Wednesday, August 13, 2008

Adina and the Terrible, Horrible, No Good, Very Bad Day

I didn't wake up with gum in my hair, but you'll have to trust me: It sucked.

Tomorrow will be better. I get to see patients again, and in a fancy, schmanzy hospital in Glendale. I will miss County, with its eight-hour average ER wait time, jail ward, and cavalcade of wacky patients. But I don't really speak Spanish much, which was always a frustrating limitation. Let's hope this hospital also features some interesting elements. Otherwise, I'll have nothing much to write about on my blog, and you'll be stuck reading my minute-by-minute Talmudic analysis of the latest Heroes episode.

Tuesday, August 12, 2008

Religious Minority

Because I'm doing major mea culpa to the medicine god this week, I don't have time for much thoughtful posting. Therefore, I'm just writing to remind myself of my latest life observations. Because no one actually reads this, it functions as somewhat of a journal, which is fine with me. I'm kind of a solitary person at heart (in that I lament not spending enough time with people, yet can't be bothered to call back amazing friends, and have just skipped a party to sit on couch and drink Sam Adams Black Lager and watch the Olympics with my cats). Thus, I find this whole blog thing kinda soothing.

This week I became a Jew (doing lots of stuff) for Jesus, in the sense that I've been at three different churches for three different purposes in the last three days. And if you count my long religion talk with the Mormon kid who was one of my roommates at the Tijuana trip, and another conversation about the Armenian Orthodox Church with Haig, (who is in six-person clinical medicine group), then that officially counts as five Christian experiences this week. (The first three were at the Episcopalian church that organizes the HHAB medical trip to TJ, the Catholic church I attended to advertise for the USC Free Clinic SNAPP program, and the Salvation Army shelter where I tutor an adorable homeless kid- ok, the last one is not exactly church, but is a place filled with lots of what my friend calls "Christ love").

And yet, I am not a Believer. I should also note, however, that I retain a triumphant, zealous faith and practice in playing draydel for gelt on Chanuka, watching soldiers march in Memorial Day Parades, eating matzah/BBQ veggie burgers to honor my freedom on Passover/July 4th, playing dress up and getting smashed on Purim (it's a real commandment), deeply regretting and apologizing on Yom Kippur, breaking my pseudo-vegetarianism to eat real turkey on Thanksgiving, and greeting people with "ahoy matey" on National Pirates Day.

I find that picking the lucky religion is like classical roulette odds with Russian Roulette outcomes, although choosing a Christian one might narrow the probability to reds vs. blacks. This is because you can dip in one denomination, and still get partial credit from another one (say the bottom rung of the three celestial kingdoms of the Mormons). Or as Paul said: “I know a man in Christ who fourteen years ago was caught up to the third heaven. Whether it was in the body or out of the body I do not know-God knows.” Such different stages of heaven and hell allow for efficient faith differentiation. It is perfect for the Power(s) that Be, in that it captures the "Faithfuls' Surplus," while allowing for the less devout to sacrifice less, so long as they're willing to accept a smaller portion of the Everafter.

However, in the meantime, I'll keep going to temple, planning trips to the Western Wall, and sending my money to the Jewish National Fund, Jewish World Service, and the Simon Wiesenthal Center, et. al. There's something to be said about a religion that endures so exhaustedly that, even if you check out on it, it never officially lets you leave.

Monday, August 11, 2008

Palliative Care

This post is about a patient, approximately my age, whom I visited at the hospital last year. As usual, names and other details have been changed.

The first thing that I noticed about Maria, was not the oxygen mask into which that she desperately breathed, nor the black and blue marks that whirled along her arms ( inflicted by needles, syringes, and other abusive medical equipment), but her carefully painted fingernails. This was clearly a woman whose family lavished attention upon her. We said hello to 28-year-old Maria, who recognized us with her eyes, but could not respond due to the breast cancer, that had metastasized to her brain, bones and liver. As late as yesterday, Maria was able to express that her pain was a “9 out of 10." Today, she just stared at us intensely.

Dr. Stone, who heads the palliative care office at our hospital, felt that it was perhaps time to discuss with the family about increasing the pain medication, and about how the exhaustive poking, prodding, and procedures, should now be reconsidered. She wanted to explain that Maria could perhaps spend her last days without suffering, and with her family by her side.

Surrounding Maria’s bed were pictures of her as a little girl, as well as of the Virgin Mary, and other Catholic Saints. Taped onto Maria’s bedpost was an image of Jesus, toward which I imagined Maria used to pray, long before the drugs diminished her comprehension. Dr. Stone recommended to Maria’s sisters that there be a family meeting with Father Joe, the hospital’s priest. Instantly, Maria’s sisters felt comforted by the idea. They weren’t as religious as they had been growing up, but they knew that their mother, who was grieving in the lobby, would be happy that a pastor could be present, to console them and help them make decisions during this agonizing time.

I knew that Maria’s sisters would remember every detail of this day forever. I came to this understanding because of the experience that morning in Dr. Stone’s office, when each member of our six-member clinical medicine group went through his and her own experiences dealing with death and loss. Even though it was about the fourth time I had heard each person’s personal story, I found that each retelling provided new details and perspectives. Experiencing the last days of a loved one’s life means that little things begin to take on great importance. Do we take her to the bathroom now or later? Should we give her more pain medication? Does she want to be propped up higher on her bed? These seemingly minor concerns can drive families into tortuous doubt and bitter conflict.

This is why I was most impressed with Dr. Stone’s explanation that palliative care was as much for the patient’s families as for the patients’ themselves. Families are given the opportunity to lay on the couch, talk things over with the palliative care staff, and to drink tea in the office upstairs. The program itself allows them to gain reprieve from nurses who visit the home once a day, an opportunity which does not cost the families extra money. If possible, patients and their loved ones have the opportunity to spend the patient’s last days in their home, rather than in a stale, impersonal hospital ward.

That day in the hospital, I saw Maria’s sister, Carmella express denial that her sister was truly going to die soon, hoping she could “stay alive just until after Thanksgiving.” She was angry, saying her death didn’t make sense because “Maria was the smallest of the three sisters.” Carmella bargained with the doctors about attempting other life-extending measures, if not a whole new round of chemotherapy. Ultimately, she started to feel depressed, realizing by the end that Maria's imminent death was inevitable. However, as Dr. Stone, the nurses, and we students gave Carmella hugs, stroked her tears, and stood with her in silence, she began the process of acceptance, breathing easier, returning our hugs, and realizing how her dear sister could live her final days at greater ease, surrounded by the people who love her.

I just got back from Tijuana, and have a ton to catch up on (such as the entire first week of medical school- God, I'm gonna be so anti-social the entire week. I haaaate those weeks of "Adina repents for making foolish time management choices").
Anyway, I will just post a review of the Milton Friedman essay that I read today (excerpted from the book

In arguably his most provocative essay, Milton Friedman addresses one of the thorniest issues of our time: the relative superiority of the hamantash (triangle shaped cookie, filled with jam or chocolate and eaten on Purim) vs. the latke (oily potato pancake eaten on Chanuka). For one, Milton Friedman points out, it is unclear whether unhealthy Jewish holiday food constitutes a normative or positive discipline. I understand this epistomological conundrum. On the one hand, flavor is largely experiential and subjective. On the other hand, my bubbe makes the best latkes in town, as determined in a high powered longitudinal cohort study with p<0.05.Nobody's hamantashan or latkes ever came close.
Generally, we attempt to overcome bias by presenting both variables neutrally, but Friedman, goes one step further, and makes the radical suggestion of using "negative" terminology for the foods, namely "lob" (as in lobster) and "ham" (as in the pig product). This is Friedman at his most bold, and I am surprised that Naomi Klein hasn't come out with a "carefully" written expose about these most shocking of Friedman's viewpoints.

Wednesday, August 6, 2008

Application Essay Advice for Pre-Meds

Because it's pre-med season in town, I will try to post some advice for applicants trying to get through it unscathed. My first topic is about the AMCAS essay.

My suggestions are:

1) Tell a story

2) Feel free to brag, but be descriptive and specific (Not "I worked closely with patients," but "I held so-and-so's hand when she tearfully told me that she was ready to enter the OR."

3) Avoid phrases like "The experience taught me..." and "It was rewarding because...." Just make those things implicitly clear through your writing.

4) Show, don't tell!

Savvy readers will note that all of the above snippets of advice are basically the same. But that is because pretty much all boring application essays make the same mistake.

Pretend you're trying to impress the hot girl in Italian class. Are you going to pick her up by listing all of your extra-curricular activities, or by just making her feel like she'd have fun going kayaking with you this weekend? In other words, show your personality, not your CV.

And now, for your final viewing pleasure, my AMCAS essay. (All of the names that appear in the essay are names of people I met that summer, but none refer to the actual child being described. I will readily admit that I'm a bit of a braggart in the essay, and I will trust my audience to assume that I don't usually try to come off like I have all my **** together (which I don't). I should also note that, although I did at the time want to do international medicine, I am no longer sure that that is the case):

Exiting the subway in the Brownsville section of Brooklyn to begin my first day as head of a camp infirmary, I conjured up childhood memories of my own camp's infirmary, where scraped knees earned Ninja Turtles band-aids, and sore throats were soothed by a good dose of ice pops. This reminiscence, however, was tempered by recollections of my previous summer as an EMT serving in an economically disadvantaged neighborhood in Israel. The realities of domestic violence, acute physical illness, and emotional dysfunction in a population of Ethiopian and Russian immigrants, Ultra-Orthodox Jews, and Israeli-Arabs had dispelled my naive notions of emergency medical care. Would my experience in East New York also bring unexpected challenges? These musings were cut short by my arrival at a dilapidated public school building on a graffiti-filled block, with throngs of boisterous children running around in Camp ******* T-shirts.

As the individual responsible for the physical well-being of the campers, I felt that my primary task was to secure a safe and healthful camp environment. Thus, after helping to organize game of "Simon Says" until all the counselors arrived, I found an unventilated storage closet to function as a medical office, brought in a fan, and, over time, decorated the space with the children's artwork. Ascertaining that there was only one working water fountain for over 100 campers, I coordinated with the counselors to supervise the ongoing refilling of the children's water bottles. After noticing that soap was absent from the bathrooms, and learning that the facilities staff were too budget-strapped or overloaded with work orders to replace them, I bought and allocated soap myself. Finally, I aimed to make the medical office a safe haven for the kids, often playing games or reading with my visitors.

I soon discovered that, while there were few medical emergencies in the camp, there were plenty of ethical, practical, and cultural challenges confronting me. What should I do if, before breakfast, a child says that she is starving because she did not eat dinner the night before? What was my role if a mother told me that she cannot bring her child to the doctor because she lacks health insurance? What of the child who is afraid because she says that her brother often beats her mother? How do I effectively empathize with a child who suffers from sickle-cell anemia? Many of these problems, such as violence, depressive moods, and general illnesses can be found in any community, rich or poor. However, some issues were disproportionately prevalent as this was an economically disadvantaged community.

When I encountered these complex issues, I often dealt with them by consulting with my supervisors and peers. The counselors were role models for me, as most of them were college students from the neighborhood, and brought a wisdom born of experience. At other times, I relied on my own judgment. As an oldest child in a family whose youngest brother is fifteen years my junior, I have had my share of dealing with interpersonal conflicts, scraped elbows, and negotiated truces. Thus, when it became clear to me that five-year old Bianca was manufacturing the illnesses that required her visiting me during reading session, I proactively offered that she read with me during that time-slot.

What impressed me most of all that summer was the incredible power of a caring community. Despite the difficult realities surrounding them, the children were ambitious, intelligent, friendly, and playful. Many would pass my makeshift office, and announce, somewhat inaccurately, "Hi nurse!" Tafari informed me whenever he won relay races, while Kyana always showed me new stickers, earned for good behavior. The parents were kind and supportive, as evidenced by their filling the auditorium on "performance day," as well as the generous home-cooked soul food that they brought.

This interface of medical practice and real-life ethical and practical challenges draws me to public health, international medicine, and perhaps, specifically epidemiology. I want to address issues such as the Ebola virus or the effects of unsanitized water, but also how to make health care economically efficient and sustainable, and to explore the relationship between doctors and the communities they serve. I hope to listen to patients talk about their lives, their assessment of their illness, and their collaborative thoughts on the healing process.

On the last day of camp, many campers came by my office to sign messages on my staff T-shirt. This included eleven-year old Najee, who, while recovering from a stomach ache, had related to me some difficult emotional issues that she was facing. I had developed a good relationship with her and encouraged her to visit the camp social worker. Najee's note to me summed up my goal for the summer and my future goal as a doctor- to develop a meaningful relationship with each patient: "Dear nurse," she wrote. "Thank you for letting me talk in your office and listening to me.”

Tuesday, August 5, 2008

Safeguarding the Public

As a medical student, I endorse this ban on the substance shown above, which is a component of virtually every poison and harmful pesticide, and has arguably contributed to billions of deaths throughout history. Always listen to your health care provider. You have been forewarned.

For those skeptics can't go without a proper NMR or mass spec analysis, see the data behind the controversial substance here. Watch that year of orgo pay off before your eyes.

Monday, August 4, 2008

Thoughts on Cato University Lecture III: "Understanding the Economics of Free Markets" by Peter van Doren

Sonic the Hedgehog was always one of my favorite video game series. I especially enjoyed saving all of the furry animals that had been captured and (depending on which game), turned into robot slaves by Doctor Robotnik.

But defeating mad scientists via Sonic's cannon-ball spin is only one of many approaches to securing animal welfare. People propose to legislate minimum living conditions for animals, or heavily tax meat and animals bred as pets. Private organizations, post videos exposing unsavory animal treatment practices, aiming to influence consumers directly. Or people can act like The Wisconsin Humane Society just did. According to NPR, they simply decided to raise cash and buy out what they consider a "puppy mill," in order to dismantle it. Because I viewed Peter van Doren's lecture, in which he described free markets and various approaches to dealing with social costs, I recognized the Humane Society's deal as Coase's Theorem put to work.

Van Doren (after teaching basic microeconomic principles, and explaining the problems that public goods present) compared the approach of Pigou and Coase toward "negative externalities" or the "social costs" of market transactions. Unlike stealing tangible objects, negative externalities spring up when one party does something with his own property that unavoidably and negatively effects another party. Banning such an action, due to its (possibly minimal) harm to other people would be economically damaging and completely impractical. It is also unfair to harm other people without their consent. So a compromise must be brokered.

A simple example of a negative externality is air pollution caused by power plants. Pigou believes that the person who causes the pollution (i.e. the power plant) should be required to pay all those effected by such pollution (the city) through a tax, calculated as the approximate cost of the inflicted damage. The government would impose such a tax, so there would be little room for negotiation among the various parties. All affected members of the community would become automatic partners in the deal.

In contrast, Coase believed, according to van Doren, that, clear-cut initial property and ownership rights would solve the problem, without a need for central calculation. For example, the initial rule would be "the power plant has an absolute right to pollute the air with sulfur oxides" or "the people own the right to breathe air completely clear of sulfur oxides." In Coase's view, whether the former or latter condition is chosen does not even matter. Whatever the initial rules of "the game," both parties will bargain with each other until they broker an agreement that is equally satisfactory.

Van Doren provides a few examples of Coasian successes, such as the case of the entire 221-resident town of Cheshire, Ohio, which agreed to a complete buyout by American Electric Power Company for $20 million. He mentioned the recent case of Florida's and environmental groups' purchase of U.S. sugar, which translates to more more land reclaimed for the Everglades. Van Doren, who is suspicious of the government's ability to determine the accurate Pigouvian costs, seems to consider himself a Coasian, and believes that "the initial distribution of entitlements itself does not alter the willingness of the parties to exchange the entitlements."

I find Coase's theorem intriguing, but I do have some concerns about it. (I'm sure Dr. van Doren has considered reasonable objections, and has excellent answers for them, all of which would be beyond my scope of knowledge). A summary of some of my concerns (I'm sure that they've been mentioned by many economists): 1) Poor people can't necessarily afford to "buy in" to the table. If they get no chips with which to negotiate, they ultimately get stuck with unfair externalities 2) It is virtually impossible to rally up all relevant parties, which makes the transaction costs are too cumbersome 3) If the "harmer" doesn't have a profit motive, then some negative effects (i.e. extinction of species) can occur, no matter how why high the "purchaser" bids.

Animal rights are, admittedly, a much trickier issue than air pollution. It is difficult to determine whether the "rights" belong to the humans upset by the alleged atrocities imposed on the animal, or belong to the the animal itself. If the latter, this would mean the animal activists actually have no right to negotiate the appropriate limits of animal cruelty. The law (appropriately, in my opinion) treats animals as pseudo-living beings/pseudo-property, and the deal with the Humane Society depicts animals in their "property" incarnation.

However, according to NPR's story, the breeder of Puppy Haven is ready to retire, while the animal rights organization hopes to shut down his whole operation, and deliver the animals to eager families. What results is a market-based exchange, based on clear, well-established private property laws and driven by personal interests and values. Somewhere in Chicago, 97-year-old Ronald Coase may be smiling.

Friday, August 1, 2008

My First Drug Addicted Patient

This post is about a (likely dual-diagnosis) patient whom I visited last year. As usual, many details have been changed.

When I first saw Ms. Smith, she was sleeping quietly in her dark area behind the curtain, her two legs in casts raised on a tuft of pillows. When I called her name, she awoke and, with a sweet Southern drawl, agreed to talk to me.

Immediately, pandemonium struck. Ms. Smith desperately needed to urinate, and demanded her bedpan right away. I rushed to put on gloves, and handed her the bedpan that was under her bed. However, the bedpan had apparently not been washed after the last time it was used, and Ms. Smith screamed that she did not want it on her clean bed. I nervously washed it with soap and water at the sink, and, in the nick of time, tossed it to Ms. Smith. This was the first of many narrowly averted crises.

During the bedpan incident, I noticed Ms. Smith’s extensive injuries. She had what must have been over 100 stitches lined up along her spine. She moved her individually bundled legs with great difficulty, and was constantly clutched what she called her “busted” rib. She also had cuts and old scars on her chin and scalp, which she later explained matter-of-factly with “my ex-boyfriend was kind of bad.” When I proceeded to ask Ms. Smith about the source of her injuries, a second crisis commenced. Ms. Smith suddenly felt extremely hot, and demanded that the air conditioner be raised. Other patients in the room felt cold, however, so I looked to the nurse to make a verdict. Eventually, a compromise was reached.

Throughout the interview, these interruptions continued. Ms. Smith was clearly in terrible pain, and constantly buzzed for the nurse to administer more pain medication. When the nurse continuously refused, Ms. Smith pleaded and sobbed that the last doses did not go through when she hit the button on the drug delivery machine (I do not believe that Ms. Smith was intentionally misleading- she thought that the machine would beep when the drugs were delivered, until the nurse explained that that is not necessarily the case). Ms. Smith called her nurse so often that eventually she was summarily ignored. This proved to be problematic when Ms. Smith had legitimate concerns.

Ms. Smith had interesting things to say about her 34 years of life, but had trouble staying on point, and every few minutes of conversation were halted by her feelings of pain, or her need to readjust in her bed. While I learned a little about the source of her wounds- apparently it was caused by a (stolen) motor vehicle accident, with her intoxicated boyfriend as the driver - after a while, I realized that I had not broken much ground in my questions, and decided that I would just allow Ms. Smith to talk freely.

Ms. Smith’s chart noted that she had attended college, and her language was relatively sophisticated. However, after about 15 minutes, after I asked her to list all of the injuries she had sustained, Ms. Smith responded, “I’m not usually this religious crazy, but these last few days- by the way, all this is off the record, they can’t publish this-I have learned some things. All of life is based on opposites. Yin.Yang. Keeps the world spinning. Right.Wrong. Good. Bad. You see I could have gone to any university on scholarship, but I went to Southern State University. I wrote a paper about dogs and their origins. My grandfather used to say, “You can lead a horse to water, but you cannot make him drink- but you can put salt in his oats! Get it?” After 10 minutes of rambling, Ms. Smith would become composed and thoughtful, telling me about her childhood.

When I visited again the next day, Ms. Smith seemed to be experiencing some drug withdrawal symptoms, as she was nervously shaking and saying she was cold in the very warm room. After a while, I decided to speak to Ms. Smith principally about her drug use.

This conversation taught me a lot about the power dynamics between drugs, drug users, mental illness, and the physicians who would like for their patients to quit. I once had a certain utopian vision of a prototypical conversation about drugs between a doctor and a patient. The doctor would inquire about how the patient feels about her addiction, and how the substances have changed his life for the worse. The patient would admit that the drugs have hurt him socially, personally, mentally, physically. The patient may never actually quit- he would perhaps rebound after some bouts of trying. But I thought that at least one point was pretty much standard: that the patient would recognize that the drugs were hurting him.

This is why talking to Ms. Smith about this topic was so difficult. Ms. Smith wanted to get back to the drugs when she was out of the hospital. This was not simply because she craved them or because she had poor self-control. Ms. Smith actually believed that the drugs made her life better. When I asked her to reflect upon how the daily use of crack cocaine and ecstasy have changed her life, I thought that maybe she’d find a link between the drugs and her current homelessness, her string of abusive boyfriends, her contraction of Hepatitis B. But Ms. Smith didn’t respond that way. She believed that she never had such good friends as the people she’d met on Skid Row, friends who would tell her where all the good dealers were. She had never been so happy nor had experienced so much fun in her life before she started doing drugs. This really made me ponder- how can you help someone to “get off” drugs if she doesn’t even recognize the harm that the drugs are doing to her? The first step of addiction therapy has to be, at an absolute minimum, a admission and dislike of the addiction. So I just decided to sit and listen, all the while getting schooled on doctors’ limitations to help people.

Thoughts on Cato University Lecture II: "The March of Freedom, 2500 B.C.- 1775 A.D." by Tom Palmer

“From now, we will be able to look back and tell our children that this was the moment when we began to provide care for the sick and good jobs to the jobless…… this was the moment when the rise of the oceans began to slow and our planet began to heal…… this was the moment when we ended a war, and secured our nation, and restored our image as the last, best hope on Earth. This was the moment, this was the time when we came together to remake this great nation so that it may always reflect our very best selves and our highest ideals.” -Barack Obama, Minneapolis, June 3, 2008.

One thing that often irritates me about progressives is their vision of some perfected future, crafted in their latest folk hero’s image. A desire to improve people’s material condition is admirable. However, there often seems to be a Messianic tinge to the movement, that strikes me of naiveté, and worse, apocalyptic ambition. Such idealism scares the hell out of me, because I know that to carry out a plan to eliminate all war, strife, pollution, unemployment, or other ills, there would have to be some pretty colossal interventions. I guarantee that I much prefer the world I live in now to the one they’ll have “perfected” for me.

However, after listening to Tom Palmer’s excellent speech, “The March of Freedom, 2500 B.C.-1775 A.D.,” he convinced me that libertarians often make a similar mistake. Now, it is true that, over the past few hundred years, technological advances, industrialization, and liberalization have led to significantly improved living conditions around the world. However, too often, people tend to view history as a trajectory, in which we started out as dim-witted barbarians, endured various stages of despotism, all until the clever Europeans instituted constitutional rights with the Magna Carta. In this model, the dominant intellectual discourse continues to progress until now we are America and so can you. This libertarian-scented progressiveness has a few problems, which Palmer implied in his lecture, in which he provided a comprehensive historical account of the campaign for liberty:

1) Liberty, small-government, and personal autonomy are not new concepts, nor are they found exclusively within the Western tradition. Palmer mentioned a quote (I cannot find the source) of a University of London professor who says “Freedom is uniquely Anglo-Saxon. Other languages do not have a word for the concept.” This European exceptionalism is dead-wrong, according to Palmer. For example, in 2300 BC, Urukagina of Mesopotamia (modern Iraq) enacted a judicial code that allowed for private property rights, limited taxes, and a restriction on state monopolies.
The semi-mythical Chinese figure, Lao Tzu, has been revered by Daoists since at least the 4th century B.C. for such teachings as:

“If you want to be a great leader,
you must learn to follow the Tao.
Stop trying to control.
Let go of fixed plans and concepts,
and the world will govern itself.

The more prohibitions you have,
the less virtuous people will be.
The more weapons you have,
the less secure people will be.
The more subsidies you have,
the less self-reliant people will be.”

2)Some of today’s most authoritarian governments are thoroughly modern. Palmer points out that Iran is not some old-fashioned theocracy rooted in classical Islam. It is actually a bizarre amalgam of European fascism, Marxist economics, and Islamic-themed romanticism.

3)Freedom is not the only cherished value. Research indicates that freedom is an important factor in average happiness and prosperity, at least in a cross-sectional studies. However, some people seem to think, that, so long as we establish private property rights, there would be no more pollution or extinction of species. I’m skeptical. I also agree with many of the behavioral economists in that freedom my allow some of us to make short term decisions that lead to life-long regret, which can actually decrease our overall well-being. Some people just can’t handle their freedom. It’s still their prerogative to ruin it.

4) Some people will always crave power; thus power must always be checked. Just because people establish a truly free society, does not mean that the society is any less (or more) fragile. Some great civilizations were conquered. Others were spared by pure luck (Palmer describes the case of Ögedei Khan, who, in 1241, was just about to expand his huge empire to Austria, Germany, Italy, France, and Spain, when he got poisoned and died). And it’s not only central power that poses a threat. If some monster decides to unleash a pandemic, or build an increasingly-easier-to-develop nuclear weapon, G-d help us, because freedom will not (and this notion of an individual's power to initiate harm presents an enormous conundrum to libertarians, as we oppose individualss losing their privacy or agency). This fear means that we can never have a ribbon cutting ceremony, marking the beginning of our new earth. Vigilant oversight of power is not a battle to be won, but a continuous war of attrition. When we all die, the next generation of watchmen will simply have to take over. And others will have to watch the watchmen.