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Jumat, 03 Februari 2012

Just Business - Employee Control Fraud, Gresham's Dynamic, and the Race to the Bottom in Health Care

Since Enthoven called for the break up of the physicians' "guild," and handing over its supposed power to managers, (see post here) managers have taken over from physicians and other health care professionals as leaders of health care organizations.  Unfortunately, most of these managers are generic, often lacking knowledge and experience in health care, and understanding of its core values.  Instead, such generic managers may rely on the current management dogma.  The perils of doing so are illustrated by an analysis of the recent expose of conditions at Apple manufacturing plants in China.

The Apple Expose

The New York Times summarized in a landmark article how bad it is to work in factories building Apple products under contract in China.  Workers endure harsh conditions, toiling up to six days a week, 12 hours a day.  Meanwhile, banners remind them to "work hard on the job today or work hard to find a job tomorrow."  Workers may be exposed to hazardous, even poisonous materials (like n-hexane used to clean components).  Workers have died in explosions due to inadequate control of combustible dust. Over 18 workers at one factory attempted or committed suicide within two years.

The article suggested that while Apple managers may be well-intentioned, and "want to improve conditions in factories," the bottom line is more important:
that dedication falters when it conflicts with crucial supplier relationships or the fast delivery of new products.

In fact, because of its rigid insistence on cost control, its suppliers are sorely tempted to push their workers too hard:
Apple typically asks suppliers to specify how much every part costs, how many workers are needed and the size of their salaries. Executives want to know every financial detail. Afterward, Apple calculates how much it will pay for a part. Most suppliers are allowed only the slimmest of profits.

So suppliers often try to cut corners, replace expensive chemicals with less costly alternatives, or push their employees to work faster and longer, according to people at those companies.

'The only way you make money working for Apple is figuring out how to do things more efficiently or cheaper,' said an executive at one company that helped bring the iPad to market. 'And then they’ll come back the next year, and force a 10 percent price cut.'

So,
'You can set all the rules you want, but they’re meaningless if you don’t give suppliers enough profit to treat workers well,' said one former Apple executive with firsthand knowledge of the supplier responsibility group. 'If you squeeze margins, you’re forcing them to cut safety.'

William Black's Analysis: Employee Control Fraud and the Race to the Bottom

Writing in the Huffington Post, William K Black showed how Apple executives' relentless focus on cost could drive a race to the bottom. He began by analyzing Apple executives' explanation for out-sourcing their production:
'We shouldn't be criticized for using Chinese workers,' a current Apple executive said. 'The U.S. has stopped producing people with the skills we need.'

He noted that it is absurd to suggest that the US does not have workers with the technical skills necessary to build Apple products. He suggests, however, that these are not the skills that matter.
The suppliers want engineers and managers who will selectively apply their substantive skills. American engineers and managers cannot be counted on to provide the necessary selectivity. Apple's suppliers' often seek managers willing to order their workers to exceed the lawful workweek, to refuse to pay them for significant portions of the wages they have earned, to unlawfully employ child labor, and even to coerce abortions.

So, in the n-hexane example,
The engineer did not order the workers to use the nerve poison because he hated the workers. It was 'just business.' The nerve poison reduced cleaning time, so an engineer knowingly ordered the workers to use it and scores of other engineers did nothing to prevent the usage.

Note that Black calls this employee control fraud, deceiving the employee that he or she is working in a reasonably safe environment, and that employee health and safety is a concern, when in truth the only concern is the bottom line.

So what Apple executives, and by analogy, other multi-national corporate executives want are underlings, particularly middle and line managers who will do anything, anything to cut costs and improve the bottom line. This will produce the race to the bottom:
What we are observing is the essence of a Gresham's dynamic in which bad ethics drives good ethics out of the market.

Two aspects of this Gresham's dynamic are obscene, and both are produced by neoclassical economics dogma. Calling this process 'creative destruction' is baseless and dishonest. It is the fraudulent destruction of honest businesses, professions, and labor.

Black concluded:
firms that are anti-employee control frauds are likely to commit other forms of control fraud. Apple and its Western counterparts have driven the creation of an Asian network of fraudulent firms that has distorted international trade, hollowed out U.S. manufacturing, and created a bizarre hybrid: quasi-communist crony capitalism. It boggles the mind that theoclassical economists celebrate the corrupt result as the essence of creative destruction. The network is corrupt. It will not play by the rules. Firms like Apple help create the perverse incentives that encourage the network to cheat. Surviving U.S. manufacturing firms are whipsawed by the powerful Gresham's dynamic that the frauds produce. U.S. firms and workers are constantly pressured to reduce wages and workforce to try to compete with the foreign frauds. This is the 'Road to Bangladesh' strategy that has caused U.S. working class wages to stall for decades. Europe is retreating along this same road at an even more rapid rate. The Gresham's dynamic tilts the world in favor of fraudulent firms operating in fraud-friendly nations.
The Race to the Bottom in Health Care
Note that we have written about numerous examples of executives of US health care organizations putting revenue ahead of the health care mission, ahead of workers' morale, ahead of patients' and the public's health. Some of these examples involve executives of nominally non-profit organizations that are supposed to have charitable purposes. (Look under our heading of mission-hostile management.)

In fact, just yesterday, Dr Carl Elliott, writing for the Chronicle of Higher Education, summarized how pharmaceutical companies have out-sourced clinical research. The resulting commercial clinical research have generated conditions as bad for the research subjects as those endured by the Chinese electronics workers above:
If the past decade had an emblematic moment for clinical research, it was probably November 12, 2005, the day when Bloomberg Markets published its cover story, “Big Pharma’s Shameful Secret.” In that issue, Bloomberg reporters laid out the story of SFBC International, a contract research organization in Miami that was paying undocumented immigrants to test the safety of new drugs in a seedy motel. The SFBC owners had converted the lobby into a large waiting area with plastic chairs, and they were housing their research subjects six to a room. The medical director of the research site was unlicensed to practice medicine; the Institutional Review Board that approved many of the studies was owned by the wife of the company vice-president; and the converted motel, which had been cited for fire and safety violations, was eventually demolished. Nonetheless, SFBC had become an astonishingly successful enterprise. Just a few years before the Bloomberg Markets report, Forbes had named SFBC one of the most admired small businesses in America. Virtually every major pharmaceutical company had tested drugs with the company. In fact, with 675 beds, the converted motel was the largest research facility in North America.
Note: see our relevant posts here on SFBC International, and on contract research organizations.

Moreover, such out-sourcing has produced the sort of race to the bottom described by Black, but this time involving one of the US most important health care institutions, academic health care:
the more important reason is money. In medical schools, faculty members are often expected to generate their own salaries, either by seeing patients or getting grants and contracts. Likewise, academic departments are often expected to be financially self-sufficient, with as little support as possible from central administration. 'Eat what you kill' is the phrase used, without irony, by medical school deans and department heads. And if you are not killing it with NIH grants, you probably need to be killing it with AstraZeneca or Pfizer.

This system has not been good for human subjects, but it has not been good for academic physicians either. According to a recent study of over 5,000 faculty members at U.S. medical schools, 51 percent of respondents said that the administration is only interested in me for the revenue I generate.' Thirty-one percent said that their institution discourages altruism; 27 percent said that it does not reward clinical excellence; and over half said that it does not value teaching. Nearly half of respondents were considering leaving their current jobs; almost a third were considering leaving academic medicine altogether. Asked if their values lined up with the medical schools where they worked, over half said no. And just in case you are wondering why these physicians are not standing outside the building with picket signs, protesting the injustice of the system, the survey offers another clue. Thirty percent of respondents agreed with the statement, 'I am reluctant to express my opinion for fear of negative consequences.' [This was from an abstract by Pololi L et al.  See our relevant post here.]

Of course, this survey does does not exactly match up with the happy propaganda disseminated by the media-relations offices at most medical schools. Instead, it offers a picture of alienated, demoralized physicians, unhappy in their jobs, pressed to work according to values that repel them in order to prop up an institution that views them primarily as instruments to generate profit. In this environment, contract research makes perfect sense. It may not require much intellectual work, but it pays the bills and keeps the authorities happy. And if medical schools don’t really value intellectual work anyway, that may well be enough.
So the pressures on medical school faculty are little different from those on corporate middle management.  Their only role is to make money, mainly so that the top leaders can become multi-millionaires, and woe unto them if they object.
Summary

What is missing in all this is any organized opposition to the race to the bottom. As long as top executives can make nearly unlimited money, as long as they can do so by making their subordinates put revenue ahead of all else, as long as there are no countervailing forces, the race to the bottom will continue.

To stop it, we need some combination of efforts by honest government regulators, professional and trade organizations, civil society organizations including non-profit organizations and NGOs that really care about patients' and the public's health, and finally an activated, and properly outraged public.

As long as we think that a laissez faire policy allowing continual market dysfunction to continue, the good times for executives will keep rolling, over all of the rest of us.

Friday's Length Retention Tip!


Do you want to reach your goal?  Then ...

incorporate pre-shampoo treatments into your regimen, particularly if you're prone to dry ends.  Pre-shampoo treatments (or "pre-pooing", for short) usually consist of applying a conditioner and/or oil to your hair and letting it penetrate for an hour or so before your regular shampoo wash.  The benefit of prepooing is that it minimizes the stripping of moisture that can come with shampooing.  Note:  There is no need to apply your prepoo to your scalp; simply applying it to the hair, or even just the ends, is sufficient.

Loo's recommendation:
Coconut oil for a prepoo. (Do this overnight for penetration of the oil.)  Coconut oil is known to not only penetrate the strands, but it may minimize damage by hygral fatigue (i.e., stress on the hair due to water uptake and eventual evaporation).  


For Wednesday Hair Growth Tips, check out this post.

Kamis, 02 Februari 2012

Siemens Healthcare on solving EHR usability problems: you can just call up your pal at the next hospital

In my Aug. 2009 post "Why Siemens Healthcare Fails", I wrote:

I note that I used to admire German engineering rigor, but after seeing ill conceived, misguided position ads like the following from Siemens Healthcare, I am having sincere doubts about that country's current prowess in that domain.

My admiration fell another notch. I now see this, in a Feb. 1, 2012 article from HealthData Management entitled "User Unfriendly" on the flaws in commercial health IT that present a poor user interface/user experience (at the expense, ultimately, of you, the patient). The article's browser title bar somewhat subliminally reads "Physicians gripe that EHR's are not easy to use but improvements are coming":

... There's also no mechanism for publicizing problems with EHR interfaces, unlike the FDA's process for issues with medical devices. [User interface expert Prof. Ben] Shneiderman describes a case where a physician found a bug in an EHR that created a danger to patients. "He contacted the supplier because he thought it was something other users should know about, and the response was, 'Oh, we know-we're working on it,'" Shneiderman says. "The physician said, What? You know about it and you haven't notified everyone?' Contrast that with the Federal Aviation Administration, where problems with airplanes are publicized within hours."

The IOM report calls for substantial loosening of those contractual restrictions. "The committee views prohibition of the free exchange of information to be the most critical barrier to patient safety and transparency," the report says. "The committee urges the [HHS] Secretary to take vigorous steps to restrict contractual language that impedes public sharing of patient safety-related details. Contracts should be developed to allow explicitly for sharing of health I.T. issues related to patient safety." The report also says there should be a central place to report and publicize known issues with EHR software.

Siemens apparently has a different idea on taking responsibility for the user interfaces of their products:

Siemens Healthcare Chief Medical Officer Don Rucker, M.D., says the secrecy issue is overblown. "There are trailer loads of information out there on each of these big systems, and there are so many end users that you can just call up your pal at the next hospital."

There are trailer loads of information out there, and it's up to the end user physician to find the information and sort through it?

... Sounds perfectly reasonable to me. /not/

There are so many end users that you can just call up your pal at the next hospital [for guidance on user interface complexities and errors]?

Also sounds perfectly reasonable.
/not/

... Except, I think most EMR vendors and user-organizations sort-of disable Remote Assistance, Remote Desktop and similar programs. Even "print screen" is usually either disabled or forbidden from sharing with that "pal at the other hospital." Might have something to do with security and IP protection.

Ever try to guide someone through a complex computer interface over the phone, blind, with no real-time mutually viewed visuals? It's not easy, but ... physicians and nurses have PLENTY of time for such fritter, what with the little other work they have to do.

I also think saying busy physician, nurse and other clinical customers should "depend on their pals at the next hospital" for information on health IT difficulties is a rather condescending and patronizing statement to make (to be charitable), a backyard-mechanic attitude, but that's just me.

Why does Siemens fail?

This type of statement is a very good clue.

-- SS

Healthy Hair Feature: Niqu92

Today's healthy hair feature is Niqu92.  Though she's had a recent setback, there is much to be learned from her story ...



1) Are you natural, relaxed, texlaxed, or transitioning? (And how long?)
I was natural up until my junior year in highschool (08-09) and now im currently relaxed. I don't regret my decision at all. Although i loved my natural hair i enjoy my relaxed hair much more.

2) What mistakes have you made in your hair care journey?
I have always had long & healthy hair so i never really started a hair care journey per se until this year after many setbacks from 2011. I was on birth control pills and it made my hair fall out in clumps. On top of that i decided to go to a new stylist twice for a relaxer touchup and she did not neutralize my hair properly both times so my hair fell out from that. I also "bothered" my hair too much. I decided to start co-washing it about 5x a week and my hair became extremely thin and dry from that. I went to Great Clips for a trim and they sabotaged my hair. Due to all those setbacks i cut my hair 2-3in above BSL.

3) What is your current HEALTHY HAIR routine?
i learned from my mistakes and realized that LESS is MORE. So here is my current regimen
Once a week:
Shampoo with Design essentials
DC with Matrix Biolage Conditioning Balm or Silicon Mix
after i rinse it out, i rollerset my hair.

I moisturize my hair nightly with Silicon Mix Leave-in Conditioner and seal with Jojoba or Coconut oil
I do protein as needed (about once every 6-8wks)
I get touchups and trim every 9-10weeks
maintaining this simple regimen and finally finding a good stylist has made my hair healthy again.


4) Do you have a HEALTHY BODY routine? If so, what is it?
I work out 5-6x per week with Turbo Fire
I try my best to stay in shape because im a diabetic so being healthy is extremely important for me.
I eat healthy on the weekdays and on the weekends i allow myself to slack off and eat all the unhealthy things my heart desires.

5) Do you have any advice for those seeking healthy tresses?
Everybody is different so you have to find out what works for you. Growing long and healthy hair is possible whether youre relaxed or natural once you find the right products/techniques that work best for your hair. Also, if you have suffered from a setback it is not the end of the world. I thought i was going to die when i had to cut my hair due to my setbacks but at the end i realized it's just hair.  Hair always grows back so dont think its the end of the world. It can actually be a good learning experience.

KevinMD: How algorithm driven medicine can affect (make more dangerous, actually) patient care

Reposted from KevinMD blog on another aspect of the health IT mission hostile user experience. Emphases and comments in [red italics] are mine:

How algorithm driven medicine can affect patient care
by


Whenever someone is scheduled for an operation, the assigned nurse is required to fill out a “pre-op checklist” to ensure that all safety and quality metrics are being adhered to. Before the patient is allowed to be wheeled into the OR we make sure the surgical site is marked, the consents are signed, all necessary equipment is available, etc. One of the most important metrics involves the peri-operative administration of IV antibiotics. SCIP guidelines mandate that the prophylactic antibiotic is given within an hour of incision time to optimize outcomes. This has been drilled into the heads of physicians, health care providers, and ancillary staff to such an extent that it occasionally causes total brain shutdown.

Let me explain. For most elective surgeries I give a single dose of antibiotics just before I cut. For elective colon surgery, the antibiotics are continued for 24 hours post-op. This is accepted standard of care. You don’t want to give antibiotics inappropriately or continue them indefinitely.

But what about a patient with gangrenous cholecystitis or acute appendicitis? What if, in my clinical judgment, I want to start the patient on antibiotics right away (i.e. several hours before anticipated incision time) and then continue them for greater than 24 hours post-op, depending on what the clinical status warrants? I should be able to do that right? [No - wrong - the idiots who designed your CPOE/Pharmacy IT system forgot that robotic medicine is bad medicine - ed.]

Well, you’d be surprised. [No, actually, I'm not. I'd have been more surprised to see a system not impeding critical medical decisions tailored to the individual patient - ed.]

You see, at two different, unaffiliated hospitals I cover, the surgeons have seen that decision-making capability removed from their power. If a young patient comes in with acute appendicitis and I feel that it would be prudent to continue the Zosyn an extra couple of days, an automatic stop order is triggered [presumably cybernetically - ed.] in the department of pharmacy and the antibiotic is stopped after 24 hours, no matter what. Unless the surgeon specifically writes “please do not stop this antibiotic after 24 hours; it is being administered for therapeutic purposes, not prophylaxis [that sounds a bit like begging - ed.] ,” the antibiotic will not be sent to the patient’s floor for administration. As a result, patients end up being treated sub-optimally, and potentially harmed, due to an over-emphasis on “protocol” and “quality care metrics.”

Similarly, the 60-minute timeline for pre-operative antibiotic administration can be problematic. I have had patients come into the ER with appendicitis or cholecystitis and, in my pre-op orders, write for Zosyn or whatever, to be started ASAP, no matter what time the operation is scheduled. Not too long ago, I admitted a gallbladder over the phone at 2am. I gave the nurse admitting orders which included one for a broad spectrum antibiotic.

When I saw the patient in the morning, I added her on to the OR schedule. By the time a room opened up, it was about 10:30am. The OR nurse asked me if I wanted to give an antibiotic for the case. I told her that the patient was already on antibiotics as part of her admit orders for treatment. The nurse shook her hand. It had never been given; the floor nurse held it so that it wasn’t administered until 60 minutes before the scheduled OR time, just like the algorithm dictates — despite the fact it had been ordered nearly 8 hours prior to the case, not for peri-op prophylaxis, but for treatment of an established pathology. [This is how EHR-induced malpractice occurs, readers. Guess who bears liability? - ed.]

And there it was, the cefotetan, hanging on her IV stand. Now nothing bad happened [this time, due to luck - ed.], but here you have a situation where health care providers are so terrified of violating Quality Assurance Protocol that they end up withholding necessary treatment. It’s just astounding. [It's astounding the surgeons don't simply use a scalpel on the computer terminal network and power cables to protect their patients - ed.]

As surgeons, we have bitched and moaned. You would think that these issues would be quickly rectified. But no. It is the responsibility of the surgeon to write qualifying statements [a workaround to a 'feature' that turns medical judgment on its head - ed.] for therapeutic antibiotics because the default mode is to override a licensed physician’s clinical judgment. [Not mentioned is who is overriding that judgment through cybernetic proxy - ed.]

This is what I’m talking about when I say that blind allegiance to a top-down, systems analysis-driven algorithm can turn everyone involved in health care into a bunch of mindless drones.

Jeffrey Parks is a general surgeon who blogs at Buckeye Surgeon.


I will simply add that these issues sound like poor IT/protocol design and implementation, getting in a physician's way regarding tailoring of care to the individual patient.

An inviolable rule in health IT is - or needs to be -

"You should not have to work around something that is not in the way."

There is nothing to debate or discuss on this issue.

-- SS

Feb. 3, 2012 addendum:

Some IT person (anonymously, of course) tried to argue and debate anyway; however, they did not even do basic homework. See their comments in the comments box.

Feb. 5, 2012 addendum:

More in the comments section by someone saying they made the aforementioned comments, stating they are a hospitalist, and still trying to advance the same arguments in favor of physicians adapting to mission-hostile HIT and/or protocols rather than 'protesting too much.'

Rabu, 01 Februari 2012

Animal Theory, Going Feral in 2012

Since the late 1970s, scholarship in the field of human and nonhuman animal relations--a development of animal, environmental, and social liberation movements--has significantly developed, testing the limits of the humanism and liberalism that gave birth to it. In the 1980s and 90s, philosophers, historians, sociologists, anthropologists, feminists, socialists, and literary theorists have contributed to this academic and cultural project. Research in human and non-human animal relations has particularly come into vogue in the last decade. This new literature developed out of increasing interdisciplinary as well a younger generation with more radical political ambitions, those who were dissatisfied with the presuppositions and/or simplicity of earlier theory.

Below are a few lists of books published between 2010 and 2012 that I would love to read by the end of the year; books such as Zoopolis which re-conceptualizes interspecies ethics as interspecies justice, Critical Theory and Animal Liberation which organizes the most sophisticated collection of critical animal studies theory to date, Creaturely Poetics which articulates a movement in animal ethics away from reason and power toward vulnerability, and Social Lives with Other Animals which investigates the social formation of species identity within the particular intersections of oppression. Animalkind, Beyond Animal Rights, and Animal Ethics in Context further challenge the traditional and universal morality espoused by animal advocates for more nuanced considerations that are far from self-certain. And if these books aren't tricky enough, the first philosophy book entirely dedicated to the moral considerability of plants, Plants as Persons, is bound to give the zoocentrist a run for her money.

Tim Tyler's book CIFERAE and Dominic Pittman's Human Error, and Boddice's Anthropocentrism add further complexity to our understanding of our humanity and the hegemony of anthropocentrism while Pat Shippman and Hal Herzog explore the myths of human-animal relationships with the latest empirical research in anthropology and psychology. Then there is Meat, Animals and Public Health, and Animals as Biotechnology which offer meditations on the relationship between our treatment of animals and the intersections of human, animal, and ecological health. Last but not least, I'm majorly anticipating Kari Weil's Thinking Animals, which seems like it will provide the greatest synthesis of human-animal studies yet published.


If you are interested in contributing a book summary and review to be posted on this blog, please send me an email or comment below.

NEW DIRECTIONS IN ANIMAL ETHICS / JUSTICE:
Zoopolis: A Political Theory of Animal Rights (Sue Donaldson, Will Kymlicka, 2012)
Zoopolis offers a new agenda for the theory and practice of animal rights. Most animal rights theory focuses on the intrinsic capacities or interests of animals, and the moral status and moral rights that these intrinsic characteristics give rise to. Zoopolis shifts the debate from the realm of moral theory and applied ethics to the realm of political theory, focusing on the relational obligations that arise from the varied ways that animals relate to human societies and institutions. Building on recent developments in the political theory of group-differentiated citizenship, Zoopolis introduces us to the genuine "political animal". It argues that different types of animals stand in different relationships to human political communities. Domesticated animals should be seen as full members of human-animal mixed communities, participating in the cooperative project of shared citizenship. Wilderness animals, by contrast, form their own sovereign communities entitled to protection against colonization, invasion, domination and other threats to self-determination. `Liminal' animals who are wild but live in the midst of human settlement (such as crows or raccoons) should be seen as "denizens", resident of our societies, but not fully included in rights and responsibilities of citizenship. To all of these animals we owe respect for their basic inviolable rights. But we inevitably and appropriately have very different relations with them, with different types of obligations. Humans and animals are inextricably bound in a complex web of relationships, and Zoopolis offers an original and profoundly affirmative vision of how to ground this complex web of relations on principles of justice and compassion.


Critical Theory and Animal Liberation (John Sabonmatsu, 2011)
Critical Theory and Animal Liberation is the first collection to approach our relationship with other animals from the critical or 'left' tradition in political and social thought. Breaking with past treatments that have framed the problem as one of 'animal rights,' the authors instead depict the exploitation and killing of other animals as a political question of the first order. The contributions highlight connections between our everyday treatment of animals and other forms of social power, mass violence, and domination, from capitalism and patriarchy to genocide, fascism, and ecocide. Contributors include well-known writers in the field as well as scholars in other areas writing on animals for the first time. Among other things, the authors apply Freud's theory of repression to our relationship to the animal, debunk the 'Locavore' movement, expose the sexism of the animal defense movement, and point the way toward a new transformative politics that would encompass the human and animal alike.

Creaturely Poetics: Animality and Vulnerability in Literature and Film (Anat Pick, 2011)
Simone Weil once wrote that “the vulnerability of precious things is beautiful because vulnerability is a mark of existence,” establishing a relationship between vulnerability, beauty, and existence transcending the separation of species. Her conception of a radical ethics and aesthetics could be characterized as a new poetics of species, forcing a rethinking of the body’s significance, both human and animal. Exploring the “logic of flesh” and the use of the body to mark species identity, Anat Pick reimagines a poetics that begins with the vulnerability of bodies, not the omnipotence of thought. Pick proposes a “creaturely” approach based on the shared embodiedness of humans and animals and a postsecular perspective on human-animal relations. She turns to literature, film, and other cultural texts, challenging the familiar inventory of the human: consciousness, language, morality, and dignity. Reintroducing Weil’s elaboration of such themes as witnessing, commemoration, and collective memory, Pick identifies the animal within all humans, emphasizing the corporeal and its issues of power and freedom. In her poetics of the creaturely, powerlessness is the point at which aesthetic and ethical thinking must begin.

Social Lives with Animals: Tales of Sex, Death and Love (Erika Cudworth 2011)
The conventional trilogy of social domination, of class, 'race' and gender has been challenged by new concerns around other distinctions – of place and location, age and generation, sexuality and forms of embodied difference. Despite these important developments, sociology has mostly stopped short at the difference of species. Erika Cudworth draws on various traditions of critical theorizing in sociology and animal studies in arguing that the social is not exclusively human and that species should be understood as a complex system of social domination which is co-constituted with intra-human social dominations. This understanding of species as a social system of relations is exemplified through three case studies: the eating of animals as food, the rearing of animals in industrial agriculture and the keeping of animals as companions. These sites reveal ways in which relations of species domination shape the lives both of humans, and of domesticated animals. Social Lives with Other Animals is a critical sociology of species which takes us beyond theories of speciesism or anthropocentricity and presents a necessary challenge to the power relations in the social formations of species.

Animalkind: What We Owe to Animals (Jean Kazez, 2010)
By exploring the ethical differences between humans and animals, Animalkind establishes a middle ground between egalitarianism and outright dismissal of animal rights. A thought-provoking foray into our complex and contradictory relationship with animals. Advocates that we owe each animal due respect. Offers readers a sensible alternative to extremism by speaking of respect and compassion for animals, not rights. Balances philosophical analysis with intriguing facts and engaging tales

Beyond Animal Rights: Food, Pets, and Ethics (Tony Milligan, 2010)
Issues to do with animal ethics remain at the heart of public debate. In "Beyond Animal Rights," Tony Milligan goes beyond standard discussions of animal ethics to explore the ways in which we personally relate to other creatures through our diet, as pet owners and as beneficiaries of experimentation. The book connects with our duty to act and considers why previous discussions have failed to result in a change in the way that we live our lives. The author asks a crucial question: what sort of people do we have to become if we are to sufficiently improve the ways in which we relate to the non-human? Appealing to both consequences and character, he argues that no improvement will be sufficient if it fails to set humans on a path towards a tolerable and sustainable future. Focusing on our direct relations to the animals we connect with the book offers guidance on all the relevant issues, including veganism and vegetarianism, the organic movement, pet ownership, and animal experimentation

Animal Ethics in Context (Clare Palmer, 2011)
It is widely agreed that because animals feel pain we should not make them suffer gratuitously. Some ethical theories go even further: because of the capacities that they possess, animals have the right not to be harmed or killed. These views concern what not to do to animals, but we also face questions about when we should, and should not, assist animals that are hungry or distressed. Should we feed a starving stray kitten? And if so, does this commit us, if we are to be consistent, to feeding wild animals during a hard winter? In this controversial book, Clare Palmer advances a theory that claims, with respect to assisting animals, that what is owed to one is not necessarily owed to all, even if animals share similar psychological capacities. Context, history, and relation can be critical ethical factors. If animals live independently in the wild, their fate is not any of our moral business. Yet if humans create dependent animals, or destroy their habitats, we may have a responsibility to assist them. Such arguments are familiar in human casesùwe think that parents have special obligations to their children, for example, or that some groups owe reparations to others. Palmer develops such relational concerns in- the context of wild animals, domesticated animals, and urban scavengers, arguing that different contexts can create different moral relationships.

Read more »

EHR Workstation Designed by Amateurs

Below is an actual workstation, in an ICU of a major regional hospital, to permit interaction with an already mission-hostile EHR system:


How many things are wrong here? (Click to enlarge)


I can charitably say this workstation, in this recent picture, was designed by amateurs. Less charitably, I would use the words 'glaring incompetents.'

How many things are wrong here? For starters (commenters are welcome to suggest additions to the list):

  • Small square (4x3) monitor, when large 16x9 monitors are available quite cheaply, even at retail let alone in bulk;
  • Monitor in front of window so on sunny days, glare causes eye strain;
  • Monitor forces user to look away from the patient, with their back facing the patient behind them;
  • Standard keyboard and mouse to help spread infection, not medical-specialty devices such as membrane-based or membrane-covered keyboards and easily cleanable trackpads;
  • Very slow, small, toy-ish nettop computer, to facilitate responsiveness delays;
  • Height of ledge with keyboard/mouse and of elevated monitor on ledge does not facilitate comfortable ergonomics when sitting, note chair in background (or standing as is intended, either, although I don't recall ever making entries in the permanent paper chart on my feet). It seems nobody ever heard of an appropriate moveable workstation desk;
  • Tangle of wires behind setup, without any protective sheath or shield, facilitates "accidents."

There are probably a few more "issues" I'm missing.

There is nothing to argue here and nothing to debate. Combined with the mission hostile virtual user interfaces presented by health IT software itself, this is inexcusable.

Apart from designers, any physicians (and nurses) who would accept such poor choices - and the cause of this workstation's problems were, in fact, deliberate choices - are either weak-kneed victims of "physician's learned helplessness" themselves, or enjoy EHR-induced medical errors and lawsuits.

The workstations are poorly designed like this all throughout this hospital, including the ED.

This is not the first time I've observed this type of amateurism in hospitals. I observed similar issues in another ICU - over a decade ago.

Hospitals are truly an IT backwater.

-- SS