Pitch for a sequel to W;T

R. Horton

Some friends and I were saying we wish Margaret Edson, author of “W;t,” would write another play. Jokes about possible sequels ensued, so I imagined the following:

After witnessing and participating in the disrespectful and undignified death of Vivian Bearing, a feared and respected scholar of John Donne, Jason Posner begins to question whether biological reductionism is any more reasonable than attempts at metaphysical reductionism that John Donne paradoxically sought and repudiated. As Posner grapples with the contradiction between his desire to prolong life through medical research and his denial of the significance of suffering, he develops a yearning to create meaning out of the intersection of biological necessity, emotional fervor, and human connection.

As Posner completes his required clinical experience in the hospital and moves into the lab full time, he finds himself plagued by questions about the patients whose tissue and cells he is observing and manipulating. He begins to question the motivation of nurses, social workers, chaplains, and therapists in the hospital.

As his curiosity grows, isolated from human contact, he begins to read not only Donne’s “Devotions Upon Emergent Occasions” but patient narratives as well as caregiver narratives. He begins to realize the importance of suffering to meaning humans make of their condition.

Through the turmoil of his own imagination, he has one other realization: He realizes he will die.

Can justice be utilitarian?

R. Horton

I have always been fond of Utilitarianism and, quite frankly, impressed by the arguments of all the major Utilitarian writers. Criticisms of Utilitarianism also make sense, but they don’t seem consistent with the views of major Utilitarians. I suppose I most commonly hear Utilitarianism dismissed as a cruel philosophy that would accept sacrificing individuals so long as a larger number of people drew some advantage from the sacrifice.

This argument affects me strongly as I feel a society that is unjust to only one person is an unjust and unacceptable society. Yet, I still find myself in great admiration for Bentham, Mill, Hare, Singer, and others. What I admire about these Utilitarians is that they never ignored the plight of people (or even non-human animals) who were marginalized by society. It is precisely this inclusiveness of Utilitarianism that attracts me.

For example, in one of my bioethics classes, we had a discussion of how to respond to a pandemic. Some of my colleagues said that doctors must deal with the person in front of them with full attention. To toss this person aside, they said, would just be Utilitarian. They pronounced “Utilitarian” as if they were saying, “pure evil.” Utilitarianism seems heartless to them. Doctors making calculations as to what actions would benefit the most people. I object, however, and say that it seems more heartless to ignore the 10 people dying in the street than it does to step away from one hopeless case in the hospital. I am biased, but I happen to think the person in the hospital is likely to be more privileged than the people who are in the street, and I feel we should give priority to the poor and dispossessed.

I also noted that everyone, doctors and non-doctors, was obligated to help as many people as possible. In this way, no one should be left to die alone with no one showing concern for him or her. Utilitarians such as Peter Singer and Peter Unger make powerful arguments for devoting more attention to those dying of starvation in the world. They do not advocate, as you might expect from the criticisms leveled against them, ignoring the suffering of the poor so long as it benefits the rich. Rather, they suggest that everyone has an obligation to try to relieve the suffering of everyone else, with no one being left out of the mix. I realize things don’t happen this way, but ethicists attempt to describe how things ought to happen, not how things are likely to happen.

So, all this leaves my question about justice open. I want to say that everyone will be happier if we all live in a state that is perfectly just.* For this reason, we cannot ignore injustice inflicted on any one person. When I make this assertion, I’m taking the line that we should all follow a rule, and some will say that so-called “Rule Utilitarianism” is just another form of deontology. I think the two may be compatible. It may that I have misunderstood Utilitarianism. If that is the case, I think most Utilitarians have also misunderstood it.

*Yes, I know, we are not likely to agree on what is meant by “perfectly just.”

Is it possible to reduce “futile care”?

R. Horton

Ken Murray, MD, recently wrote an excellent essay on how doctors die. To make a short story of it, doctors reject invasive, expensive, and ineffective treatment at the end of life that may prolong life for a short time but often with great suffering. It isn’t hard to understand why doctors reject such treatment seeing how it causes much suffering and provides so little benefit. It is a little harder to understand why so many non-doctor patients receive so much of this so-called “futile care.”

Murray offers some explanations of why patients receive so much expensive care that benefits no one. For one, doctors feel they are less likely to be sued for negligence if they “try everything” and never suggest withholding any treatment. Although the financial cost of such care is often astronomical, most patients and families of patients feel it is inappropriate to suggest that someone’s life is not worth the cost of care.

Clearly, if patients and their families understood the risks associated with invasive care as well as doctors, they would make the same decisions as doctors (unless, of course, we believe doctors are inherently more rational than everyone else in the world, and a handful of doctors may in fact believe just that). The problem is that patients do not understand the drawbacks as well as doctors (and other healthcare providers), and it is extremely difficult for a doctor to suggest turning down treatment without being occasionally accused of insensitivity or cruelty.

But I think this is an overly simplistic view. Many changes in medical practice in the past few decades have led us to some of these difficulties in communication. One problem is the way both doctors and patients view autonomy and informed consent. Both medical ethicists and the courts have declared that patients must make their own decisions regarding what treatments should be sought or declined. Many see the role of doctors as one of providing a list of treatment options, explaining the risks and benefits of treatment, and stepping back to let the patient decide on which treatment is appropriate. For better or worse, we have rejected the authority of the doctor to make medical decisions for us. This has been an important and generally positive development. For example, few if any feminist ethicists would suggest we should return to an era of medical paternalism.

However, patients go to doctors because the doctor is a medical authority. While patients rightly want the doctor to present treatment options, they do not necessarily want the doctor to withhold any opinion regarding which options are most suitable. Patients do not want to take orders from doctors anymore, but they do really want some suggestions, and they want to know why their doctors favor one suggestion over another. This happens routinely in day-to-day interactions, but it is more difficult in an emergency where someone is near death and decisions must be made quickly.

When a doctor says, “There is only one treatment available that may prolong your father’s life,” loving children are likely to reply, “Please do whatever you can to save our father.” Caregiver panic is one of the most common reason people end up dying in hospitals with unwanted treatment instead of in a quiet setting surrounded only by loved ones. I knew someone a few years ago who experienced this first hand. She was caring for her father, and she knew he was dying and wanted to die at home. However, when he began struggling for breath and appeared to be suffering, she called an ambulance. It would be counterintuitive for the staff on the ambulance or in the emergency room to assume she did not want her father rescued. She did want him rescued to the extent that she wanted him relieved, but she was not thinking clearly when she called for help. Of course the doctors assumed she wanted everything possible done to save her father.

Even when panic is not the driving force behind decisions, families may not understand that their loved one will die shortly in any case. Nor do they understand that further treatment may cause great pain for the few short days or weeks remaining. Communicating this reality is a skill that some doctors have, but many find it difficult for obvious reasons.

And one final note: I have heard doctors sometimes say, “The best I can offer you is an experimental drug that was just released,” or something to that effect. The word best is confusing to patients. Of course the patient will want the best treatment available, but they often fail to realize that even the best treatment available will lead to an undesirable outcome. Also, they do not understand that “best” means the medicine has the best chance of doing what it is designed to do. It does not mean it is the best option for care overall. I don’t want to say this is a common occurrence, but it is one I have observed.

 

Jamie Dimon shoots feet

R. Horton

At an investor’s conference, Jamie Dimon, CEO of JP Morgan Chase, said, “Acting like everyone who’s been successful is bad and because you’re rich you’re bad, I don’t understand it.” He went on to say that a few bad apples don’t ruin the whole bunch. It is wrong to generalize, you see. Does he really think OWS protestors hate success? Does he not understand why the banks are targeted while other industries are not? Either he is genuinely clueless or her is trying to deflect attention from himself.

A November 12 Huffington Post article by Janet Tavakoli claims that Dimon dismissed the assertion that JPMorgan Chase was involved in foreclosure fraud. He said, Chase should carry on with foreclosures, even if it had to pay some penalties. Tavalokoli says, “JPMorgan’s role in alleged foreclosure fraud had already been made public when Dimon made these ill-considered statements.”

Tavakoli quotes from Annie Lowrey of the Washington Independent: “But the financial statement itself proved the lie. The bank said it was carefully checking 115,000 mortgage affidavits. It set aside a whopping $1.3 billion for legal costs. And it put an extra $1 billion into a now $3 billion fund for buying back bunk mortgages and mortgage products.” OWS protestors are not against success; they might just want people to succeed through hard work, creativity, intelligence, and honest business practices. They might also expect a little humility.

But not only that, Irving Picard, a trustee in the Bernie Madoff scandal, accuses JPMorgan Chase of making a half a billion dollars off Madoff’s victims and is responsible for $5.4 billion in damages. It could be a case of just taking advantage of a bad situation, but what of further investigations against JP Morgan Chase?

Earlier this year the SEC fined JP Morgan Chase $228 million for a bid-rigging scheme involving municipal bonds. Matt Taibbi compared this to mafia-style bid rigging and said, “But if the defendants are a bunch of Ivy-League educated bankers from Wall Street, what we end up getting is a negligible fine (officials will brag about this $228 million, but it’s a drop in the bucket compared to what the banks make scamming communities and governments) and, as always, no admission of guilt.”

Taibbi ends his blog post by declaring, “It’s not going to stop until people start doing hard time for these crimes, and it looks like we’re still a very long way from that.” It is just a little hard to believe that Jamie Dimon really thinks people are angry because he is successful, is it not?

Will technology destroy heroism?

R. Horton1 Comment

While heroism is a concept without rigid definitions, I will loosely define it as putting one’s own life at great risk for the benefit of others. We may say that someone who developed lifesaving technology is a hero, but his or her laudable actions may or may not fit the description of heroism I’m trying to describe. For example, developing a life-saving vaccine is a laudable achievement for anyone, but some people have developed such vaccines by their willingness to first try inoculating themselves, knowing that their inoculations could kill them.  Similarly, those who may fly test aircraft they designed put their own lives at risk in order to benefit others.

In the past, technology created a heroic elite of sorts. Not many people had an opportunity to be the first person in space. Also, not many people had the education or experience to dream of how to inoculate someone against smallpox. People with the most advanced training would put their lives on the line to test new technology, leading to even greater advances in both knowledge and skill. These people saved lives, won wars, and opened the wonders of the universe to us all. They used technology to expand their opportunities to demonstrate their courage and commitment to human advancement.

It seems to me that something has changed, though. Unmanned spacecraft are now going deeper and deeper into space to return information we only dreamed of before, but the risk to humans has now been minimized. The space explorer now sits comfortably on earth as a machine takes all the risks of space travel. Unmanned drones now conduct what would have been extremely dangerous operations only a few years ago. We still need humans to fly and take great risks, but we can now imagine a time when all flight operations may be automated. The fighter pilot and astronaut may both become obsolete.  In medicine as well, new developments are frequently mechanized with risk to humans greatly reduced.

It is hard to find a reason to complain about this development. I would much prefer to have a robot disarm a powerful explosive than to have a human risk being blown to bits. Technological advances that reduce risk are welcome, and they will never eliminate heroism. What they do, though, is shift an emphasis from the elite heroes of the recent past to the more mundane heroes known throughout history. People will always risk their lives for others without the benefit of advanced aircraft, space travel, or obscure scientific knowledge.

People will continue to rescue others from fire and drowning. Foot soldiers will continue to fight battles on the ground, often in primitive forms of combat our ancient ancestors would recognize. People with brilliant but controversial ideas will continue to express them in the face of public hostility and aggression. And people will continue to put their lives on the line to defend democracy, freedom, and human dignity.

The high cost of low taxes

R. Horton

No one likes paying taxes, and I’m no exception. I’m far from being in the top one percent of earners, but I’ve also had to pay federal, state, and local taxes all my life.

Anyway, I’d prefer to keep my money and spend it on other things. Some costs, however, are best to be borne by the public rather than by individuals. The move to lower taxes is not about reducing what we pay for services. Rather, it is about a shift from public payments to privatization. When the government does not fund basic services, the services are then provided by businesses for profit. This means the burden of payment for necessary services shift to the less wealthy while control and profits shift to the wealthy.

For example, roads benefit all of us. The alternative to having the government spend money on roads is to let private firms build the roads and charge whatever costs the public can bear. I do not happen to think this is the best way to build a modern, efficient, and functioning society. Our country needs a mobile workforce. Denying citizens this mobility is to deny what I view as a basic human freedom: the ability to move and seek better opportunities and living conditions. While I agree that people who build roads should be paid for the effort, I do not believe the construction and maintenance of roads should be driven purely by considerations for profit. When we don’t pay for roads through taxes, we pay for them through tolls.

Nor do I think education should be operated for this reason. As school funding is cut, schools must turn to corporations for sponsorship. School lunches are provided by the big food industry, and the logos of major industrial players abound in the school lunchroom.  When asked to provide more healthful alternatives, the industry lobbies our government to circumvent regulations by declaring that the tomato sauce on a pizza is a vegetable. Further, education materials, from textbooks to video lessons, are prepared by corporations and include advertising and other forms of blatant indoctrination.

And when universities lose government funding, they also seek corporate sponsorship for their research, faculty positions, and buildings. Rather than providing a forum for intellectual discovery and exchange, universities become the mechanism for generating increased profits. This means scientific research is aimed only at supporting industry and basic research is stifled. Fields that are not seen as contributing to “the economy” are constantly under attack. The arts and humanities must constantly fight to survive and themselves must rely on corporate donors to stay afloat.

A vibrant and thriving society, however, needs free intellectual and artistic expression. Relying on corporate donors suppresses dissent or even basic disagreement. This impedes intellectual progress and, more importantly, moral progress.  Of course, the higher tuition fees that result also limit educational opportunity for most of us. Higher tuition and reduced financial aid mean more students graduate heavily in debt.

It is appropriate that some health care be provided for profit and that only those willing and able to pay for it should receive it, and this is the situation even in countries that have “socialized medicine.” A health care system that is entirely privatized however creates two contradictory and unworkable conditions: 1. Health care providers make the most profit by providing unnecessary tests and treatments. 2. Insurance companies make the most profit by denying access to as much care, necessary or not, as possible. Basic health care does the most to improve life quality for a society, but it is the least profitable care to provide. Public funding for access to basic healthcare ensures that everyone has a better chance to live and be productive.

Prisons are necessary in any civil society, but prisons are increasingly built and operated by for-profit companies. Some people need to be removed from society, but it is best that no one profit by increasing the number of people incarcerated. Incarcerating people should be something we do only when no other alternative is available, and it should create a burden for all, not an opportunity for profit.

When taxes are lowered, and public spending is reduced, these basic services do not become free. On the contrary, we pay more for them (unless you are a person who makes enormous profits from them). For most of us, lowering taxes too much limits our freedom and increases our financial burden for obtaining basic services. Certainly, wasteful government spending should be eliminated and taxes should be reduced when appropriate, but public funding for basic services is essential. The United States is currently experiencing a massive move toward privatization, which is hurting our mobility, education, and health. It is also resulting in a growing prison population that is inconsistent with a just society.

The limits of client autonomy in psychotherapy

R. Horton3 Comments

In the movie, Analyze This, a psychiatrist has to deal with treating a criminal whose anxiety interferes with his ability to do his job, which includes killing people. The movie is a preposterous and rather horrifying scenario, but it doesn’t challenge accepted ethical guidelines on client autonomy—clients do not have a right to request treatment to enable them to harm others. Such demands are well outside of the scope of client autonomy.

While no one (all right, so I can’t promise there is not some sick exception out there) thinks clients should have unlimited autonomy, maximizing autonomy has been particular focus of bioethics since its inception in the 1970s. This, combined with movements in psychotherapy and feminism to empower both clients generally and women in particular, gives way to some perplexing situations. This is particularly true, to my mind, in cases of so-called “internalized oppression.”

In the 1980s, feminist philosopher Dale Spender rejected the idea of singular truths as being too oppressive, claiming instead, “Only within a multidimensional framework is it possible for the analysis and explanation of everyone to avoid the pitfalls of being rejected, of being classified as wrong.” Spender was specifically advocating a multidimensional view of reality as a way of empowering women.

Similarly, collaborative therapy intends to empower clients by rejecting preconceived notions of truth and meaning, or even of therapeutic goals. In her 1997 book, Conversation, Language, and Abilities, Harlene Anderson writes, “A therapist is not a detective who discovers the truth, or what is true or truer, false or falser.” She goes on to say, “A therapist does not control the conversation, for instance, by setting its agenda or moving it in a particular direction of content or outcome. The goal is not to take charge or intervene.”

So, what is to be done with a client who embraces and fails to question a system that is oppressive, hierarchical, and one-dimensional? If a client has embraced a system that devalues the worth of the client, it would seem honorable and right for the therapist to guide the client to question a system that is degrading and demoralizing, rather than helping the client explore ways to function more effectively within that system. Of course, a therapist may simply open a conversation and hope the client with find liberation on his or her own, but this is a disingenuous respect for multiple truths.

Commenting on the goals of multidimensional feminism, Jean Grismshaw said, “The fact that one group has power over and exploits another, cannot be reduced to anyone’s belief that this is so; nor does the fact that someone does not understand their own experience in terms of oppression or exploitation necessarily mean that they are not oppressed or exploited.”

A belief in moral progress entails a conviction that some truths are better than others. We must believe that changing what we believe can make the world better. In Plato’s allegory of the cave, the philosopher who has become enlightened will not want to return to improve the affairs of men, but it is a duty to do so. If those who are in chains do not realize they are in chains, those who are free must help them.

William James, who I believe is one of the greatest psychological theorists of all time, also rejected the certainty of truth, but he noted that when we give up certainty, we “do not thereby give up the quest for truth itself. We still pin our faith on its existence, and still believe that we gain an ever better position towards it by systematically continuing to roll up our experiences and think.” James also believed in progress—epistemic progress and social progress. A commitment to truth does not demand that we discount the knowledge or experience of others, but it does demand that we constantly seek what is better in our lives.

While we may not pass judgment on someone who does not share our values, the values we hold most deeply must remain important to us. If our own values mean nothing to us, our lives have no meaning. The postmodern therapist has values and wants others to share them; otherwise there is no point in seeking healing. If we don’t seek more valuable lives, there is no point in living.

Corporate funding of research.

R. Horton7 Comments

Many of us are suspicious of health and safety claims based on research funded by corporations that get rich off public confidence in the health and safety of their products. I don’t really trust manufacturers of drugs or genetically modified foods to tell me that they are safe. I also would feel better hearing that an oil spill is no threat to life or environment from someone other than the company that spilled the oil. (Many people seem to have made one inexplicable exception to this rule, which I will mention in the postscript.)

Further, when corporations fund research projects or labs, they gain control over what information is published. The scientists involved may have enough integrity to conduct rigorous research, but unwanted results are likely to be suppressed, especially if they will hurt the bottom line. This may be justified by claiming that only “useful” data need be published, but negative data can also be useful and can avoid wasted money and energy. If one researcher finds that something doesn’t work, publishing that data can help others avoid the same mistakes. Of course, researchers do share data, but some studies are also suppressed. Publication of misleading data and suppression of useful data are two possible hazards of corporations funding research that will affect their bottom line.

On the other hand, if corporations are the ones to benefit from research, it seems they should bear the cost of supporting labs, scientists, and related endeavors. Of course, some research is in the public interest, and I believe the public should fund it, which may be the topic of another blog. To avoid obvious conflicts of interest in research, companies should not be permitted to hire and promote researchers directly. Funding should go in to a pool and be dispersed anonymously to research labs, scientists, and universities. For profit labs could still exist, but researchers should not be beholden to a specific entity. It was not that long ago that much university research was conducted in this manner. In that sense my proposal is regressive, not progressive.

Postscript: When people get sick, many of them demand the latest drug available, even if it hasn’t been tested thoroughly. They seem to feel that their suffering from the disease is always going to be worse than the effects of the drug. I recently had a student (not a medical student) argue vehemently with me that no one had ever died during a drug trial. For those who know anything about drug trials, this over confidence is baffling, but I fear many share his optimism regarding the safety and effectiveness of experimental drugs. If you don’t know this already, let me tell you that drug testing is there for a reason; not every drug tested turns out to be safe and effective.

When cultural competence is cruel.

R. Horton

It is now common practice for organizations and businesses not only to declare their acceptance of diversity but also to proclaim their celebration of diversity. Employees may be asked to demonstrate how they value diversity in all forms. When someone says or does something insensitive or even intentionally hostile to a particular group, that employee is often ordered to receive training in cultural competence. And, just in case this scenario sounds too negative, employees and people in business often seek out cultural competence training in order to work more effectively with members of unfamiliar groups. Before traveling to China, for example, business people might study up on the social practices of Chinese people. And after a brief course and some exposure, they feel confident they are competent.

Proponents of cultural competence training assume that knowledge of another culture will result in workers who are sensitive, understanding, compassionate, and fully accepting of unfamiliar groups. This seems true intuitively and even anecdotally. I grew up in the southern United States, and I have personally known racists who soften toward other races once they get to know a few people from the once loathed group. Personal interaction does, indeed, breed greater acceptance and understanding. Sometimes.

In his book Cosmopolitanism, Kwame Anthony Appiahgives a description of Victorian adventurer Richard Francis Burton who was truly a master of cultural competence, learning many languages and traveling extensively.

Richard Francis Burton

Burton understood a variety of cultures, languages, and religions enough to be accepted among natives in some instances. He was also a racist, who recorded his negative opinions about a variety of groups, including Africans, Indians, the Irish, French-Canadians, and the Pawnee Indians. Stating that Burton refutes the idea that “intimacy must breed amity,” Appiah notes, “You can be genuinely engaged with the ways of other societies without approving, let alone adopting, them.”

Exposed to cultural competence training, a hateful person will not become a nice person. CEOs of transnational corporations tend to travel extensively and meet a variety of people. They may become more open to different cultures, if they do not happen to be psychopaths (British journalist Jon Ronsen wrote a book claiming that about four percent of CEOs are psychopaths, double the rate for the population at large). Knowledge of other cultures does, however, help us to understand the motives, needs, and desires of other groups. In reality, humans have pretty much the same motives, needs, and desires across the globe even if we have found different ways to express them.

Florida Governor Rick Scott recently angered anthropologists when he said Florida did not need to be producing any more of them. He feels there won’t be enough jobs for anthropologists, so it is a waste of resources to give them degrees. Surely a few jobs will open up when the current anthropologists retire, so it would seem short-sighted to cancel entire programs, unless you really think anthropology is a waste of time regardless of job prospects.

Anthropologists and I both suspect that is what Rick Scott really meant, but I will leave it to anthropologists to explain the value of their work. I will only note that anthropologists do the groundwork that is needed to interact with other cultures in a competent manner. With that, anthropology does increase the opportunity for profit, which seems to be the only concern these days. Never mind the fact that understanding other cultures and groups enriches our lives and makes the world a slightly nicer place to live.

My question for Ron Paul: Autonomy and health care

R. Horton

Earlier this year at the Tea Party debate, Wolf Blitzer asked Ron Paul if a person who chose not to buy health care should be left to die. Paul responded that this person’s friends and community could support him and pay his bills. Many in the audience seemed to be all right with letting this person die.

Conservatives and libertarians both express a strong commitment to autonomy, which they sometimes refer to as freedom. The new health care law is unacceptable they say, because it requires individuals to purchase insurance. People should not be required to purchase insurance, but they should be responsible for the consequences if they do not have insurance. Of course, this scenario is rarely a problem for anyone, and Blitzer asked the wrong question.

I would want to ask a different question. I want to know about the person who has worked all her life and been successful. After 20 or 30 years, she decides to expand her opportunities by starting her own business. Remarkably, her business is profitable in its first year. She can afford to buy insurance, but she cannot buy adequate coverage because she has preexisting conditions that every major insurance carrier refuses to cover. When she contracts a serious illness, she is driven into bankruptcy because of medical bills that are astronomical but quite common. Should our country let her die? Should she be permitted to slide into bankruptcy?

Autonomy is not quite as simple a question as it apparently seems to Republicans and libertarians. Philosopher Isaiah Berlin described two types of liberty: one is negative and the other is positive. For conservatives, it is imperative that individuals not be forced to do something they may not want to do and no government intrusion is acceptable. This is negative liberty. For liberals, such liberty is meaningless if one is unable to make the choices he or she desires, which is positive liberty.

Describing the liberal view of positive liberty, Berlin says,

“It is true that to offer political rights, or safeguards, against intervention by the state, to men who are half-naked, illiterate, underfed, and diseased is to mock their condition; they need medical help or education before they can understand, or make use of, an increase in their freedom. ”

While conservatives will not force someone to purchase insurance, liberals want to ensure that everyone has the option to have health care. Everyone who needs health care and cannot obtain it becomes a liberal in an instant.

The number of uninsured in the United States is said to be around 50 million, but many more than that have inadequate insurance. Unfortunately, most people do not realize they are underinsured until it is too late. Many people only learn that their treatment will not be covered by insurance after they have received the treatment. What kind of autonomy is this? What is the value of liberty if it leaves one with no options to avoid bankruptcy, untreated illness, and death? Is this really what we want to be?