Centrally Planned Healthcare

The lastest SGR Deal (click for article) sounds good, increasing doctor pay tied with quality.  However:

1.  Interventions from DC that purport to make doctors provide a higher quality of care by paying them extra for certain check-boxes and computer clicks are not effective.

2.  The doctor groups that are supporting these measures do not see, or choose not to see, the reality of #1

3.  The primary net results of these measures are:  more bureaucracy, increased cost for already overpriced medical care, more passing the buck on cost-control.

The Pessimist

Not many years ago when I was an atheist, if anyone had asked me, ‘Why do you not believe in God?’ my reply would have run something like this:  ‘Look at the universe we live in.  By far the greatest part of it consists of empty space, completely dark and unimaginably cold...Earth herself existed without life for millions of years and may exist for millions more when life has left her.  And what is it like while it lasts?  It is so arranged that all the forms of it can live only by preying upon one another.  In the lower forms this process entails only death, but in the higher there appears a new quality called consciousness which enables it to be attended with pain...In the most complex of all creatures, Man, yet another quality appears, which we call reason, whereby he is enabled to foresee his own pain which henceforth is preceded with acute mental suffering, and to foresee his own death while keenly desiring permanence.  It also enables men by a hundred ingenious contrivances to inflict a great deal more pain than they otherwise could have done...Every race that comes into being in any part of the universe is doomed; for the universe, they tell us, is running down...All stories will come to nothing: all life will turn out in the end to have been a transitory and senseless contortion upon the idiotic face of infinite matter.  If you ask me to believe that this is the work of a benevolent and omnipotent spirit, I reply that all the evidence points in the opposite direction.  Either there is no spirit behind the universe, or else a spirit indifferent to good and evil, or else an evil spirit.’

There was one question which I never dreamed of raising.  I never noticed that the very strength and facility of the pessimists’ case at once poses us a problem.  If the universe is so bad, or even half so bad, how on earth did human beings ever come to attribute it to the activity of a wise and good Creator?  Men are fools, perhaps; but hardly so foolish as that.  The direct inference from black to white, from evil flower to virtuous root, from senseless work to a workman infinitely wise, staggers belief.  The spectacle of the universe as revealed by experience can never have been the ground of religion: it must always have been something in spite of which religion, acquired from a different source, was held.

CS Lewis, The Problem of Pain

How Many Doctors Does It Take?

I had not realized that the Annals had posted my thoughts on this article a few years back, though only on the web site comments which probably did not get much read.  In any case, I think this is still relevant though perhaps too "insider" for many.

Click HERE to go to the article sample and my comment at the bottom.  Or just read my comments below.






Doctors as Bed Managers Inappropriate Use of Resources

Posted on March 7, 2009

Paul D Bunge

In the December 2 Annals, Howell et al present their case for "active bed management." In the intervention, they had hospitalists take turns doing twelve-hour shifts as bed manager, a position usually filled by a senior nurse (1). The bed manager typically coordinates the placement of the new patients from the emergency room and clinics onto the appropriate available ward. This person also tracks patients as they go in and out of the ICU and other units. The bed manager must keep track of all available beds, and negotiate as needed when beds, patients, and staff must be shuffled around to make room. Note that in the intervention, the hospitalists did not do any patient care while they filled this role.

I am not surprised at the result reported: The patients moved around the hospital more efficiently. The time that the patient remained waiting in the ER was shortened (a quality and hospital efficiency goal). The major problem with this intervention is not the result, but the cost: Whatever the possible short-term cost savings to the hospital and short-term benefit to patient comfort, the overall cost to the health care system must be factored in, which is essentially the huge cost of pulling 1/4 of the hospitalist staff out of direct patient care.

I am afraid that I must regard this intervention as both unethical and ridiculous. Unethical because "pressure from administration" lead to inappropriately removing doctors from patient care to achieve a financially-motivated efficiency goal. It is the doctor's responsibility to call foul when the administrator crosses a line and refuses the patient appropriate care. Yet in this intervention, the patients were left to the mid-level providers and others while the doctor was making phone calls.
This intervention is ridiculous in that it is already a waste that so much senior nursing time goes to administrative duties, including the role of bed manager. Are we to have the doctors do this job that would more appropriately be performed by a clerk? When the movement of patients around the hospital is dysfunctional, that is a leadership problem, not a clinical problem.

This article is an unfortunate illustration of some very important points:

1. We have strayed far away from our job, our profession, our calling: patient care. We have left it to a few weary, brave soles who we now call "primary care managers." The rest of us, with no apparent limit, gather specialty or hospitalist status, and make as clean a break as we can from the whole mess. Shame on us! And shame on us for blaming others (the government, the economy, the payment system).

2. We need to question the current band-wagon thinking that there is a shortage of physicians in this country. When our highest levels of medical learning can advocate using doctors as bed managers, we may actually have the opposite problem: an illness of too much. (see Shannon Brownlee's article for a look at this topic: http://www.theatlantic.com/doc/200712/health-care )

3. Common sense needs to find its way back into the hospital. In the days of Oryx measures and JCAHO rules and sub-rules, the doctors of the world must be the ones to bring some wisdom to the table to question quality measures that may actually decrease quality, the multiplication of pointless paperwork, and other like challenges.

Once as a young physician on the way to work, I stopped my car at the scene of an accident. I told the ambulance crew my credentials and asked if they needed my help. One wise EMT told me quite simply: "sir, it probably would be more helpful if you made your way to the hospital where you are needed and see the patients there. We can handle this part." I did just that. Perhaps more of us should do the same.

References
1. Eric Howell, Edward Bessman, Steven Kravet, Ken Kolodner, Robert Marshall, and Scott Wright Active Bed Management by Hospitalists and Emergency Department Throughput Ann Intern Med 2008; 149: 804-810

A path

A view is for gazing at, taking pictures, discussion. A path is for walking on. The Christian life is more a path than a view. It works much better when walked on and taken than when photographed and discussed.

A Framework for History

My daughter’s High School history class.  Her teacher is using an essay by Ian Johnson as an introduction to Western Civilization, to frame her students’ understanding of history.  I wrote her some advice after reading the paper.

"Beyond all that, of course, wherever liberal capitalism moves, we need to remember Marx's analysis of how capitalism in the long run generates increasingly unstable and unequal economic conditions, so that it will eventually provoke a forceful redistribution of wealth and the development of a different economic system, either within capitalist countries themselves or world wide.  As the gap between the rich and poor within the capitalist system continues to increase, with environmental disasters looming in many parts of the world, we have no reason to be complacent that the economic system which is apparently so triumphant at the moment will necessarily remain so."
                    -Ian Johnston

Basically a socialist, and a wanna-be communist.  As I once was.  Like Marx, his view of history is overly simplified as he tries to paint a picture of good and evil in the world centered around primarily breaking down ideas supporting current economic and political realities.  The promise therein is a utopian state.  A pipe dream that does not exist but for which over the years many have sacrificed many a decent government, family, and church.  Beware of such thinking, because it is naturally attractive in providing solutions to problems it purposely sets up in overly simplistic terms.  A way of thinking commonly found in educational circles and espoused by professors.  Don't pander too much to them.  Be respectful but you are allowed to respectfully disagree.

It is sad that your teacher is espousing a Marxist approach to frame your study of the history of Western Civilization.  Especially that the espousal of Marxism as a political framework nearly lead to the annihilation of Western Civilization within the last 50 years.  Beware the one who claims open-mindedness but requires a certain religious set of glasses through which to view the world. In this case the religion is Liberalism/Socialism.  Do not let this framework detract from objective learning and interpreting of facts and episodes in history.  For to only use history as bricks to build a pre-planned house is to miss the many lessons that history can teach.  Besides which the house may be quite on shaky ground.

Have a look:   https://en.wikipedia.org/wiki/Marxism   Note that if you are going to be in this class, you are going to have to work extra hard to learn truth.  However, it can be done.  But your grade may slip as you spend time reading a wider range of insights rather than succumbing to mind-numbing.  The world-view that Johnston is teaching (and apparently your teacher as well) is truly so, and it interferes greatly with a clear thinking about history and many other areas of life and study.

The Packing List

Fanny pack 

No longer stylish, but useful nonetheless.  When you quickly need bandages, a light, or gloves. Supplies are not as readily available as in a US hospital. For work in the triage tent or the ER.  We bought two fanny packs at REI, an outdoor store, before the trip.  One was way too big, so I’ll take it back after, unused.  My EMT niece and I shared the other one, trading off when the other came on shift.  Beth is my niece’s name; she wants to go to medical school.  I told her she needed Emergency Medical Technician (EMT) training if she wanted to go to Haiti with me.  So she did the class last summer.  Her nurse aunt and I guided her through IV practice on the relatives after family dinners.  Now she is pretty good.

Bandages and Chucks

Donated by Caroline from church.  Her husband was supposed to live longer, to need more home health.  But he left this world and the medical supplies were still fresh.   “Chucks?” the translator in Haiti said.  Like “Chuck Norris?”  “Yes, same Chuck” I laughed.  Refers to a large absorbent sheet with plastic on one side.  So useful when blood is dripping down.  To catch the life before it hits the floor.  Less messy.  Less dangerous than the splashing red.  For us, not for the patient.  For him it is less dangerous if he keeps his blood inside his veins where it belongs.

Cliff Bars

From Costco.  Very useful when hunger hits and rice and beans won’t come for several hours.  My wife bought two boxes for us before the trip.  I can’t stand going into Costco after a trip to Haiti.  Gives me nausea, even more than usual.  I take it out on the oversized cart--kicking it in the parking lot.  Why can’t someone even put it where it says “put carts here?”  How many suction machines could be purchased with one cart-load of junk food from Costco anyway?  Could have used another suction machine in the triage tent.  That patient, someone’s mother, hanging on by a thread.  Maybe if I had had another suction machine she would have lived.  Instead I rolled her over as the brown liquid no longer was vomited but ran out of her lifeless form, onto the floor, scattering the EMT’s like ants.  How much of that was from internal bleeding?  I will never know.  Autopsy is an unavailable luxury.  Need to move on to the next patient. 

Headlamp  

From Walgreens.  $12 on my visa.  Should have gotten two.  Or three.  So useful for guiding the needle while suturing lacerations.  Hard to see the needle sometimes at night, or during the day, when the curtains are closed to keep it cool.  I use the headlamp to crown a Haitian medical student so she can learn suturing.  Then for the trauma surgeon since I couldn’t stop a hand from bleeding.  Into a bucket this time.  Too much blood for even Chuck Norris.  A deep bleeder, since the knife had gone all the way through. “Tendons OK, though,” said the orthopedics doc.  Maybe he should have bought a headlamp, too.  On another case, he lost track of the needle long enough to poke his finger.  Wasn’t a big hole, but he looked down and there was a bit of his life oozing out in little red bump.  Only one drop, but enough to tell him the risk, bring the fear.  The patient with HIV, not on meds.  One in 300 chance of getting the disease himself.  He wandered a bit after the surgery.  What should he do?  What of his wife and kids back home?  He mentioned it to me and I whisked him off for “PEP.”  No, not a talk, but a month-long mound of HIV pills called “Post Exposure Prophylaxis.”  Reduces your risk of getting HIV from your needle stick. They have five days for you here, and you can pick up the rest when you get home.  Take some nausea meds, you’ll need them.  It’s the same approach we take in the U.S. with HIV needle sticks. 

Baby wipes

I don’t use them, but my niece does.  Some days when she can’t bear the cold grungy shower.  I am not afraid of the cold shower.  I find it refreshing actually, though painful.  You feel new after, not just clean.  But the violence of that cold water is not enough; more than just sweat gathers on me in Haiti.  And it seems I don’t deserve a hot shower.  How could I be pampered when down the hallway death approaches due to lack of adequate washing?  Where the water itself has brought death by cholera instead of the life and cleansing it is supposed to bring.

Glasses

I don’t really need them most of the time.  I can see 20/20 with one eye, at least after Lasik surgery, complements of the government, before I got out the Navy a few years ago.  But they help to read the x-rays, and God knows there’s no radiologist looking at them.  Except now there are some volunteers out of Duke helping out reading the CT scans.  That helps, except when I disagree with the read.  Hard to get a hold of them after.  Will have to leave that to the next team.  There is a European girl with several months of belly pains who comes for an ultrasound.  I talk her into a CT scan.  She can afford it and she needs it.  The radiologist from Duke says her adrenal gland has a tumor.  Let’s get her a copy of the CT; she will need that when she has a follow up in Canada.  They can compare.  See if it grows like a cancer or stays quiet, an unseen blemish of no consequence.  We hope.  I see fear in her eyes, and I do my best to speak to it.  Speak to God of it.  She has worked hard for the people of Haiti.

Pens

I always bring a whole box.  As a doctor, the last thing I need to worry about is whether I have a pen in my pocket or not.  So I don’t care if I leave them here and there around the hospital, even in the States.  If someone needs one, I hand it over.  Though at the same time I always bug the med student if he is unprepared.  They need to grow their anxiety a little sometimes.  Can’t be a good doc without some anxiety.  Didn’t know the pens would be so busy this time on a certain form:  the Haitian death certificate.  We write in English, trying to understand the form in French.  Getting the name right is easier this time, due to the printed intake form from the hospital’s new computer system.  In the Sates, I get the forms back months later:  what sort of cancer was it?  What stage?  Was it treated?  Usually I can figure out the answers to these questions by looking back through the chart.  But in Haiti the cause of death is more often a guess.  And the box of pens does nothing to make it clearer.  Nor can it hold off the power of death.  The trauma surgeon tried to take it in stride with a joke:  just fill out the death certificates when they arrive, he said, and save our time later.  The black humor of his trade; shared with soldiers, morgue workers, and the like.  I try that kind of humor some, but that shield for me is incomplete.   What gets through gathers in the pit of my gut somewhere and gnaws.

Sun block

My white skin is an extra chore, but something I can afford.  Trying to prevent a painful burn and slow the lines that are forming from various adventures.  Skin cancer risk doesn’t bother me.  I can’t fathom having it, though I have treated enough of it on others.  I bring for a week more than I can use in a month.  The excess margin our culture carries around.  Too much sun block above the eyes and it runs down in the mid-day heat and burns my eyes.  

Books

I never have much time to read during my week of work at the hospital in Haiti.  When I am off shift, there are interesting people to talk to, quite the adventurers that volunteer their time.  Some quite wacky, maybe they can’t function in America.  Unfortunately the third world gives them default leader-status, at least at first.  But most are admirable, self-giving, and illustrations of a Covey Highly-Effective book.  The airplane ride, though, gives me reading time.  It is a long way from Seattle to Miami, and layovers to make the flight cheaper are also prime reading spots.  I bring a devotional to read in the early hours before I start work.  Crucial to forming spiritual energy that rapidly depletes during the long, draining days.  My book Authentic Faith by Gary Thomas says  “Our attitude toward God is defined by our actions toward the less fortunate.”  I share a passage with one of the nurses as she feels compassion fatigue:  “As you begin to reach out to the hurting, it’s important to check your sentimentality at the door.  In reality, it’s something we need to do with our eyes fully open.”  On the plane I read a less encouraging book: When Healthcare Hurts, by Greg Seager.  After that, one realizes that there is even more hard work to be done here:  Balancing helping and giving with critical and scientific analysis.

Batteries

Didn’t need to use them.  The new headlamp lasted the whole week.  And I hardly used my otoscope this time: between the pediatrician helping me in the ER and just randomness I think, there were not too many ears to look at.  Probably should have left the C batteries in Haiti for the laryngoscopes.  It is difficult to keep the laryngoscopes ready for the next emergency.  This kind of code needs an Intensive Care Unit (ICU).  This hospital has one, an ICU that works.  The ICU is a major step up in complexity and cost in the third world.  It takes many batteries, along with working ventilators, trained ICU nurses, loads of equipment with a working supply chain, and many, many other things.  Though it doesn’t have all of the bells and whistles (and extra redundancy) of a high acuity hospital in the U.S., this oddly partnered hospital in Haiti has walked up this difficult step and is sustaining.  Probably has taken much more investment in time and money and training than anyone would have anticipated.  Someone should write a paper about it, I ponder.  Not me I hope; musing is more my line.  I put the batteries back in the garage when I get home.  A room that holds 2 cars and the boxes and bikes and lawn care stuff of an American family.  Seems wrong, like the Costco cart.  If this room were carried to Haiti, it could be another ward full of patients.   I could have accepted another person to the hospital.  Could have saved a life.  Lives for toys it seems.  Lord, have mercy on me. 

Deodorant

Seems rather pointless to put it on only once in the morning.  Like using a teaspoon to drain the ocean when I am on duty in Haiti.  Maybe it helps more when I am out of clothing and what has aired out on the bunk bed is going into service for another round.  Smelling good is another luxury.  When my wife and another niece pick us up from the airport, they are not shy to encourage us to visit the shower when we get home.  Walking around Miami in veteran Haiti underwear and then flying just did not produce an appealing fragrance for them.  Perhaps we should have sprayed on some perfume from the duty-free shops.  

Shoes with no holes

It feels like my feet are cooking in these shoes.  But flip-flops just will not do, with blood and needles and cholera.  The first time I wore these shoes here, I thought I would throw them away after.  With the bleach from the cholera tent and the ubiquitous dust from the earthquake rubble, they were not pretty.  But a shoe shine later in the Chicago airport and they were good as new.  Had them back three times since.  The first couple of times in Haiti I wondered why my legs were so swollen.  But my doctor buddy in the Navy explained heat edema to me, having had the same puzzle in Iraq.  A transient problem as the blood vessels dilate in the heat, probably worse with the salty Caribbean food and long days walking around the hospital grounds.  Beth added to her discomforts this edema and a significant reaction to the mosquito bites with quite a bit of pain.  I had to reassure her that, no she was not going to die or be disabled.  She got it.  Tears she had, but she kept them away from the patients.  During the work day, she kept a smile on her face.  That and management of chaos, skills of value ingrained in her over high school years of part time work by the McDonald’s corporation.  Who knew that Ronald would be so helpful in Haiti?

My Traveling Hat

I am very particular about my traveling hat.  This is my third over the years.  Brim bigger than the current fashionable Fedora.  Soft and wool made, so that unlike a cowboy hat, it can be crushed and bounces back to its original shape.  Helps protect my over-white facade, and makes me feel a little like Indiana Jones.  No whip though, and women don’t chase me.  I do enjoy the adventure part of these trips.  It is exciting to be there in the midst of the action.  Some are quite addicted to it, signing up for long stents with Doctors Without Borders or moving to places like Haiti full time.  I am taking it in doses.  Need to be careful not to overstep my bounds.  To avoid doing medically overseas what I cannot do well.

Money

Small bills, they said.  For tips, for food, for souvenirs.  Needing more and more each trip.  As Haiti rebuilds, there are more things to do, more ways to spend your money.  The massive fields of post-earthquake tents are gone.  There are parks again, stores.  Back to urban sprawl.  When does post-earthquake camp change back to urban slum?  Perhaps in part defined by whose hands the money passes to and through.  The shop owner now, not the developer so much.  And still there is hunger.  Still orphans and knives and no margin.  An odd, odd thing, money.  Can cause so much damage and so much good.  A thing of faith and a thing of filth.

Passport

I always carry it on my person.  I don’t know really if that is safer than leaving it in the room.  Nothing seems to get stolen out of there.  And if someone came in with a knife and wanted my passport, I am sure I would part with it rather than part with an organ.  But I doubt that would happen, with our fenced area and our guards.  Our bunks are in the back hallway of the small hospital.  Formerly private rooms for patients back before the earthquake put things on top that were on the bottom and vice versa.  Many third world hospitals are like that:  a large open ward for the poor, and private rooms for those who can afford the rent.  It helps the hospital stay afloat.  Now they are just starting to reintroduce billing, a transition back to having the patients pay.  But it is only the open bay patients now; the private rooms are still filled with volunteers.  Hard to say what is better for the health care system and the patients: not paying or paying.  But those decisions are, appropriately, in the hands of those who don’t need a passport to live here.  Of course the passport for me is the final thing on my list.  Gets me on the plane out, back to the U.S.  Don’t even need a ticket any more really:  it is an idea rather than a piece of paper, accessed by the passport.  Who you are, or who the government and the bank define you to be.  Another book of faith.  Not as solid eternally, but it helps for now.  Means to an end I hope.  The many stamps in my passport reflecting a love: for the world, for cultures, for people, for life. 

Personal Choice

Our particular society and culture places heavy value on personal choice.  Cultural heros for us are those who choose their own path in worlds dominated by moral, religious, cultural, or political beliefs and systems that limit individual choice and individual differences.  Heavy themes in screen and print are of the teen coming of age by rejecting the gray and drab given role of the family and choosing his own way, his own crowd.  Or the citizen bucking the system, the rogue cop putting things right, the individual making independent choices.  These stories of personal choice both reflect and form the way we see the world, ourselves, and our communities.

What makes the news is another form of story that represents our society's priorities.  What is most horrible about a crime, most wonderful about a success story for us is how personal choice is affected.  The holding captive women against their will for years by a controlling man.  The teen mother choosing to rise above and by determination becoming a CEO.

When it comes to the children's choices, good parents will do right by their child by doing their very best to maximize the choices given to the child.  “I had no choice,” the parent might say, “but I want to make sure my child does.”

Whether to have a child or not at all we of course want to be a choice.  “Every child a wanted child” is a slogan of those who value personal choice, as it proclaims the value of choosing to have a child rather than merely accepting the way of nature and the body in conception and childbirth.  The choice of “Family Planning” has such a positive connotation that even those who would have us submit a little more to the ways of nature would use the term “Natural Family Planning” in discussing it.

Several problems are evident with our society’s over-emphasis on personal Choice, an unhealthy extreme in the complexity that is human life and human society.  The first is the inherent contradiction in the message itself.  For the message reflects two myths that are both destructive
generally and mutually exclusive and therefore anxiety producing:  the myth that one’s individual choice is always what is best, and the myth wherein what is best is that the individual find her true self.

The first myth is what we have been talking about thus far: that personal choice must come first before societal benefit, social or religious obligations, or moral questions.  That somehow any other way makes takes away one’s personhood.  Now certainly there are many cases where one’s individuality, creativity, and choices are inappropriately suppressed, and it does limit one dramatically.  The oppressive subjugation of persons by individual, class, religion, sex, etc has
examples as long as history itself.  We are not arguing that this is not a problem of epic proportions.  But the solution proposed is an extreme overreaction that may throw out the person altogether.  For a person is such only in the midst of relationship.  Relationship to other persons, society, nature, God, ideas, and many other things.  By himself alone, what is that man but a shade and a figment and a theory?  “No man is an island.”  To say that one’s choices are not influenced, limited, and subjected in countless ways, and are completely free and from the individual alone is absolutely absurd.  The most that can be achieved from propagating this idea is that one’s individual choice becomes “free” from possibly a particular influence in a particular way.  In fact, that “freedom,” by not acknowledging the myriad of other influences upon our choices, may not be freedom at all.  Especially if the influence so discarded was based on reality, and was beneficial to the individual, the family, the society, or other things that are in relationship to the individual.

The second myth is strangely and constantly mixing with the first myth in our society, but like oil and water they cannot combine.  In this second myth, there is a secret and typically unknown inner core to the individual human, and she is not at rest until she discovers it and then acts on it.  Great pains must sometimes be taken to find this “true self” and then to be “true to one’s self.”  Perhaps she may need to “come out” of the oppressive closet of sexual repression to find her true Lesbian self.  Perhaps she was kept in a dead end monotonous job where her true self was found in writing or dancing.  Or the bearing of children killed off her true self which was to be a world traveler.

Again, the truth is not to be found in denying that there is something wonderful and creative inside of the individual waiting to be discovered and celebrated.  In fact, there are many facets and springs and untapped potentials in what are our wonderfully complex and beautiful selves.  This myth actually can lead to the suppression of the self in its wonderful complexity by limiting it to that one “true” inner thing that should define it.  It is a myth that denies the whole person to honor the part.  Typically, this is once again an attack on the established relationships, an overreaction to what can be limiting and repressive.  So the man leaves his family, does not talk to them for years, so that he can find and give expression to that one area of his life that they found unacceptable, and he invests all of his life there, stunting his growth in relationship and severing ties meant to protect him and nurture him.

The oil and water part of this whole thing is that according to this myth, one cannot choose one’s inner self.  One must discover it.  Once discovered, it must be honored.  So true freedom of choice is gone. One is encouraged to give full reign to this inner light and guide which is seen as the only true divine.   At the same time, the myth of personal choice says that one’s freedom is what must be honored above all else.  So even inner constraints must be overthrown in its
name.  What if one chooses against one’s inner self?  How can one be restricted by this inner light and still be truly free?  Thus the endless stress of the modern, at constant odds with himself in his choices and his being.  In the name of freedom she becomes a slave.  In the name of choice he loses even the ability to think about choices at all.

Perhaps we should question these assumptions, these extremes.  Perhaps we need to look back, find the balancing factors that we have laid aside in our frenzy for individual liberty and freedom of choice.