Health Care Policy

Crossing That Dark River

Dr Bob

Often in the sturm und drang of a world gone mad, there comes, through the chaos and insanity, some brief moment of clarity. Such times pass by quickly, and are quickly forgotten — as this brief instance might have been, courtesy of my neighboring bell weather state of Oregon: (HT: Hot Air)

Last month her lung cancer, in remission for about two years, was back. After her oncologist prescribed a cancer drug that could slow the cancer growth and extend her life, [Barbara] Wagner was notified that the Oregon Health Plan wouldn’t cover it.

It would cover comfort and care, including, if she chose, doctor-assisted suicide.

… Treatment of advanced cancer meant to prolong life, or change the course of this disease, is not covered by the Oregon Health Plan, said the unsigned letter Wagner received from LIPA, the Eugene company that administers the plan in Lane County.

Officials of LIPA and the state policy-making Health Services Commission say they’ve not changed how they cover treatment of recurrent cancer.

But local oncologists say they’ve seen a change and that their Oregon Health Plan patients with advanced cancer no longer get coverage for chemotherapy if it is considered comfort care.

It doesn’t adhere to the standards of care set out in the oncology community, said Dr. John Caton, an oncologist at Willamette Valley Cancer Center.

Studies have found that chemotherapy can decrease pain and time spent in the hospital and increases quality of life, Caton said.

The Oregon Health Plan started out rationing health care in 1994.

We have, at last, arrived. The destination was never much in doubt — once the threshold of medical manslaughter had been breached, wrapped as always in comforting words of compassion and dignity, it was only a matter of time before our pragmatism trumped our principles. Once the absolute that physicians should be healers not hangmen was heaved overboard, it was inevitable that the relentless march of relativism would reach its logical port of call.

Death, after all, is expensive — the most expensive thing in life. It was not always so. In remote pasts, it was the very currency of life, short and brutal, with man’s primitive intellect sufficient solely to deal out death, not to defer it. There followed upon this time some glimmer of light and hope, wherein death’s timetable remained unfettered, but its stranglehold and certainty were tempered by a new hope and vision of humanity. We became in that time something more than mortal creatures, something extraordinary, an unspeakable treasure entombed within a fragile and decomposing frame. We became, something more than our mortal bodies; we became, something greater than our pain; we became, something whose beauty shown through even the ghastly horrors of the hour of our demise. Our prophets — then heeded — triumphantly thrust their swords through the dark heart of death: “Death, where is your victory? Death, where is your sting?” We became, in that moment, something more than the physical, something greater than our short and brutish mortality. We became, indeed, truly human, for the very first time.

That humanity transcended and transformed all that we were and were to become, making us unique among creation not only in the foreknowledge of our death, but our transcendence of death itself. Life had meaning beyond the grave — and therefore had far more weight at the threshold of the tomb. Suffering became more than mere fate, but rather sacrifice and purification, preparation and salvation. The wholeness of the soul trumped the health of the body; death was transformed from hopeless certainty to triumphant transition.

But we knew better. We pursued the good, only to destroy the best. We set our minds to conquer death, to destroy disease, to end all pain, to become pure and perfect and permanent. We succeeded beyond our wildest dreams. The diseases which slaughtered us were themselves slayed; the illnesses which tortured and tormented us fell before us. Our lives grew long, and healthier, more comfortable, and more productive. Our newfound longevity and greater health gave rise to ever more miracles, allowing us to pour out our intemperate and precipitous riches with drunken abandon upon dreams of death defeated.

Yet on the flanks of our salient there lay waiting the forces which would strangle and surround our triumphant advance. Our supply lines grew thin; the very lifeblood of our armies of science and medicine, that which made our soldiers not machines but men, grew emaciated and hoary, flaccid and frail. We neglected the soul which sustained our science; the spirit which brought healing to medicine grew cachectic and cold.

So here we stand. We have squandered great wealth to defeat death — only to find ourselves impoverished, and turning to death itself for our answers. The succubus we sought to defeat now dominates us, for she is a lusty and insatiable whore. We have sacrificed our humanity, our compassion, our empathy, our humility in the face of a force far greater than ourselves, while forgetting the power and grace and the vision which first led us and empowered us on this grand crusade. Our weapons are now turned upon us; let the slaughter begin.

We will, no doubt, congratulate ourselves on the wealth we save. We will no doubt develop ever more ingenious and efficient means to facilitate our self-immolation while comforting ourselves with our vast knowledge and perceived compassion. Those who treasure life at its end, who find in and through its suffering and debilitation the joy of relationships, and meaning, and mercy, and grace, will become our enemies, for they will siphon off mammon much needed to mitigate the consequences of our madness.

It has been said, once, that where our treasure is, there will our heart be also. We have poured our treasure in untold measure into conquering death — finding succor in our victories, while forgetting how to die. The boatman now awaits us to carry us across that dark river — and we have insufficient moral currency to ignore his call.

CAT Scams

Dr Bob

cat scan cartoonThe Wall Street Journal reports on a recent New England Journal of Medicine study which concludes that doctors are over-utilizing CT scans, exposing their patients to excessive, and potentially harmful, radiation doses:

Doctors are ordering too many unnecessary diagnostic CT scans, exposing their patients to potentially dangerous levels of radiation that could increase their risk of cancer, according to Columbia University researchers.

The researchers, writing in this week’s New England Journal of Medicine, conclude that in the coming decades up to 2% of all cancers in the United States may be caused by radiation from computed tomography scans performed now. Children face the most danger, they said.

In ordering CT scans, doctors are underestimating the radiation danger … In many cases, the researchers say, older technologies like X-rays and ultrasound that expose patients to lower radiation doses or no radiation at all would work just as well.

Since CT scans were introduced in the 1970s, their use has grown to an estimated 62 million annually. An estimated four million to five million scans are ordered for children, Mr. Brenner said. Adults receive scans for diseases of the stomach, colon, breast and other areas. Children most often are scanned for appendicitis. It has become a favored technology because it provides detailed information about patients’ bodies, is noninvasive and typically is covered by health insurance.

While the scans save lives, the authors say, doctors are leaning on them over safer diagnostic tools because they underestimate the levels of radiation people receive from the scans.

The authors measured typical levels of radiation that CT scans emit. They found levels they say were comparable to that received by some people miles from the epicenters of the 1945 atomic blasts over Hiroshima and Nagasaki, Japan.

There can be little doubt that CAT scans, as well as other expensive medical imaging studies, are overutilized in medicine today. There is also no doubt that the overutilization of CAT scans in particular, with their ionizing radiation, does expose patients to significantly more radiation. It may be worthwhile to pause and think about why so many CAT scans are being performed.

Hint: It’s not because doctors don’t know that CAT scans deliver more radiation.
Continue reading “CAT Scams” →

Little Pay for No Performance

Dr Bob

If you’ve been following some of my previous posts on the insanity of the U.S. health care system, such as the Maze series, you will recall the looming ogre in payment “reform” called pay for performance. Medicare, and the me-too sycophants in the insurance industry, have been promoting and implementing a payment system which nominally will pay more for care which meets certain quality standards. This concept is based on a host of unproven assumptions — the most egregious of which are the unspoken assumptions that much care delivered is substandard, and that trivial increases in reimbursement will correct shortcomings in quality (which are vastly more likely to be due to system complexity than individual error or incompetence). Nevertheless, this lumbering freight train is rumbling down the rails toward our health heroine Nell, lashed to the tracks by Snidely Whiplash, your dastardly federal and private insurance bureaucrat.

Today’s Wall Street Journal (subscription required) reports on a JAMA study of just how well this system works. In a pilot project funded by Medicare, the stunning results are in: it doesn’t. Color me shocked:

Researchers at Duke University, examining heart-attack treatment at 500 hospitals, found that hospitals that received financial incentives to follow treatment guidelines didn’t improve their practices significantly more than hospitals that got no financial benefit.

The federal Centers for Medicare and Medicaid Services launched the pay-for-performance pilot in 2003. Participating hospitals provided the CMS with performance information for five conditions, including heart attack. Hospitals in the two highest performance levels for a condition received a bonus.

In the Duke study, published in this week’s Journal of the American Medical Association, 54 of the hospitals were participants in the CMS pilot and received the financial incentives. The other 446 “control” hospitals didn’t get such payments.

The findings showed that “the pay-for-performance program was not associated with a significant incremental improvement in quality of care or outcomes for acute myocardial infarction,” or heart attack, Duke cardiologist Eric D. Peterson and colleagues wrote in the journal article.

Of course, the usual special pleading is immediately evident: perhaps the carrots weren’t juicy enough (like that will ever happen, in a system which is economically hemorrhaging), or the sticks weren’t nasty enough (now you’re talkin’! Keep beating that dead horse, and surely it will run faster):

It’s possible the financial penalties for not complying weren’t sufficient. “Those with the poorest performance risked future financial penalty,” researchers said, but didn’t actually pay such a penalty. Bonuses for complying with performance standards totaled $17.6 million to a total of 123 hospitals in the first year and 115 hospitals in the second year.

“One read on this is that the carrots have to be bigger,” Duke’s Dr. Peterson said. Hospital officials involved in the Medicare pilot project said this winter in a conference call with reporters that financial incentives were small relative to their budgets.

Now that the data is in, you can be sure that our bureaucrats will rethink their foolish ways — or not:

Still, the findings raise the question of what the Medicare system will do next. A Medicare spokesman said the agency hadn’t seen the study and so couldn’t comment on it.

Nice. Medicare, who funded the study, hasn’t seen the results. Never let the facts get in the way of a bureaucrat on a mission — it just confuses them.

Health Care Coverage Takes a Hit

Dr Bob

Recently Barack Obama released his proposed health care plan, which bears a resemblance to several other proposals, such as Mitt Romney’s in Massachusetts, Arnold Schwarzenegger’s in California, and a number of others. Such proposals have a number of common themes: mandating insurance coverage, provided through private insurers and monitored through a government bureaucracy; taxes or penalties on businesses who do not provide coverage for their employees; often a tax on physicians and hospitals; tight regulation of insurance premiums; removal of preexisting condition restrictions; financial assistance for the poor in paying for coverage; cost “efficiencies” brought about by an increased emphasis on preventive medicine, information technology (electronic medical records), and a hoped-for reduction in premiums due to an enlarged risk pool.

At first glance, some of these proposals appear to use the existing network of health insurance plans to extend healthcare coverage to the uninsured. They also seem designed to avoid the tar baby of government-run, single-payer healthcare, which is anathema to many Americans. But the difference between these plans and single-payer, practically speaking, is far more illusory than real.

I am on record as favoring mandatory catastrophic healthcare insurance. While generally I do not favor government mandates in such areas, I find catastrophic healthcare insurance to be analogous to mandatory auto insurance: in both cases, the uninsured pass the expenses of their misfortune onto society as a whole, either directly or indirectly. I would favor such a mandate at the state, rather than the Federal level, enforced by showing proof of health insurance at the time of driver’s license renewal. Such insurance should be major medical only, covering catastrophic illness with very large deductibles. It should be purchased by the individual, rather than provided by employers. In such a scenario, the vast risk pool, large deductible, and coverage limited to major medical events should keep premiums relatively low. There should, however, be little regulation of what such policies cover, as opposed to the micromanaged mandates common in most states today. Supplemental policies to cover other services would still be available, tailored to the needs and economic abilities of the insured.

The recent sweeping proposals of presidential candidates are far removed from such simplicity, however. They will create a massive healthcare bureaucracy which will no doubt be involved in setting specific coverage requirements (doubtless at the whim of politicians), will engender cost-shifting by price controls on insurance premiums, and will almost certainly create a very large problem of access. There is no free lunch — if insurance companies are forced to lower premiums below levels required to fund their outlays, they will invariably respond by drastically reducing reimbursements to healthcare providers and hospitals. Health care providers will by necessity no longer be able to see patients in these plans, as reimbursements drop below the cost of providing the service — which is exactly the problem which Medicaid and Medicare are encountering currently. Federal control of private insurers will breed a million mini-Medicares, with so-called “private” insurers micro-managing medicine under the harsh glare of Federal hyper-regulation.

The continued linkage of health insurance to employment perpetuates the current environment where the consumer of healthcare is insulated from its costs. Taxes on businesses — whether by mandates to purchase insurance for all employees, or penalties or taxes on those who do not — are nothing more than surrogate taxes on the general population, as businesses will pass these costs through to consumers in the form of higher prices and reduced productivity. New employment will likewise be constrained due to the high entry cost of hiring and keeping workers.

The challenges manifest in our current healthcare system are legion, and highly complex. The difficulty is not merely greedy insurance companies with high administrative costs — although many insurers exemplify these problems. The insurance giants are indeed unscrupulous and unethical — but in the proposed plans they are a convenient political straw man. The real problem is that the insurance companies are no longer accountable to their customers. The camel’s nose is not merely under the tent; the camel is inside the tent — and is eating your lunch, while leaving large camel pies on your Persian carpet.

When you purchase auto insurance, you shop for coverage using price, service, and covered benefits. When you have an accident in your SUV, you expect your insurance company to pay promptly and honestly for the damages you have incurred. If they refuse to do so, or have poor service, or very high rates, you will shop for another insurer.

In health insurance, this normal accountability relationship between the insurance company and the client is broken. Your insurance premiums are not paid by you in most cases, but by your employer — and therefore you have neither flexibility nor options for seeking out the best rates for the coverage you desire. Your coverage is also likely determined by your employer, rather than by you — with some unnecessary services thrown in by state benefit mandates.

When you need healthcare services, you do not pay the physician or hospital directly, other than a small co-pay or deductible. You receive the service, and the provider then bills the insurance company to be reimbursed. The provider is constrained by contract with the insurer, and will only be paid a fixed amount determined by that contract (which, amazingly, the insurers will often refuse to disclose to the provider). If he or she excels in their field, they are not free to make separate arrangements with you at a higher price — even if your are willing and eager to pay for such excellence. If your insurance company chooses to deny a claim and refuse payment — which they do on a regular basis — you may be entirely unaware of this fact.

Hence the insurance company is shielded from accountability to you, the consumer. Your employer also has little or no influence over the insurance companies rates or payment policies. Therefore the insurance company is essentially accountable to no one — a fact which they use to gain a huge financial advantage. It is well established that insurance companies frequently deny claims filed by physicians arbitrarily, knowing that the high volume of claims processed by a physician practice will allow them to do so without consequence: over 50% of practices will simply write off the denial of payment, even if the payment was legitimately due. Practices simply do not have the time or manpower to appeal each and every one of these endless claim denials.

We have allowed the insurance companies — and Federal payers as well — to come between the patient and the insurer. In older, simpler times, it was quite different: you paid the physician directly, and submitted your bill for his or her services to the insurance company, who in turn sent you a check. Under this system, you were fully aware of what the physician was charging, and were fully aware of how promptly and appropriately the insurance company reimbursed you for your healthcare expenses. If they denied a claim, you, their customer, would be on the phone demanding to know why, and if you were not satisfied with the answer, would ultimately change insurance carriers. The physician required far fewer employees to massage and process claims, and as a result their overhead — and fees — were lower.

When politicians — or anyone else — begin talking about “efficiencies” brought about by preventive medicine or information technology — be afraid, be very afraid. Preventive care, as I have discussed elsewhere, is a healthcare talisman, wildly shaken with chanted incantations and ritual dancing as the solution to most, if not all, of our healthcare problems. Other than in selected areas such as prenatal care, or screening for hypertension, cholesterol, or diabetes (which are already routinely done), preventive medicine largely comes down to the Big Three: weight loss, smoking cessation, and regular exercise. If you believe you can get the population at large to embrace these lifestyle changes en mass through some national healthcare policy, you have been spending entirely too much time at the bong.

The idea that large financial return may be gained by simply implementing electronic medical records is beyond naive, bordering on moronic. The entry costs of such systems are enormous, and the complexities of integrating them into healthcare are extraordinary. Keep in mind that much of the current demand for electronic medical records has been driven by the government’s extraordinary documentation requirements imposed by their own reimbursements system. The benefits of electronic medical records are substantial, but cost savings is quite simply not one of them. Any long-term cost-savings would not be seen until there is near universal utilization and standardization — a scenario which is many, many years in the future. In the short term, conversion to electronic medical records substantially increases expenses and complexity, and tends to drive costs up, not down.

The current crop of healthcare reform proposals are an intoxicating blend of wishful thinking, heavy-handed government regulation, and unfulfillable promises. The politicians are inhaling deeply on their health-care hookahs — and hoping that the sweet aroma obscures the reality that they are only blowing smoke.

My Favorite Medical Myths

Dr Bob

A recent post over at the Advice Goddess regarding access to health care caught my eye. Like many such posts, there was a brisk repartee in the comment section on the topic of fixing our daunting health care access problems. Many of the comments were knowledgeable and informative; some, as is always the case, were idiotic or pedantic. One comment in particular, however, caught my eye, posted by a fellow from the liberal side of the political spectrum. It was a rather lengthy screed, which is excerpted here only in part:

I notice that people who enjoy making reflexive attacks on any and every possible change in the current system have this one thing in common: They love to mock the idea of preventive medicine. …

One other point that isn’t being made by the right wing: The number of students accepted by American medical schools was increased substantially about a third of a century ago (partly by the opening of more campuses by state schools), and then was held static. Some attribute this freeze to pressure from the medical lobby (it creates an artificial scarcity of doctors). We should increase entry level spots in medical schools by fifty percent or so (i.e.: what we did in the ’70s etc), and open many more spaces in nursing schools. Curiously, the federal government could cover the tuition of every medical student in the country for a small fraction of what we spend on medical care in total, and it would solve some serious problems for the rest of us by taking the financial bind off the entry level physician…

Of course none of this is all that hard to figure out. The major paradigm shift occurs if you stop thinking about medical care as the exercise of market place free enterprise in which doctors compete to make the most money, and instead view it as a public necessity.

Now, my intent is not to beat up the poor fellow; he is, after all, a liberal, and therefore possessed of a profoundly misguided understanding of human nature and motivation, and a strong inherent (and incoherent) proclivity for finding in government the solution to every imaginable problem. He is more to be pitied than censured. But his comment prompted me to begin thinking about some of the more common medical myths; those axiomatic convictions which seem to drive every discussion about healthcare policy, and show up in virtually every comment section on a health policy-related post. This particular gentleman’s comment mentions at least two such myths, and therefore provides lush green fodder for a rambling rumination on my part.

So here you have it: Some of my very favorite medical myths, time-tested truisms redolent with pertinence and pathos, but replete with error.
Continue reading “My Favorite Medical Myths” →

Boutique & Box Store

Dr Bob

Home DepotA recent article in the Wall Street Journal (subscription required) addressed an interesting new phenomenon in medical practice: the micro-practice. Physicians, weary of being forced to see large volumes of patients because of HMO requirements or financial pressures, coupled with high practice overhead and burgeoning paperwork, are striking out in a very different direction. Some physicians — especially in primary care — are opening small offices without office staff, seeing far fewer patients with much lower overhead, using technology to bridge the gap. As of now, these practices are quite rare, and represent a significant risk to the physician, generally resulting in substantial reduction in income. Nevertheless, it allows these physicians to practice a simpler form of medicine, spending far greater time with patients, having more free time for themselves, and returning to some of the priorities which brought them into medicine in the first place.

Now, I am skeptical that this particular model for medicine will gain wide acceptance. Nevertheless, I believe it represents a trend toward alternative practice models outside the standard framework of large-volume, federal and third-party insurance-driven enterprises. Another similar trend, also small in numbers, is the so-called boutique practice, where patients pay cash, often subscribing on an annual basis to a practice which then provides full services, including appointments on demand, greater access to the physician by phone, routine preventive care, longer appointment times, and other amenities.

I expect to see an increasing divergence in healthcare along similar lines. One analogy would be the box-store versus the boutique. The box store is large, has everything you might need at low prices, provides little in the way of services or amenities — think, Costco or Home Depot-healthcare. For those unwilling to partake of such Wal-Mart style health care, and who have the means to seek alternatives, there will be health care services provided with excellent service and benefits not available in the box store, such as plenty of time with the physician and short waits in the waiting room.

When talking about the social economics of providing health care, it is useful to think of it as a triangle: at one point is quality, and a second point, affordability, and a third point, access. There’s only one problem with this unlovely triangle: one can only have two of the three points at one time. Hence, if you have widespread access to health care which is very high quality, it will not be affordable; if you have broad access and affordability, quality — perhaps not necessarily medical quality, but service quality and access to more expensive or optional medical services — must be constrained. We are currently seeing in large measure the third side of the triangle: we are providing very high quality healthcare, which while expensive, is still relatively affordable — but the cost we are paying is limited access. There is simply no way to have all three points of the triangle.

There is a huge and growing access problem in American health care today, with tens of millions of Americans without insurance, and many more — especially those at or below the poverty level on Medicaid — who cannot find access to physicians because of their own limited financial resources, or the inability of physicians to accept reimbursement from federal programs which pay below the costs to provide the services. The pressure to resolve this dilemma at the political level is very large, and some form of universal coverage seems inevitable in the relatively near future.

In order to provide such broad-based coverage, however, the necessary limit on financial resources — whether federally financed, or paid for through employer-funded or personal-based insurance — must by nature result in a reduction in quality. This is not to say that substandard medicine will be practiced, although there is an increased risk of this; more importantly, there will be significant restrictions in access to optional, high cost technology, and an inevitable decline in service. Universal health care coverage, while critically important, will invariably lead to long waits for an appointment, very little time with the physician, seeing a different doctor at each visit, and having to wade through many levels of support staff to communicate with your doctor. This is already becoming far too common even under our current system due to intense cost-cutting pressures.

While such a universal coverage arrangement may prove very functional from the standpoint of providing basic care for large numbers of people, it will not prove satisfactory to many Americans who have become accustomed to a far more personal and consumer-driven model of health care delivery. There will, therefore, be strong financial incentives to provide alternatives to box-store medicine — and in fact, we are already beginning to see this.

The best contemporary examples of this alternative system of boutique medical care can be seen today in plastic surgery clinics, LASIK eye centers, and the growing trend toward high-end specialty hospitals catering only to orthopedics or other subspecialty care. While social engineers tend to decry such two-tiered healthcare systems, in fact, these alternatives respond far better to true market forces then does the lumbering dinosaur of federally-funded or third-party insurance-controlled health care. Plastic surgery clinics compete on price, service, and quality for a facelift, tummy-tucks, or a breast augmentation; high-end clinics charging more must be a higher standard of quality as well as provide extraordinary service. Consider the dramatic decrease in cost for elective corrective eye surgery with LASIK: prices have dropped dramatically over the past few years as high-volume LASIK clinics compete for patients. Hospitals, faced with a drain of better-paying patients toward specialty hospitals which provide a higher quality of service and a more satisfying patient experience must now re-examine their own quality issues, and are pressured to provide nicer facilities, better food, more nurses per patient, and other service-oriented improvements.

Beware of those — especially of the political persuasion — who promise unlimited, high-quality health care which is affordable. It does not, and cannot exist. We clearly need to address coverage for those in need of health care who cannot currently afford it, for health care, while not a right, is most certainly a very large part of our quality of life and well-being. The boutique model of health care service will not address this problem, in spite of the pipe dreams of libertarians who believe that free market solutions can solve all problems. This two-pronged approach may well provide a uniquely American solution to the worldwide dilemma of providing high-quality care, excellent service and access, and affordability Virtually all countries providing socialized, government-funded health care are struggling with the box-store problem. Poor service, long waits for care and “elective” surgery (like heart bypass and cancer surgery), and spiraling costs are the rule. But we in America have become accustomed to the highest quality of health care in the world, delivered quickly — for those who can afford it.

Perhaps it is time we abandon a utopian vision for health care, and settle on something, though imperfect, which may end up working quite well in the American healthcare system. It may well come from the ground up rather than from the top down.

More Embryonic Stem Cell Info

Dr Bob

I’ve recently referenced an excellent article on the huge gap between hype and reality with embryonic stem cell research (as opposed to the real and growing applications of adult stem cells), and Michael Fumento again points out the huge gap between myth and reality here (HT: Instapundit). Maybe the word is starting to get out — although I’m not holding my breath.

On a separate note, I’ve been quite busy lately, with several personnel changes in the office in the works, but have a few essays near completion on the Faith series (part 1 and part 2 here), Moving the Ancient Boundaries, as well as updates on the Narrows Bridge construction — so stay tuned.

God bless, back soon.

Embryonic Stem Cells

Dr Bob

A.M. MoonIf you have any interest in the ongoing debate, ethical issues, and clinical promise of embryonic stem cell research, you should take a few minutes and read this excellent article by Maureen L. Condic at the always-excellent First Things magazine.

Dr. Condic is an associate professor of neurobiology and anatomy at the University of Utah School of Medicine and conducts research on the development and regeneration of the nervous system.

You will find the article immensely helpful at clearing away the fog generated by ESCR proponents and their supporters in the media, politics, and the shallow, vapid, intellectual pools of Hollywood.

Do yourselves a favor and give this a read — and save a copy as a reference for the next time someone waxes poetic about their promise, or the “cruelty” of exercising the utmost caution in pushing ahead with such research.