Check out this new blog

I've been working for a few months with Dan Callahan, Shep Nuland, and Mary Crowley of the Hastings Center to develop a new blog. It's called Over65. Our aim is to foster a voice for progressive-minded folks over 65 who will comment thoughtfully on health care, social security, and other aging-related issues. We felt that there's a lot talk about  the Medicare generation, but not enough talk from that group. We think of the blog as the first step in what we hope will become a series of linked projects, aiming to build a foundation for more thoughtful policy discussion of issues involving aging and intergenerational equity than has happened to date.

I'll be travelling for two weeks, and will look forward to returning to both blogs when I'm back

Old against young in Japan

If you read about a country with economic problems where "already indecisive leaders [are] loath to upset retirees from the baby boom who make up more than a quarter of the population and tend to vote in high numbers," you might guess that the article was about the U.S. and Medicare. It's not.

It's about Japan and the value of the yen.

In 2007 the Japanese yen was trading at 123 to the dollar. In the post-2008 economic crisis the yen was seen as a safe haven currency. Its value went up. It now trades for about 78 to the dollar.

So what does the exchange value of the yen have to do with intergenerational conflict? An article in today's New York Times explains why the old and the young are fighting about currency.

The strong yen makes imports cheaper. Cheaper imports drive down domestic prices as well. Older people on fixed incomes can buy more. What cost them 123 yen in 2007 costs them only 78 yen now. But a strong yen makes exports more expensive, and Japanese industry - very export dependent - is suffering. This hurts the young.

Japanese political scientists say the government has tolerated the strong yen out of fear of the elderly. Shigeru Ono, a 62 year old retired oil company manager who lives on a monthly pension of 130,000 yen (approximtely $1,660), understands the intergenerational conflict:

The strong yen and deflation have been a boon for us baby boomers. But I also know that they cannot be good for my son’s generation.

The U.S. is struggling to contain the cost of Medicare. Japan is struggling with the impact of a strong yen. In families, grandparents cherish children and grandchildren. But in wider society the relationship between generations is playing out differently.

The future well being of both countries depends in large measure on the balance of competition and cooperation between old and young.

Massachusetts nibbles at the cost bullet

On the last day of the legislative session, the Massachusetts Senate unanimously approved a 350 page health reform bill. The House approved it by 132-20. Governor Patrick has said that he will sign it. (The bill itself is not yet available on line - I've read about it but not yet seen it.)

Like the Affordable Care Act, the Massachsetts bill includes a wide range of policy steps - creating an oversight agency, promoting transparency about costs, supporting wellness programs, encouraging global budgets and an end to fee-for-service, and more. But the key component is the line in the sand about overall health care costs: between 2013 - 2017 cost increases should not exceed the growth of the state economy. For 2018 - 2022 cost increases should be at least 0.5% below the state economy growth.

So what happens if costs exceed the target?

Since total health care cost is the sum of thousands of independent charges (by hospitals, medical offices, equipment vendors, and more) and payments (by insurers, patients, government, and more), there's no one to hold accountable and no real enforcement mechanism.

Representative Steven Levy's twitter comment on the cost containment commitment was (1) "lol" and (2) "only concrete thing in it is more bureaucracy and fees." He's not right, but he's not completely wrong.

Even without a true accountability structure or enforcement mechanism, the cost commitment matters. The situation reminds me of all the times my wife and I said to our sons some form of - "we expect you to do XYZ." By the time they were teen agers they were smart enough to ask - "what happens if I don't do XYZ?" We tried to avoid too much sabre rattling and generally said something like "we expect XYZ to happen - if it doesn't we'll deal with it then..."

Of course XYZ didn't always happen. Sometimes there were consequences. Sometimes there were apologies and resolutions to do better. Occasionally our sons would persuade us that XYZ was the wrong expecation - it should have been ABC. But we always took it seriously if XYZ didn't happen.

Managing a state with 6.5 million residents and $80 billion in health expenditures is rather more complex than managing a four person family, but I expect the same process I experienced as a parent to happen in Massachusetts.

Until now we've not had explicit expectations for health costs. Now we do. Measuring how we're doing in relation to a commitment is different than wringing hands over "unsupportable cost increases." Our legislators and Governor have made a promise. It's not clear how they, and we the citizens, will accomplish it. But we can't avoid paying attention to it, working on it, learning from what happens, and taking next steps.

The law sets a process in motion. It's not a silver bullet. It's more like tying a string around  a finger to ensure vigilant attention. But that's more than our state, or any state in the U.S. has done before.

Jekyll and Hyde in Medical Practice

 I've written many times about how doctors who exploit patients sexually can provide excellent care to and be idolized by their other patients. I just learned from my friend Dr. Brian Hurwitz that the same can be true for doctors who murder their patients!

I first met Brian when I spent three months at the King's College London Centre for Medical Law and Ethics in 1992. He was doing an MA at the Centre, and allowed me to spend a fascinating day with him in his general practice surgery. For the past ten years he's been D'Oyly Carte Professor of Medicine and the Arts and Director of the Centre for the Humanities and Health at King's College.

Brian sent me a not-yet-published chapter he's written about Dr. Harold Shipman, the GP who was ultimately found to have been a serial killer who murdered more than 250 of his patients. The chapter included this remarkable quote from the son of one of the patients Dr. Shipman was found to have murdered:

I remember the time Shipman gave to my Dad. He would come around at the drop of a hat. He was a marvellous GP apart from the fact that he killed my father.

Shipman never admitted his guilt and refused to talk with psychiatrists, as did his surviving family. He committed suicide in prison in 2004. Although many colleagues and members of the community where he practiced noted strange occurrences in Dr. Shipman's practice, no one was prepared to draw the retrospectively obvious conclusion - a trusted, beloved physician was killing his  patients!

I think the best comment about people like Shipman comes from "The Shadow," an old time radio detective whose adventures I followed as a child. (The Shadow had the gift of invisibility.)

Who knows what evil lurks in the hearts of men? The Shadow knows!

Who's taking care of Mom?

The July Journal of the American Geriatric Society has a disturbing article - "Hiring and Screening Practices of Agencies Supplying Paid Caregivers to Older Adults."

Researchers at Northwestern School of Medicine posing as prospective clients seeking a caregiver for an elderly adult relative, contacted 180 agencies and asked about hiring, screening, and supervisory practices. Their findings aren't pretty!

67% of the agencies required experience, but this was often assessed by self-report. 62% checked references. 92% checked criminal background within the state, but no agencies checked other states, meaning that someone who had been convicted elsewhere would appear to have a clean record. English language proficiency was assessed via the interview, and no agencies assessed health literacy (ability to understand physician recommendations, dosage schedules, and so forth). 31% conducted drug screening. 7% verified citizenship or visa status. Training and supervision were very limited. The researchers conclude:

The screening and training practices in use by caregiver agencies are highly variable and often of poor quality. Using an agency to hire paid caregivers may give older adults and their families a false sense of security regarding the background and skill set of the caregivers.

Home care for the elderly has the makings of a perfect storm. It brings together vulnerable elderly with a marginalized population of poor, often immigrant, workers. This is a setup for exploitation - sometimes of the elderly by the "caretaker," and sometimes of the caretaker by the agencies that hire them.

When my father, who lived 1,000 miles from where I was, lost his vision and entered the early stage of cognitive decline, my cousin needed a place to live and moved in with him. He provided eyesight, companionship, and driving. My father provided lodging and paid for food. It was a true win/win situation.

But this kind of good luck is the exception, not the rule.  Agencies, like the 180 surveyed in the study, are filling a vacuum in our fragmented society. Unfortunately, as the study reveals, being hired by an agency is not a reliable stamp of approval.

Teaching Ethics in High School and Middle School

I'm in Vermont at the Bread Loaf School of English, a Middlebury College program in which the students, primarily high school and middle school English teachers, can get a Master's degree in the course of five summers. My wife has been teaching here every summer since 1992 and I've been enjoying the potential for (a) telecommuting and (b) swimming and hiking in Vermont.

This year the Bread Loaf program has a new format for elective workshops, and I'm doing one next Friday on teaching ethics in high school and middle school. I've never taught at that level, but I've taught medical ethics at Harvard Medical School for many years, and I wanted to see whether and how that experience could be extended to pre-college English classes. I hope the participants learn as much as I have in preparing for the workshop.

Since the content of the medical school course isn't relevant for pre-college English classes, I dissected out the underlying goals I have for the medical students. I identified five:

1. Strengthen ability to identify ethical issues, ideally combined with a zest for tackling these issues – a capacity that can be called “moral imagination” or “moral sensitivity.”
2. Impart systematic approaches to resolving ethical questions – approaches, not answers.
3. Enhance skills and attitudes that promote considering the views of others in a respectful manner – listening to those we’re talking with and, imaginatively, to the views of other stakeholders to the issue. 
4. Cultivate the habit of using our own "gut" reactions as “data” for ethical reflection, not necessarily as “truth.” This doesn’t come naturally to most adults, and is even more challenging for adolescents. 
5. Enhance capacity to reason to a justifiable conclusion and articulate the rationale for our conclusions.

In preparing for the workshop I came upon the work of Tom Wartenberg, Professor of philosophy at Mount Holyoke college, who teaches a course in which undergraduates (a) examine children's books through the lens of articulating the implicit philosophical content of the stories and (b) train to lead discussions for fifth graders at a nearby charter school. (The website is very worth a visit.) In an interview he described his objectives for elementary school children as essentially the same as my objectives for Harvard Medical students. His aim is to teach children how to "philosophize," not about the content of philosophy per se. The children dove into the discussions with the same gusto that makes teaching the course to medical students such  a privilege and pleasure.

Apart from the specific content focus of ethics education, the attitudes and skills required for reasoning about ethical issues are the fundamental requirements for democratic participation. I'll depend on the teachers who participate in the workshop for ideas on whether and how including ethics in high school and middle school English classes is (or is not) a promising practice in an era dominated by standardized testing.

Sexual Intimacy in the Nursing Home

The most recent issue of the Journal of Medical Ethics has an excellent article from the Centre for Evidence-Based Aged Care in Australia - "Dementia, sexuality and consent in residential aged care facilities."

The authors' argue that "while we must abide by laws regarding consent and coercion, in general we [in the West] expect to be able to engage in sexual behaviour whenever, and with whomever, we choose." In their view, nursing homes should allow for sexual intimacy and interfere only for clearly defined reasons, rather than treating sexuality as a special privilege that must be earned by requiring both parties to "prove" decisional competence, and, often, to require permission from families.

The authors are drawing on the concept of "dignity of risk." Meaningful life entails taking risks. If we agree with John Stuart Mill that as long as individuals are (a) not causing harm to others and (b) understand the nature and consequences of their proposed actions ("decisional competence"), then(c) their liberty should not be constrained. The authors recognize, but do not discuss in depth, the challenge of assessing "competence" in the presence of dementia. To my reading they underestimate the potential risks, as when one party erroneously believes that the other is their spouse or partner. But they're right that we tend towards excessive prudishness with regard to sexuality in our parents and grandparents.

This was the explicit focus of teaching when I was a medical student. We were in our 20s, so patients in their 70s and 80s were the age of our grandparents. When teaching us how to take a medical history our instructors warned us that we might feel uncomfortable asking about sex with patients in that age range. They reminded us that we were doctors-in-training learning a medical role, not prurient children or grandchildren peeking through keyholes into a bedroom.

My father was something of a ladies man. He outlived three wives and, over the years, I was aware of a number of his girlfriends. In the final months of his life he suffered from dementia and heart failure, along with blindness, and was in a nursing home. On a visit that turned out to be just two days before his death, we returned to his room to find an elderly woman lying on his bed. I said in what must have been a saccharine-toned voice "this is my father's bed." She responded, with a mischievous smile and a twinkle in her eye, "I know."

Knowing that flirtation was alive and well so near the end of my father's life is a happy memory for me!

(The full article is only available by purchase, but a free abstract is available here.)