September 22, 2009
Dear Marion,

Chance would have it that I opened your letter within
seconds of its appearance in my e-mail box. I had decided
to call it quits early, in order to be bright-eyed and efficient
when the FedEx truck drives up this morning and the lady Hermes, -
the rumbling that you hear is all the ancient Greeks rolling
over in their graves at her reversal of sexual role, -
Lady Hermes, as I said, knocks on the porch door to accept
the 7 lb. box containing a bulky styrofoam cold box containing
three plastic bags with chilled water between which are nestled
a 10 ml. vial of rabies vaccine and two plastic jackets each
with 50 paired 1 ml. vials, - 25 doses - of distemper vaccine,
ready to be shipped back to Revival Animal Health in Orange City, IA.
It's all because of the little mini-Mephisto that befriended me.
I wonder what he would have turned into if I'd let him into the
house and put some enchanting music, say Eine kleine Nachtmusik
in the CD player. In any event, when when the next FedEx quarterly
statement reports an increase in the number of shipments, and the
economists declare the recession to be over and the recovery to
have arrived, you'll give credit where it's due: to the little pooch
that finally got FedEx rolling again, and you'll be reminded that
Goethe was correct: even my mini-Mephisto proved himself "ein Teil
von jener Kraft, die stets das Boese will, und stets das Gute schafft." -
a fragment of that power which seeking evil, accomplishes what's good.

I've reread your letter, much appreciative of its intelligence,
wit and charm. It's obvious that you do understand to an extraordinary
degree. The Oerlinghausen episode was nothing more than a literary
flourish. Here I was, stuck in Konnarock with this huge bowl of Jello
that I wanted to be made to shake and tremble in order to prove my point.
I needed a classical earth-shaker. I myself am no table-banger, but
opposed as I am to out-sourcing, a firm believer in keeping business
in the family, it occurred to me suddenly that our grandfather was cut
out for the job.  When I asked him, whether he'd bang the table for me
to set the Jello in motion, all he answered was: Quod licet Jovi, non
licet bovi, and his hand came down so hard on the polished walnut that
the bowl would have been catapulted off the table, if Elfriede hadn't
caught it in time.  

I'm fascinated and somewhat pleased with my belated discovery of
communal - as opposed to individual consciousness. It's obvious that
access to this consciousness remains strictly individual, subjective
and inward. However the awareness of communal consciousness makes
sense not only of casting ones vote as one in ten million, it also
makes sense of all manner of other ritual, in itself of no practical 
consequence, but meaningful as a contribution to, if not indeed
a bond with the communal reality. It's my experience that concepts
such as my newly discovered communal consciousness usually take
months if not years for the process of fermentation, but when it's
complete, they provide the ultimate intoxication.

The appended letter with the thirty-two theses about health care reform is
only a draft which invites radical criticism and invites fundamental revision.
It's incomplete, lacking among others, essential considerations
concerning insurance, academic and practical education, the legal
quagmire, and the consequences of social and economic inequality 
for the doctor-patient relationship. If your're willing to make the
effort to read and to think about these problems, I have 59 years'
experience to contribute. I am embarrassed by the Malthusian insight
that only a reduction in aggregate human population will reduce
carbon dioxide emissions into the stratosphere, and that whether
or not global warming is real and reversible, infinite population
increase and human survival on the planet are incompatible. Please
let me know what you think.

Jochen

_                       * * * * *

September 21, 2009
Dear Marion,

It's seventeen minutes past midnight, 43 minutes 'till
bedtime, which I'll use to get started on the next assignment
you gave me: health care reform. I have been in the health
care racket for 59 years. I started medical school in 1950.
until you came up with the question, no one's ever asked me
How _I_ think health care should be reformed, I figure here's
my chance. I don't want to miss it.  Might not have another one.
And when you read what I think, you'll quickly understand
why I haven't been asked.

I'm going to take the opportunity to propound some theses;
Whether I can come up with as many as 95 of them I don't know,
but there isn't a hospital door I know, on which I can post
them, and if I did, - no, they wouldn't have me arrested for
defacing private property with graffiti. They'd obtain
psychiatric consultation and have me committed.

Thesis #0:
For theoretical advice, go to Plato.
If it's a practical matter, consult Aristotle.
Plato has wonderful and charming and inspiring ideas, he's a great poet,
but the transition from his ideas to my reality is hard to make.
Aristotle's writings are aporetic. They're sets of questions,
but when you leaf to the end of the chapter
to find the answers, the answers aren't there.
Makes one feel frustrated, to have made such effort,
and still not to know what to do.
Remarkably, the consequences of studying the two authors
may be similar. Each in his own way leads one to a deeper
understanding of oneself and ones world,
and, rightly or wrongly, makes the insolubility of problems
more acceptable.

Thesis #1:
Advice is distinct from Decision.
Advice is a set of statements about what I think, what I feel
what I remember, what I understand, what I have learned,
what I expect. Advice is not decision. Advice is rhetotic,
Decision is action.

Thesis# 2:
No Decision can be made in a vacuum.
I can't make a decision in a vacuum,
I can't make a decision which is hypothetical,
which for one reason or another is precluded
from being carried out.
Every honest decision is an existential crisis,
and a pretend decision is no decision at all.
A decision which has no consequences
is not susceptible to being made.

Thesis #3:
Decisions are never optional.
When circumstances require a decision, 
then failure to act is also a decision.
If I were in a position of authority,
I'd do the best I could with the information available to me.
A person in authority presented with a decision
cannot avoid it, inasmuch as declining to decide
is also a decision.

Thesis #4:
It's axiomatic that there is no "perfect"
solution to any problem, and to the health care problem in particular.
A problem that has a conclusive solution is no problem.
From my worms' eye view of the situation, there is in sight
no rational solution to the health care problem.
The best one can do is pray and trust to luck that matters somehow
get better rather than getting worse. 

Thesis #5:
Obstacles to a rational solution may not be susceptible to remedy,
Such obstacles should at least be recognized, identified and understood.
Articulation of the apparent insolubility of a problem may make it soluble.

Thesis #6:
Animals do not require health care.
The sparrows don't have health care and neither do cockroaches or rats.
Humans are animals; therefore humans don't require health care either.

Thesis #7:
"Health care" is prerequisite for neither human health,
for human happiness nor for human survival.
Until about 150 years ago, human race evolved, developed,
survived and flourished
with virtually no health care in the modern sense at all.

Thesis #8:
In the near term, the total absence of health care would 
degrade human life.
There would be devastating outbreaks of cholera, plague,
influenza and other infectious diseases.
Although the total absence of health care would 
very likely diminish the earth's population,
there is no reason to believe that 
the total absence of health care would 
extinguish human life.

Thesis #9:
In the long term, the total absence of health care
would not necessarily change human life for the worse;
because if human activity is responsible for global warming
and global warming is deleterious to human health,
then the absence of health care,
by decreasing the number of humans,
thereby decreasing human activity
and thereby decreasing global warming,
might in the long run actually improve
human health and well-being.

Thesis #10:
The prevalence of global warming and its ultimate effects if any,
on human life are uncertain to an extent that it is at this time
unwarranted to forego the benefits of all health care.

Thesis #11:
The most dire consequences of the absence of all health care
the cholera, plague, infantile paralysis, tetanus, dysentery,
rabies and all sorts of fatal respiratory diseases which one
would expect in the absence of all health care, may be
eliminated or controlled with minimal cost by vaccination,
by securing the food and water supply and preventing air pollution.

Thesis #12:
Illness is part of life.
When illnesses can be prevented 
or cured at slight economic cost, with great short term
economic benefit, this should be done.

Thesis #13:
Death is the natural end of life.
In many instances death can be postponed.
The postponement of death is sometimes of great benefit,
but not always.
For one who lives long enough,
there always comes a time when death is a blessing.

Thesis #14:
Our purpose should be to try 
to prevent the premature death
of otherwise healthy and productive people.

Thesis #15:
Our purpose should be to try to prevent,
to mitigate, or to cure illness,
but only when this can be done effectively at acceptable cost.

Thesis #16:
Illness and death should not be demonized.
We shouldn't seek to conquer them at all costs.
As a matter of fact, we shouldn't seek to conquer them at all.
We should learn to live with them, to negotiate with them,
and ultimately to make our peace with them.

Thesis #17:
For purposes of healthcare reform,
life and illness and death must be treated as personal,
individual, subjective experiences.
Making life and illness and death objective
by institutionalizing them is destructive of human dignity.

Thesis #18:
Human relationships must be understood
as either personal or official.
Personal relationships are inherently symmetric and consensual
and are governed by reciprocity of communication, understanding,
intuition, feeling and action.
Official relationships are inherently asymmetric and authoritative,
and are governed by interpretation and application of statutes
and regulations.

Thesis #19:
A physician acts in an official capacity when he or she
establishes a diagnosis, or institutes medical or surgical therapy.

Thesis #20:
A physician acts in a non-official capacity when he or she mediates
between the patient and the imperatives of the clinical situation.

Thesis #21:
The official functions of the physician must always be effectively
subordinated to his or her personal, unofficial functions.

Thesis #22:
The goal of health care reform must be to maximize the effectiveness
and efficiency of the physician's performance of his official functions,
while providing uncompromised security for his/her unofficial functions.

Thesis #23:
By definition, a business man entertains an adversary position
to his customer, inasmuch it is the interest of each of them to
maximize his financial benefits from the relationship.

Thesis #24:
The practice of medicine is not a business
and cannot be treated as such.

Thesis #25:
The physician cannot be deemed a business man in his official
capacity because that capacity is controlled by the imperatives 
of science which are incompatible with an adversary relationship
and the need to maximize profits.

Thesis #26:
The physician cannot be deemed a business man in his un-official
capacity because that capacity is controlled by the imperatives 
of a personal relationship which is incompatible with mutually
adverse interests.

Thesis #27:
A the practice of medicine is not susceptible to legal or
administrative regulation because neither the official nor
the unofficial functions of the physician can be conclusively
subsumed in language.

Thesis #28:
No regulations, guidelines or directions are adequate to the
physician's official duties of diagnosis, medical or surgical
therapy. That's why after 4 years of college and 4 years of
medical school, it requires at least 4 more years of post-
graduate training to be able to practice medicine. If a choice
were required, the practitioner who had only 4 years of 
postgraduate clinical experience would be a more competent
physician by far than the practitioner who had only the benefits
of 8 years of classroom training.

Thesis #29:
Regulations, guidelines or directions purporting to monitor
to control or to prescribe the physician's official duties
of diagnosis, medical or surgical therapy will, to the extent
that they are applied or enforced, impair, stifle or extinguish
any non-trivial activity.

Thesis #30:
Regulations, guidelines or directions purporting to monitor
to control or to prescribe the physician's unofficial duties
of mediating between the patient and the imperatives of
the clinical situation will be meaningless because neither
the patient's psychic disposition nor the specifics of the
clinical situation can be anticipated or defined.

Thesis #31:
The nature and quality of medical care
provided in a given social, political and economic setting
will be determined neither by regulations nor by financial
(dis)incentives, but by the cultural ambience in which the
medical care is rendered.

Thesis #32:
The contemporary social, economic and legal environment has
shifted the control of medical practice from physicians to
their patients, with the consequence that it is now the 
cultural expectations, the emotional sensitivity and the
intellectual astuteness of patients which determines the
quality of medical care.