prolong life in contravention of patients’ wishes. Sometimes people mistakenly receive unnecessary treatment that causes complications. And sometimes care suffers because of doctors’ scheduling issues. But it’s easy to abstract away to an ideal medicine based on benevolence and reason, and then view everything else as rare and unfortunate deviations from the norm.

House of God goes the whole way and does a full figure-ground inversion. The outliers become the norm; good care becomes the rare deviation. What’s horrifying is how convincing it is. Real medicine looks at least as much like the bizarro-world of House of God as it does the world of the popular imagination where doctors are always wise, diagnoses always correct, and patients always grateful.

There have been a couple of studies finding that giving people health insurance doesn’t make them any healthier – see for example the RAND Health Insurance Experiment and the Oregon Medicaid Experiment. I’ve always been skeptical of these studies, because it seems logical that people who can afford health care will get more of it, and there are ten zillion studies showing various forms of health care to help. that helps. Insulin helps diabetes. Antibiotics help sepsis. Surgery helps appendicitis. To deny claims like these would be madness, yet the studies don’t lie. What is going on?

And the answer has to be somewhere in the bizarro-world of House of God. Real medical treatment looks precious little like the House MD model of rare serious disease -} diagnosis -} cure. At least as often, it’s like the House of God model where someone becomes inconvenient -} send to hospital -} one million unnecessary tests. Everyone agrees this is part of the story. House of God is a brilliant book in that it refactors perception to place it in the foreground.

But it’s brilliant because in the end it’s not just a Catch-22-style romp through hilarious bureaucratic mishaps. There is as much genuine human goodness and compassion in this book as there is in any rousing speech by a medical school dean. The goodness is often mixed with horror – the doctor who has to fight off hordes of autopsy-consent-form-seekers to let a dying patient spend his last few seconds in peace, or the one who secretly slips euthanasia to a terminal patient begging for an end to the pain because he knows it’s the right thing to do.

The question posed here is “what do you do in a crazy cannibalistic system where it’s impossible to do good work and everyone is dying all around you?”, and the answer is “try as hard as you can to preserve whatever virtue you can, and to remain compassionate and human”. The protagonist swings wildly between “this is all bullshit and I’ll just make fun of these disgusting old people and call it a day” and “I need to save everybody and if I don’t I should hate myself forever”, and eventually like everybody, comes to some kind of synthesis where he recognizes he’s human, recognizes that his patients are human, and tries to deal with it with whatever humor and grace he can manage.

It’s hard enough for a book to be funny, and it’s hard enough for one to be deep, but a book like House of God that can be both at once within the space of a few sentences is an absolute treasure.

III.

I talked to my father about House of God, and I told him a few parts that seemed unrealistic. He told me that those parts were 100% true in 1978 when the book was written. I looked into it more, and ended up appreciating the work on a whole new level.

Uncle Tom’s Cabin is credited with kickstarting the emancipationist movement and maybe even causing the Civil War. The Jungle is famous for launching a whole new era of safety regulations. House of God has a place beside them in the pantheon of books that have changed the world.

The book’s “Second Law” is “GOMER GOES TO GROUND”: demented old people will inevitably fall out of their hospital bed and injure themselves. The book has a whole funny/horrifying scene where the senior resident explains his strategy for this eventuality: He leaves their beds low enough that patients won’t kill themselves when they fall, but high enough that they’ll probably break a bone or two and have to go to orthopaedic surgery – which takes them off his hands. Later, a medical student apes this procedure, a patient falls and breaks a bone or two, and everyone freaks out and tells him that it was a joke, that of course you don’t really arrange skeletal fractures for old people just to save yourself time, what kind of heartless moron could think such a thing? This is some nth-level meta-humor: the reader probably mistook it for real advice because it meshes so seamlessly with all of the other madness and horror, yet most of the other madness and horror in the book is easily recognizable by practicing doctors as a real part of the medical system. Actually, on the n+1st meta-level, I’m not at all sure that the resident wasn’t meant to be completely serious and then backtracked and called it a joke when it went wrong. For that matter, I’m far from sure this wasn’t a real medical practice in the 1970s.

I see enough falls that I wasn’t surprised to see them as a theme, but I thought the book exaggerated their omnipresence. My father said it didn’t – there were just far more falls back in the Old Days. Now hospitals are safer and falls are comparatively rare. Why? Because the government passed a law saying that insurance wouldn’t pay hospitals extra money for the extra days patients have to stay due to fall-related injuries. I am so serious about this. This, I think, is the n+2nd meta-level; amidst all its jokes-played-straight the book treats encouraging falls as an actual in-universe joke, and yet in the real world once hospitals were no longer incentivized to let patients fall the falls stopped.

How did people become aware of this kind of thing? How did the movement against it start? A lot of it seems to be because of House of God. Everyone in medicine knew about this sort of thing. But House of God made it common knowledge.

People were scared to speak up. Everyone thought that maybe they were just a uniquely bad person, or their hospital a uniquely bad institution. Anyone who raised some of these points was met with scorn by prestigious doctors who said that maybe they just weren’t cut out of medicine. House of God shaped medicine because it was the first thing to say what everybody was experiencing. Its terms like “gomer” and “turf” made it into the medical lexicon because they pointed to obvious features of reality nobody had the guts to talk about before.

Shem writes an afterword where he talks about the reaction to the book. Junior doctors and the public loved it. Senior doctors hated it. He tells the story of going to a medical conference. Someone asked who he was, and he said jokingly “I’m the most hated doctor here”. His interlocutor answered “Oh, don’t worry, I’m sure you’re not as bad as the guy who wrote that House of God book.”

But House of God gets credit for helping start movements to cut intern work hours, protect doctors from sleep deprivation, reduce patient falls, and teach empathy and communication skills. The moral of the story is: the courage to tell the truth is rare and powerful. More specifically: the courage to tell the truth is rare and powerful not just in Stalinist dictatorships and violent cults, but in apparently normal parts of everyday First World life. All of these differently loaded terms like “culture of silence” and “political correctness” point at a fear of rocking various boats with nothing but your imperfect first-person knowledge to go on. But a tiny crack in the wall can make a big difference.

IV.

In a closing scene, Dr. Basch and all of his fellow interns – interns who had broken into tears weekly, gotten burnt out, starting seeing psychiatrists, considered suicide, all this stuff, these interns who had smashed up against the unendurable horrors of medicine and held themselves together only by the promise that it would soon be over – the minute they graduate internship they change their tune:

It looked like all but two or three [interns] would stay. The Runt and I were definitely leaving; Chuck hadn’t yet said. The others were staying. In years to come they would spread out across America into academic centers and Fellowships, real red-hots in internal medicine, for they had been trained at the Best Medical School’s best House, the House of God. Although a few might kill themselves or get addicted or go crazy, by and large they’d repress and conform and perpetuate the Leggo [the Chief of Medicine] and the House and all the best medical stuff. [Eddie] had been praised by the Leggo that he could start off the second year as ward resident, with “a free rein” on his interns. And so, saying already that the internship been “not so bad,” he was preparing to indoctrinate his new charges: “I want them on their knees from day one.”

Shem’s author mouthpiece character Berry says:

It’s been inhuman. No wonder doctors are so distant in the face of the most poignant human dramas. The tragedy isn’t the crassness, but the lack of depth. Most people have some human reaction to their daily work, but doctors don’t. It’s an incredible paradox that being a doctor is so degrading and yet is so valued by society. In any community, the most respected group are doctors. [It’s] a terrific repression that makes doctors really believe that they are omnipotent healers. If you hear yourselves saying, ‘Well, this year wasn’t really that bad,’ you’re repressing, to put the next group through it. [But] it’s hard to say no. If you’re programmed from age six to be a doctor, invest years in it, develop your repressive skills so that you can’t even recall how miserable you were during internship, you can’t stop.

Shem’s thesis is that it isn’t just about not wanting to make waves or offend the Chief of Medicine. It’s about denying your you own pain by identifying with the system.

This puts me in a weird spot. My internship (I find myself saying) wasn’t so bad. I can give you some arguments why this might be true – things have gotten a lot better since The House of God was published (with no small credit to Shem himself), a small community hospital in Michigan is less intense than Harvard Medical School’s training hospital, psychiatry interns sometimes have it easier than internal medicine interns since everyone knows this isn’t a permanent deal for them.

And yet I distinctly remember one night a long time ago, coming home from high school. I had noticed that all of the adults around me said high school was some of the best years of their lives and I would miss it when I was gone, and yet high school seemed objectively terrible. I wondered if there might be some bias or bizarre shift in memory that happened sometime in people’s twenties and gave them a localized amnesia or insanity. So I very distinctly recall telling myself “My current assessment is that high school is terrible, and if you ever find yourself remembering that high school was lovely, please be aware that your memories have been hijacked by some malevolent force.”

And God help me, but every single part of my brain is telling me that high school was lovely. I fondly remember all the friends I made, the crazy teachers I had to put up with, the science competitions I won, the lunches spent in the library reading whatever random stuff I could get my hands on. It seems like it was a blast. It’s hard for me to even trust that one memory as anything more than imagination or the product of a single bad day. But although high-school-me had a lot of issues, he generally had a decent head on his shoulders, and if he says my memories have been hijacked, then I grudgingly believe him.

So was my intern year a good learning experience? I have no idea and I’m not sure anyone else does either. It’s another type of figure-ground inversion: parade of horrors broken only by the occasional triumph, or clear sailing with a few bad moments?

On my last day of internship, one of my colleagues who was moving on said “I’m going to miss hating this place”. I’ve always remembered that phrase. Now I wonder if it’s some kind of weird snapshot of the exact moment of transition, the instant when “nightmarish ordeal” morphs into “halcyon days of youth”. This is why medicine has to be written as magical realism. How else to capture a world where people reliably go going from agony to Stockholm Syndrome in the space of a day, and where the transition day is so intermixed with the general weirdness that it doesn’t even merit special remark?

I found myself having more emotions reading House of God than I’ve had about anything in a long time. I don’t really know why. But I think it has something to do with this resignation to the general incommunicable weirdness all around anyone who works in medicine. Somehow Shem manages to avoid the normalization of insanity that happens to every young doctor, capture the exact subjective experience and write it down in a way that makes sense. And then, having put his finger right on the unbearable thing, he makes it funny and beautiful and poignant.

I tell her. Again I tell her about Dr. Sanders bleeding out in my lap, about the look in Potts’s eyes that night before he jumped, about my pushing the KCl into poor Saul. I tell her how ashamed I am for turning into a sarcastic bastard who calls the old ones gomers, how, during the ternship, I’d ridiculed them for their weaknesses, for throwing up their suffering in my face, for scaring me, for forcing me to do disgusting things to take care of them. I tell her how I want to live, compassionately, with the idea of death clearly in sight, and how I doubt I can do that, ever again. As I think back to what I’d gone through and what I’d become, sadness wells up and mixes with contempt. I put my head into Berry’s folds and weep, and curse, and shout, and weep.

“. . . and in your own way, you did. Someone had to care for the gomers; and this year, in your own way, you did.”

“The worst thing is this bitterness. I used to be different, gentle, even generous, didn’t I? I wasn’t always like this, was I?”

“I love who you are. To me, underneath it all, you’re still there:” She paused, and then, eyes sparkling, said, “And you might even be better.”

“What? What do you mean?”

“This might have been the only thing that could have awakened you. Your whole life has been a growing from the outside, mastering the challenges that others have set for you. Now, finally, you might just be growing from inside yourself.

He also frames all of it in the language of psychoanalysis, which is jarring and sounds preachy. I’ve ordered the sequel, Mount Misery, about his training as a psychoanalyst. Expect a review of that soon.

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jonathaneidsness
1473 days ago
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Westminster, Colorado
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Cops are asking Ancestry.com and 23andMe for their customers’ DNA

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DNA

Gabriella Peñuela

When companies like Ancestry.com and 23andMe first invited people to send in their DNA for genealogy tracing and medical diagnostic tests, privacy advocates warned about the creation of giant genetic databases that might one day be used against participants by law enforcement. DNA, after all, can be a key to solving crimes. It “has serious information about you and your family,” genetic privacy advocate Jeremy Gruber told me back in 2010 when such services were just getting popular.

Now, five years later, when 23andMe and Ancestry Both have over a million customers, has one million customers and Ancestry has over 800,000 genetic samples, those warnings are looking prescient. “Your relative’s DNA could turn you into a suspect,” warns Wired, writing about a case from earlier this year, in which New Orleans filmmaker Michael Usry became a suspect in an unsolved murder case after cops did a familial genetic search using semen collected in 1996. The cops searched an Ancestry.com database and got a familial match to a saliva sample Usry’s father had given years earlier. Usry was ultimately determined to be innocent and the Electronic Frontier Foundation called it a “wild goose chase” that demonstrated “the very real threats to privacy and civil liberties posed by law enforcement access to private genetic databases.”

The FBI maintains a national genetic database with samples from convicts and arrestees, but this was the most public example of cops turning to private genetic databases to find a suspect. But it’s not the only time it’s happened, and it means that people who submitted genetic samples for reasons of health, curiosity, or to advance science could now end up in a genetic line-up of criminal suspects.

Both Ancestry.com and 23andMe stipulate in their privacy policies that they will turn information over to law enforcement if served with a court order. 23andMe says it’s received a couple of requests from both state law enforcement and the FBI, but that it has “successfully resisted them.”

23andMe’s first privacy officer Kate Black, who joined the company in February, says 23andMe plans to launch a transparency report, like those published by Google, Facebook and Twitter, within the next month or so. The report, she says, will reveal how many government requests for information the company has received, and presumably, how many it complies with.

“In the event we are required by law to make a disclosure, we will notify the affected customer through the contact information provided to us, unless doing so would violate the law or a court order,” said Black by email.

Ancestry.com would not say specifically how many requests it’s gotten from law enforcement. It wanted to clarify that in the Usry case, the particular database searched was a publicly available one that Ancestry has since taken offline with a message about the site being “used for purposes other than that which it was intended.” Police came to Ancestry.com with a warrant to get the name that matched the DNA.

“On occasion when required by law to do so, and in this instance we were, we have cooperated with law enforcement and the courts to provide only the specific information requested but we don’t comment on the specifics of cases,” said a spokesperson.

As NYU law professor Erin Murphy told the New Orleans Advocate regarding the Usry case, gathering DNA information is “a series of totally reasonable steps by law enforcement.” If you’re a cop trying to solve a crime, and you have DNA at your disposal, you’re going to want to use it to further your investigation. But the fact that your signing up for 23andMe or Ancestry.com means that you and all of your current and future family members could become genetic criminal suspects is not something most users probably have in mind when trying to find out where their ancestors came from.

“It has this really Orwellian state feeling to it,” Murphy said to the Advocate.

If the idea of investigators poking through your DNA freaks you out, both Ancestry.com and 23andMe have options to delete your information with the sites. 23andMe says it will delete information within 30 days upon request.

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jonathaneidsness
1872 days ago
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Westminster, Colorado
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Three Arguments against War

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Authors Jason Kuznicki

I show a lot of interest in vice issues. I belong to a population that has been—fairly or unfairly—associated with vice. But in a sense, vice legislation is small potatoes. The biggest thing separating conservatives from libertarians is the question of war.

As I see it, there are three distinctively libertarian arguments against war. These are over and above the obvious objection to war, which is in no way particular to libertarians: war is intrinsically a calamity and an evil.

These three arguments could each be thought of as particularly libertarian takes on why war is bad, but they should not be understood as the sudden, libertarian discovery that war was is bad. (Even if at times it really does feel like we’re the only consistently antiwar folks out there.) They’re embellishments at best, but they do help to illustrate the libertarian way of thinking, and if they turn even a few people more antiwar, then so much the better.

1. War Is the Health of the State

Hang around us long enough, and you’ll hear it: War is the health of the state. But what it really means isn’t as obvious as it should be. Even many libertarians probably don’t know what Randolph Bourne meant when he coined the phrase, back in 1918.

Bourne conceptually split what we might call “the United States” into three distinct things: the country, the government, and the state. Yes, these terms are often used interchangeably—rightly or wrongly—along with a gaggle of others, but Bourne was very clear about what he meant in each case, and I find the payoff exquisite.

The country was not political. It was simply the people. As Bourne described it: “a loose population spreading over a certain geographical portion of the earth’s surface, speaking a common language, and living in a homogeneous civilization.”

That’s easy enough. The state was a different thing entirely:

But State is essentially a concept of power, of competition: it signifies a group in its aggressive aspects. And we have the misfortune of being born not only into a country but into a State, and as we grow up we learn to mingle the two feelings into a hopeless confusion.

The State is the country acting as a political unit, it is the group acting as a repository of force, determiner of law, arbiter of justice. International politics is a “power politics” because it is a relation of States and that is what States infallibly and calamitously are, huge aggregations of human and industrial force that may be hurled against each other in war.

In Bourne’s terminology, the state was not a group of people. It was not a tangible thing at all. The state was an idea—an idea of all of us doing something powerful together.

Bourne observed, I think fairly, that most would mingle their feeling for the country into their feeling for the state. They would mix the feeling they had for their families, for their favorite local grocer, or for baseball… into something potentially more sinister, and certainly more violent. And the state appears to get the better of the deal: It started out as just an idea, and it took on the illusion of reality, and it became able to influence people to do things.

Yet the state is a dangerous thing to love. In part, that’s because of the government:

[Government] is the machinery by which the nation, organized as a State, carries out its State functions. Government is a framework of the administration of laws, and the carrying out of the public force. Government is the idea of the State put into practical operation in the hands of definite, concrete, fallible men… Government is the only form in which we can envisage the State, but it is by no means identical with it. That the State is a mystical conception is something that must never be forgotten. Its glamour and its significance linger behind the framework of Government and direct its activities.

The state is a myth, as Ernst Cassirer would later write. When we believe strongly enough in a myth, we don’t make the myth come true, of course. But we commonly get something else instead, something unintended and potentially harmful. As for the state-myth, believing in it gets us not the state, but ever more government.

Now I believe that government may be good or bad, needed or unneeded, in various circumstances. Whatever the case, it will never be as pretty as the myth of the state to its believers. Government exists to try to do the impossible, to realize a myth. Much of the libertarian enterprise consists simply of pointing out the yawning gap between the state and the government: you want this, but they give you that. And you pay for it, every single time, and you tell yourself that there is no difference.

One might almost say that a libertarian is one who loves the country, mistrusts the government, and despises the state; and in this context, “Smash the state!” need not be an anarchist slogan at all. On the contrary, it is one that I could wholeheartedly subscribe to, even despite my doubts about anarchism. We would all be better off if we tasked the government with chasing fewer illusions.

The application to war is now obvious: War is a great, collective, state-like enterprise, in which we imagine that the United States (a state!) goes to war, using each of us as needed to achieve the goal. War is where we most vividly and fervently imagine the state, the great Power that unites us all. War makes the state come to life.

In reality, of course, the war isn’t fought by the state, which is only an idea. The war is fought by the government, which is a collection of people. Ideas don’t suffer, but people do, and they can also inflict untold cruelties on others. Thinking too much of states tends to make us forget all that. It makes us shovel more and more power at the government, even as we forget, or conceal, the fact that the state and the government are not the same.

2. War is the Death of Markets

Aside from the immediate destruction of war, libertarians often add that war has more widespread and less obvious harmful effects. We believe that much of what’s good about society is to be found in the market, which allocates resources about as efficiently as we can hope for, which realizes gains from specialization and trade, and which gives consumers more choices than they tend to enjoy under other systems of production.

War wrecks all of that: It destroys industrial capital in the most direct sense imaginable. It destroys the security of property that would otherwise allow entrepreneurs to begin long-term projects. It destroys the price system, through widespread government appropriations, rationing, and price and trade controls. It destroys commercial networks of assurance and trust. Re-establishing all of these afterward can take years or even decades, and during this time, people continue to suffer relative to what might have been. As Ayn Rand put it: “The trader and the warrior have been fundamental antagonists throughout history. Trade does not flourish on battlefields, factories do not produce under bombardments, profits do not grow on rubble.”

Commerce is ideally about giving value for value; war is ideally about destroying things that other people value. A contrast in principle can hardly be more stark than that, even while the effects in practice have perhaps been too little documented by economic historians. Admittedly, there is something a little impolite about it: Beyond the immediate carnage and privation, war casts a long, cold shadow, but it may not do to measure it too precisely.

Now, those who find capitalism an incidental or a detrimental component of modern society are unlikely to find this objection persuasive, of course! And conventional wisdom holds that war is good for the economy. Conventional wisdom is apt to be dead wrong, and here I believe that it is, at least for any humane definition of what an economy ought to be doing.

The claim that war is good for the economy comes from two directions. First, it is shown that some economic sectors—or to be precise, some lucky participants in some economic sectors—will make enormous profits from any war. And they do! But these profits come at the price of inevitable and much larger losses elsewhere in the economy. The profits at hand are not net gains. They are the small but very visible revenue component of a social balance sheet that runs deeply into the red, even if we very callously disregard the human costs of war.

Second, it is shown that GDP will commonly rise during a war. But GDP is a poor measure of economic well-being. GDP commonly rises during natural disasters, too, as people undertake new (albeit decidedly unwelcome) economic activity, all to get back what they formerly enjoyed. The wealth lost in a natural disaster isn’t subtracted from GDP, and that lost in a war isn’t counted either.

It cannot be good for an economy to take raw materials, laboriously make them into finished products, and then destroy those finished products without consumers ever having benefited from them. And yet apart from whatever goals a war may accomplish, that is precisely what war does. Those who praise war’s good economic effects are displaying a particularly ghoulish example of the broken window fallacy.

All that time we’ve spent on war, all the resources, all the lives - what if it were used on something else? It doesn’t have to be anything terribly grand. (If Randolph Bourne’s right, it might be better if it’s not grand at all.) What might we have had? How many comfortable, ordinary, decent lives? How many scientific discoveries? What literature and art? If we humans are developing toward something really great—and I firmly believe that we are—how much closer would we be?

3. The Invisible Hand Makes War Worse

The productivity of capitalism has made war a much nastier affair than ever before. As Ludwig von Mises wrote:

If the efficiency of capitalism is directed by governments toward the output of instruments of destruction, the ingenuity of private business turns out weapons which are powerful enough to destroy everything. What makes war and capitalism incompatible with one another is precisely the unparalleled efficiency of the capitalist mode of production. (Human Action, p 828.)

Two notes: First, to a great degree this holds true for noncapitalist countries as well, in that they will sooner or later acquire any technology developed in a capitalist country. As long as capitalism exists somewhere, there will be transfers. And although command economies are bad at providing consumer goods, they are often good enough at making weapons.

Second, while the Manhattan Project was indeed a government endeavor, it was conducted by the government of a capitalist country, a fact I find revealing, because the tyrannies of the day didn’t do it. The Manhattan Project was also virtually the last endeavor needed to make war as deadly as anyone could wish: We’re in Mises’ endgame now.

To be sure, his argument amounts to some serious fire-eating. Conceivably, one could have raised the very same stylized fact in an argument not against war, but against capitalism: Let us not pursue capitalism, one might have argued, because one day capitalism will give us the capacity to destroy the earth. That’s a capacity we’re better off without! (If you don’t believe this, simply expand the number of parties who have that capacity and/or lower the costs of doing so until you are convinced.)

There are two problems here: First, at least for us, the horses have already left the barn. For Mises, too: he wrote and revised Human Action in the early days of the atomic era, when these questions were perhaps more to the front of the mind than they are today. We can’t go back to the days before nuclear weapons. Still less the days before dynamite. We can disarm, and disarmament might even be a good idea, but we can’t unlearn. War will always have the potential to be deadlier, from here on out, no matter what we do.

Second, those horses would probably have left the barn regardless of our intentions. Although Mises does not make this point explicitly, it seems clear to me that what he describes is an invisible hand process—a product of human action, but not of human design. No one needs to intend to make war more deadly. It simply becomes that way whenever greater production efficiencies are realized. Technologies with otherwise innocent industrial applications are often and easily turned to war, even without the incentives that governments face to be the first in developing new weapons.

What emerges is a consequentialist constraint on our behavior, whether we live under capitalism or not, and whether we like capitalism or not. War has changed for the worse, forever. The ancient world may have glorified it, and may at times have made war the very foundation of civic virtue, but we simply can’t anymore. A new foundation must be found, or the idea given up entirely.

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jonathaneidsness
2156 days ago
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Westminster, Colorado
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Liberalism, Libertarianism, and the Illiberal Security State

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Henry Farrell’s thorough levelling of Sean Wilentz’s charge against Snowden, Assange, Greenwald and their ilk–that they are driven by a suspiciously libertarian animosity to the liberal state–put me in mind of a thought that’s been rattling around my noggin for a while, which is this: the actually-existing, so-called liberal state is impossible to justify on the mundane liberal terms most intellectuals claim to accept. But this is generally overlooked, and I blame libertarianism. Not really. I blame confused liberals. Libertarianism has only antagonized them into confusion.

Libertarianism, as it’s generally taught and understood, isn’t a philosophy of government so much as an argument against the possibility of legitimate government. Libertarians tend to reject standard justifications of political authority. Liberals, who wish to defend the possibility of a legitimate state, have become accustomed to rebutting such libertarian arguments. Of course, it’s crazily illogical to reason that the actually existing state is justified on liberal terms just because the libertarian critique of the state is false, and a legitimate liberal state is possible. That’s really silly. Yet I feel like I’m running into this sort of reasoning all the time. There’s something about the libertarian-liberal dialectic that leads liberals to confuse the identification of the illegitimate, illiberal practices of the actually-existing state with the libertarian argument against the very possibility of legitimate state.

I guess it’s not so hard to see what that something might be. The existence of unacceptably illiberal practices of actual “liberal” states raises a perfectly good question about whether it is realistic to expect states to refrain from these practices, or whether there’s something in the basic logic of the state that tends inevitably toward the abuse of power. Simply admitting that this is a good question seems to play rhetorically into the hands of libertarians, something the champions of the possibility of the good state are loath to do.

But liberals ought to be able to stand their ground better than this. It is a little puzzling to me how seldom one hears liberals argue that standard policies of state secrecy, as they are actually implemented, run afoul of standard democratic theories of legitimacy in a very straightforward way. Or maybe it’s not so puzzling.

Liberals and socialists often accuse libertarians, not without justice, of acting as unwitting apologists for plutocracy. Many free-marketeers do have a bad habit of confusing our unjustifiably rigged political economy with a very different laissez faire ideal, and their defenses of the actually-existing “free enterprise system” really do redound to the benefit of those the system is rigged to enrich. Likewise, liberals do have a bad habit of confusing actual, nominally liberal states with a very different liberal ideal, and their defenses of the actual “liberal state” do tend to redound to the benefit of the insidiously illiberal segments of the state that cannot be justified or accounted for on almost any standard liberal theory of legitimacy. The point being that too many “liberals” are really conservative apologists for the status quo political order, just as too many “libertarians” are really conservative apologists for the status quo economic order.

One thing we have learned from the Wikileaks and Snowden controversies is that the defense of the illiberal activities of the actually-existing state cuts across superficial partisan lines, and that the dominant political philosophy of both American parties is a venerable ideology of realpolitik imperial supremacy that deploys the rhetoric of liberalism as pacifying propaganda and recasts the completely mundane application of basic liberal-democratic principles–the kind at work in the activities of Wikileaks and Snowden–as irresponsibly adolescent, anarchical, and even libertarian (eww!) challenges to the very idea of the liberal state. “Liberal” apologists for the actually-existing criminal state spook actual liberals from the practice of actual liberalism by insinuating darkly that any doubts about the liberal legitimacy of the security state probably makes you a loathsome, possibly racist Paultard. In any case, that’s the thrust of Wilentz’s TNR piece.

However, the fact is, mundane liberalism is flatly incompatible with the security state as we know it. That anyone spurred to action against the illiberal security state by the democratic jusificatory ethos of mundane liberalism has come to seem a little “libertarian,” and may even therefore confess some personal “libertarian” sympathies, suggests to me a problem with “liberalism” as it is embodied in actual political discourse and practice. It suggests that liberalism is effectively a corrupt form of statist institutional conservatism, and that the democratic justificatory ethos of mundane liberalism has somehow survived within the ethos of “libertarianism,” even if, as an explicit doctrinal matter, libertarians are generally hostile to the ideas of democracy and the legitimate liberal state. It’s nice that libertarians have kept liberalism alive, but it would be even nicer if it were possible for liberals to espouse liberalism without therefore being confused for libertarians.

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jonathaneidsness
2507 days ago
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Westminster, Colorado
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From the comments (Dan Hanson on ACA)

7 Comments and 17 Shares

Dan writes:

The front end technology is not the problem here. It would be nice if it was the problem, because web page scaling issues are known problems and relatively easy to solve.

The real problems are with the back end of the software. When you try to get a quote for health insurance, the system has to connect to computers at the IRS, the VA, Medicaid/CHIP, various state agencies, Treasury, and HHS. They also have to connect to all the health plan carriers to get pre-subsidy pricing. All of these queries receive data that is then fed into the online calculator to give you a price. If any of these queries fails, the whole transaction fails.

Most of these systems are old legacy systems with their own unique data formats. Some have been around since the 1960′s, and the people who wrote the code that runs on them are long gone. If one of these old crappy systems takes too long to respond, the transaction times out.

Amazingly, none of this was tested until a week or two before the rollout, and the tests failed. They released the web site to the public anyway – an act which would border on criminal negligence if it was done in the private sector and someone was harmed. Their load tests crashed the system with only 200 simultaneous transactions – a load that even the worst-written front-end software could easily handle.

When you even contemplate bringing an old legacy system into a large-scale web project, you should do load testing on that system as part of the feasibility process before you ever write a line of production code, because if those old servers can’t handle the load, your whole project is dead in the water if you are forced to rely on them. There are no easy fixes for the fact that a 30 year old mainframe can not handle thousands of simultaneous queries. And upgrading all the back-end systems is a bigger job than the web site itself. Some of those systems are still there because attempts to upgrade them failed in the past. Too much legacy software, too many other co-reliant systems, etc. So if they aren’t going to handle the job, you need a completely different design for your public portal.

A lot of focus has been on the front-end code, because that’s the code that we can inspect, and it’s the code that lots of amateur web programmers are familiar with, so everyone’s got an opinion. And sure, it’s horribly written in many places. But in systems like this the problems that keep you up at night are almost always in the back-end integration.

The root problem was horrific management. The end result is a system built incorrectly and shipped without doing the kind of testing that sound engineering practices call for. These aren’t ‘mistakes’, they are the result of gross negligence, ignorance, and the violation of engineering best practices at just about every step of the way..

…“No way would Apple, Amazon, UPS, FedEx outsource their computer systems and software development, or their IT operations, to anyone else.”

You have to be kidding. How do you think SAP makes a living? Or Oracle? Or PeopleSoft? Or IBM, which has become little more than an IT service provider to other companies?

Everyone outsources large portions of their IT, and they should. It’s called specialization and division of labor. If FedEx’s core competence is not in IT, they should outsource their IT to people who know what they are doing.

In fact, the failure of Obamacare’s web portal can be more reasonably blamed on the government’s unwillingness to outsource the key piece of the project – the integration lead. Rather than hiring an outside integration lead and giving them responsibility for delivering on time, for some inexplicable reason the administration decided to make the Center for Medicare and Medicaid services the integration lead for a massive IT project despite the fact that CMS has no experience managing large IT projects.

Failure isn’t rare for government IT projects – it’s the norm. Over 90% of them fail to deliver on time and on budget. But more frighteningly, over 40% of them fail absolutely and are never delivered. This is because the core requirements for a successful project – solid up-front analysis and requirements, tight control over requirements changes, and clear coordination of responsibility with accountability, are all things that government tends to be very poor at,

The mystery is why we keep letting them try.

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jonathaneidsness
2592 days ago
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Westminster, Colorado
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2592 days ago
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6 public comments
danielna
2575 days ago
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Sounds about right.
NYC
neilcar
2591 days ago
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Nice analysis of healthcare.gov's failings.
Charlotte, North Carolina
glenn
2592 days ago
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As someone who runs an IT software consulting firm, this is absolutely bang on.
Waterloo, Canada
DGA51
2592 days ago
But not at all uncommon in government contracts -- especially for computer systems. Why do you think so many of the other ones are outdated legacy systems. Because their replacements didn't work.
glenn
2592 days ago
Yes it's common in government to have more issues with governance. But private sector companies have a lot of legacy systems as well. It's tough to justify replacing them because maintenance of the same systems sucks up a large portion of the annual IT budget.
mcmegan
2593 days ago
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One of the best analyses I've seen of ACA problems-- and government contracting problems. Read the comments, though, because a guy whose wife worked on the project really unleashes.
StatsGuru
2593 days ago
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Amazingly incompetent.
freeAgent
2593 days ago
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This seems like it's probably accurate.
Los Angeles, CA
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