Thursday, April 11, 2019

Vote For Me!


If I were running for the Democratic nomination, here's what I might say:


If only “Make America Great Again” were more than a duplicitous slogan! It's not a bad thing to aspire to. You all know how much I deplore The Trump Crime Family Administration, in all its malevolence. But let's take the slogan that they have made so hateful. Let's compete. What would it take to get America back on track?

Countries should make their citizens safe – safety first! How can we make America safe – not just “safe again,” but “safer than ever?”

  • To start with the most obvious: minimize the danger of gun violence. It is a scandal for our children to be learning duck and cover in the schools, for God's sake. We need not only to do the so-called “common sense gun reform,” but let's repossess the combat weapons that are out there, the weapons of mass murder. Let's do what Australia did. And let's renew our efforts to limit guns in cities – there was a Supreme Court decision that said we can't do that, but that was from a very conservative and distorted Supreme Court. That decision shouldn't last forever. Everyone deserves to be safe from guns!

  • Let's make it safe to get sick in America! Health care has been increasingly recognized as a right for Americans, not a privilege for those who have money. The ACA was a great step forward, but it still leaves out too many, and with large deductibles and copays, under-insurance has actually risen! We need increased coverage, and better coverage. Making Medicare a choice for everyone would be a great next step for coverage, and it would also reduce total cost. Add in anti-trust enhancement and lowering drug costs, and you have a much safer America. And don't forget, when conservatives protest that “it's too expensive to expand Medicare,” it's not! Americans are already paying for it, it's just a question of redirecting the payments. Make health care available for all, and America would be getting greater.

  • Let's make America safe on its roads and bridges – physical infrastructure. But infrastructure is more than that. It's also broadband everywhere. And most importantly, we need to make our human infrastructure what it should be – education for all, not middle of the pack or bottom, but best. That means probably doubling the budget for education everywhere, affordable child care so it's possible to study and work even if you're not rich, and making education affordable, including more and more technical education. Without tending to our physical and our human capital, we can't possibly be great. Educated and supported people are safer people.

  • Let's make America safe for breathing and drinking water, let's understand how humans have been burning up the earth, and stop it. To think that business will suffer if we make the earth habitable for our children – all our children – is just an absurd proposition. “Short-sighted” doesn't really capture it – how about “suicidal?” The Green New Deal might not be right in its methods, but it sure is right in its principles, and that's the important part. Climate change needs to be attacked with a vengeance, the way we attacked the Depression and World War II! It can be done while the economy actually prospers, not suffers, if we pay attention to distributing the jobs well, and concentrate of the welfare of everyone, not just the company officials. Extreme weather events will just become more and more severe – avoiding them will actually save a lot of money. Let the business officials earn their salaries and perks by changing their companies in a way that preserves the earth. Now, that would be being great, wouldn't it? Wouldn't it be great to make the Earth safe for our children?

  • Let's make America just. The basis of justice is democracy, and democracy rests on an informed and participative population who vote, without disqualifications. America is changing in the way it looks – as it always has. We started as English colonies, with caucasian stock and African slaves. Then came Germans, and Irish, and Jews, and Eastern Europeans, and Asians, and Indians, and Mexicans, and Middle Easterners, and others. The idea of America is that we do not consist of one racial stock, but that we consist of an idea, which is ever-renewable and updatable. The votes of everyone, unimpeded by disqualifications that simply ensconce the current holders of power, direct how these updates are enacted. The principles of HR 1 need to be passed into law so that justice is increasingly assured. A just America is a safer America.

  • Let's make the world safe again by reuniting with our friends abroad. “No man is an island,” and neither is a country. Countries have more in common than they have against one another. There is no Planet B, and as we make technological progress, there should be plenty for everyone if we work together. They say that good wishes and cooperation is passé, but I don't believe that for one minute. Authoritarianism is always a threat, and now perhaps more than at any time since the 1930's. But if we can rescue America from the threat of authoritarianism, then other countries can, too. We can be an inspiration again. We need to be leaders in standing up for the rights of people everywhere to be safe, and free.

There are other elements of making America great, but these principles are a start. It's a viewpoint; it's my viewpoint. And I believe it is the viewpoint of virtually everyone running for the Democratic nomination for President. What a banquet of great people running for President we have!

Let's not let the Orwellian Trump Crime Family Kakistocracy define what greatness is. They think only of how they can make a profit. Let's not let the Trump Crime Family hijack democracy in a coup using the methods of democracy to undermine it. We still have a democracy, we just have to use it.

I'm looking to what we can do and what should be, and I'm asking for your vote to make it happen.

Budd Shenkin

Monday, April 1, 2019

I Will Keep You Alive: A Cardiovascular Romance


I

I Will Keep You Alive: A Cardiovascular Romance

by Bob and Adele Levin

I've just read a really terrific book. It's a book occasioned by two heart attacks suffered by Bob Levin, the second one so severe that he was placed in an induced coma for two and a half days, seven stents placed, and a mitral valve operation done later on. Heart transplant was discussed. He was very sick. But, as a benefit of the exquisite progress made in modern cardiac care, now, eight years later, he is hardy, healthy, happy, and much wiser and deeper. More and more people are having this experience nowadays, but I've never read an account like this, with scientific accuracy, precise rendering of the feelings at each stage, the details of what being a patient and the wife of a patient entails procedurally, the adjustment of thoughts as the process goes along, and the adjustment of the marital relationship as one helps the other. And most cogently and beautifully described and delineated, extremely importantly and crucially, this is an account of what a great doctor can do for her patient, and what the very best doctor-patient relationship imaginable looks like. This is what great perceiving and writing (and not over-writing!) looks like.

In other words, I liked it a lot.

IWKYA is written in alternating voices of Bob and his wife Adele, who both bring extraordinary qualifications to the job. Although Bob's background as an applicant's attorney for workers' compensation doesn't help a lot – or maybe it does, seeing all those people in need – he is a graduate of the storied writing program at San Francisco State, a terrific professional writer of both fiction and non-fiction, and an established authority on underground comics, of all things. He also knows a lot of psychiatry, probably mostly through Adele. Adele is also a graduate of the SFSU writing program with multiple short story writing credits and is a retired psychotherapist. So they're great writers, not of the flowery type, but of the closely observed and precisely and efficiently expressed variety. And, they have a longtime very close and romantic marriage, dating from the time Bob drove cross-country to find Adele again after they had dated at Brandeis. Who better, then, to write about the new but increasingly common experience of severe illness with successful recovery? To me, this book rivals Joan Didion's The Year of Magical Thinking, which would please them both, since she is a hero to them.

They both describe events clearly and factually, and their reactions at each step. It's the precise description at every step that is extraordinary. The details! So perfectly set out, no overacting, matter of fact with extraordinary facts, including the ordinary indignities of the hospital, where wife's sleeping area can be two chairs pulled up facing each other, here in one of the most profitable hospital chains in the country, Sutter. Read it and weep, administrators – this is your responsibility.

Each step is new to Bob and Adele, but each brings back their personal memories as they struggle with the present, as when Adele recognizes her present fears in light of her long history of fears gathered from her mother's inordinate fearfulness that she passed on. Bob reflects on his mother's too-long life and her debilitation as she dies in the middle of his long ordeal. At each step their pasts inhabit their presents, as is true for all of us, but it's rare for us to see it as clearly as they do. They rise and they fall, they are hopeful and afraid – but this is cliché, and not worthy of how they freshly describe their steps. Let me just say that one will never understand better the step-by-step impact on a close family of the process of acute and severe illness than from reading this book.

Their unstinting frankness is particularly startling and impressive, each matching the other as the voices alternate. They think of each other constantly. They hold hands and kiss. They worry about each other. Bob wonders when he will be well enough to drive so Adele can stop having fender-benders. Well into the process Adele exclaims that what she could really use most is a good orgasm. As he recovers, Bob is disappointed to hear he's not ready for sex, but can console himself with masturbation. These two really have a good marriage. Extraordinary, really.

The recounting of details brings up another point: IWKYA brought home to me again how in so many ways, we have entered the era of Star Trek Medicine. It's amazing how much medicine has accomplished, how these little magic catheters are climbing up inside us and fixing things, how doctors put their fingers into our hearts and mess around with them and have lots of options of what they can do. This isn't the focus of the book, but their precise details make it impossible for the sensitive reader to miss. The world might be going to hell, but cardiac medicine is most emphatically not.

And yet, with all the magic techniques and equipment, where you might think computers and algorithms might take over the decision process, this is far from true. There is still a huge need for human judgement. (Mothers and fathers, you can still urge your children into a medical career! We ain't finished yet! And it's not just the human touch that's important, it's the human brain and the human experience.) Which is where we get to the heroine of the book, cardiologist Louisa Muñoz, known here in the text as Dr. Fleur but then, in a stylistic coup, identified by her real name in the appendix at the end, as though the main text has been fiction, which it most decidedly has not been.

If you read nothing else, read this appendix, where Bob and Dr. Muñoz have lunch, and she reflects on the case. Dr. Muñoz embodies everything we could hope for in a doctor who takes charge of a challenging case. She knows what she is doing – she tells Bob that he is lucky to have her at this time, because she just passed her Boards and so she is completely up to date and hasn't forgotten anything yet – and she cares, she befriends, and all three of them fall in love. But that's after a long introductory period, where she sizes them up (and vice-versa), figures out how she can best serve them, with startling perceptive power. She retains her objectivity, but he represents to her all that she could have hoped for – she saves a patient who would have died, (I Will Keep You Alive, page 159) and he turns out to be a very dear human being. And she turns out to be all that Bob and Adele could wish for, all that any of us could wish for, a caring and immensely capable doctor who takes charge in just the right way. When Bob's mitral valve needs to be evaluated and perhaps replaced, she sends him to the local cardiac surgeon who is technically excellent, but who takes over in such a bumptious and self-important way that she has to wrest control back from him, because she says it's not time yet to operate, that she and not he will decide when it's time, and then sends Bob to another surgeon over in San Francisco who is more sensitive and sensible, and who himself exercises exquisite judgement when he gets into the heart, and figures he can tighten the valve instead of replacing it.

[Note to health policy people – this is why patients have to be able to go out of network!]

This, sports fans, is what we need to appreciate. This is how doctors should work, this is the attitude and the skill they need to develop and maintain, this is the ideal. Teachers of medicine – if I were you, I would make this whole book mandatory reading for trainees, and I would dwell on this appendix.

I could go on. I've been known to go on. I could discuss each of their pages with many more pages of my own and go well over 200 pages for this 164 page book (note that, everyone – a short book long on impact. Teachers – especially good for those med students who were selected for their scientific rather than humanistic abilities, which would be the great majority of them.) But I'm just going to stop here.

I've been a doctor and a policy analyst for a long time, and I've read a lot of medical books. This is one of the very best.

https://www.amazon.com/Will-Keep-You-Alive-Cardiovascular/dp/0997221429/ref=sr_1_1?keywords=bob+levin&qid=1554159797&s=gateway&sr=8-1

Budd Shenkin

Tuesday, March 26, 2019

Regulating To Fix Surprise Billing And Constricting Networks


About 18 years ago my son Pete had a big accident that took him to the Sutter Roseville Medical Center, the designated trauma center for the American River area where the 4,700 pound live oak tree fell on him. It was a very rocky course, he lost a kidney and had multiple fractures to the lateral processes of his lumbar spine and had a prolonged recovery lasting months, but the spinal cord was intact, his other kidney works fine, and he is alive and well and just gets a sore back sometimes. God smiled on us, is the way we looked at it.

What didn't smile on us was the surprise bill we received from the Sutter Roseville trauma surgery team. They obviously have no competition, since they are the only trauma surgeons at the only trauma hospital in the area. So why should they sign agreements with health insurance companies to join their approved networks, thus agreeing to a fee schedule that generally calls for lower payments for their services than if they had no restraint at all? Why should the hospital insist that they do so when they contract with them; what's in it for them? Fairness to patients? Don't be naive, we're talking about money here.

Despite the fact that we were well insured, we were then faced with many thousands of dollars of fees that the insurance wouldn't cover. This is called “surprise billing.” We protested – I'm a doctor and I don't take these things lying down – and eventually Blue Shield paid since it was an emergency and we really had no choice. Which didn't prevent them from claiming tens of thousands of dollars from the payments Peter received from the insurance companies that covered the liabilities of the parties who were responsible for the tree's having fallen. But that's insurance companies. No wonder they are hated. It is a hatred well earned.

We found out later that our situation was not unique, and today, all these years later with so many families having suffered, “surprise billing” has at long last become an issue to be solved. There are obvious very directive solutions available, such as requiring that all doctors with hospital contracts be part of the networks with every insurance company that the hospital has contracts with, but that has not been our governmental style, when special interests are well represented but people in general are not.

There is another out-of-network issue that is somewhat related and also troublesome. Sometimes you need a doctor or a facility that is outside of your insurance network. It might be a specialized service available only at a university, for instance. Or it might be just a specialist who is of decidedly higher quality than who is in your network. Your insurance company is supposed to negotiate with the needed out of network service provider and pay the bill, but they will predictably object that you really didn't have to go out of network, that the adult oncologist would have been “good enough,” and your child really didn't need a pediatric oncologist, or that their network member was good enough despite the opinion of your primaryc are doctor. Patients might have to fight for this to be covered, it can take a long time, the result is not preordained, and isn't that just what you need when you are dealing with illness, uncertainty about finances? It's really a disgrace, IMHO.

The issue can actually be rather subtle. The best primary care doctors want to act as the patient's medical fiduciary, looking out for the patient's best interest in every way, beholden only to the patient, not to the company who employs him or her, or to the payer. Sometimes, that means finding the best person and facility for the patient with every condition and for every test. Networks, based on who signs up for whatever reason, and those who don't sign up for whatever reason, constrains the ethical duty of the health fiduciary. What can be done to enable the doctor to refer the patient for the patient's best interest, despite network relationships? Something should be done.

In a recent paper in the New England Journal of Medicine, Prowell et al. suggest some remedies for the surprise bill in emergency care, and for paying for the necessary out-of-network care with “inadequate networks,” “without squelching desirable market dynamics,” as the saying goes. (https://www.nejm.org/doi/full/10.1056/NEJMp1815031)

What they propose is “streamlined dispute resolution.” This depends on the health plans and providers submitting to binding arbitration to determine what charges are “reasonable.” Admirably, they turn to the final offer method employed by Major League Baseball for a model.

In this approach the arbitrator must choose one of the two parties’ final offers, rather than determine the “right” amount independently. Although arbitration has some administrative costs, narrowing the options and disseminating precedents simplifies the process and encourages the two sides to reach a settlement on their own.”

They suggest that this technique could be used in each case when an out-of-network provider who rendered a service refused to accept the insurance company's offered payment, or it could be done prospectively.

While what they suggest would be an improvement over the current restrictive and patient-unfriendly non-system, it's really ridiculous to approach such a systematic problem on a case-by-case basis. Patients just should not be subjected to all this pressure, all this decision-making when they have such limited information. And primary care docs shouldn't have to waste time in fulfilling their fiduciary duty, time that could be better used inputting data to their EHR's. The law and organizations should work for this vital duo, not the other way round.

So, here's what I suggest. One, we need to compel hospital-based doctors to belong to the same networks that their hospital does. That's just got to be the law. What should be the rate of their pay? Well, why not use that same final-offer method? It's true that rates can't just be standard throughout a state or a region; sometimes there are scarcities and sometimes plethoras, and the market needs to be used to find proper rates. I would think the final-offer method should serve that purpose quite well. Exit the surprise billing problem.

Two, out-of-network ambulatory consultations, tests, and even prolonged care needs to be available to the vital duo (primary doc and patient) on a routine basis. One way to do this would be to introduce a law that out-of-network providers be paid at 110% of the rate they are paid by their highest paying network of which they are a member (or maybe second highest?) Not only is this obviously better for patients, but with this increased competitive pressure on networks providers who are currently protected by the assured in-network referrals, the quality of the network providers themselves should improve. It's true that a few providers are members of no network at all; for them, a percentage of Medicare rates could be established, or they could just be generally unavailable ( but only if there were an adequate number of similar providers available.) Presto! Free choice of patient and primary care provider would become much more of a reality, and market competition would be enhanced.

Freedom is a precious thing, but the time for freedom in medicine is long past. It is ruled by oligopolistic insurance companies, oligopolistic providers, and to a lesser extent by government. Our system will be replaced neither completely nor soon; what we need are rules and regs that progressively move it toward true competition in price and quality, and which progressively give patients a better deal. That's what my proposed new rules would do.

It's time to think straight and stop kow-towing to outdated concepts and imperfect understandings, and to show a little courage. Time's a wasting.

Budd Shenkin

Tuesday, February 19, 2019

Proposal: Presidential Pardon Reform Amendment


Amending the Presidential Pardon Power of the Constitution

The Presidential Pardon Reform Amendment

Being of an optimistic nature, at least at times, I can see this terrible Trump period as an interlude, a long and destructive one qualifying not just as a political (and moral) correction but rather as a full-fledged bear market, but an interlude nonetheless. America has risen from ashes more than once to be stronger and more just. So I am looking forward optimistically to the Trumpgate reform era. I'd like to think there would be Nuremburg-like hearings, perp walks, orange jump suits, national humiliations and referrals to the International Court of Justice for Crimes Against Humanity, steps that would serve justice, expiation, and deterrence. That's a dream. But realistically, we'll probably have to settle for reforms. But if they are good ones, in the end that will be good enough.

Most reforms will take the route of legislation. It's possible, however, if the anti-Trump tide becomes very, very strong, that this time may be a little different,and that Constitutional amendments might be considered in addition to legislation. The odds are always against a Constitutional amendment because they are so hard to do – two-thirds of each house of Congress and then three-quarters of the states are necessary. Still, it has happened 17 times since the first 10 were passed in 1791. Some have had profound importance, such as XIII and XIV after the Civil War, and XIX, women's suffrage, after that decades-long movement. Other more obscure amendments have been more like minor housekeeping. But who can tell when the next ones will declare themselves important and be passed?

Of the currently suggested amendments, the more profoundly needed ones will probably not make the grade. To succeed, amendments need both vigorous sponsorship and little opposition. Lack of opposition can arise from profound changes of power (Civil War) or opinion (suffrage), or because no one else's ox is sufficiently gored for that opposition to mobilize (issues of Presidential succession, forbidding a sitting Congress to raise its own pay.) I think this time there is one issue that might get through, though, depending on Trump's actions. I'll come to that possibility after mentioning a few others that would be more important, but which are unlikely to pass.


The range of possible amendments

The most needed amendments face long odds for passage because, no matter how impassioned the support, there are vested interests strongly opposed. For years the original 1787 compromise on state representation has caused great unfairness in the Senate and the Electoral College. In the Senate Wyoming has 2 Senators representing 550,000 people, while California has an equal number of Senators representing 40 million. The Electoral College system has elected both Bush 43 and Trump without a plurality of the popular vote, again by over-empowering smaller states. Yet, Constitutional amendments correcting this over-tilt toward the small states will be opposed by … well, the small states (and the conservative interests who are allied with them), and without their voting for their own diminution of power, there is no deal.

Similarly, a Constitutional amendment revising the much-reviled Citizens United SCOTUS decision, a decision that delivers excessive power to the corporations, will have great trouble being passed because … well, because corporations wield great power. At some point both of these situations will have to be revised, but it's hard to see how that happens without profound changes in the politics of the country, which could and should happen, but surely that time has not come yet.

A third possibility for amendment arises from the Merrick Garland spectacle, where the vague term “advise and consent” was interpreted in an excessively partisan manner by Mitch McConnell and the Republicans. A related fourth possibility would be limiting a Justice of SCOTUS to a term of perhaps 15-20 years. It is possible there would be enough intensity to wage the battle for these amendments, but it would seem that but the force of conservatism and partisanship would have to subside to an extent not currently foreseeable. One can hope, and the opposition to these would be less than for the first two. The proposed changes would be closer to housekeeping than marking a profound change of power, so they could pass, if not immediately. We shall see.

There is a fifth possibility, however, that although it is not so basic an issue as any of the above, it is also not so threatening to any constituency, and I could see it being pursued and passed if the proper conditions ensue. What would be the proper conditions? That would entail Donald Trump seeking to assert the power of the Presidential pardon to curtail the Russia investigation, to protect himself from that involvement and/or his financial infringements of the law, or doing the same for his family and/or his associates. It is this possibility I want to pursue in the rest of this post.


The problem with pardons

If Trump chooses to further misuse the Presidential pardon – he has already misused it simply by mentioning the possibility of using it in the current Special Counsel investigation – the cry to revise the system of Presidential pardons could become overwhelming. In that case, we could have The Presidential Pardon Reform Amendment (PPRA).

The President's ability to issue pardons is currently unfettered. There have been apparent miscarriages of justice in recent year related to this unfettered ability. The first instance I cite here is President Ford's pardoning of Richard Nixon to save the nation the convulsion of a trial and the inevitable sharpening of differences in an already acutely divided country. Just because a pardon is controversial doesn't mean it was wrong, and in Ford's defense, it might or might not have been a misjudgment, but it was not self-interested. In fact, he knew at the time it would hurt his chances for reelection, as indeed it did. Still, this pardon might have been a misbegotten profile in courage. What it certainly did was to hijack the course of justice and the faith of Americans in equality before the law, and to place the President in a separate category from ordinary citizen.

Far more egregious was President George H. W. Bush's 1992 pardoning the perpetrators of the Iran-Contra scandal, which was issued as a lame duck after he had been defeated by Bill Clinton. Iran-Contra was a particularly seedy and nefarious scheme of the executive branch to deceive the legislative branch in important policy decisions of war and peace. The miscreants were very prominent and powerful establishment people, many of whom were personally close to President Bush; they were relieved of probable conviction and prison terms. Not only was deterrence and equality before the law poorly served by these pardons, but those involved themselves were not sufficiently chastened. Since they were not convicted, they were not only not punished, they were also not publicly shamed. Even today we are faced with one of those pardoned, Elliot Abrams, unabashed, ready to serve the present Trump Administration in an official capacity in the same Latin America area where he funded death squads in the 1980's, and from which he should rightfully be banned. And even more than this: President Bush had only narrowly missed being one of the indicted, his ties could have been further elucidated by continued prosecution, and thus the pardon was close to a self-pardon. See this contemporaneous account: https://archive.nytimes.com/www.nytimes.com/learning/general/onthisday/big/1224.html#article.

To my mind this pardon was execrable, and is insufficiently appreciated as such. The perpetrators still think they were right to do what they did, damn the laws and the Constitution. In their minds they were righteously fighting Communism. The should have been able to think that from prison.

President Clinton had his own well-publicized last-day-on-the-job pardon that further besmirched the dignity and probity of his Presidency. He pardoned the shameless arms dealer Mark Rich (and Pincus Green as well) who traded with countries and people forbidden by United States law, and whose wife was a Democratic donor and Clinton supporter and intimate. More sordid than subverting the Republic, Clinton issued the pardon and slunk away, too naughty to be shamed. Once again, the principle of equality of the law was vitiated. Friends in high places is a particularly debilitating disease for a republic. https://www.justice.gov/archive/pardon/adams1.htm.

And now we are faced with the amoral Trump Crime Family Presidency. The Founding Fathers did not harbor illusions that Presidents and officials would be angels, but it seems clear that they never thought the Presidency would sink to the level of our current experience. Would they ever have imagined a President holding the scepter aloft with a pardon to bless those who will “stay strong” with omerta and those who are members of his own family? Did they imagine the President holding pardons as a threat against the working of justice of the state?

In sum, misuse of the Presidential pardon now seems less an aberration than a pervasive practice. The progression of poorly deployed pardons has become a tool contaminated by malignant precedents.


The Federalist Explantion

The detailed explanation for how the Presidential Pardon came to be is given by Hamilton in Federalist #74. He takes almost for granted the need for a pardon ability to be lodged somewhere, because the law is a blunt weapon, and there must be release from the accidental unwarranted cruelty of such a blunt instrument that in inappropriately applied. Human judgement and human mercy must have a place in the workings of the state. Hamilton takes more pain in thinking about whether the pardon should be lodged with just the chief executive, or distributed more broadly among a group. He opts for the individual on several bases, including this observation:

The reflection that the fate of a fellow-creature depended on his sole fiat, would naturally inspire scrupulousness and caution; the dread of being accused of weakness or connivance, would beget equal circumspection, though of a different kind. On the other hand, as men generally derive confidence from their numbers, they might often encourage each other in an act of obduracy, and might be less sensible to the apprehension of suspicion or censure for an injudicious or affected clemency. On these accounts, one man appears to be a more eligible dispenser of the mercy of government, than a body of men.”
And also:
It is not to be doubted, that a single man of prudence and good sense is better fitted, in delicate conjunctures, to balance the motives which may plead for and against the remission of the punishment, than any numerous body whatever.”
Hamilton can't seem to help it – in that day of giants, even though they had their share of thieves, sharpies, and dullards, he couldn't help but see the President as a man of high character. We know better. The years have given us more information of theory in action than was available to Hamilton and Madison. Their arguments and theories still hold, but their choices were not extensive enough. They assumed the need for pardon, as we should also. They then posed their choice, however, as that between lodging the choice in just the President or in a group. It seems to me we can postulate a third choice.


The case for the Presidential Pardon Reform Amendment (PPRA)
One way of limiting the Presidential options would be to make certain classes of pardons illegal – family members, for instance, or making certain crimes ineligible, or making preemptive pardons ineligible. The possibility of self-pardon could also be clarified by specifically excluding it. The problem with making the eligibility for pardons more specific, however, is that it is always impossible to cover every nefarious possibility. You can never specify every disadvantageous situation that will occur, and a clever perpetrator will usually find a way around a prohibition. Instead, I propose that we find a solution between the single chief executive and a group decision. I propose we use the principle of requiring a co-signature:
I propose a Constitutional amendment whereby the power of the President to pardon is abridged by requiring the cosignature of the Speaker of the House of Representatives.
This is not a foolproof solution. The two individuals can conspire toward a common end, which would be especially possible when both offices were held by the same party. Two office holders of poor character would not be an unknown situation; such unworthy characters could well trade favors in behalf of cronies. But imagine how much more unlikely the unwarranted pardon would be if two signatures were required rather than one. Imagine how much more difficult it would be to perpetrate an assault on the integrity of the state if two signatures are needed rather than one. Imagine the enhanced vigor that would be experienced by the House in this era that has handed so much power to the Executive, which the founders imagined would be much the weaker institution.


How would it have worked in the past?
How would a co-signature requirement have affected the three pardons cited? When Ford was President the Speaker was Carl Albert, a centrist Democrat. Would he have confirmed Ford's choice? Probably yes, which would have provided good cover for Ford; the choice would have been seen as one of the ongoing Establishment, rather than that of a single actor. If he hadn't assented, well, who knows what would have happened? In any case, it seems somehow more just for an institutional decision to be made by a wider group than a single person. Different pardons are different.
The Speaker of the House for Bush's pardon was Tom Foley, another Establishment Democrat. I would say it would have been highly unlikely that Foley would have approved this self-serving pardon and justice would have been well served.
The Speaker of the House for Clinton's last-minute pardons was conservative (and currently jailed) Republican Dennis Hastert. There is no way in the world he would have approved the Clinton rush job. Justice delivered.
On the other hand, for every reform there are Unforeseen Consequences. What might these be for the Presidential Pardon Reform Amendment? It is by definition hard to see the unforeseen. As Hamilton observed, there might be a loosening of the sense of responsibility for delivering justice when the responsibility is more diffuse. The bureaucratic procedures that now exist within the DOJ might be more pervasive and forestall just but politically dangerous acts of charity. It's hard to say.
Possibly the worst UC would be that pardons enter more fully into the partisan political process. Trading in pardons between the President and the Speaker as leader of each of their parties might abrogate the quality of mercy, which would be an awful shame.
It's amazing that, when all is said and done, when institutions and laws are manipulated, in the end, it is the quality of the human beings involved that makes the biggest difference.


Is PPRA a practical reality?
To pass a Constitutional amendment, the issue must be one of manifest importance so that enthusiasm and intensity is high, and yet of low controversy. For enthusiasm to be high enough, Trump would have to use the pardon power even more egregiously that he has so far. The odds of this occurring are high. If Trump starts to brandish the power of the pardon to protect himself, or if he has already done so and it becomes more obviously apparent, I can't imagine that the need for the amendment wouldn't be obvious.,
So, then, who would be against the PPRA, and how intensely? The most intense opposition for proposals emanates from vested interests, from one's ox being gored. It is this element that sets the PPRA apart from other possible amendments, because it's hard to discern which significant vested interests would oppose it. There might be principled opposition by those who support a super-strong presidency. There might be principled opposition by those who fear the entry of the pardon system more routinely into the political system with its wheeling and dealing, its trade making, its partisanship. But if the Trump pardon misuse outrage becomes outrageous enough, it will be obvious that norms will have to become laws, and something will have to be done. The PPRA might become necessary in those circumstances. I could even well imagine that passing this amendment could become part of the process of healing the rift between the parties.


It is a shame is that the other amendments that have been mentioned are more central to improving the republic – electoral and representational reform and Citizens United are more important. I wish they would be possible, but I could only see that if the politics of the nation undergo a major change, which it could, but it will take years. Meanwhile, I'd grease the wheels of amending the Constitution by instituting a co-signature requirement for the Presidential Pardon. And who knows, maybe the process of passing PPRA will grease the wheels for these more important reforms.


Budd Shenkin


PS – Here is Federalist # 74
http://avalon.law.yale.edu/18th_century/fed74.asp

The Command of the Military and Naval Forces, and the Pardoning Power of the Executive
From the New York Packet.
Tuesday, March 25, 1788.

HAMILTON

To the People of the State of New York:
THE President of the United States is to be "commander-in-chief of the army and navy of the United States, and of the militia of the several States WHEN CALLED INTO THE ACTUAL SERVICE of the United States.'' The propriety of this provision is so evident in itself, and it is, at the same time, so consonant to the precedents of the State constitutions in general, that little need be said to explain or enforce it. Even those of them which have, in other respects, coupled the chief magistrate with a council, have for the most part concentrated the military authority in him alone. Of all the cares or concerns of government, the direction of war most peculiarly demands those qualities which distinguish the exercise of power by a single hand. The direction of war implies the direction of the common strength; and the power of directing and employing the common strength, forms a usual and essential part in the definition of the executive authority.
"The President may require the opinion, in writing, of the principal officer in each of the executive departments, upon any subject relating to the duties of their respective officers.'' This I consider as a mere redundancy in the plan, as the right for which it provides would result of itself from the office.
He is also to be authorized to grant "reprieves and pardons for offenses against the United States, EXCEPT IN CASES OF IMPEACHMENT.'' Humanity and good policy conspire to dictate, that the benign prerogative of pardoning should be as little as possible fettered or embarrassed. The criminal code of every country partakes so much of necessary severity, that without an easy access to exceptions in favor of unfortunate guilt, justice would wear a countenance too sanguinary and cruel. As the sense of responsibility is always strongest, in proportion as it is undivided, it may be inferred that a single man would be most ready to attend to the force of those motives which might plead for a mitigation of the rigor of the law, and least apt to yield to considerations which were calculated to shelter a fit object of its vengeance. The reflection that the fate of a fellow-creature depended on his sole fiat, would naturally inspire scrupulousness and caution; the dread of being accused of weakness or connivance, would beget equal circumspection, though of a different kind. On the other hand, as men generally derive confidence from their numbers, they might often encourage each other in an act of obduracy, and might be less sensible to the apprehension of suspicion or censure for an injudicious or affected clemency. On these accounts, one man appears to be a more eligible dispenser of the mercy of government, than a body of men.
The expediency of vesting the power of pardoning in the President has, if I mistake not, been only contested in relation to the crime of treason. This, it has been urged, ought to have depended upon the assent of one, or both, of the branches of the legislative body. I shall not deny that there are strong reasons to be assigned for requiring in this particular the concurrence of that body, or of a part of it. As treason is a crime levelled at the immediate being of the society, when the laws have once ascertained the guilt of the offender, there seems a fitness in referring the expediency of an act of mercy towards him to the judgment of the legislature. And this ought the rather to be the case, as the supposition of the connivance of the Chief Magistrate ought not to be entirely excluded. But there are also strong objections to such a plan. It is not to be doubted, that a single man of prudence and good sense is better fitted, in delicate conjunctures, to balance the motives which may plead for and against the remission of the punishment, than any numerous body whatever. It deserves particular attention, that treason will often be connected with seditions which embrace a large proportion of the community; as lately happened in Massachusetts. In every such case, we might expect to see the representation of the people tainted with the same spirit which had given birth to the offense. And when parties were pretty equally matched, the secret sympathy of the friends and favorers of the condemned person, availing itself of the good-nature and weakness of others, might frequently bestow impunity where the terror of an example was necessary.
On the other hand, when the sedition had proceeded from causes which had inflamed the resentments of the major party, they might often be found obstinate and inexorable, when policy demanded a conduct of forbearance and clemency. But the principal argument for reposing the power of pardoning in this case to the Chief Magistrate is this: in seasons of insurrection or rebellion, there are often critical moments, when a welltimed offer of pardon to the insurgents or rebels may restore the tranquillity of the commonwealth; and which, if suffered to pass unimproved, it may never be possible afterwards to recall. The dilatory process of convening the legislature, or one of its branches, for the purpose of obtaining its sanction to the measure, would frequently be the occasion of letting slip the golden opportunity. The loss of a week, a day, an hour, may sometimes be fatal. If it should be observed, that a discretionary power, with a view to such contingencies, might be occasionally conferred upon the President, it may be answered in the first place, that it is questionable, whether, in a limited Constitution, that power could be delegated by law; and in the second place, that it would generally be impolitic beforehand to take any step which might hold out the prospect of impunity. A proceeding of this kind, out of the usual course, would be likely to be construed into an argument of timidity or of weakness, and would have a tendency to embolden guilt.
PUBLIUS.

Thursday, February 14, 2019

The Terrible Gaussian Curve


One of my Harvard Medical School classmates just notified us on our class listserve that one of our classmates, John Gunderson, has died. John transferred in from Dartmouth in our third year, so I hardly knew him, but it turns out that this was very much my loss. Here is his obit in the NYT – he was a real star: https://www.nytimes.com/2019/02/08/obituaries/dr-john-gunderson-dead.html.

Another of our classmates, Anna Kadish, responded that “as time passes we will unfortunately be seeing more of these.” Indeed we will. We are all about 77 years old; we are an age cohort.

I hate the fucking Gaussian Curve – also known as the Bell Curve. The left arm of the curve has the early demisers – I still miss poor Paul Schnitker, that nervous and intense thin blond smoker from Yale, very much at the heart of our class because he came early and stayed late to our long, large dining room tables at Vanderbilt Hall where most of us lived the first two years. He graduated, did an internship, joined CDC, and almost immediately was killed in a plane crash in the field, I think Nigeria. Classmate Al Hurwitz called to tell me and I just didn't know what to say or do, my emotions were not available to me. I still haven't cried for Paul, which is maybe why I still feel it so acutely. I'd say we all do. Intense and sensitive and endearing Paul was well and truly loved. He was about #1 on the left arm of the curve.

Harris Funkenstein, the sensitive son of the psychiatrist who did most of the interviewing for applicants and was known to ask interviewees to open a window he had nailed shut, drowned in Florida, also on the left arm of the curve. As the curve rose gradually, others died. Mike Lisanti, my 3rd year roommate. Rich Schulman, our class president, an intense cardiologist from nearby Swampscott, Mass, who moved to Rhode Island. Others, too. The left arm is rising. The highest rate if dying hasn't been hit yet.

I hate that fucking curve. It is inexorable. I imagine I'll accept my own death pretty well, I guess, but I sure resent my friends and classmates dying. Nobody gets out of this alive; pisses me off. Equanimity eludes me. I can't take solace in the odds that we have all already surmounted – after all, how many sperm were fighting for that singular ovum when ours was the only one who won? Pretty soon we'll be dropping like flies in the middle of the curve. So many people to be missed. And if we are not among them, if we come out on the descending right arm of the curve, well, it's just a question of years. The end is completely predictable for these lives which have themselves been so unpredictable.

I wrote a poem a year or two ago. It's a short poem:

We live in the memories of our friends and loved ones,
And then not even that.

I hate that curve.

Budd Shenkin

Sunday, December 30, 2018

NBA All Star Weekend -- Territorial Pick 3 on 3 Tournament!


We all come from someplace. From the very first, when all that exists for us is our mother and us, to when it includes daddy and sibs and neighbors and schoolmates and other schools we play our games against to summer camps to select teams to college, way up to the NBA itself, no matter how far we ascend, we all come from someplace. We know our origins, we are fond of our origins, we honor the people who made us who we are, and we are thankful, nostalgic, and even patriotic about where we come from.

Me, I'm still a sucker for Philadelphia, even though I've lived in Berkeley for 45 years. Philly is where I grew up, where I had my first hoops outside my house, who knows why my Mom insisted that we have hoops outside our houses, but we did, all three of them, each one higher than the last, up to 10 feet finally. Philly is where I finished my homework by 8 o'clock so I could watch the Big 5 compete on Channel 12 from Wilmington in black and white. God, I loved Guy Rodgers and Temple, and St. Joe's! And my high school teams, you probably heard about my high school, Lower Merion. I tell people that my own crossover move, copied through the years at LM, is what later sent Kobe on his way. It's a nice joke.

While my first hero was Joe Fulks, and then Paul Arizin, the overriding superhero of all was, of course, Wilt, from Overbrook High, just northwest of me when I lived in West Philadelphia, and just southeast of me in Lower Merion. Wilt, the God. How strange it seemed when he up and left for Phog Allen and Kansas for college! What was he doing in those cornfields? Especially a black guy? And then the Globetrotters as he waited to come to the NBA. In those days the college game was bigger than the NBA, and truth to tell, there were a bunch of Jewish guys and other what we would now call “minorities” or “ethnics” who were trying to create and sell the pro game. So they knew that guys like me knew who “our” guys were. They were the guys who came from where we came from.

So, to promote interest, the owners laid claim to their own guys, guys who grew up there, or at least went to college there, which was frequently the same thing. Thus was born the “Territorial Pick” in the draft. The Philadelphia Warriors got a bunch of guys that way – Arizin, Rodgers, Ernie Beck from Penn, Tom Gola from LaSalle, and then Wilt. (https://en.wikipedia.org/wiki/NBA_territorial_pick.) You can look it up. Our guys were our guys, and we cheered for them, and loved them.

Philly-ball was different from New York-ball, from Chicago-ball, from Indiana-ball, at least that's the way it seemed, and our guys were our guys. Sometimes you still hear in interviews with the players how they heard of other guys growing up, how they played with and against them, how they still have that sense of where they're from. Now that the NBA is so big, so worldwide, they don't need that localism anymore. Now that free agency has been established – a good thing – and now that fantasy teams are so popular that the NBA GM's and even the players themselves play it with real teams like Miami and the Warriors, we're used to non-localism. But, that doesn't mean that localism is dead. At least I don't think it is. Especially in my mind, it isn't. I still sit and watch, me in my chair and Ann on the couch at 90° on the other side of the side table from me, and I'll say – “He's from Philadelphia!” And, from another sport, every time Hallie Jackson or Jake Tapper says something about the Eagles, I say, “Eagles!” and Ann grins and puts her hands over her eyes as if to say, “Oh, no, Philadelphia again!”

All of which is a long-winded way of getting around to my very practical suggestion. The league has wisely tried to make All Star Weekend an entertaining event time, with the three point contest and the dunking contest. All that's missing is the players game of Horse – hey, come to think of it, wouldn't that be great??? Or Team Horse??

But I digress; that's not my suggestion. My suggestion goes back to localism. What I'm proposing is this: a 3 on 3 Territorial Pick Tournament. 3ON3TPT – why not? Here's how it would work:

The teams would consist of players who grew up in the same place, specifically, where they went to high school. Each team would have an organizer, which could be a retired player or a current player, and they would choose five players a piece, three starters and two subs. The games would be 15 minutes long, half court, and the subs could come in only once. Retired players would be eligible – if Wilt were still around, he could have played until age 70. It would be The Chicago Guys vs. Philly Cheesesteaks; Bay Area Bombers vs. LA Slugs; North Carolina Stalkers vs. Indiana Larrys. The Serbian Sluggers. Maybe have 6 or 8 teams a year with single elimination.

It could work lots of ways, but you get the drift. Bring back Where You're From, back from the chaos of free agency and fantasy leagues. We all have a sense of where we're from. That never goes away.

Tell me that wouldn't be a winner!

Budd Shenkin

Sunday, November 18, 2018

What Price Nostalgia?




I'm pretty sure my now-classic Omega Seamaster watch was a college graduation gift. It must have been my Aunt Bea (actually my maternal great-aunt) who gave it to me. She gave me mother of pearl cuff links for use with a tuxedo when I graduated from high school and was set to go to Harvard. She had a taste for the finer things, and a taste for formality. It's kind of funny to think of what she thought would happen at college, vs. reality. For her, Harvard equaled formal social events. My paternal grandmother, another Eastern European immigrant, was overwhelmed when she heard my next door neighbor in the dorm was named Sam Saltonstall. “Stay close to him,” was her advice. She didn't know that Sam's main passion was his trumpet, and I think the famous surname weighed on him. My God, they must have thought, from immigrant to Harvard in two generations. What a country! I don't think they knew I was there to work, hard. But what the hell.

Aunt Bea was the eldest of the five Chertak sisters, “Litvaks” my father claimed, an industrious group full of hopes, I imagine. Bea had become a Philadelphia socialite. Mysteriously to me, she would arrive at our house in her Buick driven by a uniformed chauffeur from her luxurious house (at least luxurious to me) on the Main Line. But grand and blond as her entrance might have been, what arrived to the four of us kids was the warmth she exuded from her corpulent body and outstretched arms. With no children of her own, we were as close as she was going to get. How she had arrived at her chauffeur-driven status we couldn't guess, nor how she had become a socialite, which had included her membership on the board of the Robin Hood Dell, the outside summer setting for the Philadelphia Orchestra. Later on she moved into town at the Rittenhouse Plaza with her likewise childless sister Sadye. We visited them often; they noted affectionately how we liked to eat the nuts which they had on a silver platter on a coffee table, beside a slim silver bowl with a few cigarettes. As an awkward teenager with a photography hobby, I took pictures of Sadye's late in life second wedding at their apartment. I developed them and enlarged them myself, and some of those pictures were on constant private display under the thick glass table tops of their bedroom bureaus. They were still there when Sadye died and all the grandnephews and nieces reviewed the remaining contents of their lives.

My father complained that other husbands only had one mother in law but he had five – our holiday dinners included my grandmothers, Sadye and Bea, sometimes Dorothy and Bill from New York, and sometimes others. A big crowd in a small suburban development home. My Dad resented how many relatives there were on his wife's side – I don't think he thought that they sufficiently respected his rightful status as king, or maybe he just felt like an outsider with only his mother representing his side – and he seemed to resent especially Bea's pretensions, but we loved her warmth. We loved the family playing 21 (Blackjack) after the table had been cleared, with the kids “helping,” and Uncle Bill going “bank-o!” with his bet, and everyone saying “Oohhhh!” at his wild sally. When I was in high school we had a nickname for Bea, I think initiated by my friend Ed Packel - “Wide Zorch.” Even though it was mildly derisive, she loved it. When she would arrive at our house, she would say, “What is it you call me?” We would giggle, “Wide Zorch!” She would say with her widest smile, “I'll Zorch you!” I can't help smile with tears in my eyes, verily as I write this. Aunt Bea, what a character.

Aunt Sadye would reminisce about the 1920's. “They were wonderful,” and she'd shake her head a little at past enchantments. It might have been something like our 1970's. In the 20's Bea and Sadye would spend summers together in Paris every year. I have a couple of menus, one inscribed to Bea from “The Major,” whoever he was. I framed it and put it on our wall. Bea's French pretty much stopped with “Comment ça va,” I think. But when she said it, it was with brio. The memories.

We never heard that much about their history, at least I didn't, but I heard some from my sisters, who probably heard it from my mother in girl-to-girl talk. Turns out that Bea had gone to work as the secretary of the owner of a big Philadelphia department store, House of Wenger. Before you knew it, Mrs. Wenger was out and Bea was in. At least that's the way I heard it. Or maybe he was never married, but I think he was. In any event, that explained the money, which in turn explained the social standing. He was older and gone well before I arrived, but Bea was very much there until I was in medical school. The last I saw of her was when I came to see her in the hospital and all I saw was her going to some test on a gurney, and she looked my way and said, “Buddy!” with hope and connection to her world of love, and then off she went. Like the last time I saw my Dad in his hospital bed on a Friday night as I flew into Philadelphia from San Francisco, and his “girlfriend” at his bedside said, “Buddy's here!” and I showed him a short video clip of The Producers, his favorite show, on a portable video players, and he smiled and pointed at it – another cherished memory of laughing – and in the morning I got a call that he was gone. What are you going to do?

I think it was Aunt Bea who gave me my Omega Seamaster watch when I graduated from college. Probably. My father marveled at it, I think. He told me how special it was. It was almost like it was a present to both of us. I'm wondering if he could have given it to me, but that's not the way he rolled, and proud as proud could be of me, his gifts were more utilitarian. I owed nothing for four years of college and four years of medical school, there was never any question. I took it with gratitude, but he never asked me for that. All I had to do was to do my best, which I did, and the bargain was complete.

I wore that Seamaster for years, I replaced the strap a couple of times and finally came up with a Speidel expandable band, but then other watches came, the Seamaster lost its crown at some point, and I kept it in the top drawer of my Nakashima dresser for decades. A few years before he died at age 92 when I visited my father in Philadelphia, he pulled out his new watch to show me. It was one of the first digitals. He said, “I finally got the watch that does everything I want it to do! Here it is. And I got it for free from my dry cleaner!” I guess it was a Casio, but it could have been a Timex. Date and time, and probably even a stopwatch, all powered by a little battery.

It's true, I'm my father's son in so many ways. For years now my watch has been a Casio. The latest version is a Casio W-201, $15.68 from Walmart. It did everything I ever needed; what could be better as I went from exam room to exam room? Indestructible; let my patients pee or poop on it, I don't care! The band wears out before the battery dies, amortized at what, $1.75 a year? Comfortable, waterproof, you don't have to move it on your wrist to activate a self-winding feature.

Of course, practicality isn't everything, is it? The Seamaster is just what my admiring father said it was, a classic. In these days of watches as jewelry, even though I eschew jewelry for myself, there it is, I have it. It wouldn't be wrong to wear it for, I guess, occasions, or even every day if I wanted. And its a twofer. I look at it and I remember, not only Bea and the family, but my place in it, her love, my Dad's love, the original family, their pride, their foibles. And the jewelry part is just a throw in, although I can point to it with pride.

No need to choose. It cost me $750 to clean up the Seamaster, add a new crown, and add a nice leather strap. Estimated value of this classic, $1,250. Estimated value of the superior functioned Casio, $15.68 minus two years of depreciation. I'm wearing them both. At different times.

In the end now, at least for the present, it appears that I prefer the Seamaster. Not for the luxury, that wouldn't be Shenkinesque. For the memory, for the feeling. I like it. Works for me. The memories. The mysteries that were never explained.

I wonder who this guy The Major was?

Budd Shenkin