Thursday, December 31, 2009

Music of the Year, 2009 ed., or, I'm Still Cool, I think. I hope. Maybe?

I went to another sing-in of Handel’s Messiah this year. It was very pleasant, and very amateur, but it reminded me of how much I really do love that oratorio. That, in turn, made me think about all of the other amazing music I’ve listened to this year. Which, in turn, made me think that I needed to blog about said music. So, without further delay, here are some of my favorite albums of 2009.

1. Arcade Fire, Neon Bible. Oh. My. Gosh.

2. Vampire Weekend, Vampire Weekend. Weak, I know. This is a 2008 album. I don’t care, because this album hit me with a vengeance this year. I mean, this entire album just rocks. I’ve witnessed it make a 23 yo female have a near-epileptic attack from the compulsion to dance and I’ve also seen it keep a car full of three typically-noisy kids quietly occupied for a 20 minute car ride to the fish store. Unbelievable. And not to mention the sweet tunes. I really can’t wait for Contra, the sophomore album to come out on 01/11/10.

3. Phoenix, Wolfgang Amadeus Phoneix. I heard about this band first on NPR’s All Songs Considered. A French band that sings only in English, hearing their interview I was very unenthused. Then they started playing, and I stopped caring that they were Frogs. These guys rock. I saw them live this month, too. Really, just great, fun sounds. Listen close to their drummer. And that vibrating tone at the end of “Rome” was honestly the coolest noise I’ve ever heard at a live show.

They opened with “Lisztomania” in the C-bus, too.

4. The National, Boxer. Wait, this one is a 2007 album. See #2. Except I hadn’t heard of them at all until this year. I freaking love this guy’s baritone. I mean, really, really, love his voice. And yes, since you asked, I would marry it.

5. Animal Collective, Merriwether Post Pavillion. This feels like a cop-out to me, to choose Animal Collective as one of my year’s best. Everyone else is doing it. But they’re doing it for a reason. This album was not an instant winner – I had to listen to it a couple of times before it grew on me – but then it was like cancer, except the fun kind that led to more and more enjoyment, not the other sad depressing kind. By the way, what is it about writing about music that makes people use horrible imagery? I mean, that wasn't the worst thing I've ever written, but it's up there.

6. Various, Dark Was The Night. This is another total cop-out. But an awesome one. Besides being such a great title, this is a 2-disc compilation put together as an AIDS benefit. That should be enough reason in some of your heads - with my liberal bleeding-heart, how could I not put something like that in my “Best of 2009” list? You’re right, I had to.

7. Brad Paisley, American Saturday Night. Some silly lyrics. Great guitar work. It works. Americana through and through.

8. We Are Scientists, Brain Trust Mastery. Yes, made famous by the Nick & Norah show, but this is a great album in its own right.

9. Oren Lavie, The Opposite Side of the Sea. I don’t usually like music videos, and I don’t usually consider them art. This video is definitely the exception to the rule. I link to the youtube videos just because I’m lazy and don’t want to hassle with uploading mp3 files and then linking just them. This video of Her Morning Elegance, co-directed by Lavie, is definitely the exception, and you should watch it for sure.

10. Blind Pilot, 3 Rounds and A Sound. I heard about these guys while driving to church at 6:45 one morning. I was so excited about them I had to pull out my phone, call myself, and leave the band name on my voicemail so I would remember the name. And then I missed their show in Salt Lake the weekend after Thanksgiving because I had to give a stupid talk on stupid Sunday about keeping the stupid Sabbath day holy. Stupid Karma.

Honorable Mentions:

a. The Sounds, Crossing the Rubicon. Unashamed pop.

b. Yeah Yeah Yeah’s, It’s Blitz. One of my friend’s favorite bands, I missed out on their show this year because of a stupid rotation. Super-pop at its best. While I didn’t listen to it enough for it to qualify as one of my favorites, it really is a great album.

c. The Mountain Goats, The Life of the World to Come. Probably one of the most interesting albums, as each song is based off a biblical passage. I think this didn’t make my favorites list simply because I had such high expectations after last year’s Heretic Pride. Still, though, this is a great album, and it’s all Biblically based. Sunday approved!

d. Built to Spill, There is no Enemy. I have liked this band for a while, but they had fallen off my radar until this year. I went up to Boise, ID for an interview for work. My flight got in early, and I didn’t know anyone in town. So I looked up concerts in Boise. Built to Spill was playing for $10 later that night. I hitched a ride over there, bought a ticket, walked to Beto’s, and then listened to the weirdest set of opening bands ever. A Hank Williams solo act followed by a speed metal band followed by an indie-rock band and finally the band I wanted to see. I quickly remembered why I’d liked them so much. The album is solid, but I particularly like the song “Hindsight.”

e. Dirty Projectors, Bitte Orca. Similar enough to Animal Collective that they got bumped down here, but still a very good record.

So, there’s my (latest) attempts at being a hipster; too bad I'm not more comfortable in skinny jeans. This is some of the stuff I loved in 2009. What about you?

Sunday, December 27, 2009

(Hopefully) The Last Time That Will Happen, or, On Temples, or, Training for Life

I have not lived in Bountiful for over five years. Count them. Today I gave my fourth talk in my parents' church in that time. Count that. Can I take this opportunity to whine? I mean, isn't part of the benefit of moving out the fact that you do not "have the opportunity" to give a talk or hold a calling in the old ward anymore? And four times? I mean, I'm supposed to be on vacation! Am I the only one this seems ridiculous to?

Although I do not want to turn this blog into a religious rant site, I am posting my church talk below again. As I mentioned before, talks are, I think, a particular challenge for me to write. Again, by way of warning, although I have written the talk out word-for-word, please remember that this was intended to be spoken, not read.

On Temples, or, Training for Life

Today I would like to ostensibly talk about Temples, but specifically I want to talk about the strength that comes into one’s life by living correct principles; but first, a bit about me. I competed in several triathlons this year. I use the word “competed” here in the loosest possible sense. Obviously crossing the finish line and the thrill associated with the finish was a great feeling. However, the reason I engaged in these races was not to finish fastest. I did not race to win; I did not race to beat the other competitors. The race served as a goal for me to fix my eyes on as I prepared for the tasks required. A prize that I could visualize as I trained and tried to drag myself to a gym last winter. A boring gym. In a boring winter.

I would like to suggest that the race is similar to the Temple – and that training for the race is analogous to preparing ourselves to enter the Temple. All analogies are flawed, and my point is not to suggest that the ordinances we receive in the temple setting are unimportant. But by training, by preparing ourselves, by becoming worthy to enter the House of the Lord, and then by maintaining that high level of performance, that high level of worthiness, that high level of Christian living – doing those things required to enter the Temple are what I see as the real payoff of being a temple attending individual. Obviously, if you so believe, there are also the small payoffs and prizes of salvation and exaltation associated with the ordinances as well.

Turning to a talk from General Conference. Brigham Young, in the April 1861 conference, lends some support to this idea that the preparatory process associated with temple worship is a vital portion of the temple experience. In a talk about why Jesus had not yet returned, he discussed how every job requires the proper tool. For fishing, poles, boats, and nets are all requisite. To save the people, he says, a Temple is required. Listen to his words: “If we are to be saved in an Ark as Noah and his family were, it will be because we build it.” The Lord commanded Noah to build his Ark. Brigham continues with his reasoning, “If we build a Temple here, it will be because we need one. And if we really need one, we are going to go to work and build it. Will we count the cost? No!” If salvation is our goal, what import is a worldly cost to us? “I care not what it will cost, so long as we are occupied in a good work, it keeps us out of mischief and unrighteousness. . . If you wish this Temple built, go to work and do all you can this season. Some say, ‘I do not like to do it, for we never began to build a Temple without the bells of hell beginning to Ring.’ I want to hear them ring again. All the tribes of hell will be on the move if we uncover the walls of this temple, but what will it amount to?”

For some of our younger friends in the audience, let me first briefly describe the temple. The temple is a place we go to engage in sacred ceremonies and make covenants with God. The ceremonies are a formal way prepared to teach some of the same material taught in the scriptures, namely, that we are children of God, we have sinned and fallen out of his presence, and that Jesus Christ was sent to redeem us. These doctrines are presented in a slightly different way, but there is nothing new or particularly earth-shattering in the doctrine presented. Which is to say, there is nothing surprising or crazy that goes on there. The covenants we make in the temple are also straightforward. The temple covenants are natural extensions of the covenant we just renewed by taking the Sacrament of the Lord’s Supper, where we covenanted to be willing to take upon us the name of Christ. In the temple, we make further covenants that are in accordance with taking upon us His name; we covenant to obey the commandments, we covenant to sacrifice for the Lord, we covenant to live the gospel, and we covenant obey the law of chastity.

Let me illustrate with a historical example how these covenants affect our lives. Previously, as the Saints were fleeing the United States in 1846, there was much hardship. Many left too late in the season. Many of us have ancestors that were in these parties. We know these stories well, where westbound groups met many different hardships. Mud, snow, Indians, marauders, disease, hunger. When word reached the leaders, relief parties were rallied, almost instantly. Listen again to President Young after hearing about one of the struggling groups of West-bound Saints. He says, “Now is the time for labor. Let the fire of the covenant which you made in the House of the Lord, burn in your hearts, like flame unquenchable.” The wagons, unsurprisingly, soon rolled East to rescue the stranded Saints.

“What was it that gave those early Saints such strength, such drive, and such determination to face the great challenges of the work of the Lord?” Elder Bednar asked in a recent conference. It was the fire of the covenant that burned in their hearts, a covenant made clear in the temple. It was their commitment to worship and honorably hold a name and stand. It was their commitment to live worthy to bear such a name as “Christian.” It was their commitment to live worthy to enter the Temple. It was their commitment to prepare. We have all committed to be willing to take upon ourselves the name of Christ. Will we, brothers and sisters, live up to these covenants and stand in the Lord’s house, prepared, as he has asked?

The most nourishing doctrine of our Church is perhaps the Eternal nature of families. It would simply not be “heaven” to us as Mormons if we were not to be united with our parents, our grandmas and grandpas, our eternal companions (knock on wood) and our posterity. This union, this cementing of family ties, comes through the sealing power used in the sacred ordinances of the temple.

The most satisfying doctrine, to me, is that of universal ordinance work. By vicariously performing ordinances for all for the sons and daughters of Adam and Eve, God effectively removes the ordinance variable from the equation of exaltation. By making it a universal common denominator, God effectively “cancels out” these necessary ordinances, thereby providing these blessings to all of his children, regardless of their situation in life. What more satisfying, glorious principle can exist?

As we attend the Temple, we not only foster a greater sense of community by seeing each other working to prepare to meet God, but when we attend the Temple we are also constantly reminded of the potential that our fellow human beings have. From our close ward friends to those other ward members we don’t get along with so well, from our neighbors to strangers; when we attend the temple we are reminded of THEIR divine potential. We realize THEIR great worth. Although he never attended the Mormon temple, CS Lewis had great insight into this principle and saw the powerful blessings associated with community worship. From his sermon, “The Weight of Glory,” he says,“ It is a serious thing to live in a society of possible gods and goddesses. To remember that the dullest and most uninteresting person you may talk to may one day be a creature which, if you saw it now, you would be strongly tempted to worship, or else a horror and corruption such as you now meet – if at all – only in a nightmare.

“All day long we are in some degree helping each other to one or the other of these destinations. It is in light of these overwhelming possibilities, it is with awe and the circumspection proper to them, that we should conduct all our dealings with one another. All friendships. All loves. All play. All politics.

“**There are no ordinary mortal. You have never talked to a mere mortal. . . but it is immortals whom we joke with, work with, marry, snub, and exploit. . . next to the blessed sacrament itself, your neighbor is the holiest object presented to your senses. If he is your Christian neighbor, he is holy in almost the same way, for in him also Christ vere latitat, the glorifier and the glorified, Glory Himself, is truly hidden.” In him, our neighbor, is God.

As we prepare to enter the Temple we are constantly reminded of our neighbors worth. Of the eternal and glorious destiny of all of our Father in Heaven’s children. This, the true Spirit of Elijah, the recognizing that all who now live, all who have lived, and those yet to come, are part of our heavenly family. They all deserve our love, respect and service. Everyone. The Petersons. The Clarks. The Marstons. The Mormons. The Catholics. The Muslims. The Jews. The Atheists. They all deserve our love, respect and service. This, the Spirit of Elijah, is one of the central themes taught in the Temple. That everyone is deserving of our love, respect and service is one of the basic tenets of leading a good life.

The Temple is a wonderful place; the Temple functions as a place of focus, a reminder of how to live our lives, a prize to remind us how to train for the race of life. The Temple acts as a place to remind ourselves of our relationship with God, a place to remind us of the potential worth of our fellow man, and a place to help us understand the eternal nature of families. But the Temple also acts as a goal, a reminder, a glittering prize that we can focus on as we strive to live our lives in a better way. May we all bring ourselves in line with the teachings of Christ and thus enjoy a richer life, enjoying the blessings associated with being prepared, is my prayer, in the name of Jesus Christ, amen.

Friday, December 18, 2009

Saturday, December 5, 2009

Nerd Stuff of the [Time Period], or, Science is Awesome

Click here for an explanation, if you don't get it. And if you thought that was funny, watch this video below. Otherwise, you should probably skip it.

Can you believe it has been 10 years since The Matrix came out? The movie is still incredible. But this tribute may be even more incredible than the original:

I thought this was just fun. But remember, Carl Sagan said, "The beauty of a living thing is not the atoms that go into it, but the way those atoms are put together."

Speaking of atoms, please, please click over here and play with the slide bar along the bottom of the frame. It is one of the best examples of orders of magnitude I have ever seen. And just friggin' sweet.

Mom, stop reading here. You too, Aunt Janet.

Click here to see a picture of the ultimate owning in online chatting. Really, really awesome. Nerds are already taking over the world. One chat room at a time. Even the dirty ones.

Thursday, December 3, 2009

Best Movie of the [Time Period], or, The Fantastic Mr Fox

Exceptional. Just plain exceptional. Best use of my night, for sure.

The animation, the story, the dialogue, the characters riddled with depth and believability despite their, well, obvious problem of being-drawn-images-of-animals-dressed-in-human-clothing, combine to make The Fantastic Mr Fox one of the best films I've seen this year.

Perhaps my favorite scene in the film included this bit of dialogue.

Mr. Fox: I'm trying to tell you the truth about myself.
Mrs. Fox: I don't care about the truth about yourself.

And if you see the movie the fact that this is my favorite line does not make it seem like I'm a bitter, crotchety bachelor with misogynistic views of the problems in relationships. Or just stupid. Or just a hopeless romantic. If you see the movie (which you should), you will simply be forced to agree with me that these lines are a really beautiful and clever use of words, and are but one great moment in an exceptional film.

Just plain exceptional.

Tuesday, December 1, 2009

OVERHEARD LINES: Welcome To Church, or, Kleptomaniacs Anonymous

In the foyer at Church:
Guy: I heard the woven cable bike locks are the hardest to get through.
Dude: Eh - they're not so tough.

Sunday, November 29, 2009

Last Time That Will Happen, or, Keeping The Sabbath Day Holy, or, Why I Hate Sunday, or, My Sacrament Talk

Clearly I haven't been writing much lately. This past month I was all over interviewing for residency, but I just got back home. I have had a few ideas for upcoming posts, including The Adventures of a Mormon Sommelier, and the Best TV Opening Credits Ever. But, most recently I wrote a talk for my church services, where the homilies or sermons are typically given by a couple members of the congregation. I was the concluding speaker and went until the normal time, but the Bishop stood and took about 7 minutes after me. I am not sure whether I am proud of this or embarrassed -- or maybe it was completely unrelated. While he did not clearly recant any of my words for me, he may have been trying to. It was difficult for me to write this talk, so I thought I would share it here. By way of preface, please remember this was written to be spoken, not read, and intended it to be humorous frequently. Some Most of those jokes fell flat. Surprise, surprise.

Why I Hated Sundays

Brothers and Sisters, I hate Sundays. Or at least, I used to hate them. Now I just don’t look forward to them very much. Why? Well, first and foremost, background. The Sabbath, by Hebrew definition, means “day of rest.” When the Lord gave the command to Moses to “Remember the Sabbath day and keep it holy” he also added, “Six days you shall labor and do all your work.” Josephus, the First Century historian, wrote that the Sabbath day was “set apart from labor and dedicated to learning our customs and laws.” This teaching nicely dovetails with D&C 59:10 where the Lord instructs that the “Sabbath Day is appointed unto you to rest from your labors and to pay thy devotions unto the Most High.” (Incidentally, we have the Jewish labor unions of the 19th century to thank for the 5 day workweek and 2 day weekend. Since a large portion of workers were Jewish and wanted Saturday off to worship the labor bosses capitulated. But since an even greater portion of workers wanted Sunday, “the Lord’s Day” to worship, we got both days off, and road trips became possible.) And what do we do as Mormons do with that two day weekend? I believe it is summarized well in the 14th Article of Faith:

We believe in meetings, all that have been scheduled, all that are now scheduled, and we believe that there will yet be many great and important meetings scheduled. We have endured many meetings and hope to be able to endure all meetings. Indeed, we may say that if there is a meeting or anything that resembles a meeting or anything that we may possibly turn into a meeting, we seek after these things. (Robert Kirby, SL Tribune)

On a more serious note, part of the reason I have not always looked forward to Sundays is epitomized in an experience I had in Elder’s Quorum last week. Before the Bishop or President Moody have conniptions, this experience was in my parents’ ward in Utah. Priesthood opening exercises were good – great even. A boldly sung hymn. Warm welcomes. Elder’s quorum started out with the usual announcements and invitations to do service in the middle of the workday. With about 30 minutes left of the block, a teacher came to the front of the room and an iPod was turned on. For the remainder of the time, Elder Holland’s talk from this past session of conference was played. En toto. That was the lesson. Approximately 3 minutes of comments were made at the end of the lesson. Then we dismissed. While Elder Holland’s is a good talk – some may even say an instant classic – I will confess I took little from the class other than a sense of bewilderment that I had to listen to the same material a second time, and that the opportunity to discuss and explore these inspired words in a more personal setting was being completely ignored.

But remember, I don’t hate Sundays anymore, even though this stellar EQ lesson was just last week. Why don’t I hate them anymore? Let me turn to one of my favorite passages from the Epistles: Paul wrote: (1Cor13:11 NRSV)

“When I was a child, I spoke like a child, I thought like a child, I reasoned like a child; when I became a man, I put an end to childish ways.”

When I was a little younger, I expected to come to church and be, served plugged in and recharged. I expected to come and have others take care of my spiritual needs. I came to church expecting not only to be fed, but to be spoon-fed.

Brothers and sisters, this is obviously the wrong attitude. Church is not here to let us sit back and become better people. Now please do not misunderstand me. I am not trying to say that I have "put away all my childish ways" and am now a "man" in all gospel-senses. I am only trying to say that I think I have moved past this one childish thought. Let me use another favorite scripture. Moroni, near the end of his life, wrote (Mormon 9:27) “. . . hearken unto the words of the Lord, and ask the Father in the name of Jesus for what things soever ye shall stand in need. Doubt not, but be believing, . . . and come unto the Lord . . . and work out your own salvation with fear and trembling before him.” Moroni here tells us that the purpose of the gospel, including the Sabbath day, is to learn. He also says that it is our responsibility to learn it. We need to figure it out individually. Sometimes that means 9 hours of meetings on Sunday. It almost always means that the Sabbath is not a day of rest anymore, like I wanted it to be as a child. The Sabbath may not be the most restful day anymore, but that is okay. To quote Eugene England, “If we constantly approach the Church as consumers, we will never partake of its sweet and filling fruit. Only if we can lose our lives [in church service] will we find ourselves.” “If we only ask ‘What has the Church done for me?’ we will not think to ask the much more important question, ‘What am I doing with the opportunities for service and self-challenge with which the Church provides me?’” (England, Why the Church is as True as the Gospel.)

No church talk about keeping the Sabbath Day Holy would be complete without a discussion of “do’s and don’ts.” Guidelines certainly exist for keeping the Sabbath day holy, but they are inadequate. The only appropriate set of guidelines that I have found for appropriate Sabbath day activity is this: you should be doing things on Sunday to help yourself and others become better people. For a professional cyclist, he or she may not feel it appropriate to go for a bike ride on Sunday. For the rest of us who do not get to ride bikes much, Sunday may be a wonderful day to take that opportunity to enjoy God’s Green Earth from a bike saddle. Indulge me for a moment on this topic; while preparing for this talk, I came across a blog that had a posting regarding Sabbath day activity lists, asking for commenters to add their own insights into what they, and their typically young families did or did not do on Sundays. It seemed to quickly devolve into something of keeping-up-with-the-Joneses. One commenter would say they didn’t watch team sports on Sundays. The next would say they only watched Discovery Channel, and that as a family. The next said that they never watched TV on Sundays. The next said that they sold their TVs and were forging ahead with a plan to feed the world. Not only did these comments not seem helpful, they started creating a sense of anxiety in me. I watch TV. I have not been working for world peace enough, and so on. Am I not doing what is right? I want to share a word of caution that my grandfather once gave to my sweet mother, who was an accomplished violinist. When mom was about 14, she was asked to perform a piece in church. She practiced and practiced, but she choked when the time came and did not do so well. She of course was devastated. But Grandpa Kirton came to the rescue, taking her into the front room, sitting her down, and saying, “My sweet Collie, you are good enough.” He went on to say that by comparing herself to others, she was setting herself up to either be puffed up in pride or racked with self-doubt and feelings of inadequacy. Comparing yourself to others is a good way of setting yourself up to fail, because you will always come up short in some aspect. So it is with Sabbath Day observance. I hope we can remember that, while there are basic guidelines, each individual and each family’s path, is, ultimately, their own path. Do not let anyone tell you otherwise. Your best is good enough.

Allow me to discuss another reason why attending church and keeping the Sabbath day holy are important. Martin Luther wrote that “Marriage is the school of love.” Note that he did not say that marriage is the product or result or home or goal of love. Marriage is the school. Marriage is what teaches someone how to love. I think part of the reasoning behind this is because at times, I have heard, you want to murder your companion. But marriage does not just teach you how to not kill your companion; rather, marriage teaches you how to deal with and love and cherish your companion. Church, similarly, is the school of godliness. At least half of you, if you had the choice, would choose to never associate with me. At least half. Yet here you are. Forced to associate with me. Typically, we see each other at least once a week. And by that forced association, you are made better people. Not by associating with me, necessarily (though that is often the case – eg Chris Sorensen). But in learning to deal with and work alongside and worship together with people that you would otherwise choose to avoid. By doing this we all become a little more, well, Godlike. Is there anything more Godlike than learning to care for and take responsibility “for the personal and marital, the physical and spiritual welfare of people we may not already love [or] (may even heartily dislike)[?], and thus we learn to love them. It stretches and challenges us, even when we are disappointed and exasperated in ways we would not otherwise choose to be stretched and challenged. . . [church] gives us a chance to be made better than we may have chosen to be – but ultimately want to be.” (E. England, Why the Church is as True as the Gospel –edited with brackets). Is it any wonder that attending church meetings is such an important part of keeping the Sabbath day holy?

Let me close with the words of President Spencer W. Kimball, “We do not go to Sabbath meetings to be entertained or even solely to be instructed. We go to worship the Lord. It is an individual responsibility, and regardless of what is said from the pulpit, if one wishes to worship the Lord in spirit and truth, he may do so by attending his meetings, partaking of the sacrament, and contemplating the beauties of the gospel. If the service is a failure to you, you have failed. No one can worship for you. (Ensign, Jan 1978, p4-5, emphasis mine).

What beautiful opportunities the Sabbath presents us with. A chance to mingle and serve people we do not always want to be around, a chance to actively pursue our spiritual needs, and a chance, as Josephus said, to take a day “set apart from labor and dedicated to learning our customs and laws” and finally, the Sabbath presents us with a chance, to practice true religion which James, the brother of Jesus, wrote that (James 1:27) “Religion (and I might add Sabbath observance) that is pure and undefiled before God, the Father, is this: to care for orphans and widows in their distress, and to keep oneself unstained by the world.” That is the only “do’s and don’t’s” list I will give. And that is why I don’t hate Sundays anymore.

Friday, November 13, 2009

So What If It Was On A Treadmill?

5 miles. Barefoot. Felt great.

Wednesday, September 30, 2009

OVERHEARD LINES; or, Relaxed Fruits, or, Enlightened Culinary Styles

Dude, to dude: "Hey, I left my banana hammock in your kitchen. Can you bring that to the restaurant?"

Wednesday, September 16, 2009

Looney Tunes Lied To Me!, or, Midnight Snacks

Have you ever had a fundamental, foundational portion of your world-view removed, suddenly? Right before you crawl into bed? Well, I did, just now.

I turned out my light, began crossing the room, and stepped squarely on a banana. Not only did I not slip, the banana still tasted great. Footy, but great. Turns out having your cornerstones removed isn't such a big deal after all.

Monday, September 14, 2009

Poem-ish type writing of the time period

Dark and cold we may be, but this
Is no winter now. The frozen misery
Of centuries breaks, cracks, begins to move,
The thunder is the thunder of the floes,
The thaw, the flood, the upstart Spring
Thank God our time is now when wrong
Comes up to face us everwhere
Never to leave us till we take
The longest stride of soul men ever took.
-Christopher Fry

Tuesday, July 28, 2009

Supreme Snark, or, People Eating Tasty Animals

A lot of stuff comes into my Google Reader. Lots of lame stuff. Some not lame stuff. Medical blogs, photography blogs, friends' blogs, sports blogs. Well, you get the picture. One of my favorite posts, that I have kept "unread" for a month so I can laugh at it every time I open up Google Reader, is simply the below Bulletin Board WIN.

Friday, July 24, 2009

Modern Medicine At Its Finest, or, Good Thing Dad Does Not Wear Hats

I recently came across this article, from the Journal of the American Medical Association. I found it interesting. I think you will too.


If anyone had insisted 25 years ago that tuberculosis was only slightly hereditary, but distinctly communicable, they would have been laughed at. The germ theory has now become a doctrine of ever-widening scope, and we realize that many affections are directly communicable and only a few hereditary. At the present moment it seems that even for so old-fashioned an affection as baldness a complete change of opinion as regards etiology is taking place. As with tuberculosis, so it has long been noted that baldness is likely to run in families. The sons of bald fathers are all the more likely to become bald young, and it is not the rule to find a single bald brother where there are a number in a family. On the other hand, daughters seldom become bald, but then the women folk rarely use the combs and brushes of the male members of the family, while boys not only use such articles in common, but often exchange hats, have their hair cut frequently at barbers, and in general are not rarely in circumstances in which they are likely to contract the disease, if it is communicable.

It is nearly ten years now since Sabouraud at the Pasteur Institute pointed out that premature baldness is practically always associated with the presence of certain bacteria. The seborrheic condition causing what is known as dandruff, on which early baldness probably often depends, he demonstrated to be a very probable result of the presence of these micro-organisms. Bacteriologic investigations made since have tended to confirm this opinion, and while they have failed to show the existence of any specific germs, they have made it appear probable that microbes play an important roˆ le in causing the increased desquamation of the epithelium which chokes up hair bulbs and finally leads to their obliteration. Undoubtedly the ordinary conditions of scalp hygiene among men are favorable to the development of these germs. The circulation to the scalp all comes from the vessels of the neck and finds its way over the bony skull to be distributed to the hair bulbs. It is especially likely to be interfered with by the pressure of the hat band, and that this is an important factor in the etiology of alopecia can be seen from the fact that baldness always begins just above the occipital prominence at the back or above the frontal bosses anteriorly, that is, just where the pressure of the hat band on the blood vessels is most likely to be occlusive. This interference with the circulation lowers the resistive vitality of these parts of the scalp and consequently provides opportunities for the growth of micro-organisms. It must not be forgotten, moreover, that these three points mentioned are especially liable to infection. The comb and brush are used particularly in arranging the whorl of hair in the occipital region and in parting the hair and brushing it back over the frontal bosses anteriorly. If infection plays an important role, then, in the production of baldness, these are just the parts that, theoretically, should be first affected, and from which infection should spread to the other parts of the head. As a matter of fact this is what occurs in practice.

Greater care should be taken with regard to brushes and combs, especially in families in which early baldness is the rule. The hair brush should be dipped in an antiseptic solution several times a week. Combs should be boiled regularly and frequently, and under no circumstances should
members of precociously bald families use other combs or brushes than their own, or allow them to be used on them, in barber shops, unless they are assured of their sterilization beforehand. These precautions may seem a high price to pay for the prophylaxis of premature baldness, and many will prefer to take the chance of becoming bald, but some have such a horror of the affliction that they will willingly put themselves to much trouble to prevent it.

JANUARY 14, 1903
JAMA. 1903;40:249 as quoted in JAMA. 2003;289(4):494 (doi:10.1001/jama.289.4.494)

This all just begs the question, why were bald men using combs 100 years ago?

Skip to 1:17 in the clip. Worth it.

Thursday, July 23, 2009

The Difficult Truth, or, Health Care Reform

After President Obama's address last night, this seems like a good time to talk health-care reform. Two large issues come to mind when I think about the need for reform.
1. The elimination of "just to be sure" medicine. Defensive driving is a very good thing. Defensive medicine is sometimes a good thing, but it is almost always a very expensive thing.

2. The second is an issue about the need to apply cost-benefit ideas to medical care, is covered better in an article posted below. I realize this a horrible idea, but the world is a horrible place. I'm not ecstatic about this, believe me, but please, read the article. I know it's long. (Click on the title for the link to the original article).

July 19, 2009

Why We Must Ration Health Care

You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?

If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life? If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed.

In the current U.S. debate over health care reform, “rationing” has become a dirty word. Meeting last month with five governors, President Obama urged them to avoid using the term, apparently for fear of evoking the hostile response that sank the Clintons’ attempt to achieve reform. In a Wall Street Journal op-ed published at the end of last year with the headline “Obama Will Ration Your Health Care,” Sally Pipes, C.E.O. of the conservative Pacific Research Institute, described how in Britain the national health service does not pay for drugs that are regarded as not offering good value for money, and added, “Americans will not put up with such limits, nor will our elected representatives.” And the Democratic chair of the Senate Finance Committee, Senator Max Baucus, told CNSNews in April, “There is no rationing of health care at all” in the proposed reform.

Remember the joke about the man who asks a woman if she would have sex with him for a million dollars? She reflects for a few moments and then answers that she would. “So,” he says, “would you have sex with me for $50?” Indignantly, she exclaims, “What kind of a woman do you think I am?” He replies: “We’ve already established that. Now we’re just haggling about the price.” The man’s response implies that if a woman will sell herself at any price, she is a prostitute. The way we regard rationing in health care seems to rest on a similar assumption, that it’s immoral to apply monetary considerations to saving lives — but is that stance tenable?

Health care is a scarce resource, and all scarce resources are rationed in one way or another. In the United States, most health care is privately financed, and so most rationing is by price: you get what you, or your employer, can afford to insure you for. But our current system of employer-financed health insurance exists only because the federal government encouraged it by making the premiums tax deductible. That is, in effect, a more than $200 billion government subsidy for health care. In the public sector, primarily Medicare, Medicaid and hospital emergency rooms, health care is rationed by long waits, high patient copayment requirements, low payments to doctors that discourage some from serving public patients and limits on payments to hospitals.

The case for explicit health care rationing in the United States starts with the difficulty of thinking of any other way in which we can continue to provide adequate health care to people on Medicaid and Medicare, let alone extend coverage to those who do not now have it. Health-insurance premiums have more than doubled in a decade, rising four times faster than wages. In May, Medicare’s trustees warned that the program’s biggest fund is heading for insolvency in just eight years. Health care now absorbs about one dollar in every six the nation spends, a figure that far exceeds the share spent by any other nation. According to the Congressional Budget Office, it is on track to double by 2035.

President Obama has said plainly that America’s health care system is broken. It is, he has said, by far the most significant driver of America’s long-term debt and deficits. It is hard to see how the nation as a whole can remain competitive if in 26 years we are spending nearly a third of what we earn on health care, while other industrialized nations are spending far less but achieving health outcomes as good as, or better than, ours.

Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. If we ration we won’t be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend. When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?

Last year Britain’s National Institute for Health and Clinical Excellence gave a preliminary recommendation that the National Health Service should not offer Sutent for advanced kidney cancer. The institute, generally known as NICE, is a government-financed but independently run organization set up to provide national guidance on promoting good health and treating illness. The decision on Sutent did not, at first glance, appear difficult. NICE had set a general limit of £30,000, or about $49,000, on the cost of extending life for a year. Sutent, when used for advanced kidney cancer, cost more than that, and research suggested it offered only about six months extra life. But the British media leapt on the theme of penny-pinching bureaucrats sentencing sick people to death. The issue was then picked up by the U.S. news media and by those lobbying against health care reform in the United States. An article in The New York Times last December featured Bruce Hardy, a kidney-cancer patient whose wife, Joy, said, “It’s hard to know that there is something out there that could help but they’re saying you can’t have it because of cost.” Then she asked the classic question: “What price is life?”

Last November, Bloomberg News focused on Jack Rosser, who was 57 at the time and whose doctor had told him that with Sutent he might live long enough to see his 1-year-old daughter, Emma, enter primary school. Rosser’s wife, Jenny, is quoted as saying: “It’s immoral. They are sentencing him to die.” In the conservative monthly The American Spectator, David Catron, a health care consultant, describes Rosser as “one of NICE’s many victims” and writes that NICE “regularly hands down death sentences to gravely ill patients.” Linking the British system with Democratic proposals for reforming health care in the United States, Catron asked whether we really deserve a health care system in which “soulless bureaucrats arbitrarily put a dollar value on our lives.” (In March, NICE issued a final ruling on Sutent. Because of how few patients need the drug and because of special end-of-life considerations, it recommended that the drug be provided by the National Health Service to patients with advanced kidney cancer.)

There’s no doubt that it’s tough — politically, emotionally and ethically — to make a decision that means that someone will die sooner than they would have if the decision had gone the other way. But if the stories of Bruce Hardy and Jack Rosser lead us to think badly of the British system of rationing health care, we should remind ourselves that the U.S. system also results in people going without life-saving treatment — it just does so less visibly. Pharmaceutical manufacturers often charge much more for drugs in the United States than they charge for the same drugs in Britain, where they know that a higher price would put the drug outside the cost-effectiveness limits set by NICE. American patients, even if they are covered by Medicare or Medicaid, often cannot afford the copayments for drugs. That’s rationing too, by ability to pay.

Dr. Art Kellermann, associate dean for public policy at Emory School of Medicine in Atlanta, recently wrote of a woman who came into his emergency room in critical condition because a blood vessel had burst in her brain. She was uninsured and had chosen to buy food for her children instead of spending money on her blood-pressure medicine. In the emergency room, she received excellent high-tech medical care, but by the time she got there, it was too late to save her.

A New York Times report on the high costs of some drugs illustrates the problem. Chuck Stauffer, an Oregon farmer, found that his prescription-drug insurance left him to pay $5,500 for his first 42 days of Temodar, a drug used to treat brain tumors, and $1,700 a month after that. For Medicare patients drug costs can be even higher, because Medicare can require a copayment of 25 percent of the cost of the drug. For Gleevec, a drug that is effective against some forms of leukemia and some gastrointestinal tumors, that one-quarter of the cost can run to $40,000 a year.

In Britain, everyone has health insurance. In the U.S., some 45 million do not, and nor are they entitled to any health care at all, unless they can get themselves to an emergency room. Hospitals are prohibited from turning away anyone who will be endangered by being refused treatment. But even in emergency rooms, people without health insurance may receive less health care than those with insurance. Joseph Doyle, a professor of economics at the Sloan School of Management at M.I.T., studied the records of people in Wisconsin who were injured in severe automobile accidents and had no choice but to go to the hospital. He estimated that those who had no health insurance received 20 percent less care and had a death rate 37 percent higher than those with health insurance. This difference held up even when those without health insurance were compared with those without automobile insurance, and with those on Medicaid — groups with whom they share some characteristics that might affect treatment. The lack of insurance seems to be what caused the greater number of deaths.

When the media feature someone like Bruce Hardy or Jack Rosser, we readily relate to individuals who are harmed by a government agency’s decision to limit the cost of health care. But we tend not to hear about — and thus don’t identify with — the particular individuals who die in emergency rooms because they have no health insurance. This “identifiable victim” effect, well documented by psychologists, creates a dangerous bias in our thinking. Doyle’s figures suggest that if those Wisconsin accident victims without health insurance had received equivalent care to those with it, the additional health care would have cost about $220,000 for each life saved. Those who died were on average around 30 years old and could have been expected to live for at least another 40 years; this means that had they survived their accidents, the cost per extra year of life would have been no more than $5,500 — a small fraction of the $49,000 that NICE recommends the British National Health Service should be ready to pay to give a patient an extra year of life. If the U.S. system spent less on expensive treatments for those who, with or without the drugs, have at most a few months to live, it would be better able to save the lives of more people who, if they get the treatment they need, might live for several decades.

Estimates of the number of U.S. deaths caused annually by the absence of universal health insurance go as high as 20,000. One study concluded that in the age group 55 to 64 alone, more than 13,000 extra deaths a year may be attributed to the lack of insurance coverage. But the estimates vary because Americans without health insurance are more likely, for example, to smoke than Americans with health insurance, and sorting out the role that the lack of insurance plays is difficult. Richard Kronick, a professor at the School of Medicine at theUniversity of California, San Diego, cautiously concludes from his own study that there is little evidence to suggest that extending health insurance to all Americans would have a large effect on the number of deaths in the United States. That doesn’t mean that it wouldn’t; we simply don’t know if it would.

In any case, it isn’t only uninsured Americans who can’t afford treatment. President Obama has spoken about his mother, who died from ovarian cancer in 1995. The president said that in the last weeks of her life, his mother “was spending too much time worrying about whether her health insurance would cover her bills” — an experience, the president went on to say, that his mother shared with millions of other Americans. It is also an experience more common in the United States than in other developed countries. A recent Commonwealth Fund study led by Cathy Schoen and Robin Osborn surveyed adults with chronic illness in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom and the United States. Far more Americans reported forgoing health care because of cost. More than half (54 percent) reported not filling a prescription, not visiting a doctor when sick or not getting recommended care. In comparison, in the United Kingdom the figure was 13 percent, and in the Netherlands, only 7 percent. Even among Americans with insurance, 43 percent reported that cost was a problem that had limited the treatment they received. According to a 2007 study led by David Himmelstein, more than 60 percent of all bankruptcies are related to illness, with many of these specifically caused by medical bills, even among those who have health insurance. In Canada the incidence of bankruptcy related to illness is much lower.

When a Washington Post journalist asked Daniel Zemel, a Washington rabbi, what he thought about federal agencies putting a dollar value on human life, the rabbi cited a Jewish teaching explaining that if you put one human life on one side of a scale, and you put the rest of the world on the other side, the scale is balanced equally. Perhaps that is how those who resist health care rationing think. But we already put a dollar value on human life. If the Department of Transportation, for example, followed rabbinical teachings it would exhaust its entire budget on road safety. Fortunately the department sets a limit on how much it is willing to pay to save one human life. In 2008 that limit was $5.8 million. Other government agencies do the same. Last year the Consumer Product Safety Commission considered a proposal to make mattresses less likely to catch fire. Information from the industry suggested that the new standard would cost $343 million to implement, but the Consumer Product Safety Commission calculated that it would save 270 lives a year — and since it valued a human life at around $5 million, that made the new standard a good value. If we are going to have consumer-safety regulation at all, we need some idea of how much safety is worth buying. Like health care bureaucrats, consumer-safety bureaucrats sometimes decide that saving a human life is not worth the expense. Twenty years ago, the National Research Council, an arm of the National Academy of Sciences, examined a proposal for installing seat belts in all school buses. It estimated that doing so would save, on average, one life per year, at a cost of $40 million. After that, support for the proposal faded away. So why is it that those who accept that we put a price on life when it comes to consumer safety refuse to accept it when it comes to health care?

Of course, it’s one thing to accept that there’s a limit to how much we should spend to save a human life, and another to set that limit. The dollar value that bureaucrats place on a generic human life is intended to reflect social values, as revealed in our behavior. It is the answer to the question “How much are you willing to pay to save your life?” — except that, of course, if you asked that question of people who were facing death, they would be prepared to pay almost anything to save their lives. So instead, economists note how much people are prepared to pay to reduce the risk that they will die. How much will people pay for air bags in a car, for instance? Once you know how much they will pay for a specified reduction in risk, you multiply the amount that people are willing to pay by how much the risk has been reduced, and then you know, or so the theory goes, what value people place on their lives. Suppose that there is a 1 in 100,000 chance that an air bag in my car will save my life, and that I would pay $50 — but no more than that — for an air bag. Then it looks as if I value my life at $50 x 100,000, or $5 million.

The theory sounds good, but in practice it has problems. We are not good at taking account of differences between very small risks, so if we are asked how much we would pay to reduce a risk of dying from 1 in 1,000,000 to 1 in 10,000,000, we may give the same answer as we would if asked how much we would pay to reduce the risk from 1 in 500,000 to 1 in 10,000,000. Hence multiplying what we would pay to reduce the risk of death by the reduction in risk lends an apparent mathematical precision to the outcome of the calculation — the supposed value of a human life — that our intuitive responses to the questions cannot support. Nevertheless this approach to setting a value on a human life is at least closer to what we really believe — and to what we should believe — than dramatic pronouncements about the infinite value of every human life, or the suggestion that we cannot distinguish between the value of a single human life and the value of a million human lives, or even of the rest of the world. Though such feel-good claims may have some symbolic value in particular circumstances, to take them seriously and apply them — for instance, by leaving it to chance whether we save one life or a billion — would be deeply unethical.

Governments implicitly place a dollar value on a human life when they decide how much is to be spent on health care programs and how much on other public goods that are not directed toward saving lives. The task of health care bureaucrats is then to get the best value for the resources they have been allocated. It is the familiar comparative exercise of getting the most bang for your buck. Sometimes that can be relatively easy to decide. If two drugs offer the same benefits and have similar risks of side effects, but one is much more expensive than the other, only the cheaper one should be provided by the public health care program. That the benefits and the risks of side effects are similar is a scientific matter for experts to decide after calling for submissions and examining them. That is the bread-and-butter work of units like NICE. But the benefits may vary in ways that defy straightforward comparison. We need a common unit for measuring the goods achieved by health care. Since we are talking about comparing different goods, the choice of unit is not merely a scientific or economic question but an ethical one.

As a first take, we might say that the good achieved by health care is the number of lives saved. But that is too crude. The death of a teenager is a greater tragedy than the death of an 85-year-old, and this should be reflected in our priorities. We can accommodate that difference by calculating the number of life-years saved, rather than simply the number of lives saved. If a teenager can be expected to live another 70 years, saving her life counts as a gain of 70 life-years, whereas if a person of 85 can be expected to live another 5 years, then saving the 85-year-old will count as a gain of only 5 life-years. That suggests that saving one teenager is equivalent to saving 14 85-year-olds. These are, of course, generic teenagers and generic 85-year-olds. It’s easy to say, “What if the teenager is a violent criminal and the 85-year-old is still working productively?” But just as emergency rooms should leave criminal justice to the courts and treat assailants and victims alike, so decisions about the allocation of health care resources should be kept separate from judgments about the moral character or social value of individuals.

Health care does more than save lives: it also reduces pain and suffering. How can we compare saving a person’s life with, say, making it possible for someone who was confined to bed to return to an active life? We can elicit people’s values on that too. One common method is to describe medical conditions to people — let’s say being a quadriplegic — and tell them that they can choose between 10 years in that condition or some smaller number of years without it. If most would prefer, say, 10 years as a quadriplegic to 4 years of nondisabled life, but would choose 6 years of nondisabled life over 10 with quadriplegia, but have difficulty deciding between 5 years of nondisabled life or 10 years with quadriplegia, then they are, in effect, assessing life with quadriplegia as half as good as nondisabled life. (These are hypothetical figures, chosen to keep the math simple, and not based on any actual surveys.) If that judgment represents a rough average across the population, we might conclude that restoring to nondisabled life two people who would otherwise be quadriplegics is equivalent in value to saving the life of one person, provided the life expectancies of all involved are similar.

This is the basis of the quality-adjusted life-year, or QALY, a unit designed to enable us to compare the benefits achieved by different forms of health care. The QALY has been used by economists working in health care for more than 30 years to compare the cost-effectiveness of a wide variety of medical procedures and, in some countries, as part of the process of deciding which medical treatments will be paid for with public money. If a reformed U.S. health care system explicitly accepted rationing, as I have argued it should, QALYs could play a similar role in the U.S.

Some will object that this discriminates against people with disabilities. If we return to the hypothetical assumption that a year with quadriplegia is valued at only half as much as a year without it, then a treatment that extends the lives of people without disabilities will be seen as providing twice the value of one that extends, for a similar period, the lives of quadriplegics. That clashes with the idea that all human lives are of equal value. The problem, however, does not lie with the concept of the quality-adjusted life-year, but with the judgment that, if faced with 10 years as a quadriplegic, one would prefer a shorter lifespan without a disability. Disability advocates might argue that such judgments, made by people without disabilities, merely reflect the ignorance and prejudice of people without disabilities when they think about people with disabilities. We should, they will very reasonably say, ask quadriplegics themselves to evaluate life with quadriplegia. If we do that, and we find that quadriplegics would not give up even one year of life as a quadriplegic in order to have their disability cured, then the QALY method does not justify giving preference to procedures that extend the lives of people without disabilities over procedures that extend the lives of people with disabilities.

This method of preserving our belief that everyone has an equal right to life is, however, a double-edged sword. If life with quadriplegia is as good as life without it, there is no health benefit to be gained by curing it. That implication, no doubt, would have been vigorously rejected by someone like Christopher Reeve, who, after being paralyzed in an accident, campaigned for more research into ways of overcoming spinal-cord injuries. Disability advocates, it seems, are forced to choose between insisting that extending their lives is just as important as extending the lives of people without disabilities, and seeking public support for research into a cure for their condition.

The QALY tells us to do what brings about the greatest health benefit, irrespective of where that benefit falls. Usually, for a given quantity of resources, we will do more good if we help those who are worst off, because they have the greatest unmet needs. But occasionally some conditions will be both very severe and very expensive to treat. A QALY approach may then lead us to give priority to helping others who are not so badly off and whose conditions are less expensive to treat. I don’t find it unfair to give the same weight to the interests of those who are well off as we give to those who are much worse off, but if there is a social consensus that we should give priority to those who are worse off, we can modify the QALY approach so that it gives greater weight to benefits that accrue to those who are, on the QALY scale, worse off than others.

The QALY approach does not even try to measure the benefits that health care brings in addition to the improvement in health itself. Emotionally, we feel that the fact that Jack Rosser is the father of a young child makes a difference to the importance of extending his life, but his parental status is irrelevant to a QALY assessment of the health care gains that Sutent would bring him. Whether decisions about allocating health care resources should take such personal circumstances into account isn’t easy to decide. Not to do so makes the standard inflexible, but taking personal factors into account increases the scope for subjective — and prejudiced — judgments.

The QALY is not a perfect measure of the good obtained by health care, but its defenders can support it in the same way that Winston Churchill defended democracy as a form of government: it is the worst method of allocating health care, except for all the others. If it isn’t possible to provide everyone with all beneficial treatments, what better way do we have of deciding what treatments people should get than by comparing the QALYs gained with the expense of the treatments?

Will Americans allow their government, either directly or through an independent agency like NICE, to decide which treatments are sufficiently cost-effective to be provided at public expense and which are not? They might, under two conditions: first, that the option of private health insurance remains available, and second, that they are able to see, in their own pocket, the full cost of not rationing health care.

Rationing public health care limits free choice if private health insurance is prohibited. But many countries combine free national health insurance with optional private insurance. Australia, where I’ve spent most of my life and raised a family, is one. The U.S. could do something similar. This would mean extending Medicare to the entire population, irrespective of age, but without Medicare’s current policy that allows doctors wide latitude in prescribing treatments for eligible patients. Instead, Medicare for All, as we might call it, should refuse to pay where the cost per QALY is extremely high. (On the other hand, Medicare for All would not require more than a token copayment for drugs that are cost-effective.) The extension of Medicare could be financed by a small income-tax levy, for those who pay income tax — in Australia the levy is 1.5 percent of taxable income. (There’s an extra 1 percent surcharge for those with high incomes and no private insurance. Those who earn too little to pay income tax would be carried at no cost to themselves.) Those who want to be sure of receiving every treatment that their own privately chosen physicians recommend, regardless of cost, would be free to opt out of Medicare for All as long as they can demonstrate that they have sufficient private health insurance to avoid becoming a burden on the community if they fall ill. Alternatively, they might remain in Medicare for All but take out supplementary insurance for health care that Medicare for All does not cover. Every American will have a right to a good standard of health care, but no one will have a right to unrationed health care. Those who opt for unrationed health care will know exactly how much it costs them.

One final comment. It is common for opponents of health care rationing to point to Canada and Britain as examples of where we might end up if we get “socialized medicine.” On a blog on Fox News earlier this year, the conservative writer John Lott wrote, “Americans should ask Canadians and Brits — people who have long suffered from rationing — how happy they are with central government decisions on eliminating ‘unnecessary’ health care.” There is no particular reason that the United States should copy the British or Canadian forms of universal coverage, rather than one of the different arrangements that have developed in other industrialized nations, some of which may be better. But as it happens, last year the Gallup organization did ask Canadians and Brits, and people in many different countries, if they have confidence in “health care or medical systems” in their country. In Canada, 73 percent answered this question affirmatively. Coincidentally, an identical percentage of Britons gave the same answer. In the United States, despite spending much more, per person, on health care, the figure was only 56 percent.

Peter Singer is professor of bioethics at Princeton University. He is also laureate professor at the University of Melbourne, in Australia. His most recent book is “The Life You Can Save: Acting Now to End World Poverty.”

This article has been revised to reflect the following correction:

Correction: July 19, 2009
An article in The Times Magazine this weekend about the argument for rationing health care in the United States misstates the number of years it would take under the current system for the country to spend nearly a third of what it earns on health care. It is 26 years from now, or 2035, not 15 years.