Psyche, Science, and Society

Obama to Take On Torture?

By Michael Isikoff
[From the magazine issue dated Dec 1, 2008]

Despite the hopes of many human-rights advocates, the new Obama Justice Department is not likely to launch major new criminal probes of harsh interrogations and other alleged abuses by the Bush administration. But one idea that has currency among some top Obama advisers is setting up a 9/11-style commission that would investigate counterterrorism policies and make public as many details as possible. “At a minimum, the American people have to be able to see and judge what happened,” said one senior adviser, who asked not to be identified talking about policy matters. The commission would be empowered to order the U.S. intelligence agencies to open their files for review and question senior officials who approved “waterboarding” and other controversial practices.

Obama aides are wary of taking any steps that would smack of political retribution. That’s one reason they are reluctant to see high-profile investigations by the Democratic-controlled Congress or to greenlight a broad Justice inquiry (absent specific new evidence of wrongdoing). “If there was any effort to have war-crimes prosecutions of the Bush administration, you’d instantly destroy whatever hopes you have of bipartisanship,” said Robert Litt, a former Justice criminal division chief during the Clinton administration. A new commission, on the other hand, could emulate the bipartisan tone set by Tom Kean and Lee Hamilton in investigating the 9/11 attacks. The 9/11 panel was created by Congress. An alternative model, floated by human-rights lawyer Scott Horton, would be a presidential commission similar to the one appointed by Gerald Ford in 1975 and headed by Nelson Rockefeller that investigated cold-war abuses by the CIA.

The idea of such panels is not universally favored among Obama advisers. Some with ties to the intelligence community fear the demoralizing impact on intelligence officers, said one source who had discussions with Obama aides about the idea. But during the campaign, both Obama and Eric Holder, slated to be nominated as attorney general, sharply criticized the use of torture and the legal rulings that permitted them. Holder called some Bush counterterror policies “excessive and unlawful.”

The legal rulings on interrogation are among matters being reviewed by an Obama transition team headed by David W. Ogden, once chief of staff to former attorney general Janet Reno. The team has already moved into the first floor of Justice. Detainee policies are an even stickier issue—underscored last week when a federal judge ordered the release of five Bosnians held at Guantánamo Bay. Obama is committed to shutting down Gitmo. But his advisers are wrestling with what to do about the remaining 250 detainees there, especially those considered dangerous. Obama is unlikely to continue the military tribunals started by President Bush. One idea his advisers are exploring is the creation of new national-security courts. But a spokesman for Obama’s transition team said that decisions on all of these issues won’t be made till after the new national-security team is in place.

5 Myths About Our Ailing Health-Care System

By Shannon Brownlee and Ezekiel Emanuel

With Congress ready to spend $700 billion to prop up the U.S. economy, enacting health-care reform may seem about as likely as the Dow hitting 10,000 again before the end of the year. But it may be more doable than you think, provided we dispel a few myths about how health care works and how much reform Americans are willing to stomach.

1. America has the best health care in the world.

Let’s bury this one once and for all. The United States is No. 1 in only one sense: the amount we shell out for health care. We have the most expensive system in the world per capita, but we lag behind many developed countries on virtually every health statistic you can name. Life expectancy at birth? We rank near the bottom of countries in the Organization for Economic Cooperation and Development, just ahead of Cuba and way behind Japan, France, Italy, Sweden and Canada, countries whose governments (gasp!) pay for the lion’s share of health care. Infant mortality in the United States is 6.8 per 1,000 births, more than twice as high as in Japan, Norway and Sweden and worse than in Poland and Hungary. We’re doing a better job than most on reducing smoking rates, but our obesity epidemic is out of control, our death rate from prostate cancer is only slightly lower than the United Kingdom’s, and in at least one study, American heart attack patients did no better than Swedish patients, even though the Americans got twice as many high-tech treatments.

Moreover, the quality of health care is different in different parts of the country. The Centers for Medicare and Medicaid Services have issued a list of 26 measures of quality, such as making sure that heart-attack patients being discharged from the hospital get a prescription for a beta blocker or aspirin to help reduce the risk of a second attack. It turns out that quality is all over the map, and it isn’t necessarily better in the places we might expect, such as academic medical centers. Worse still, according to the Congressional Budget Office (CBO), there appears to be no connection between how much Medicare and other payers spend on patients in different parts of the country and the quality of the care the patients receive. You are no more likely to get that beta blocker or aspirin in Los Angeles than in Portland, even though Medicare spends twice as much per beneficiary in Los Angeles.

2. Somebody else is paying for your health insurance.

Nope. Even when your employer offers coverage, he isn’t reaching into his own pocket to cover you and your fellow employees; he’s reaching into your pocket, paying you lower wages than he would if he didn’t have to pay for your health insurance.

Rising health-care costs are partly to blame for stagnant wages. Over the past five years, health insurance premiums have risen 5.5 times faster on average than inflation, 2.3 times faster than business income and four times faster than workers’ earnings. Four times. That’s why wages have been nearly flat since the 1980s, even as U.S. productivity has been going up. In effect, about half the money you should be earning for being more productive is being sucked up by ever more expensive health-insurance premiums.

If you pay taxes, you’re also paying for the health care provided through state and federal programs such as Medicare, Medicaid, the Veterans Administration and the military. All told, the average family of four is coughing up $29,000 a year for health care through taxes, lower wages and out-of-pocket medical expenses.

3. We would save a lot if we could cut the administrative waste of private insurance.

The idea that we could wring billions of dollars in savings this way is seductive, but it wouldn’t really accomplish that much. For one thing, some administrative costs are not only necessary but beneficial. Following heart-attack or cancer patients to see which interventions work best is an administrative cost, but it’s also invaluable if you want to improve care. Tracking the rate of heart attacks from drugs such as Avandia is key to ensuring safe pharmaceuticals.

Let’s just say that we could wave a magic wand and cut private insurers’ overhead by half, to what the Canadian government spends on administering its health-care system — 15 percent. How much would we save? Not as much as you may think. Private insurers pay a little more than a third of what we spend on health care, which means that we’d cut a little more than 5 percent from our total budget, or about $124 billion. That’s not peanuts, but it’s not even enough to cover everybody who’s currently uninsured.

More to the point, we only get to save it once. That’s because administrative waste isn’t what’s driving health-care costs up faster than inflation. Most of the relentless rise can be attributed to the expansion of hospitals and other health-care sectors and the rapid adoption of expensive new technologies — new drugs, devices, tests and procedures. Unfortunately, only a fraction of all that new stuff offers dramatically better outcomes. If we’re worried about costs, we have to ask whether a $55,000 drug that prolongs the lives of lung cancer patients for an average of a few weeks is really worth it. Unless we find a cure for our addiction to the new but not necessarily improved, our national medical bill will continue to skyrocket, regardless of how efficient insurance companies become.

4. Health-care reform is going to cost a bundle.

Only if you think that covering the uninsured is our only priority. Yes, making health care available to all citizens is the right thing to do. But it isn’t the only thing to do. We also have to fix the spectacularly wasteful and expensive way doctors and hospitals deliver care.

Our physicians are working within a truly dysfunctional, often chaotic system that prevents them from caring for us properly. Between 50,000 and 100,000 patients die each year from preventable medical errors. According to the Centers for Disease Control, 1.7 million Americans acquire an infection while in the hospital and nearly 100,000 of them die from it. Laboratory imaging tests are routinely repeated because the originals can’t be found. Patients with such chronic illnesses as heart failure and diabetes land in the hospital because their physicians fail to monitor their condition. When patients have multiple doctors, there’s often nobody keeping track of the different medications, tests and treatments each one prescribes.

Our doctors and hospitals are failing to provide us with care we need while delivering a staggering amount that we don’t need. Current estimates suggest that as much as 20 to 30 percent of what we spend, or about $500 billion, goes toward useless, potentially harmful care.

There are two bright spots. One: We can improve the quality of care and cut costs without rationing. There are models out there for how to do it right — the Mayo Clinic, the Geisinger Clinic in Pennsylvania, the Cleveland Clinic and California’s Kaiser Permanente are just a few of the organized group practices that are doing a better job for less. Their doctors are better than average at using the best medical evidence available. They’re more likely to be using electronic medical records, which can help keep track of patients who have multiple physicians and need complex care. And they’re less likely to provide unnecessary care.

Two: Even moderate reform of the delivery system would improve care and save money. The Lewin Group’s analysis shows that a bill proposed by Sen. Ron Wyden, an Oregon Democrat, calling for a more comprehensive overhaul of the health-care system than either McCain’s plan or Obama’s could actually insure everyone and save $1.4 trillion over 10 years. More reform is cheaper.

5. Americans aren’t ready for a major overhaul of the health-care system.

We may be readier than you think. A recent study published in the New England Journal of Medicine found that only 7 percent of Americans rate our health-care system excellent. Nearly 40 percent consider it poor. A whopping 70 percent believe it needs major changes, if not a complete overhaul.

Now is not the time to think small, to cover a few million Americans and leave the bigger job of controlling costs and improving quality for another day. We can’t afford not to reform the delivery system as soon as possible. At 17 percent of gross domestic product, health care is the biggest single sector of the economy, and it’s consuming a larger and larger proportion every year. According to CBO projections, health care will account for 25 percent of GDP by 2025 and 49 percent by 2082. That’s simply unsustainable. Any plan that reforms health care has to do more than simply cover the uninsured. The nation’s health and wealth depend on it.

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Shannon Brownlee, a visiting scholar at the National Institutes of Health Clinical Center, is the author of “Overtreated.” Ezekiel Emanuel, an oncologist and author of “Healthcare, Guaranteed,” is chairman of the center’s Department of Bioethics. The views expressed here are the authors’ own.

“Under Coercive Conditions”

By Andrew Sullivan

Ben Wittes ups the Orwellian ante:

Detainees who pose a grave national security threat might be unprosecutable for a variety of reasons: because of deficiencies in the criminal law as it stood in 2001, because evidence against them would not stand up in court, because the government might not have enough evidence to convict or because it obtained key evidence under coercive conditions.

“Under coercive conditions”. Excuse me, but what does that mean in English? Try: Because they got intelligence from torturing people. Coercion means force. It means they forced “information” out of them. Not coax, trick, lure, force. That means they had no choice. The only way in which a human being can seriously have no choice is by subjecting them to such severe mental and physical pain and suffering that they have no option as human beings but to tell their torturers something.

This is the defining line of torture: not some arbitrary comic book technique, but a psychological and physical fact: pushing another human being to the point where choice becomes unavailable to him or her. You can do this in any number of ways; it can take three seconds of electrocution or it can take two months of sleep deprivation. But the line it eventually crosses is the same line. Throughout human history, human beings have known what that line is, and the West was constructed an a disavowal of ever crossing it again. Why? Because a society that endorses torture commits itself not to limiting, but to extinguishing human freedom. And a protection of human freedom in its most minimal form is what our entire civilization os premised on.Once that force is unleashed – and it is pure evil – it is almost impossible to stop it destroying your entire system of government. Maybe Europeans like me, who grew up in a land where torture was practiced by government widely in the distant past, and had that history dinned into us, understand this more acutely than those who have never known anything but a New World. But trust us Old Worlders passionate about the New: America and torture are mutually exclusive as ideas and realities. You can have one or the other. You cannot have both.

So when I read an American use the meaningless euphemism – “under coercive conditions” – as if force can be a condition that hovers in the air without anyone accountable for it, I shudder. When I read him tiptoe around what we are actually talking about, and express sympathy for those who tortured, illegally and secretly and against their oath of office, I shudder some more. Because we are numbing ourselves from moral responsibility.

Even the word “torture” can be too vague and abstract a term. So let us state in plain English how Bush, Cheney, Tenet, et al. actually got information. They did it by subjecting prisoners to repeated drowning, or freezing, or heating, or sadistically long sleeplessness, or shackling or crucifying them until the pain could be borne no longer, or beating them until they pleaded for mercy, or threatening to kill or torture their children or wife or parents. Or all of the above in combination, in isolation, and with no surety of ever seeing the light of day again, with no right to meaningful due process of any kind, sometimes sealed off from light and sound for months at a time, or bombarded with indescribable noise day and night in cells fro which there was no escape ever. This is what “under coercive conditions” actually means. It drove many of the victims into jibbering shells of human beings; it killed dozens; it drove others still to hunger strikes to kill themselves; and it terrified and scarred and “broke” the souls of many, many others. For what? Intelligence that cannot be trusted, and the loss of the sacred integrity of two centuries of American history.

And people wonder why I seem so angry and concerned about this issue, about its centrality to this election, and about the unique, once-in-a-century chance to put it behind us before it infects us beyond cure.

We cannot know hope until we end torture.