Quinn "Ishmael"

"I stopped making a fool of myself, but something died inside of me - something I'd always sort of liked and admired. In it's place grew a scar - a tough spot but also a sore spot."

An Open Society and Its Enemies by Karl Popper

Summary with reference to some notes I made as well as a website that has an outline and some outtakes posted by Rafe Champion.
http://www.the-rathouse.com/OpenSocietyOnLIne/AATheProjectwithIndex.html

Overall it was too long and not very well organized. If forced to summarize in once sentence, I might write.

Democracy has the potential to support an open society where rationalism is allowed to challenge religion/tradition including ongoing critical analysis of our institutions using methodologic nominalism and alternative interpretations of history so that these institutions can enact piecemeal reforms that can be tested rather than reforms aimed at an imaginary utopia that would tempt us with the tyranny of populism or authoritarianism.

Closed society of law or religion is static, some amount of human instinct pulls us toward a closed/tribal society for including or excluding because we sense the lost group spirit of tribalism.
  Tribalistic and collectivist societies assign social customs a natural law status. Lacks critical dualism. Refers to human nature or natural as "the good". Individuals unlikely to challenge traditions.   
Totalitarianism makes all knowledge political, impedes critical thinking. Communal group think.
Avoids class war by giving ruling class absolute power. Keeps ruling class united.
Cannot tolerate criticism (even of its history) because it challenges the principle of authority itself. 
Plato promoted collectivist justice (keep your place in social hierarchy), propagated belief that individualism is not compatible with altruism by promoting using the theory of natural rights and the social contract theory of human society. 

Strain in transition from closed to open society. 

Requires critical dualism, aka awareness of distinction between natural laws and man made traditions.
"I may perhaps briefly formulate what seems to me the most important principles of humanitarian and equalitarian ethics."
Minimize suffering, promote tolerance, avoid tyranny.

First, "tolerance towards all who are not intolerant and who do not propagate intolerance. So  the moral decisions of others should be treated with respect, as long as such decisions do not conflict with the principle of tolerance."

Second. "The recognition that all moral urgency has its basis in the urgency of suffering or pain. I suggest, for this reason, to replace the utilitarian formula 'Aim at the greatest amount of happiness for the greatest number', or briefly, 'Maximize happiness' by the formula 'The least amount of avoidable suffering for all', or briefly, 'Minimize suffering'. Such a simple formula can, I believe, be made one of the fundamental principles (admittedly not the only one) of public policy. (The principle 'Maximize happiness', in contrast, seems to be apt to produce a benevolent dictatorship.) We should realize that from the moral point of view suffering and happiness must not be treated as symmetrical".

Third, "to resist tyranny by safeguarding the other principles by the institutional means of a legislation rather than by the benevolence of persons in power."  

Open society supported by ideas of individuality, criticism, and humanitarianism. Require political freedom and human rights.

Open society --> moral universalism.
All knowledge is provisional. Individual critical frame of mind.

Only democracy provides an institutional mechanism for reform and transfer of power nonviolently, provides possibility of reform and possibility of reason, but does not inself provide reason. "And should he live to see the day when the majority vote destroys the democratic institutions, then this sad experience will tell him only that there does not exist a foolproof method of avoiding tyranny. But it need not weaken his decision to fight tyranny, nor will it expose his theory as inconsistent."
Majority rule is no better than any other tyranny if it's power is unlimited. Aka new law passed both house and senate and signed by president but violates supreme court precedent without the court would be parliamentary sovereignty.

Rafe summarized Popper in 7 points:
(1) Democracy cannot be fully characterized as the rule of the majority, although the institution of general elections is most important. For a majority might rule in a tyrannical way.  In a democracy, the powers of the rulers must be limited; In a democracy, the rulers—that is to say, the government—can be dismissed by the ruled without bloodshed. Thus if the men in power do not safeguard those institutions which secure to the minority the possibility of working for a peaceful change, then their rule is a tyranny.

(2) We need only distinguish between two forms of government,  democracies and tyrannies.

(3) A consistent democratic constitution should exclude only one type of change in the legal system, namely a change which would endanger its democratic character.

(4) In a democracy, the full protection of minorities should not extend to those who violate the law, and especially not to those who incite others to the violent overthrow of the democracy.

(5) A policy of framing institutions to safeguard democracy must always proceed on the assumption that there may be antidemocratic tendencies latent among the ruled as well as among the rulers.

(6) If democracy is destroyed, all rights are destroyed. Even if certain economic advantages enjoyed by the ruled should persist, they would persist only on sufferance.

(7) Democracy provides an invaluable battle-ground for any reasonable reform, since it permits reform without violence. But if the preservation of democracy is not made the first consideration in any particular battle fought out on this battle-ground, then the latent anti-democratic tendencies which are always present may bring about a breakdown of democracy.

All long-term politics are institutional, democratic institutions check and balance power. Institutions are like fortresses, they "cannot improve themselves, that is the task of the citizens and those who criticize democracy on 'moral' grounds fail to distinguish between personal and institutional problems. In the short term we may wish for better leaders, in the long term we need better [impersonal] institutions." Impersonal meaning they limit discretionary decisions of rulers/civil servants.
Tendency toward to discretionary short term decisions by individuals "must greatly increase the irrationality of the system, creating in many the impression that there are hidden powers behind the scenes, and making them susceptible to the conspiracy theory of society with all its consequences—heresy hunts, national, social, and class hostility." -Popper

"One needs a certain detachment to embark on the long-term task of re-designing the 'legal framework'. But governments live from hand to mouth, and discretionary powers belong to this style of living-quite apart from the fact that rulers are inclined to love those powers for their own sake." - Popper

  Utopian engineering (aiming for most good, ends are rational so means towards ends therefore rational) much more dangerous than piecemeal engineering (addresses most urgent evils). "It was probably George Orwell who pointed out that for the totalitarians, control of the past is essential to the control of the future and so history has to be re-written, even to the extent of airbrushing out important figures from group photographs when they fall from favour with some later regime. On top of that, criticism of failures on the way to the goal has to be suppressed, otherwise doubt may be cast on the very goals themselves, the people may cease to have confidence in the leadership." - Rafe

"As opposed to a utopia, blueprints for piecemeal engineering are comparatively simple. They are blueprints for single institutions, for health and unemployed insurance, for instance, or arbitration courts, or anti-depression budgeting, or educational reform. If they go wrong, the damage is not very great, and a re-adjustment is not very difficult."
"Popper considered that the Marxist theory of politics was fatally flawed because it did not warn Marxists or socialists to be alert to abuses of power (other than economic power) and the need for institutional checks and balances on all forms of power, even after the revolution ushered in the new utopian era of the  classless society." - Rafe

Piecemeal engineering is better, but still suffers from public choice theory and dangers of interventionism (democratic policy biased to favor expressive interest and neglect utilitarian considerations, expressive interest vs instrumental interest).

Personalism vs institutionalism. Pure institutionalism is also impossible because institutions are made up of people and functioning depends on the people involved.   

Historicism gives undue respect to events in the past and their ability to predict the future. Historical determinism allows such things as "the chosen people". Attempt to put a broader meaning into events and create laws of history in order to predict in a pseudo scientific way. Under its pressure the historicist substitutes the irrational and apparently factual question : 'Which way are we going? What, in essence, is the part that history has destined us to play?'" - Rafe

The meanings of history:
"For example, the interpretation that man steadily progresses is incompatible with the interpretation that he steadily slips back or retrogresses. But the 'point of view' of one who looks on human history as a history of progress is not necessarily incompatible with that of one who looks on it as a history of retrogression; that is to say, we could write a history of human progress towards freedom (containing, for example, the story of the fight against slavery) and another history of human retrogression and oppression."
"The proliferation of narratives and points of view is not an invitation to relativism because all interpretations have to stand up to criticism and historians need to be conscious of their own point of view, to be willing to reconsider it, and to avoid as much as possible giving in to unconscious bias in the selection and interpretation of facts. Of course the selection of evidence is just that, selective, but the point is to use the evidence in a critical and not an uncritical manner. As a public document the historical narrative will have to stand up to criticism from other people who may not be charitably inclined towards the views of the author. Desirable features of the story in addition to its capacity to stand up to criticism will include its  fertility, its ability to prompt fresh ideas and elucidate new sources of information, also its topical interest and the way it illuminates the problems of the day." - Rafe
"To sum up, there can be no history of 'the past as it actually did happen'; there can only be historical interpretations, and none of them final; and every generation has a right to frame its own. But not only has it a right to frame its own interpretations, it also has a kind of obligation to do so; for there is indeed a pressing need to be answered. We want to know how our troubles are related to the past, and we want to see the line along which we may progress towards the solution of what we feel, and what we choose, to be our main tasks. It is this need which, if not answered by rational and fair means, produces historicist interpretations (what has history destined us for?).

"There is no history of mankind, there is only an indefinite number of histories of all kinds of aspects of human life. And one of these is the history of political power. This is elevated into the history of the world. But this, I hold, is an offence against every decent conception of mankind. It is hardly better than to treat the history of embezzlement or of robbery or of poisoning as the history of mankind. For the history of power politics is nothing but the history of international crime and mass murder (including, it is true, some of the attempts to suppress them). This history is taught in schools, and some of the greatest criminals are extolled as its heroes.
A universal history of mankind would have to be the story of all men and women "the history of all human hopes, struggles, and sufferings" because nobody is more important than anyone else (a highly egalitarian view!). But that history cannot be written, it is far too rich, all narratives have to be selective and focussed. But with this we arrive at the many histories; and among them, at that history of international crime and mass murder which has been advertised as the history of mankind.
But why has just the history of power been selected, and not, for example, that of religion, or of poetry? There are several reasons. One is that power affects us all, and poetry only a few. Another is that men are inclined to worship power. But there can be no doubt that the worship of power is one of the worst kinds of human idolatries, a relic of the time of the cage, of human servitude. The worship of power is born of fear, an emotion which is rightly despised. A third reason why power politics has been made the core of 'history' is that those in power wanted to be worshipped and could enforce their wishes. Many historians wrote under the supervision of the emperors, the generals and the dictators.
And, indeed, our intellectual as well as our ethical education is corrupt. It is perverted by the admiration of brilliance, of the way things are said, which takes the place of a critical appreciation of the things that are said (and the things that are done). It is perverted by the romantic idea of the splendour of the stage of History on which we are the actors. We are educated to act with an eye to the gallery.
The whole problem of educating man to a sane appreciation of his own importance relative to that of other individuals is thoroughly muddled by these ethics of fame and fate, by a morality which perpetuates an educational system that is still based upon the classics with their romantic view of the history of power and their romantic tribal morality which goes back to Heraclitus; a system whose ultimate basis is the worship of power. Instead of a sober combination of individualism and altruism (to use these labels again)—that is to say, instead of a position like 'What really matters are human individuals, but I do not take this to mean that it is I who matter very much'—a romantic combination of egoism and collectivism is taken for granted. That is to say, the importance of the self, of its emotional life and its 'self-expression', is romantically exaggerated...

It is under the influence of such romantic ideas that individualism is still identified with egoism, as it was by Plato, and altruism with collectivism (i.e. with the substitution of group egoism for the individualist egoism). But this bars the way even to a clear formulation of the main problem, the problem of how to obtain a sane appreciation of one's own importance in relation to other individuals.

History has no meaning, I contend. But this contention does not imply that all we can do about it is to look aghast at the history of political power, or that we must look at it as a cruel joke. For we can interpret it, with an eye to those problems of power politics whose solution we choose to attempt in our time. We can interpret the history of power politics from the point of view of our fight for the open society, for a rule of reason, for justice, freedom, equality, and for the control of international crime. Although history has no ends, we can impose these ends of ours upon it; and although history has no meaning, we can give it a meaning."

- Popper

And maybe ask the questions 'What are we to choose as our most urgent problems, how did they arise, and along what roads may we proceed to solve them?'

Methodological essentialism vs nominalism. Nominalism aims at describing how a thing behavies. Essentialism "claims that true belief (knowledge) results from either (a) an intuitive grasp of the essence of things, or (b) clarification or explication of the concept of the (various) things." Rafe


Rationalism includes empiricism and intellectualism. It is "roughly, an attitude that seeks to solve as many problems as possible by an appeal to reason, i.e. to clear thought and experience, rather than by an appeal to emotions and passions.
It may be better to explain rationalism in terms of practical attitudes or behaviour. We could then say that rationalism is an attitude of readiness to listen to critical arguments and to learn from experience (of various points of view). It is fundamentally an attitude of admitting that 'I may be wrong and you may be right, and by an effort, we may get nearer to the truth.' It is an attitude which does not lightly give up hope that by such means as argument and careful observation, people may reach some kind of agreement on many problems of importance; and that, even where their demands and their interests clash, it is often possible to argue about the various demands and proposals, and to reach — perhaps by arbitration — a compromise which, because of its equity, is acceptable. to most, if not to all…" -Popper

Also emphasized judging argument rather than person arguing. Anyone can be a source of information and ideas regardless of level of agreement between us. "Rational unity of mankind".

Irrationalism:
"I do not overlook the fact that there are irrationalists who love mankind, and that not all forms of irrationalism engender criminality. But I hold that he who teaches that not reason but love should rule opens the way for those who rule by hate. Those who do not see this connection at once, who believe in a direct rule of emotional love, should consider that love as such certainly does not promote impartiality. And it cannot do away with conflict either.  It is our duty to help those who need our help; but it cannot be our duty to make others happy, since this does not depend on us, and since it would only too often mean intruding on the privacy of those towards whom we have such amiable intentions. The political demand for piecemeal (as opposed to Utopian) methods corresponds to the decision that the fight against suffering must be considered a duty, while the right to care for the happiness of others must be considered a privilege confined to the close circle of their friends." - Popper

Un Traductor (2018)

Film, Cuba

Watch again

Powerful

Heart of Darkness by Joseph Conrad

Read this once in high school. Listened to the rest while driving across Ohio, still didn't quite resonate with me...

"Narrative Medicine: A model for empathy, reflection, profession, and trust" by Rita Charon

Narrative medicine as a framework for clinical work that can apply the concept of narrative and all existing knowledge about the narrative in order to provide skills, methods, and texts to "imbue the facts and objects of health and illness with their consequences and meanings for individual patients and physicians". 

Narrative knowledge finds meaning and significance in stories through cognitive, symbolic, and affective means. 

- particular understandings about one situation by one participant or observer

- illuminates the 'universally true' by revealing the particular. 

- inter-subjective domains of human knowledge and activity

- teller and listener

- meaning is apprehended collaboratively, it's all about the "inter-subjective domain"

Complements logicoscientific knowledge. 

- detached and replaceable observer comprehends replicable and generalizable knowledge. 

- illuminates the 'universally true' by transcending the particular

Narrative competence = ability to acknowledge, absorb, interpret, and act on the stories of others. Sounds very similar to the definition of compassion. 

Some of the central narrative situations:

1. physician and patient

- "to find the words to contain the disorder and its attendant worries gives shape to and control over the chaos of illness"

- "acts of witnessing"

2. physician and self: reflection in practice

- calibrating the physician, attunement to engagement and compassion.

- identification of my own emotional responses to patients

- make sense of my own life journey

- written pieces shared with patients

3. physician and colleagues

- "Only when physicians have the narrative skills to recognize medicine's ideals, swear to on another to be governed by them, and hold one another accountable to them" can they live up to society's expectations of the ideal physician.

4. physician and society

- healthcare reform depends upon grave and daring conversations about meaning, values, and courage.

5. physician and their family

6. patient and patient's family

7 patient and patient's self

- what is wrong with me? why did this happen to me? what will become of me?

8 patient and other patients

9 patient society

Can the narrative bridge the divide between physicians and their selves, patients, colleagues, and society?

Six Amendments by John Paul Stevens

Addition to the constitution's supremacy clause.

"This Constitution, and the Laws of the United States which shall be made in Pursuance thereof; and all Treaties made, or which shall be made, under the Authority of the United States, shall be the supreme Law of the Land; and the Judges and other public officials in every State shall be bound thereby, any Thing in the Constitution or Laws of any State to the Contrary notwithstanding."

Gerrymandering

"Districts represented by members of Congress, or by members of any state legislative body, shall be compact and composed of contiguous territory. The state shall have the burden of justifying any departures from this requirement by reference to neutral criteria such as natural, political, or historic boundaries or demographic changes. The interest in enhancing or preserving the political power of the party in control of the state government is not such a neutral criterion."

Campaign Finance

"Neither the First Amendment nor any other provision of this Constitution shall be construed to prohibit the Congress or any state from imposing reasonable limits on the amount of money that candidates for public office, or their supporters, may spend in election campaigns."

Sovereign Immunity

"Neither the Tenth Amendment, the Eleventh Amendment, nor any other provision of this Constitution, shall be construed to provide any state, state agency, or state officer with an immunity from liability for violating any act of Congress, or any provision of this Constitution."

Addition to 8th amendment

"Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments such as the death penalty inflicted."

Second amendment add 5 words

"A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms when serving in the Militia, shall not be infringed."

The Girl with the Dragon Tattoo by Stieg Larsson

What a page turner! I listened to this while driving across the country and almost didn't want to stop to eat or get gas or anything because it was so suspenseful. Saw what you will about whether or not it qualifies as literature, but it certainly made me think about sexual abuse, human trafficking, and the role of police in new ways that I may not have ever thought about if I had not read this series.

Being Mortal by Atul Gawande

My absolute favorite book of the year. What an amazing ability Gawande has to write so clearly about such complicated and emotionally explosive topics. Unbelievable how he winds in the threads of his own life and experiences with careful research about experts in the field of aging and death.

America's Bitter Pill by Steven Brill

Cool history about the backroom politicking involved in getting Obamacare passed. Reminded me of Remedy and Reaction by Paul Starr. Always disturbing to hear about the power of money in our political process.

A Brief History of Time by Stephen Hawking

Went over my head for the most part, but amazing to hear such a great mind express itself so precisely through the written word.

Flat, Hot, and Crowded

Couldn't finish it, just too repetitive. A lot of would've, should've, could've that just made me frustrated.

Talk Like TED by Carmine Gallo

Listened to a few chapters, and learned some interesting patterns about the most popular online TED talks, should probably finish the book to see what the other ones are, but most are common sense, like telling stories, identifying emotion, finding common ground with the audience, etc

My Antonita by Willa Cather

Really enjoyed the descriptions of place, and got a good sense of time, but found the story a bit restrained, almost censored. 

Adirondack Distance Festival

Slowest out of the three times I've done it

Mile splits as follows for first half

6:26

6:21

6:17

6:43

7:17

7:05

6:37

6:40

7:11

6:48

7:00

8:11

6:57

+40 sec = 1:30:18

"First Do No Harm: A qualitative research documentary" by Alyson and Timothy Holland

Medical tourism = medical voyeurism

- assumption that you can go to developing world and have an impact

- have a service mentality

- it's like outsiders coming to a trauma bay just to see amazing things

- exotic

Motivations

- travel

- experience

- resume

- work with and for communities

- going abroad to learn things that you're actually going to use?

So...

- good intentions are insufficient to warrant a trip

- humility that other ways sometimes work better

- consider each trip as entirely an educational experience, and attempt to have an experience with as little impact as possible

Assessing the impact and known harms of visiting healthcare professionals

- Often ineffectual

- steals resources from domestic learners and volunteers

- because you need community support, that community support requires person power

- can drain the systems they visit

- does your presence create a drain on the healthcare system (interpreters etc)

- lots of energy to get visiting people up to speed

- undermine local professionals by creating the appearance of higher quality care

Preparation

- often a majority is fundraising instead of culture and language training

- standards should remain the same, if you don't have the training, don't do it, you can always make things worse

- must be prepared to resist opportunities that exist without structured learning experiences (cowboy medicine)

So why do it?

- a good doctor can adapt to any condition

- a doctor is not just a doctor of their country, but a doctor of people who live in different countries 

Aiming for sustainability

- Only those who learn the language, spend years, and partnership

- Cooperative partnered collaborative where both sides gain

- donor recipient relationship abolished

- long term vision

- not a gap to fill, financial/knowledge transfer useful

- what can we learn from you?

- what can we do for you? (not help)

Minimizing the harms

- pre-departure training

- cultural sensitivity

- humility

- organized structure with goals and limitations

No such thing as global health, it's just health

- how can you serve health to people in different places

- what are we doing and why are we doing it?

- challenge our place in global health

How to Change the World: Social Entrepreneurs and the Power of New Ideas by David Bornstein

So interesting how I picked up this book at the end of winter break and it continued the trail of ideas from where my social determinants of health class had left off. So many theories of behavior change recognize the role of the larger community but in the effort to avoid victim blaming, these theories fail to recognize some amazing individuals. So are these success stories inevitable and any number of people could connect the social resources or do they truly require a social entrepreneur?

Bornstein chronicles the organizational history of Ashoka Innovators for the Public and outlines this more individualistic theory of change.

The stories were really amazing, and for that you should read the book. But the real insight for me was the compilation of principles that defined successful change. The examination of commonalities between these change-agents. That's what was really cool to see.

Considering the gaps in social infastructure as potential markets is enlightening. "Firms arise where markets and one-on-one transactions don't conrdinate well enough" (175). Bornstein uses College Summit as an example, where the benefits of a college education are broadly distributed and the only way to bring them together is through a firm. The beneficiaries of that kid making it include the high school where she came from, the city that won't have to pay to assist her, the college that increases diversity, the company that hires her, the government that taxes her, and then all those indirect effects on peers, not to mention individual wealth and well-being. All those smaller amounts "add up to a return to society well in excess of the $1000 that changed her life but any single one of them wouldn't be enough to economically justify paying to changer her path" (175).

Mosaic meeting of multiple programs allowed some other principles to emerge.

1. Get youth in leadership role.

2. Enlist "barefoot" professionals. The real professionals are too expensive and too rare, so you must train ordinary citizens to reach underserved markets at scale.

3. Work to change legal frameworks to give as much advantage as possible. Lobby and be active in the media.

4. Help small producers capture greater profits. Just increasing profits pushes toward larger enterprises which tend to rely less on human labor and more on technology. This actually increases poverty and the shift of village to city. Instead of maximizing production, must seek to maximize producers and the best way to do that is to ensure that they get a decent profit, enough to motivate them to stay in their villages and towns and not move to a slum near a megalopolis.

5. Link economic development to environmental protection

6. unleash resources in the community you are serving

7. Link citizen, government, and business sectors for comprehensive solutions.

8. Institutionalize listening

9. pay attention to the exceptional

10. design real solutions for real people

11. focus on the human qualities of workers

Six qualities of successful social entrepreneurs. Willingness to;

1. self-correct
2. share credit
3. break free of established structures
4. cross disciplinary boundaries
5. work quietly (John Woolman)
6. strong ethical impetus (think mission driven)

Chapter 19 discusses the work of James Grant, a champion of the GOBI movement to within primary care, the core of selective primary care which epitomizes the conflict within medicine about how many of the social determinants of health should society allow healthcare to manage or shape. Ignoring this larger debate, Grant was able to focus his energy on child mortality and championed oral rehydration and child immunization to reduce mortality significantly. He even got a war to go on hold in order to vaccinate children in El Salvador, but even this action could be seen in the larger light of his unwillingness to focus on the larger causes of that war (his own country's militarism).

Bornstein concludes with the idea of blueprint copying as the most efficient way to transmit and implement knowledge. He criticizes social movements for using only idea diffusion that come detached from their implementation details, forcing adopters to go through the slow and painful process of working out the kinks before they can take advantage of good ideas.

And finally how do we make social entrepreneurialism as cool as profit-oriented entrepreneurialism? Both the citizen and business sectors market products and services to fill gaps. Both are operational that are inventive and productive when political and cultural environments are supportive. Both sectors exist to create value for society. If they are so similar, then competition should drive huge improvements, the same way that competition increased productivity so much when markets gained mobility through technology. But how do you assess various organizations and allocate capital correctly when success is not measured in dollars? Bornstein warns against using numerical metrics and asks instead for judgement, the way that the law applies judgement. I wonder why he distrusts such measures as DALYs or other measures meant to compare diverse services. His idea is to fund citizen sector research analysts to publish expert opinions.

Support social entrepreneurship as a career through private funding, education, recruitment, and media.

Flight Behavior by Barbara Kingsolver

I masterful example of how difficult it can be to explain climate change to non-scientists. Ultimately before you tell anyone anything, you have to ask and listen, that's what this book reminded me of. The story was almost secondary. It was more an exploration of the very real disconnect between two very different realities, that of the scientists and that of rural and conservative America.

Small is Beautiful: A Study of Economics as if People Mattered by E. F. Schumacher (1974)

I. The Problem of Production
We are "inclined to treat as valueless everything that we have not made ourselves" (11). Schumacher blames even Marx for falling into this trap in the labor theory of value.  Fossil fuels, "the tolerance margins of nature", and "the human substance" are the three categories of capital that Schumacher claims we "cheerfully treat as income" (16).

II. Peace and Permanence
Economic growth has "no discernible limit, and must necessarily run into decisive bottlenecks when viewed from the point of view of the environmental sciences" (23). Rather than growth, the central concept of wisdom within economics should be permanence. "The cultivation and expansion of needs is the antithesis of wisdom. It is also the antithesis of freedom and peace" (26). "Every machine that helps every individual has a place but there should be no place for machines that concentrate power in a few hands and turn the masses into mere machine minders, if indeed they do no make them unemployed" (28).

Small scale operations are less likely to be harmful to the natural environment. People will take better care of their land than anonymous companies that imagine the whole universe "is their legitimate quarry" (29).

III. The Role of Economics
The verdict of "uneconomic" kills many activities that should proceed. Fascinating history about the birth of the discipline of economics, and how many predicted that its separation from social philosophy. Sure enough, economics alone has moved into the center of public concern. Economic growth, expansion, performance have become an obsession of all modern societies. Activities branded as "uneconomic" are questioned about their right to even exist. The judgement of economics is "extremely fragmentary; out of the large number of aspects which in real life have been seen and judged together before a decision can be taken, economics supplies only one--whether a thing yields a money profit to those who undertake it or not" (35). The fragmentary nature gives undue weight to the short term over the long term, and is based on a definition of cost which excludes all 'free goods' or environmental capital (36). "If economic thinking pervades the whole of society, even simple non-economic values like beauty, health, or cleanliness can survive only if they prove to be 'economic'" (37).

IV. Buddhist Economics
   Modern Western economics views labor as a necessary evil, simply a cost, to be reduced to a minimum if not eliminated. This view of economics also claims that work is a disutility for the worker, a sacrifice of leisure and comfort, and wages are a compensation for the sacrifice.
   The Buddhist point of view gives work at least 3 functions; a way to utilize faculties, a way to enable teamwork through common task, and a way to bring goods and services needed for a becoming existence (45). Work and leisure are complementary and cannot be separated without "destroying the joy of work and the bliss of nature".

V. A Question of Size
Rural to cities move explained. Those who have nothing to sell but labor remain in weakest bargaining position. Schumacher argues for "production by the masses rather than for the masses" (61).

VI. The Greatest Resouce -- Education
Humanities provides 6 main ideas that fail to overcome economic values because they lead to "an abyss of nothingness" (74).

1. evolution
2. competition
3. class struggles are based on economics
4. Freud
5. relativism
6. positivism which denies the possibility of objective knowledge about meaning and purpose of any kind.

Education is breaking down due to a lack of metaphysical training. There is no thought about the levels of being. We have abandoned the cardinal vurtues, the seven deadly sins, but "what new ideas have taken their place?" (83). How can one think about virtue, love, and temperance with the above 6 ideas?

VII. The Proper Use of Land
Agriculture should keep man in touch with living nature, humanize and ennoble man's wider habitat, and bring forth food and other materials which are needed for becoming life. Modern economics recognizes only the latter.

VIII. Resources for Industry
IX. Nuclear Energy -- Salvation or Damnation
X. Technology with a Human Face
The goal is to have enough time to make a good job out of any work, to enjoy oneself, to produce real quality, even to make things beautiful.
Schumacher calls for the use of "intermediate technology". Accessible, more advanced than primitive.

XI. Development
A dynamic approach is required because an economic approach fails to recognize the value of abandoning efficiency and maximal profits in favor of meaningful and human work.

XII. Social and Economic Problems Calling for the Development of Intermediate Technology

XIII. Two Million Villages
XIV. The Problem of Unemployment in India
What is education for? The specialization of tasks (and sacrifice in humanness of work that that implies) means that a college education requires 150 years of peasant work to supply. What what do the peasants get back for it? Therefore Schumacher's essential questions are: "is education to be a passport to privilege or is it something which people take upon themselves almost like a monastic vow, a sacred obligation to serve the people?" (173). "Can we establish an ideology that issists that the educated have taken upon themselves an obligation and have not simply acquired a passport to privilege" (173)? The presence or absence of this ideology affects the content of education. If the former view is taken, then education focuses on village life, manual labor, social justice, etc. But the latter suggests that you need electricity, cement, and steel before we can do anything at all.

XV. A Machine to Foretell the Future
A theoretical warning to not mix up events and acts, future and past, certain and uncertain. Predictions vs forecasts. Forecast vs feasibility study.

XVI. Towards a Theory of Large-Scale Organization
Achieve smallness within large organizations.

XVII. Socialism
Pure market economics are "an institutionalization of individualism and non-responsibility" (213).
Ownership is not a decisive question. "There is no case for public ownership if the objectives to be pursued by nationalized industry are to be just as narrow, just as limited as those of capitalist production: profitability and nothing else" (217).

XVIII. Ownership
XIX. New Patterns of Ownership
Middle road between privatization and capitalism. Points out that people hate being taxed and thus fight against public expenditure. "The need for public expenditure should thus be recognized in the structure of ownership of the means of production" (229).

"All the educational, medical, and research institutions in any society bestow incalculable benefits upon private enterprise -- benefits for which private enterprise does not pay directly as a matter of course, but only indirectly by way of taxes, which are resisted, resented, campaigned against, and often skilfully avoided...It is illogical that payments for benefits obtained by private enterprise from the infrastructure cannot be exacted by the public authorities by direct participation in profits but only after private appropriation of profits has taken place. Private enterprise claims that its profits are being earned by its own efforts, and that a substantial part of them is then taxed away by public authorities. This is not a correct reflection of the truth. A large part of the costs of private enterprise has been borne by the public authorities -- because they pay for the infrastructure" (229)

Schumacher goes on to propose three spectrum on which decisions could be made
Freedom--Totalitarianism
Market Economy -- Planning
Private ownership -- Collectivized ownership
In the simplest interpretation, this gives 8 combinations.

He suggests a middle road on all three spectrums. First that the 'public hand' should receive 1/2 of distributed profits of large-scale private enterprise by means of 50% ownership of the equity of such enterprises" (239). Public shares wouldn't have voting rights normally, but woul dhave the right to information and observation.


Epilogue
The idea of economy, work, and technology that sustains "the human substance" continuously reappears in this book. Work that takes away any hint of humanity, becoming a merely mechanical activity, turns the worker himself into "a perversion of a free being" (29). The "humanization" of work would lower GDP, decrease profits, and decrease the way that the current "standard of living" is calculated. Schumacher argues that the calculation leaves out key factors that would be wise to include.

Wisdom is also thrown around quite casually, with what seems to me a lack of theoretical and philosophical underpinning. Schumacher suggests that we need a revision of the ends which economic means are meant to serve.

Remedy and Reaction by Paul Starr (2011)

Part I reviews some of the origins of healthcare reform referencing a lot of the work that Starr did in his previous work. Again the beauty of his language extends into the titles and subtitles of his chapters which I will outline with comments here.

• Stumbling toward Comprehensive Reform
• political deadlock
• the American path to health insurance
• Frustrated ambitions, liberal and conservative
• the shaping of the Clinton health plan (Starr was part of the Clinton's huge team of experts, and has fascinating inside information.
• getting to no
• the rise of a reform consensus 2006-2008
• Romney and MA model
• toward minimally invasive reform
• making 2008 a healthcare election
• Obama and the rollercoaster to reform
• why healthcare reform passed and climate legislation didn't

The Affordable Care Act as Public Philosophy 

 This was the part of the book that really forced me to think. Previous sections were interesting and enlightening, but this analysis of legislation within the paradigms of some philosophical ideas really sparkled. 

Overall, Starr contends that the goal of the ACA was to align one major institution (healthcare) so that it agrees more closely with principles of justice and efficiency. Starr presents the ACA's provisions as they bear upon central problems of public philosophy.

fairness and equality
Rights versus obligations of individuals and states. For states, the question is whether healthcare is a service that the community has an obligation to provide (like basic education). If it is, then the principle of "actuarial fairness" should be abandon. Rather than each person paying for what they use, the cost of care should be spread over the healthy and sick evenly "to avoid imposing burdens on the sick that effectively bar them from access to medical care" (242). Starr invites consideration of the European ideal of "solidarity". He is careful to delineate that the "moral interest in ensuring care for the sick does not require shared responsibility for services such as cosmetic surgery or amenities such as private hospital rooms" (242). 

Starr notes that we do have one federal right to health care, The Emergency Medical Treatment and Active Labor Act but that this is funded by shifting costs to insured patients, "a hidden transfer that the American public has apparently preferred to being openly taxed for the same purpose" (242). The ACA "attempts to extend shared responsibility without entirely banishing actuarial fairness, and it makes the health insurance system more inclusive without flattening its tiered and unequal structure" (243). In an unregulated insurance market, the liability equals 11:1 between a 60yo and a 20yo American. That means older adults would pay 11 times as much for insurance. A pure "community rating" insurance would charge these people the same amount. The ACA limits differences in rates to a 3:1 ratio. Ironically the increased burden falls largely on the poor and middle class who are under 400% (this is where subsidies stop) of the poverty line because those over this level buy insurance independently and most get it through employers, few of which ask older workers to pay more than younger workers for insurance. 

While libertarians cringe at the young paying for the old, shared responsibility can be described as "enlightened self-interest" as those young workers will almost inevitably be old soon enough. 

Subsidies were clarified as a way to make insurance premiums a scaled percentage of income, so that premiums are 3-4% of income for the working poor, and up to 9% of income for those at 400% of poverty level. They're calculated based on second lowest priced silver plan in each area.

The levels are also explained clearly:
   Bronze covers 60% of healthcare costs
   Silver covers 70%
   Gold covers 80%
   Platinum covers 90%

responsibility and freedom
Conservatives support freedom while liberals support equality? Starr argues that a conservatives are using a "shriveled conception of freedom"  that fails to recognize that "health itself is a matter of personal freedom" (247). He reminds libertarians that "there are no rights without a government to protect them" and that "freedom is impossible without the framework of law that the state upholds". Starr recognizes that conservatives fear "arbitrary and capricious" government power, but reminds them that these same interests should motivate them to be concerned about private power, such as that of an insurance company. A law that wields government power in order to reduce arbitrary and unreasonable private powers "may also increase individual freedom". 

federalism and finance
   The subsidiarity principle has solid rationale for keeping decisions at no higher level of government than is necessary. "History complicates theory". Leaving healthcare to the states would mean "denying access to medical care and insurance" for "millions of the poor and near-poor in the South and Southwest" (253). 
   Financing is complicated.

health and the public household
   Health insurance as insurance against unexpected costs or as prepayment for medical services? If you believe the former, than moral hazard is a big deal, and people should pay out of pocket for ordinary expenses. The prepayment model  conceives that limiting coverate to catastrophic costs "creates perverse incentives favoring technologically intensive services to the neglect of primary care and prevention" (259). 
   The ACA supports new nonprofit Patient Centered Outcomes Research Institute to compare clinical effectiveness. "But the law bars use of the findings as mandates or guidelines for coverage or payment" (263). If the Independent Payment Advisory Board gets struck down by the supreme court there will be trouble, because "if we cannot say no to paying for services that are clinically ineffective, we will surely have no choice but to limit services that are clinically valuable" (263).  

The Peculiar Struggle
"Other democracies long ago resolved whether they have an obligation to provide care for the sick and protection against medical costs" (279).  

"If the special interests were arrayed on one side and the suffering masses on the other, the conflict would fit easily into a familiar populist picture of the world. But though the health insurers, drug companies, and other interests profit from the health system, they are not alone responsible for maintaining it. The bias against change also comes from members of the protected public. No other major democracy created a financing system that provides the biggest tax breaks to the people with the best private insurance; no other major democracy established a separate program for the elderly. A variety of other programs protect particular groups. These partial measures have become major obstacles to the efforts to control costs and to extend protection to the uninsured. The resistance to reform didn't arise because Americans were such determined individualists that they rejected all government help; much of the resistance has come from members of an entitled majority with a privileged position in the public-subsidy system. The potency of these entitlements lies in the psychology of self-exemption they instill; the beneficiaries do not understand themselves as benefiting from government assistance or as sharing a common condition with the excluded. The tax subsidies are nearly invisible to those who receive them; Medicare invites the elderly to believe that they have earned its benefits, whereas other claimants have not. Morally armed, they can reject helping others in need as a matter of high principle; after all, Americans shouldn't look to the government for help" (280).

The Social Transformation of American Medicine by Paul Starr (1982)

Should be required reading for all student physicians. Absolutely brilliant historical account of the beginnings of the profession and industry of healthcare in the United States.

Key ideas outlined in Starr's chapter titles and subtitles that I might be able to describe to you if you asked include;

• professional sovereignty
• the market and professional autonomy
• legitimate complexity
• origins of medical sectarianism
• explained origin of homeopathy, eclectics, and orthodox
• reconstitution of the hospital
• Hill Burton Act
• public health vs private practice
• capitalism and the doctors
• professional resistance to corporate control
• the struggle for healthcare reform
• why America lagged
• The New Deal
• Socialized medicine and the Cold War
• health insurance origins
• the birth of the blues
• private social security
• focus on research
• how the medical center gained power
• 1970-1974
• contradictions of accommodation
• generalization of rights
• conservative assimilation of reform
• 1975-1980
• generalization of doubt
• liberal impasse
• The coming of the corporation

And that's where he leaves off in this masterful work.