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Mea Maxima Culpa:
At least a dozen people have seen fit to remind me what a blockhead I am for ascribing the Tolstoy quote in the February column to Chekhov. You were all quite correct. My eleventh grade English teacher is hanging his head in shame. Secondly, in the opening lines of last month’s column I used the term “government” instead of “federal government.” Let it be understood that there is both a practical and a moral role for cooperative government action in healthcare; but it is at the state level and not the national level. Most of the other democracies which I mentioned (that are larger than the average Texas county) administer care at the regional or provincial level, Canada being the most obvious example.


Quixotic ramblings on holy matrimony, the definition of ‘poor’ and why Pope Francis needs our prayers.

This month I present a potpourri of concepts and Quixotic explorations of ideas mostly brought on by travel, cocktail parties and my obsessive study of obscure topics. Hold onto your hats. My first topic is the current struggle which the country seems to be having over marriage. More specifically, our country’s insistence on confusing marriage with holy matrimony. What makes matrimony holy? What does “holy” even mean? And has it changed over time? If you’re wondering what makes this an emergency medicine issue (worthy of space in this magazine) the reason is this. As the Supreme Court rules from afar on the California Defense of Marriage Act, we daily interact with the soft underbelly of society. We know that “families” – no matter how you define them – will continue to come through our doors in crisis. We are the ones who experience and understand “the new normal” better than any sitcom writer ever could. When it comes to dealing with the consequences of social change, we’re at the tip of the spear.

This is a definitional as well as a financial problem. It has to do with estate taxes, benefits, division of property. This is what Ludwig Wittgenstein would call “a language problem.” Without going into the classic confrontation between Wittgenstein and Karl Popper at the Cambridge Moral Society Club meeting of 1946, I would simply say that words matter, and we don’t always understand words the way others understand them. And it is important to emergency physicians, because words may decide whether we get paid under one insurance company or another for a “spouse’s” health plan. Definition does make a difference.

Let me begin with the current situation in which this current right is dependent on a curious agreement between liberals and conservatives that human rights originate in government to be “dispensed to the people according to their pleadings.” This quote from Wendell Berry flatly contradicts the founding principle of American democracy. Liberals absurdly think government provides these rights and conservatives take a position on this issue that implicitly violates the 15th and 19th Amendments. The conservatives are in an intellectual dark hole on this one because to deny homosexual people the right to marry is to define the state as having this right at all! We have now taken both the “pursuit of happiness” and the 14th Amendment and tossed them out the proverbial window. Marriage should be defined by virtue of copulating – or potentially copulating – relationship and should preclude all governments. If grounded in procreative potential then it is a way in which we acculturate human begins and has a rationale that should only allow government to recognize it but not control it. The blissful union of people existed long before there was a government, and no government should have a right to control it.

In the obverse, if marriage is grounded in the actions and premises of the state, the government has then “invented marriage” and it is dependent on spontaneous political largesse. It is then a relationship which can be legislated, making the government a party at stake in everyone’s bedroom. Big Brother is watching. In such a society the state may want to control not only your right to copulate but who you do it with for the “enrichment of the nation state.” Sieg heil!

When did marriage become a public as opposed to a private concern? I don’t think many people want a government agency to inspect, approve and certify their intimate desires. Does the state have a role? Yes, in recognition. There’s a need for the protection of children, adoption, divorce, property rights, etc. But nothing more. Recognition: yes. Permission: never. Let believers make matrimony holy. Let the churches, synagogues and mosques bless such unions and pronounce them holy matrimony. “Those that God has joined together let no man put asunder.” Let everyone be joined together as lawfully copulating parties. Don’t let the state set the bar for approval. All of us are guilty of prurience and failure to care. Love is an active verb and no action of the state can say otherwise. I’m a libertarian and think most things aren’t anyone else’s business. As emergency docs we see it all and know that a Supreme Court decision won’t change the human gut level problems that we see in the emergency department. No matter what is decided, we will still need to deal with individuals as individuals, and couples as couples. Judgment is not our job. Intelligent care is, and families are families no matter what the state decides.

On another subject, there is a new Pope in town and he is openly talking about the poor. Like marriage, the poor are a matter of definition. Just because you are on some government welfare program may not mean that you are poor. I have seen many people on government programs who have exceptionally great jewelry and unbelievably good fur coats. Some consider themselves to be in extreme poverty when they are forced to drink a domestic Pinot Gris. Poverty is a shifting concept and one which countries or regions need to define dynamically.

The new Pontiff, Francis, has asked a fundamental question: Do we really care about the poor or are they just another political tool? Who represents the poor? In the frighteningly accurate words of David Mills, “The Democrats’ main idea of helping [the poor] is to give them small amounts of money while pursuing policies that destroy their family structures and commitments; that are the real source of economic security and success.” His comments on the Republicans are even more stinging. “Most republicans either dismiss [the poor] as parasites (“the 47 percent”) or assume blithely that the general economic growth will help them as well rather than immure them from poverty.” It is interesting to watch people grow silent at university cocktail parties when I ask them to name twenty poor people, by name. They can’t. To these people the poor are a political abstraction, not someone to be truly helped. The pinheads believe the poor are a repressed political class who are sitting in garret rooms reading Marx and Engels. If only they could break free of our capitalist stronghold they would have a rebirth of a Golden Age that never really existed.

What a bunch of crap! You and I know the poor as people. They are a conglomerate of problems that defy a simple answer. They are the 21-year-old mother with three small children and no male kicking in support. They are the burned out druggies, alcoholics, schizophrenics and depressives. I have yet to meet a poor person who has an adequate command of Marx and not a one who could discuss Rawls, Kant or Proust.

The poor have always been with us. Until the 1900s hospitals were merely warehouses for the poor and mentally deranged. Whether we will go back to this function of the hospital is still an open question. While the Pope is blessing people, I hope he blesses us. The emergency department is still the only place in the community where you can get help at any hour of the day or night without putting down a dime.

Like it or not, we are still the first line in dealing with poverty.

We as emergency physicians have an obligation to provide some realism and input to the plans and programs that the well-meaning but misguided have put forward to deal with those that the world has forgotten. If the Pope is a man of the people, he will open the way for multiple ways to solve the problem. The goals for Sudan are much different than they are for Haight-Ashbury. “Sic transit gloria mundai.”

Remember, Pope Francis, that the policies of the private sector, the government – even the church – are often smoke and mirrors and are not indicative of real success. Our prayers go with you. It’s a tough job.

We’ll leave the formal refutations to the real philosophers. But perfection is illusory. Our perception of ourselves and our world is imperfect and we look “through a glass darkly.” Aristotle, no friend of democracy, said it best: “The best is often unattainable. And therefore the true legislator and statesman ought to be appointed not only with that which is best in the abstract but also with that which is best related to under the circumstances.”

For emergency physicians, functioning as we do, this means actions taken to control care and cost and availability without killing the goose. Local political compromises amongst people with diverse interests and beliefs are essential to make a system work that provides all people some solace and relief of pain. Making the impossible work is what we do as emergency doctors.

Si fueris Romae
When in Rome

 

Comments   

# Marriage, Poverty and the Pope Leslie 2013-05-15 09:48
Oh Henry! You have done it again. This "sermon on the mount" is perhaps one of your best.
“-----No matter what is decided, we will still need to deal with individuals as individuals, and couples as couples. Judgment is not our job. Intelligent care is, and families are families no matter what the state decides.”
“----The emergency department is still the only place in the community where you can get help at any hour of the day or night without putting down a dime. Like it or not, we are still the first line in dealing with poverty.”

These are not only true emergency medicine maxims but “gospel” truths in an increasingly apathetic and secular world. Perhaps Hospitals but especially the Emergency Department may be the only true “House of God” left and emergency physicians are the new Kohanim.
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