Medicine

The Revenge of the Fifth

Dr Bob

Revenge of the Fifth

MercuryIt seemed like such a great idea at the time… His name is Darin. Of course, that’s not his real name, but he is a casual friend of mine. A bright young man, possessed of good looks, a warm smile, and a soft-spoken demeanor. Darin is brilliant with computers–not merely competent, as many are, but a true geek, tear-’em-down-and-rebuild-’em smart, fearless in the depths of sockets and motherboards, Windows registries and Unix terminals. A true success story, you might say, bright future, make some girl very happy. But Darin was toolin’ down the freeway of goin’ nowhere fast.

You see, Darin had a little problem: a fondness for the grape and the snort which always seemed to get the best of him. Not that he didn’t try: he was in and out of AA rooms more often than a pastor’s wife at church socials, always returning beaten and remorseful, determined to do better this time. “This time” rarely lasted more than a few weeks or months.

Darin was quiet, but a man of passion. He was always in love. Intoxicated with the flush of a new romance, that rush of euphoria so real yet so maddeningly transient. Each new girl was “the one”, but nights of passionate, drug-enhanced sex soon proved impotent to overcome the waning charms of Miss Demeanor, the rumpled sheets, and the rumblings of his restless soul. Before long he was again cruising for some other codependent wench, herself seeking a sodden soul to save. Like an ugly tie wrapped up pretty under the Christmas tree, Darin’s package looked good at first glance, but he quickly proved to be a daddy’s nightmare: “no phone, no food, no rent”, as the song goes. Soon he was once again welcome only in his mother’s house, with whom he could do no wrong.

Unfortunately, the same could not be said of Darin: someone did him dirty, stiffing him out of a good deal of cash, and forgiveness was not one of his many charms. The details are murky: a computer built or repaired, promises made but not kept. There was much lighthearted chatter at the coffee houses–was it Darin’s fault, or his nemesis? No matter–like a quiet bubbling cauldron in a witch’s lair, Darin was cooking up his favorite dish: a rip-roaring resentment. Not visible on the outside, of course, but raging like a Jerry Springer slug-fest in the conference rooms of his mind. It was the perfect mixed drink: a perceived injustice blended with that unique obsessiveness which addicts possess seemingly in endless measure.

It is not clear when the brainstorm struck–an idea so brilliant, so flawless, that it would right all injustices and settle all disputes: Darin would break into his detractor’s home and steal back the computer which tortured him so. No mere larceny, mind you, but the picture-perfect crime, a liberation to rival Paris in ’45. Carefully timed when the enemy was not at home, staged so not even Sherlock Holmes would presume that Darin might be the perpetrator. Sweet revenge, sweetly executed.

Like tightly-written computer code, Darin’s nimble mind set the parameters, checked the variables, and executed commands in a tight loop whose efficiency and speed wasted no cycles. The Day of Vengeance arrived, with only one small ingredient missing: courage. But Darin had that algorithm factored as well: a fifth of Vodka erased all fears, drowning all doubts. By stealth of night, with watches synchronized and bottle drained, the window glass parted to usher him to glory. The mission was underway.

No one knows whether anyone heard the shattering of glass, but despite his stealth the disruption somehow caught the notice of neighbors. When the police arrived, the cause of the disturbance became evident: there was Darin, passed out on the floor, beside the untouched computer he coveted. Fate had struck a cruel blow–his celebratory blackout had arrived on the wings of Mercury rather than with the spoils of Mars. He awakened to handcuffs and an open-ended reservation at the Gray Bar Hotel.

All good stories–even true ones–should have a moral, but Darin’s story eludes easy lessons. He was taken by that peculiar insanity which alcoholics possess in abundance, even while sober. When Darin hatched his master plan, he was not drinking, but engaged in one of his countless attempts to clean up. For the alcoholic, the danger lies not in the bottle, but in the brain. The sane among us make mistakes, to be sure: wisdom comes from experience, and experience often comes from lack of wisdom. But facing the inevitable consequences of bad choices, we generally rearrange our lives and priorities to ensure that such a travesty does not happen again. Not so the alcoholic. Obsessively repeating behavior long ago proven destructive, he nevertheless pursues the optimism of denial which says the next time will be different. This baffling disconnect from reality cascades from farce to tragedy, as the alcoholic perceives no problems other than those bastards who are out to get him.

There is much resistance to the idea that alcoholism and addiction are a disease. Much of this comes from conservatives, and those of religious conviction, whose proper emphasis on personal responsibility and moral rectitude sees in the alcoholic only reckless hedonism and wanton irresponsibility. These qualities the addict has in spades, but less obvious is the driving obsessive compulsion, the thought disorder which is their engine. The medical evidence for the disease model of alcoholism and addiction is deep and wide, as I have detailed in part elsewhere (see also this and this for more on the topic). The liberals have this one right: the alcoholic is a victim of his or her genetics, and the addition of a mind-altering drug–which one is probably moot–starts a swirling whirlpool whose vortex holds only misery, destruction and death. Not many survive its power.

Yet defining deviance from normal as disease also has its risks: the proliferation of social disorders redefined as diseases seems endless, and points to the abrogation of all responsibility for one’s actions. It can become laughable at times.

Several years ago, I saw a patient, a healthy, athletic women in her 40’s, who was covered under Medicare. Medicare covers the elderly, but also those with chronic renal failure and the disabled, so I inquired as to the nature of her disability. I was informed she had “hyperactivity disorder.” Attention deficit hyperactivity disorder (ADHD)? No, just hyperactivity disorder–she was restless. A black belt in Karate, she traveled around the country constantly, competing in tournaments and teaching seminars. She was disabled, in short, because she couldn’t sit still. No “cripple” jokes around her, no siree, unless you wanted your skull crushed by a foot you’ll never see coming.

The concern about labeling alcoholism, or any other behavioral disorder, as a disease is the tendency to tolerate and rationalize the resulting behavior, to use the “disease” label as an excuse for selfish, self-centered behavior destructive to one’s self, society, and those around you. The issue is not disease or no disease, but rather what drives the behavior and what can be done to change it. The paradox about 12-step programs–which have the only reliable track record for successful recovery from addiction–is that they emphasize the disease as the problem, and honesty, integrity, and personal responsibility as the solution. They do not excuse the behavior while admitting the disease, and this blend of honesty and humility, acceptance and tough love, works like nothing else. It is, as recovering alcoholics are quick to point out, a spiritual program: the Catch-22 of a body which craves alcohol without limit and a mind which denies the resulting problems cannot be solved any other means.

But as any recovering alcoholic will tell you, the problem is not the booze; it is not even the obsessive, irrational mindset which drives the drinking. Both these problems are symptoms of an underlying decay, one of spiritual dimensions, characterized at its core by extreme self-centeredness. The pursuit of happiness by feeding this monster creates not the promised joy but rather pain and emptiness. Alcohol hides that pain for a while, until the monster, growing ever stronger by its constant feeding, kills its host spiritually, emotionally, and often physically.

But addiction is hardly alone as a symptom of this dark core. The list of destructive behaviors arising from its belly is endless: obesity, sexual promiscuity, compulsive overwork, materialism, computer obsession, gambling, the pursuit of beauty over character, the lust for money and power. Some may be biologically-driven; some learned behaviors or dysfunctional coping. All seek to fill a hole with no bottom, providing the wrong salve for the pain, and more of the same when the salve makes the wound fester.

And what of Darin? In many ways he is fortunate: his life is on hold, and forced reflection and change are his for the taking–should he choose to grasp them. The price is high; it might have been much higher. Yet his choice–and ours–is the same: feed the monster, or turn life over to One whose burden is light, who alone can fill that deep inner void.

Dancing With Death

Dr Bob

Dancing with Death

The war rages on. It is a battle with ancient roots, deeply embedded in religion, culture, and the tensions between rich and poor. It is a war of contrasts: high technology and primitive cultural weapons; knowledge versus ignorance; speed and urgency against the methodical slowness of an enemy who knows time is on his side.

It is a war in which enormous strides have been made, with countless victories large and small.

The enemy is death. The avenger is medicine. And the war is going very poorly indeed. In many ways, the gains of modern medicine against death and disease are truly impressive: longer life expectancy; progress and cures against heart disease, cancer, and diabetes; surgical and procedural marvels hard to imagine even 15 or 20 years ago. Yet, it is these very advances which seem to lie at the heart of a growing problem. We are so engaged in the battle, so empowered by our growing capabilities, that we have lost sight of the bigger picture. While pushing back the adversary of death, we are ever so steadily being destroyed by the very battle itself.

Several recent experiences have driven this dichotomy home for me. Last week, I was asked to evaluate a man who had been hospitalized for a over a week. A nursing home resident in his late 80’s, his overall health was fair to poor at best, and he suffered from severe dementia. He was unable to communicate in any way, and could recognize no one — not even his wife of many years, who remained in possession of her full facilities. He was admitted to the hospital with a severe urinary tract infection with a highly resistant bacteria, and septic shock. When he arrived at the ER, the full extent of his dementia was not apparent to the physicians there, and his wife insisted that all measures be engaged to save him. Aggressive medical care was therefore initiated — intensive care unit, one-on-one nursing care, hemodynamic monitoring, drugs to support blood pressure, intravenous nutrition, and costly antibiotics. After nearly two weeks of such intensive therapy, the patient largely recovered from his life-threatening infection — returning to his baseline of profound dementia. Yet the underlying risk factors which led to it — his age, a chronic bladder catheter and bacteria-harboring stones, diabetes, — remained in place, lying in wait for another, inevitable opportunity, in a matter of weeks or months. The cost of his hospitalization was easily in 6 figures.

In another situation, an elderly women presented to the hospital with signs of a serious, life-threatening infection in her abdomen. A healthy widower, she lived independently with her sister prior to her illness. Emergency surgery was performed, and an abscessed kidney removed. Her medical condition deteriorated after surgery, with coma due to stroke and failure of her remaining kidney brought on by the infection.

The patient’s sister and living companion communicated the clear final wishes of the widower: a women of strong faith, she wished no extraordinary measures, such as ventilators or dialysis, to extend her life needlessly. She was comfortable with death, and not afraid. The staff prepared to allow her to die gracefully, comfortably, and in peace.

But such was not to be. There was no living will, and the sister did not have legal authority to make such decisions. But the widower’s daughter, a nurse living out-of-state with little recent contact with her mother, arrived in town demanding that aggressive measures be taken to save her. A nephrologist (kidney specialist) was called in. A superb physician, compassionate and dedicated, he had been successfully sued in a similar case after recommending that dialysis be withheld in a patient with a grim prognosis. This was a mistake he would not make twice: the widower was transferred to another hospital, placed on dialysis, and died 3 weeks — and a quarter of a million dollars — later, in an ICU. She never woke up.

The issues which these two cases bring up are numerous, complex, and defy easy answers. They touch upon the subjective measure of quality-of-life and what it is worth; the finite limit of economic health care resources; the relative responsibilities of physicians, patients, and their families in end-of-life decisions; the pressures placed on the health care system and its practitioners by after-the-fact second-guessing in an aggressive tort environment; and a host of others greater or lesser in weight and substance, up to and including the meaning of life itself.

All the players bear responsibility in this passion play. Physicians excel at grasping what they can accomplish, but are woefully inadequate for the task of deciding whether such things should be done. In the urgency of acute care, delay to consider the ramifications of a decision to treat may cost an opportunity to save a patient for whom such treatment is desirable; better always to err on the side of salvage. Pressured by family, potential litigation, or instinct, the path of least resistance is to follow your training and use your skills. And physicians themselves are uncomfortable with death, though inundated in its ubiquity.

Family members naturally resist the agonal separation of their loved ones, often harboring unrealistic hopes and expectations of recovery in the face of inevitable death. A curious dance of denial often ensues between physician and family, as each, unwilling to face the unpleasantness of the inevitable, avoids the topic at all costs. The physician hides behind intellect, speaking of blood counts, medications, and ventilators, or at best tiptoeing around the core issue with sterile terms like “prognosis.” Family members hesitate to ask questions whose answers they already know. Too rarely are the physician and family willing to place the subject squarely on the table, in all its ugliness and fearfulness. Decisions which need to be made are put off, unspoken and deferred. The clock ticks on, the meter is running, and only the outcome is not in doubt.

The tort system provides a ready outlet for the anguish and anger of death of a loved one. In such a period of intense emotional turmoil, the real or perceived indifference of physicians (often a mechanism of detachment by which doctors deal with the horrors of death and illness); the parade of unfamiliar medical faces as no-name consultants come and go during the final days; the compounding burden of crushing financial load from the extraordinary costs of intensive terminal medicine; the Monday-morning quarterbacking by the tort system of complex, often agonizingly difficult medical decisions in critically-ill patients: all present a toxic and intoxicating brew which impels the health care system forward to leave no avenue untravelled, no dollar unspent in prolonging life beyond its proper and respectful end.

This march of madness is not without resistors. Seizing on the high costs, the futility, and especially the lack of personal control fostered by impersonal, highly technical terminal care, the euthanasia movement is maneuvering into the gap. Cloaked in slogans of personal autonomy and “Death with Dignity”, active euthanasia proponents seek to replace the sterile prolongation of a now-meaningless life with the warm embrace of Death herself. Terrified by an out-of-control dying process, an end of a life which embodies all meaning, they seek to control death as their final act of significance. But Death will not be controlled, and those who dance with Death are seduced by her siren. Euthanasia starts with compassionate intent, but ends with termination of the useless. Man does not have the wisdom to control death; The Ring-bearer is corrupted by its power.

Our discomfort with death is our confusion about life. Man is the only species cognizant of his coming demise — who then, in the ultimate paradox, lives his entire life pretending it will not happen. Our Western culture, enriched with a wealth of distractions, allows us to pass our living years without preparing for the inevitable. When the time arrives, we use all the weapons at our disposal — wealth, technology, information, law — to resist the dragon. We drive it back for a time — at enormous cost, personal, financial, physical and emotional. Death always wins — always.

I am not of course yearning for a return to the past, a passive resignation to the inevitable anabasis of disease and death. The benefits of medicine and the forestalling of death are precious and powerful gifts, which have greatly benefited many. But like all such great powers, they are useful for good or ill. When the defeat of death becomes an end in itself, detached from the meaningfulness of life lived, it has great destructive energy.

We must learn how to die. And to learn how to die, we must learn how to live — how to seek the transcendent, the power of love, and sacrifice, and giving which makes life rich and enduring. The selfish, the superficial, the transient all gratify for a time, but when this is all we possess, we grasp desperately to their threadbare fabric when beauty and health give way to weakness, fear and death. All great religions understand this: the meaning of life transcends life. In the Judeo-Christian view, life is an opportunity to draw ourselves and others closer to the light and goodness of God, with the promise of an even greater life and deeper relationship after death. Yet even for the agnostic or secular among us, service to others — personal and social — has the potential to endure long after us. None of us will be remembered for our desperate clinging to life in its waning days, but rather for the lives we touched, the world we made better when we lived.

The Children Whom Reason Scorns

Dr Bob

The Children Whom Reason Scorns

You Also Bear the BurdenIn the years following the Great War, a sense of doom and panic settled over Germany. Long concerned about a declining birth rate, the country faced the loss of 2 million of its fine young men in the war, the crushing burden of an economy devastated by war and the Great Depression, further compounded by the economic body blow of reparations and the loss of the German colonies imposed by the Treaty of Versailles. Many worried that the Nordic race itself was threatened with extinction.

The burgeoning new sciences of psychology, genetics, and medicine provided a glimmer of hope in this darkness. An intense fascination developed with strengthening and improving the nation through Volksgesundheit: public health. Many physicians and scientists promoted “racial hygiene” — better known today as eugenics.

The Germans were hardly alone in this interest — 26 states in the U.S. had forced sterilization laws for criminals and the mentally ill during this period; Ohio debated legalized euthanasia in the 20’s; and even Oliver Wendall Holmes, in Buck v. Bell, famously upheld forced sterilization with the quote: “Three generations of imbeciles are enough!” But Germany’s dire circumstances and its robust scientific and university resources proved a most fertile ground for this philosophy.

These novel ideas percolated rapidly through the social and educational systems steeped in Hegelian deterministic philosophy and social Darwinism. Long lines formed to view exhibits on heredity and genetics, and scientific research, conferences, and publication on topics of race and eugenics were legion. The emphasis was often on the great burden which the chronically ill and mentally and physically deformed placed on a struggling society striving to achieve its historical destiny. In a high school biology textbook — pictured above — a muscular German youth bears two such societal misfits on a barbell, with the exhortation, “You Are Sharing the Load!–a hereditarily-ill person costs 50,000 Reichsmarks by the time they reach 60.” Math textbooks tested students on how many new housing units could be built with the money saved by elimination of long-term care needs. Parents often chose euthanasia for their disabled offspring, rather than face the societal scorn and ostracization of raising a mentally or physically impaired child. This widespread public endorsement and pseudo-scientific support for eugenics set the stage for its wholesale adoption — with horrific consequences — when the Nazi party took power.

The Nazis co-opted medicine fully in their pursuit of racial hygiene, even coercing physicians in occupied countries to provide health and racial information on their patients to occupation authorities, and to participate in forced euthanasia. In a remarkably heroic professional stance, the physicians of the Netherlands steadfastly refused to provide this information, forfeiting their medical licenses as a result, and no small number of physicians were deported to concentration camps for their principled stand. As a testimony to their courage and integrity, not a single episode of involuntary euthanasia was performed by Dutch physicians during the Nazi occupation.

Would that it were still so.

In April 2001, the Netherlands became the first country in the world in which euthanasia and assisted suicide could be legally performed — although preceded by several decades of widespread illegal, but universally unpunished, practice. The Dutch had come into the public consciousness periodically over the previous 15 years, initially with the consideration of assisted suicide laws in Oregon, Washington, Michigan and elsewhere in the early 90’s, and again with their formal legalization of physician-assisted suicide and euthanasia in 2001.

Again in 2004, they showed up on the ethical radar, with the Groningen Protocol for involuntary euthanasia of infants and children.

The Groningen Protocol was not a government regulation or legislation, but rather a set of hospital guidelines for involuntary euthanasia of children up to age 12:

The Groningen Protocol, as the hospital’s guidelines came to be known, created a legal framework for permitting doctors to actively end the life of newborns deemed to be in similar pain from incurable disease or extreme deformities.

The guideline stated that euthanasia is acceptable when the child’s medical team and independent doctors agree the pain cannot be eased and there is no prospect for improvement, and when parents think it’s best.

Examples include extremely premature births, where children suffer brain damage from bleeding and convulsions; and diseases where a child could only survive on life support for the rest of its life, such as severe cases of spina bifida and epidermosis bullosa, a rare blistering illness.

The hospital revealed it had carried out four such mercy killings in 2003, and reported all cases to government prosecutors. There were no legal proceedings against the hospital or the doctors.
While some are shocked and outraged at this policy of medical termination of sick or deformed children (the story was widely ignored by the mainstream media, and received only limited attention on the Internet), it was merely a logical extension of a philosophy of medicine widely practiced and condoned in the Netherlands for many years, much as it was in Germany between world wars. It is a philosophy where the Useful is the Good, whose victims are the children whom Reason scorned.

Euthanasia is the quick fix to man’s ageless struggle with suffering and disease. The Hippocratic Oath — taken in widely varying forms by most physicians at graduation — was originally administered to a minority of physicians in ancient Greece, who swore to prescribe neither euthanasia nor abortion — both common recommendations by healers of the age. The rapid and widespread acceptance of euthanasia in pre-Nazi Germany occurred because it was eminently reasonable and rational. Beaten down by war, economic hardship, and limited resources, logic dictated that those who could not contribute to the betterment of society cease being a drain on its lifeblood. Long before its application to ethnic groups and enemies of the State, it was administered to those who made us most uncomfortable: the mentally ill, the deformed, the retarded, the social misfit. While invariably promoted as a merciful means of terminating suffering, the suffering relieved is far more that of the enabling society than of its victims. “Death with dignity” is the gleaming white shroud on the rotting corpse of societal fear, self-interest and ruthless self-preservation.

It is sobering and puzzling to ponder how the profession of medicine – whose core article of faith is healing and comfort of the sick – could be so effortlessly transformed into a calculating instrument of judgment and death. It is chilling to read the cold scientific language of Nazi medical experiments or Dutch studies on optimal techniques to minimize complications in euthanasia. Yet this devolution of medicine, with some contemplation, is not hard to discern. It is the natural gravity of man detached from higher principles, operating out of the best his reason alone has to offer, with its inevitable disastrous consequences. Contributing to this march toward depravity:

  • The power of detachment and intellectualism: Physicians by training and disposition are intellectualizers. Non-medical people observing surgery are invariably squeamish, personalizing the experience and often repulsed by the apparent trauma to the patient. Physicians overcome this natural response by detaching themselves from the personal, and transforming the experience into a study in technique, stepwise logical processes, and fascination with disease and anatomy. Indeed, it takes some effort to overcome this training to develop empathy and compassion. It is therefore a relatively small step with such training to turn even killing into another process to be mastered.

  • The dilution of personal responsibility: In Germany, the euthanasia of children was performed with an injection of Luminal, a barbiturate also used for seizures and sedation of the agitated. As a result, it was difficult to determine who was personally responsible for the deed: was it the nurse, who gave too much? The doctor, who ordered too large a dose? Was the patient overly sensitive to the drug? Was the child merely sedated, or in a terminal coma? Of course, all the participants knew what was going on, but responsibility was diluted, giving rationalization and justification full reign. The societal endorsement and widespread practice of euthanasia provided additional cover. When all are culpable, no one is culpable.

  • Compartmentalization: an individual involved in the de-Baathification of Iraq said the following:

    There is a duality in Baathists. You can find a Baathist who is a killer, but at home he’s completely normal. It’s like they split their day into two twelve-hour blocks. When people say about someone I know to be a Baathist criminal, ‘No, he’s a good neighbor!’, I believe him.
    Humans have the remarkable ability to utterly separate disparate parts of their lives, to accommodate cognitive dissonance. Indeed, there is probably no other way to maintain sanity in the face of enormous personal evil.

  • The banality of evil: Great evil springs in countless small steps from lesser evil. Jesus Christ was doubtless not the first innocent man Pilate condemned to death; soft porn came before child porn, snuff films, and rape videos; in the childhood of the serial killer lies cruelty to animals. Small evils harden the heart, making greater evil easier, more routine, less chilling. We marvel at the hideousness of the final act, but the descent to depravity is a gentle slope downwards.

  • The false optimism of expediency: Solve the problem today, deny any future consequences. We are nearsighted creatures in the extreme, seeing only the benefits of our current actions while dismissing the potential for unknown, disastrous ramifications. When Baby Knauer, an infant with blindness, mental retardation and physical deformities, became the first child euthanized in Germany, who could foresee the horrors of Auschwitz and Dachau? We are blind to the horrendous consequences of our wrong decisions, but see infinite visions of hope for their benefits. As a child I watched television shows touting peaceful nuclear energy as the solution to all the world’s problems, little imagining the fears of the Cuban missile crisis, Chernobyl and Three Mile Island, the minutes before midnight of the Cold War, and the current ogre of nuclear terrorism.

    Reason of itself is morally neutral; it can kill children or discover cures for their suffering and disease. Reason tempered by humility, faith, and guidance by higher moral principles has enormous potential for good – and without such restraints, enormous potential for evil.

    The desire to end human suffering is morally good. Despite popular misconception, the Judeo-Christian tradition does not view suffering as something good, but rather something evil which exists, but which may be transformed and redeemed by God and grace, to ultimately produce a greater good. This is a difficult sell to a materialistic, secular world, which does not accept the transformational power of God or the existence of spiritual consequences, or principles higher than human reason.

    Yet the benefits of suffering, subtle though they may be, can be discerned in many instances even by the unskilled eye. What are the chances that Dutch doctors will find a cure for the late stage cancer or early childhood disease, when they now so quickly and “compassionately” dispense of their sufferers with a lethal injection? Who will teach us patience, compassion, unselfish love, endurance, tenderness, and tolerance, if not those who provide us with the opportunity through their suffering, or mental or physical disability? These are character traits not easily learned, though enormously beneficial to society as well as individuals. How will we learn them if we liquidate our teachers?

    Higher moral principles position roadblocks to our behavior, warning us that grave danger lies beyond. When in our hubris and unenlightened reason we crash through them, we do so at great peril, for we do not know what evil lies beyond. The Netherlands will not be another Nazi Germany, as frightening as the parallels may be. It will be different, but it will be evil in some unpredictable way, impossible to foresee when rationalism took the first step across that boundary to kill a patient in mercy.

The Law of Rules

Dr Bob

The Law of Rules

DaisiesIn contemporary political discourse, we often discuss the Rule of Law, especially in our postmodern culture where bad behavior is often justified (and excused) by situation, upbringing, or historical injustice. But no one ever talks about the Law of Rules.

Recently in the office I reviewed one of Medicare’s bulletins, clarifying (at least in intent, if not in practice) their regulations in some arcane area of reimbursement for surgical procedures. Few outside of the health care field have any idea of the complexity of regulations governing medicine. When last I checked some years ago, Medicare had about 150,000 pages of regulations in the Federal Register, approximately 3 times of the volume of the IRS tax code. American medicine is more highly regulated than Soviet state industry ever was, and getting more so by the day.

Without launching into a diatribe on the evils of government-funded and regulated medicine (perhaps another time), it strikes me that the explosive growth of rules, laws, and regulations in society as a whole is a reflection of an underlying shift in our culture, values, and individual moral integrity.

There are two ways to encourage good behavior in individuals and society: from within or from without. Human beings are morally flawed (a surprisingly controversial statement in our current, “values neutral” culture), and therefore in order to maintain a peaceful, stable, functioning society, laws – and the means to enforce them – are required. Laws exist not for the good in man, but rather for the evil, as a restraining force. If man were morally perfect, no laws would be necessary. Yet law cannot create morality, but serves only to protect the good in society from the evil. The more moral goodness exists in a society–restraint from harming one’s neighbor, acts of service, honesty, integrity — the fewer laws are needed and the better those laws already in place function. As individuals (and consequently the society they constitute) change from being other-oriented and self-restrained to self-centered and self-seeking, the more law-breaking occurs, the greater the enforcement required, and the more laws are required to manage and restrict human behavior. Hence the Law of Rules: Rules beget more rules.

We humans are intelligent, resourceful beings who are ever looking for new ways to achieve the goals and desires important to us. If our intent is to deceive, steal, or harm, there is almost always a way around existing law to accomplish our aims. The result of this is twofold: harsher enforcement of existing laws and more laws to cover the loopholes discovered by our innovative selves, as society seeks to protect itself. Hence the result of a deterioration in individual moral restraint is both more laws and harsher penalties. The logical end result of such a progression is something resembling totalitarianism: there are laws about everything, and brutal punishment for their violation — selectively applied, invariably.

We often hear totalitarian regimes such as China or the former Soviet Union boast of their low crime rates and the safety of their streets. And Islamic countries and cultures often proclaim their inherently higher moral status over us libertines in the West, cutting off the hands of robbers and the like. But while it is possible in large measure to restrict behavior through law and retribution, such measures do not make a society or its individuals moral as a consequence. In fact, the effect is quite the opposite. Laws intended to restrict evil behavior often have the unintended consequence of negatively impacting those intent on good. So, for example, the law designed to discourage fraud in Medicare by the few (a worthy goal) results in less time for patient care, restriction of access to care by the needy, and the exodus of good health care providers to other professions to escape their crushing burden — all bad outcomes affecting far more people than the few who would game the system. One need only look at the extreme effects of Islamic teaching on some of its more, , exemplary adherents, with the wanton murdering of women, children, unbelievers–and even other Muslims–to conclude that constrictive law-abiding society does not promote moral goodness as a consequence.

What’s the answer? Other than a fundamental reversal in individual moral virtue–an inside-out change–I fear there are few good alternatives. But I am not gloom-and-doom about the prospects for such change–I have seen and know of too many who have undergone such a change to be pessimistic, and am convinced of the existence of a God capable of implementing such change.