Wednesday, May 15, 2013

Cocktails: A Taxonomy for the Perplexed

Cocktails are delicious works of art, but like other arts they have a vocabulary all their own and often inconsistently applied.  Bartenders presumably understand this vocabulary from the inside, by intensive memorization and experimentation, but many of us would just like to better understand how various drinks are related, as an aid to memory or discovery.  I don't claim any expertise in this area and I won't cite any sources, as this is just my overlay on Wikipedia, and not intended to convey precision or universality, but I will define my terms as I go, and I will attempt not to claim any more precision than I can offer.

First, a word on varieties of ethanol for human consumption.  If the base substance to be fermented has more than 10% simple sugars, then it is a must and can be directly fermented, yielding wine.  If the base substance has less than 10% simple sugars, then its carbohydrates must be converted to simple sugars by malting (germinating) and/or mashing (cooking) before yeast can grow.  Yeast dies at roughly a 15% alcohol concentration (30 proof), so higher values must be achieved by distillation after fermentation.  The flavor of the resultant fluid is dependent on the original fermented mixture, any flavors added after fermentation and before distillation, and any flavors added after distillation.  If the original mixture was a must, and is thus a wine once fermented, the distilled product is a brandy.  If the original mixture was a mash, then the fermented product is, broadly speaking, whisky.  So all distilled alcohols are either brandies or whiskeys.  Their more specific names are the result of particular ingredients, flavorings, process details, brands, or regional appellations.  Many of these are strictly governed by law and custom, and as with other taxa governed by law and custom, idiosyncrasy is the rule.  Recipes are generally trade secrets and ingredients unlisted, so for labels without strict government regulation, taxa are generally more evocative than explanatory.

Vodka is whisky "in the Russian style," perhaps at one time connoting some potatoes in the mash, but now basically means whisky made cheaply, which is to say first distilled to a very high proof and/or heavily filtered (meaning the quality of the mash is less relevant, since the distillate is nearly pure alcohol with almost no flavor) and then bottled with very little aging, so that flavoring agents must be dissolved directly into the alcohol rather than slowly leached.  Southern Comfort is basically traditional American vodka.  More traditional whiskeys are distilled to a lower percentage, allowing residual flavors from the mash, and aged which allows flavors to leach into the whisky from the wood and previous contents (usually wine) of the barrel, and some of the whisky (the "angel's share") evaporates each year, lessening the amount of water added at bottling.  Naturally the losses, inventory costs, and demand invariance of this process add substantially to the costs.  Gin is from this perspective halfway between traditional whisky and vodka in that the flavoring agents (traditionally juniper with other botanicals) are added after fermentation but before distillation.  This process yields a cheaper product than traditional whiskeys, because cheaper mash can be used and aging avoided, but it requires more accurate distillation control than vodkas because the aromatics must be distilled with the ethanol.  Bourbon is whisky with a mostly-corn mash, and tequila is basically whisky with a mostly-agave mash.

Rum is distillate of fermented molasses, which is boiled down sugar cane.  It's nearer to brandy in that sugar cane contains sufficient sugar to ferment directly, so the cooking is just for the physical concentration of the sugar, but this does lend a taste partly reminiscent of a mash.

A liqueur is a distillate produced by any of the above methods with a much sweeter and fruitier than alcoholic flavor.  There may be no brightline between orange vodka and triple sec, but the latter traditionally carries fruit flavors from fermentation and distillation as well as infusion, and is thicker and sweeter.  Bitters, meanwhile, are similar in process to liqueurs, but with bitter and botanical (often gentian) rather than sweet and fruity in flavor.  Vermouth is both a liqueur and a bitter.  Liqueurs, bitters, and vermouth can all be drunk neat as semi-medicinal digestifs, but are more popular in cocktails.  Juices are relatively newer additions to mass-market cocktails due to their need for refrigeration; traditional non-alcoholic sweeteners are simple syrup (just reduced sugar water, with a high enough sugar content to slow spoilage) and grenadine (reduced pomegranate syrup).  Shaking is a way to chill drinks quickly without watering them down or mechanical refrigeration, and is necessary for incorporation of thick or poorly soluble mixers, but is often frowned on for more expensive distillates because it introduces air bubbles which sharpen their alcoholic flavor (called "bruising").

So just what is a cocktail?  Originally, a blend of at least one distilled alcohol, at least one bitters, and at least one other ingredient, in contrast to a shot (neat), rocks/lowball (alcohol with just ice or water), or a highball (alcohol with soda water).  The original cocktail is now called, without irony, the old fashioned, a blend of whisky, bitters, and simple syrup.    As a modifier of mixed drinks, as of wines, dry is simply opposed to sweet.  Beyond the old fashioned, the most classic cocktails are the Martini, of gin and vermouth, and the Manhattan, of whiskey (usually rye) and vermouth.  These already raise a definitional problem, in that they are drinks of two ingredients, but remember that vermouth is both a liqueur and a bitter.  The Negroni is a Manhattan with bitters beyond the vermouth.  Substitution of the primary distillate is typically indicated by preface (e.g. vodka martini) whereas substitution of a liqueur (triple sec is the most common) and bitters for the vermouth results in a new cocktail, of which there are innumerable varieties, e.g. the Brooklyn, with whisky, vermouth, cherry liqueur and bitters. Grenadine is also frequently indicated as a sweetener, especially for tropical-themed drinks.  If mint is used as the "bitter" botanical, the drink is a julep.  Use of a cream or cream liqueur as the sweetener makes an especially large difference to the flavor and texture of the drink, and is sometimes combined with coffee as the bitter flavor, as in a White Russian, Black Russian, Mudslide, etc.  A cocktail with egg in addition to the cream is an egg nog.

A mixed drink made with sour instead of bitter flavors is, equally straightforwardly, a sour.  Traditional sours, beyond the obvious whiskey sour, include the sidecar (brandy), margarita (tequila), daiquiri (rum), last word (gin), jack rose (apple brandy), and kamikaze (vodka).  If you layer rather than mix your sour, that's a -Sunrise.  Makers of sours frequently choose citrus liqueurs in replacement, addition, or partial replacement of the citrus and simple syrup, especially in drinks where a strong citrus element is desired without watering down, with triple sec being the most common.  Creams and cream liqueurs can't normally be used in sours (because they'll curdle) but the alcohol and acid can "cook" an egg white if properly prepared, which is sometimes used to give a creamy texture and dairy flavor.  The egg without the sour is a flip, which has gone out of fashion over health concerns.  Sours sometimes have bitters as well, as in Planter's Punch (dark rum daiquiri with bitters).  A punch, technically speaking, is just a large-scale sour, which can mean anything with over two shots of liquor, sometimes with the mixer scaled up as well.

A fizz is the marriage of a highball and a sour (i.e. a sour with soda water).  The most famous is the Tom Collins (gin fizz).  A Tom Collins with egg is a Ramos (which takes ten minutes to make properly), and with champagne instead of the soda water it's a French 75.  A whiskey fizz is a hari kari, and a rum julep fizz is a mojito.  A fizz with multiple liquours is a -Tea; a fizz without any sweet to counterbalance the sour is a rickey.

In time, a highball came to mean any straightforward drink of alcohol and one substantial mixer, served in something nearly a water glass (to accentuate the vertical bubbling and/or accommodate the volume of the weak mixer), whereas a cocktail came to be any drink of three or more ingredients, served in a conical glass (more appropriate in volume to the stronger drink and said to prevent de-emulsification).  Whether a sour was a highball or a cocktail depended on whether it was made in a cheap bar (from pre-made mixer, and weak) or an expensive one (by combining fresh citrus juice and simple syrup, and in lower proportion to the alcohol).  This system probably makes a good deal of sense for pricing purposes given the obvious contrasts in ingredients and bartender time, but does little to classify flavor profiles.

With further development, highballs came to be understood as any drink served in a highball glass (including drinks like Planter's Punch and Long Island Iced Tea that are strong and complex), and cocktails as those suited to a cocktail glass, even if you're just calling gin on the rocks a Martini.  From the perspective of the recipient, the glass is perhaps a clearer indicator than the ingredients (do people who order vodka martinis extra dry even realize they're just getting chilled vodka?), but it's obviously even less helpful as an aid to memory or discovery of mixed drinks you like.  Even more confusingly, the Martini at some point lent its name to the cocktail glass, becoming a Martini glass (and thus anything mixed into it as a -tini) and the Tom Collins at some point lent its name to the highball glass, such that any carbonated highball can be a -Collins.  Margaritas are generally served in coupe glasses (invented for cheap sparkling wine) because they offer a more generous rim for salting, and so now any mixed drink served in a broad rather than tall or conical glass is a -rita.  Even the shot, as a single pour, has been redefined by its glass, such that a mixed drink in a shot glass (like a B52) is a shooter.  Old Fashioneds, because they were invented before the cocktail glass, are frequently served in lowball/rocks glasses, which are now often called Old Fashioned glasses.  In short, it's useful to know the names of various pieces of glassware (though beware those who insist on more differentiation than actually exists) and it's useful to categorize mixed drinks, but be careful not to confuse the overlapping terminology.

With the advent of refrigeration, affordable juice cocktails came into style, served as -tini's to foodies, frozen -rita's in chains, and premixed highballs in cheap bars.  They provide strong flavors which cover poor alcohol (or the taste of alcohol at all for those less accustomed) and simplify mixing by providing acid, sugar, and flavor in a single ingredient.  These include the Cosmopolitan (vodka sour with cranberry juice), Screwdriver (vodka sour with orange juice)(and indeed any alcohol mixed with orange juice as a -Driver), Singapore Sling (gin sour with pineapple juice), Bronx (Manhattan with orange juice), Queens (Manhattan with pineapple juice), strawberry daiquiri, pina colada (daiquiri with pineapple juice and cream of coconut), and Bloody Mary (vodka sour with tomato juice and pepper bitters).  Stronger drinks use liqueurs in partial replacement of the juice (and citrus to avoid over-sweetening).

Let me know in the comments if you think I've mis-stated anything or didn't cover a topic you'd like to read about.

UPDATE:  It's also worth checking out tips for how to order a drink, and what various drinks mean socially (warning:  not-PG) in addition to their flavor profile.

Thursday, March 7, 2013

What is Non-Dualism?

I am a beginner in Eastern philosophy, but I recently purchased Milton Scarborough's Comparative Theories of Nonduality: The Search for a Middle Way and David Loy's Nonduality: A Study in Comparative Philosophy, both of which attempt to bring the Eastern and Western traditions into dialog.  This entry, hopefully the first in a series of reflections on these works, focuses on the question of what  nondualism means in Scarborough's first chapter "Western Dualism and Buddhist Nondualism."

The author begins with racism as an example of dualism ("Dualism Observed"), and ends with an account of the Buddha's journey from the lap of luxury through strict asceticism to the Middle Way ("Buddhist Nondualism and the Middle Way"), thereby framing the importance of nondualism in ethical terms.  Positions bordering on dualism are dangerous, even if not strictly erroneous:
binary oppositions and even binary distinctions have become the objects of criticism; such binaries are not, it turns out, utterly innocent. For one thing, they are a first step, a necessary one, toward dualism. This fact alone is not sufficient cause to reject them, but perhaps it should send up a red flag of warning.  Moreover, despite being essential to reflection, distinctions are dangerous because of the variety of ways in which they can mislead us into distorting our experience of reality.
This is consistent with an ethical focus, whereby activities not wrong in themselves can still be troubling if they make us more likely to commit wrongs. "More important for the purposes of this volume, however, is the notion of a metaphysical middle way, which is expressed in the Buddha’s doctrines of no-self (Anatman), impermanence (anicca), and dependent co-origination (pratityasamutpada)."  So while the impact may be ethical, the underlying question of the volume is metaphysical.  So what are the possible Western formulations of the insights underlying nondualism?

Is Non-Dualism Non-Sense?
One strong sense of non-dualism would be conceptual non-dualism, the claim that all distinctions are meaningless.  Like verificationism, this seems self-refuting, because it presumes a distinction between the meaningful and the meaningless.  Scarborough rejects this sense of non-dualism and its consequent problems, however: "It is important to state that mere difference, opposition, polar opposition, or even contradiction, however, still do not in the strictest sense constitute dualism."

Is Non-Dualism (Physicalist) Monism?
Scarborough follows that denial with the affirmation that
For both the West and Asia, dualism consists of a dichotomy in which the paired terms, concepts, or things have a static substance or fixed essence...Substance is an unchanging, underlying, metaphysical reality in which the qualities or attributes of a thing inhere. A fixed essence consists of changeless attributes, qualities, or meanings that are essential to the nature or identity of a concept or thing. Contradictions or dichotomies with substances or fixed essences are dualisms.
This might be interpreted, especially in light of his reference that "Descartes’s metaphysical dualism of mind and body consists of 'thinking substance' and 'extended substance'" to mean mere substance monism, or physicalism.  As I've pointed out, however, there are problems with simultaneously holding to physicalism and common-sense distinctions of physical objects.  Insofar as these distinctions are physical, this doesn't necessarily reduce non-dualism to non-sense, but it would vitiate Scarborough's claim that "mere distinctions and the binary terms that usually express them are helpful. They demarcate semantic domains, enabling us to be discriminating."  Indeed, he even grants the retorsion argument:
Such distinctions make us intelligent and civilized, give us increased clarity and control, defuse arguments, ease our journey in myriad ways, and even delight us. For both philosophy and other modes of thinking, they are the coin of the realm, the air thought breathes, the energy that propels it forward.They are the indispensable tools for acknowledging boundaries and the ticket price for entry into intelligible reflection or discourse. They are not to be abandoned or disparaged. Indeed, they cannot be abandoned because they are unavoidable. If we think about the matter realistically, utter silence is not an option.
Furthermore, while supervenience physicalism is certainly substance monism, the distinction between that which supervenes and that which is supervened upon would itself seem to be the kind of dichotomy essential to identity of things that non-dualists wish to reject.

Is Non-Dualism Idealism?
Of course there's another substance monism available besides physicalism, namely pure idealism.  Indeed Westerners often characterize Buddhism in just this way.  An idealist reading of nondualism, however, seems incompatible with Scarborough's worry that "despite being essential to reflection,
distinctions are dangerous because of the variety of ways in which they can mislead us into distorting our experience of reality."  He gives three reasons why this is so:

One rather common and simple way they can mislead us is by prompting us to draw boundaries too narrowly and precisely...A guidebook depicted Arkansas as a woodland state dotted with lakes; Oklahoma was said to be a plains state. Yet as we drove across the state line from Arkansas into Oklahoma, the woods did not vanish, the land did not flatten out...Only after continuing for 75 miles or so into Oklahoma did the landscape, which had changed imperceptibly slowly, suddenly appear different. “Woodland” and “plains,” to be sure, are not altogether wrong. In a rough-and-ready way they are helpfully descriptive, yet compared to the actual terrain, they are clearly simplifications.  
A second way binary distinctions distort is by numerical simplification...Consider sex, for example. It is usually described by a binary opposition that has become a full-blown dualism...we have believed that there are but two sexes, male and female. But why merely two? Is it because there are two kinds of chromosomes (XX and XY) involved in the genetic determination of sex? Yet the dualism of the sexes preceded our knowledge of chromosomes... 
There is a third distortion, one that characterizes dualism in particular. To speak of an essence or substance that is fixed, permanent, or eternal is to deny time and change. Perhaps during the era of Parmenides and Heraclitus it was possible to point to the flowing water of a river as an example of change and to a mountain as an example of the unchanging. At least as late as Newton one could still speak of the “fixed stars.” Edmund Halley, a contemporary of Newton, was the first to understand that even the so-called fixed stars move. Until Charles Lyell, geologists did not understand that rocks were still being laid down by water and also that due to ice, wind, sand, and water were being altered by erosion. Until Charles Darwin, biology continued to speak of fixed species. Until the arrival of the Big Bang theory, astronomers and other physicists could speak of fixed physical laws. Nowadays, we talk of “natural history.” We understand all of these former fixities as flowing; stasis is merely what moves relatively more slowly than other things. If there is something absolutely eternal or fixed, it is beyond perception. At best, such concepts survive largely as “limiting concepts.”

How can an idealist worry about simplifications relative to the actual terrain or the potency of nature discovered in perception?  These passages sound too realist for even the weak idealism of Rorty's liberal pragmatic irony, let alone the strong idealism of Hegel or Berkeley traditionally associated with Buddhism.  As Scarborough says with regard to Hegel, idealism "for all of its genius, does not fit all situations."

Is Non-Dualism Aristotelianism?
You might be tempted to dismiss this as the nuttiest theory you've ever heard, but hear me out.  First, while Aristotelianism might speak of multiple substances, underlying metaphysical realities with fixed essences, they aren't opposed realms, or contradictories.  The method of division is not a method of opposition, as species are understood together in their shared genus.  Change is attended to rather than denied, and distinctions are drawn carefully from perception, avoiding overreach.  Aristotle's anthropology seems resilient to

the seemingly endless pendulum swings of Western culture, what I term the “zigzag effect.” Descartes, Leibniz, and Spinoza, for example, established a rationalist epistemology that affirmed the power of unaided reason to arrive at clear and certain knowledge by means of innate ideas, deduction, intellectual intuition, or a priori categories.  This was the zig. Locke, Berkeley, and Hume launched a contrary movement that emphasized the role of sense data generated, in most cases, by causal relations with an external, physical world. Here was the zag. Both movements were overstatements, lacking descriptive sensitivity and nuance.

Furthermore, Scarborough links non-dualism with the Buddhist Middle Way:  "Food is neither to be rejected nor pursued gluttonously but ingested as medicine. Neither extreme asceticism nor lavish living eliminates ego; both strengthen it."  That certainly sounds very similar to Aristotle's golden mean.  And in metaphysics, also, both Aristotle and the Buddha would apparently affirm a contingently existing (neither astitta nor nastitta) self (namarupa) made up of proper parts (skandhas), making choices with multiple causes.  They might differ over the temporal directedness of causality, but that would seem to pale next to their commonalities.

Is Non-Dualism Phenomenology?
Without discarding the Aristotelian parallels, it's also worth considering whether nondualism might be well understood as a branch of phenomenology (especially as there are Aristotelian branches of phenomenology, like transcendental Thomism).  As Scarborough notes:

Such a metaphysical middle way also implies an epistemological middle way. If the self is constituted in and by a web of causal relations, it is not independent of the world. Thus, while there can be a subject-object distinction, there can be no subject-object dualism. The absence of an inner-outer, subject-object gap to be inexplicably crossed means that the necessity of complete skepticism is ruled out.

That certainly sounds an awful lot like, say, the phenomenology of Cassirer or what is sometimes described as Lonergan's non-dualism.  It's not clear, however, why Scarborough jumps from the rejection of naive realism to the rejection of certainty:

On the other hand, since knowledge is based on the self’s experience as part of the web of interacting events, absolutely certain knowledge is rejected as well. The self cannot step outside the web in order to view it as an object arrayed with utter clarity before either the eye or the mind’s eye.

There's no real argument there, especially since Scarborough's treatment of Nagarjuna on interdependence sounds suspiciously like Lonergan's account of explanatory knowing (which gives rise to ontological pluralism rather than dualism):

On the other hand, if asked to define “present,” we would almost certainly do one of two things: (1) supply a synonym for “present” or (2) offer a definition that includes a reference, tacit or explicit, to “future” and/or “past.” In the first case, one might say that the present is “now” or “this very moment,” which may not be helpful because those terms themselves may need to be defined. In the more likely second case, one might say, “The present is what comes after the past and before the future.” Nagarjuna’s tactic is to focus on the second case, pointing out that the meaning of any one of the three terms is dependent on the meaning of the other two. Consequently, the terms are interdependent. Viewing the words as interdependent leads to viewing the three concepts of time and then the three realities of time as interdependent,

It's clear why metaphysics must be interdependent in order to make sense of our experience, but it's not clear why this means it must be destabilizing, unless the fixed essences are understood to be those of naive realism.  Lonergan's notion of the empirical residue also seems consonant with Nagarjuna's account of emptiness, since while it's not real (it has no immanent intelligibility to be verified) it is nonetheless the ground of the real.  It remains unclear to me whether the Two Truths are better understood as an idealism (transcendence of the conventional world) or as critical realism (acceptance of the conventional world as contingently known).  Much of Scarborough's account, which is unfortunately too long to quote, makes the latter seem plausible even if it is ambiguous.  The difficulty with ascribing non-dualism as critical realism comes in with his account of attachment:
What concerned Nagarjuna is that if people became bound to the doctrine of emptiness, then liberation would elude them. After all, clinging to views is itself a form of clinging (tanha), the principal cause of suffering, according to the Buddha’s Four Noble Truths). Clinging to “right view” (Buddhist teaching that leads to awakening) itself binds one to suffering. The ultimate meaning of emptiness, then, is the cessation of clinging to any views at all, even Buddhist ones.
That's presumably the perspective underlying Scarborough's critique of Kant and his medieval forbears:

Kant’s attempt at a synthesis of the two positions, based as it was on the oppositions of a priori vs. a posteriori, phenomenal vs. noumenal, form vs. content, and theoretical reason vs. practical reason was no more satisfactory than the long disintegrated and overly simple “medieval synthesis” of revealed theology with natural theology and faith with reason. There was merely the substitution of one set of oppositions for another, a sleight of thought that brought but a temporary and illusory relief. The real culprit, the intellectual habit of reliance on simple binary oppositions, was left unidentified and, thus,
“allowed” to perpetuate its deleterious effects.
But what's the real objection here?  Is it just that the claims are too simple, which the critical realist would affirm in the case of Kant and also in the case of predominant naive realist readings of the medieval synthesis?  If the claim is stronger than that, why doesn't it destabilize Nagarjuna's language beyond any capacity for meaning?  Scarborough critiques Derrida, saying that deconstruction is predicated on opposition, but couldn't Derrida return the favor here?  Or is the claim again about contingency, that what privileges Nagarjuna over Kant is the understanding that knowledge comes from emptiness and will itself be transcended?  If so, the transcendental Thomists are on the same page, as "All that I [Thomas] have written seems like straw compared to what has now been revealed to me" (A Taste of Water : Christianity through Taoist-Buddhist Eyes by Chwen Jiuan Agnes Lee and Thomas G. Hand).  “Not being able to do the work of the angels in choir, we can at least write about them,” but we should not become so attached to such writing as to not joyously join the angels in choir.  It's difficult to understand what stronger claim for contingency against essences could be made without either reverting to naive realism or giving up on meaning itself.

Tuesday, March 5, 2013

The Abortifacient Controversy

In my recent post on the German bishops' decision to administer emergency contraception to rape victims at Catholic hospitals, I noted that the bishops' decision had less to do with when contraception is licit (in short, in rape there is no conjugal act to impair) and more to do with their finding of fact that Plan B is not an abortifacient.  Much as pregnancy outside of marriage can be painful, especially to rape victims, babies are innocent gifts from God in all cases, and that pain cannot be weighed against their lives, which is why abortion is always illicit even in cases of rape.  That God transfigures the effects of evil into gifts of love is the very meaning of the cross of Christ.  Knowledge of the wrongness of abortion is fortunately not dependent on faith, but the hope born of faith can be critical for understanding pains as not unreasonably burdensome, as Martin Rhonheimer explains:
What in principle looks intrinsically reasonable and human, such as the ideal of inseparable fidelity in marriage or the unconditional respect for human life, ends up appearing to unassisted human reason, at least in many cases,  as unattainable in practice and therefore unreasonable and even inhuman. So—and this is my main point—Christian morality, to a large extent, throws light on the possibility of living a moral life which fully meets the intrinsic demands of human nature. This means that we can speak of a true specific Christian humanism which differs from the purely secular humanism of the nonbeliever. Thus, what initially appears unreasonable regains reasonableness through faith, hope and charity. That is how faith in fact rescues reason and reason recovers all its power to make faith both human and effective. Rightly understood, reason therefore needs revelation for being capable of effectively working as moral reason and to maintain the  “reasonableness of morality.”
But why should anyone object to or be confused by the German bishops new policy (indeed, why wasn't it their old policy?) if emergency contraception doesn't impede the conjugal act and doesn't cause abortions?  Well, the main problem is that Plan B, the most effective and widely used drug, says on the box that it can impede implantation of an embryo in the endometrium.  Others say that labeling is irrelevant.  At least two complicating issues are in play here:  first, what is the definition of pregnancy, and second, how certain do we have to be about the drug's mechanism of action?  The journal article drawn on by NCR provides useful information about how Plan B works, but clouds the issue by assuming that the moral evil of abortion can only be perpetrated on a woman who is pregnant.  What?  While conception, generally referred to medically as fertilization, is the morally relevant point at which new life begins (contrary understandings of quickening or ensoulment being scientifically illiterate), pregnancy is generally defined as implantation, because that is when the mother's body responds to the conception.  So articles or studies which define abortifacient effects as only the loss of the fetus after implantation don't address the full moral question, even if they are scientifically convenient because the results are easier to measure.  On the other hand, those who consider emergency conception to be abortifacient often unhelpfully conflate Plan B, the most commonly prescribed drug, with the earlier RU-486 (known to cause abortions) and the more recent Ella (as yet largely unstudied).

But how certain are we of the efficacy of Plan B itself?  Despite some skepticism around the timing of the findings, substantial review of the literature shows basically no evidence for an abortifacient effect.  Of course absence of evidence is not evidence of absence, and it's certainly reasonable to be cautious when human life is at risk.  The notion that only 1-3% of women given Plan B might become pregnant (such that any rare abortifacient effect would be yet more miniscule) is no advantage, because those numbers also mean Plan B is rarely helpful for its intended effect (and they're also a major cause of the difficulty of studying the phenomenon). That's presumably why some women might exemplify heroic virtue and, like pacifists in wartime, put earthly defense aside for eschatological hope.  But given the near-total absence of evidence for an abortifacient effect, and the evidence that Plan B does effectively delay ovulation and thicken cervical mucus, any extremely rare abortive effect would clearly fall under the doctrine of double effect.  The Church, after all, does not forbid driving because a child might be killed.  Hospitals and rape victims should feel no moral qualms, compunction, or guilt about the administration of Plan B given our current medical knowledge.  Administration of a pregnancy test first is reasonable, since after implantation Plan B can only be harmful, but administration of an ovulation test is a needless delay and may prevent Plan B from working due to its secondary mucosal effects and the imprecision of the ovulation test.  Certainly when facing the alternative of not being able to give rape victims appropriate medical care, the German bishops made the right decision.

Friday, March 1, 2013

Contraception Casuistry

In response to l'affair Sandra Fluke and the more recent approval by the German bishops for emergency contraception for rape victims at Catholic hospitals, it's worth understanding why the Church's position often seems so complicated (or even contradictory) to outsiders.  I'd like to begin by distinguishing between three different realms of moral discourse:
  1. Prophecy, in which the word of God is proclaimed to a sinful culture.  Here the goal is not to pinpoint the details of sinful behaviors or judge individual persons, but rather to proclaim the truth to a culture that has forgotten or ignored it. When the prophets of old demanded that Israel stop worshiping Mammon, they didn't generally dwell on the finer points of what constituted worship and what was merely public order or respect for the beliefs of others.  Prophecy particularly addresses those who act in willful ignorance of God's law.  
  2. Reconciliation, in which the individual sinner, induced by prophecy to contrition for his sin, is guided back to God.  Here the focus is frequently less on the sinful act than on the penitent's frame of mind and habitual patterns of behavior, and what can be done to overcome those.  Reconciliation particularly addresses those who want to obey God's law but struggle to be consistent in their wills.  
  3. Casuistry, in which particular cases are analyzed in the light of prophecy.  Casuistry is particularly addressed to those who want to follow God's will but are genuinely unsure of how particular concrete actions would help or hinder that process.  
Now obviously what is said in the modes of prophecy, reconciliation, and casuistry cannot contradict each other if all human affairs participate in the same eternal law of God, but as they address themselves to three very different (though overlapping) audiences, their modes of discourse will be rather different.  Where prophecy is required, reconciliation and casuistry fail, as they assume the audience desires to know God's will and how to follow it.  Where reconciliation is required, prophecy reduces to scrupling and casuistry to laxity.  Where casuistry is required, both prophecy and reconciliation are inadequate:  neither gives Catholic hospitals detailed guidance in difficult cases.  In Lonergan's terms, prophecy addresses the problem of major inauthenticity, while reconciliation addresses the problem of minor (which is not to say less important) inauthenticity, and casuistry navigates the boundary between the two.

So from a prophetic point of view, contraception is morally wrong, and we live in a contraceptive culture.  We must proclaim the virtue of chastity, and uphold the model of a chaste marriage.  From a reconciliation point of view, if you are using contraception, please embrace the power of fasting and sacraments this Lent to excise the evil and grow closer to God.  But what about from a casuistry point of view?  What counts as contraception?  When is it wrong?  Well, that's what this post is all about.

Contraception, a moral evil
So, what is contraception?  To contracept is to attempt to prevent sex from achieving its dual natural ends of marital union and fecundity.  So contraception is an intentional act, a human act, which interferes with the purpose of sex, another intentional human action.  Contraception is evil precisely because it interferes with a good and is never necessary (abstinence is always possible).  Murder is still murder even if the gang leader said you'd be next if you didn't follow through.  This doesn't mean that from the perspective of reconciliation these pressures can't reduce culpability, but it doesn't mean that contraception is ever appropriate.  It is an intrinsic evil, and intrinsic evils are never permissible.

How can any action ever be intrinsically evil, such that nobody can ever morally do it, no matter what other good may come or evil be avoided?  Long answer, shorter answer, shortest answer.  Which is to say that if you're a Catholic you can take it on authority, or if you're an Aristotelian you can follow the shortest answer, but if you're a reductionist about action you'll have to work through the long answer, and you might need some metaphysics besides.  What about contraception in particular, why would it merit joining a list filled with murder, rape, and slavery?  Long answer, shorter answer, shortest answer.  Again, if you're not a Catholic or an Aristotelian, the assumptions relied on by the shortcuts won't be very palatable to you.  Remember that the intrinsic evil of an action is not dependent on the gravity of its effects, which explains why lists of intrinsically evil acts seem odd to modern ears, with contraception, fornication, and masturbation next to rape, murder, genocide, and slavery.  The claim is that each can be known to be always wrong, not that their moral gravity is the same.  Similarly, because the wrongness of the acts isn't dependent on their moral gravity, performance of an intrinsically evil act can never be justified on the basis of some supposed good.  Now this doesn't deny the terrible consequences of contraceptive culture, but it does mean that contraception's evil isn't dependent on statistical arguments.

Things that aren't intrinsically evil because they aren't contraception, even if they look like it
Natural family planning is not contraception, even if it as effective as contraception in governing the timing of births.  Why?  Is this not just casuistry in the sense of laxity, a consigliere finding supposedly licit means to achieve illicit ends?  No, because abstinence is always licit when mutually chosen by the couple, and natural family planning is merely periodic abstinence.  It does not presume to remove from God the question of whether a particular act of intercourse achieves its natural end of procreation.  Of course, just because NFP isn't contraceptive and thus isn't intrinsically evil doesn't mean it can't be evil in particular cases.  A spouse who selfishly desired to avoid children would be committing an evil, just not because he was using an evil means.

Another indisputable case where birth control is allowed is that of rape, as Archbishop Chaput teaches and Fr. Saunders explains.  Since the woman victimized by rape did not consent to sexual intercourse, there is no union whose fruit is denied.  Just because birth control in such cases is not the human act of contraception, however, does not mean that all methods are licit, because as those two article make clear the health and life of a potentially-already-conceived child is crucial.  In cases where an intrinsic evil is not in play, we must weigh consequences, and the potential death of an innocent person is a mighty consequence indeed.  The German bishops decided to license emergency contraception precisely because they decided it was not an abortifacient--those wishing to be more cautious can follow the protocol Fr. Saunders describes.

The church has long taught (though it must be carefully understood) the doctrine of double-effect; medicine prescribed for a licit medical purpose is wholly licit, whatever its unintended contraceptive purpose, though the trade-offs must be weighed.  Georgetown may have bizarrely and tragically not complied with that policy, but the teaching itself is quite clear and fully elaborated.  The church does not presume to argue with doctors on the question of medical fact.

Also quite clear are the cases of oral, anal, and other non-vaginal sexual encounters, whether hetero- or homosexual.  In such cases the act itself is basically masturbatory and therefore illicit, but insofar as the act itself has no possibility of procreation, there's nothing to contracept, whatever devices may be used.  In heterosexual cases the act itself may be contraceptive, but no further contraceptive device could therefore make it so.  In fact, the use of barriers to prevent disease transmission may be a first step towards responsibility, the realization that sex has consequences and must be an act of love for the other person.

Controverted Cases
Beyond the clear cases of contraception and the clear cases of non-contraception, there are of course the controverted cases.  In controverted cases, where the connection between the prophesy and the concrete situation is least clear, the wisdom of the person pronouncing judgment is paramount.  Since I  have little ethical training, have never been married, and hold no ecclesiastical office, I will merely outline the cases and point to further resources while refraining from judgment.

The first controverted case is that of Catholic institutions facing the HHS mandate.  Of course, it's not only committing intrinsically evil acts that is always evil, but being an accomplice to them is as well.  One who desires the act is a formal accomplice, whereas one who provides support necessary for accomplishing the act without desiring it is only a material accomplice.  Material cooperation is not itself an intrinsic evil (no evil object is intentionally chosen), so the evil done is evil done as a consequence, and thereby can be weighed against the good done as a consequence.  Since the good done by Catholic hospitals and healthcare institutions is presumably substantial, compliance with the HHS mandate might be justifiable (if not desirable) if the cooperation implied was only material and remote.  But of course what degree of cooperation is implied by the legal structures involved is open to question (12345).  It's also unclear whether the revisions are sufficient to change the situation, with most bishops against for several reasons, but some relieved.  Of course no Catholic bishop is going to support a plan which promotes intrinsic evil and burdens his flock just because the Church will only have some remote material rather than formal cooperation, but if that's as much as we're likely to get under the First Amendment and it's sufficient to avoid closing our schools and hospitals, then it's nonetheless an important victory.

A second controverted case is whether spouses may use condoms to prevent STD transmission.  The argument for is that preventing the transmission of an STD to one's spouse is clearly a loving intention, and the contraception is not intentional but merely a double effect.  The argument against is that abstinence seems like a more loving alternative.  Martin Rhonheimer and Janet Smith squared off over this issue (12, 3, 4, 5, 6, 7).

A third controverted case is that of fornication.  Humanae Vitae only speaks explicitly to the marital case, presumably because in fornication the unitive aspect is already severely defective, and thus there is no close connection between unity and procreation.  Put differently, the sexual act is already sinful under the species of fornication, and so the species of contraception is irrelevant.  One might think that as with non-vaginal intercourse and the STD case, the use of contraception might be a first step towards responsibility.  Nonetheless, authorities have been reluctant to give approbation to this use of contraceptives, likely because their use could indicate premeditation or an even more defective view of human sexuality and more presciently because it would be confused as approbation for the fornication itself.

Wednesday, February 27, 2013

Lent, Confession, and Penance

"By the sweat of your brow you shall eat bread, until you return to the ground, from which you were taken; For you are dust, and to dust you shall return." - Genesis 3:19
I don't normally offer much of a pastoral nature, insofar as I'm not a pastor and most readers of this blog probably either aren't Catholic or are Catholics with a rich parish life who don't need to be told this stuff.  Nonetheless, a major point of this blog is to record thoughts I've frequently shared or links I've frequently referred to people, and I am often asked about Lent, so I thought it was worth passing on some of the better resources I've encountered.

First, an overview from Timothy Cardinal Dolan, Archbishop of New York:



We begin Lent with the humility of ashes, but it also contains many liturgical changes you might notice at Mass, and a number of other canonical norms which Catholics are often poorly informed about.  Yes, it's important to know who must give up what on Ash Wednesday and Good Friday, but it's important not to add to the law, which many unwittingly do by passing on personal or familial devotions as if they were obligatory.  Which doesn't, of course, mean that such devotions aren't valuable, as the Holy Father aptly explains.
"Turn away from sin and be faithful to the Gospel." - Mark 1:15
The other formulation for the imposition of ashes reminds us of the most important task of Lent, the Sacrament of Reconciliation.  Going to confession is always scary, especially if you've been away for a long time, because as St. John Chrysostom says, "you have seen the face of Christ in His glory":



But as John Paul II was fond of quoting the Angel's annunciation to Mary:  "Be not afraid!" which continues "for behold, I bring you good news of a great joy which will come to all the people."  And the Sacrament of Reconciliation is indeed that great joy, in which we offer up our intrinsic disorder to God's transcendence.  Without confession, we cannot truly see nor bear the cross.  We tire of asking forgiveness, but God the father of mercies never tires of forgiving us.  In addition to good advicea helpful FAQ and the official bulletin inserts, here's a video that may help lessen your fear enough to help you courageously experience this great joy:



UPDATE:  Our new Pope Francis reminds us sinners to seek God in mercy and solidarity with the poor

Monday, February 25, 2013

Healthcare Economics

If you live in the U.S. and not under a rock, you've likely been hearing a good bit of brouhaha over healthcare costs--both how high they are and who pays them.  If you're not quite up on what's going on, this Time article is a great place to start.  What that article and most others give, however, is a narrative, not an argument, so let's break this down.

TL;DR:

The cost trend problem is just as bad as in Europe, will likely fix itself, and if not it might be hopeless.  We pay 27% more than Europe for the same procedures because in the 70s we brought the government into the market with Medicare and simultaneously reduced residency slots, leading to much higher physician salaries.  Solution:  pass HR6352.

First, are we actually paying too much?

The Time article makes much of the "charge master" or list rates--but of course this is an ethical or maybe political problem but not an economic problem.  In any industry, whether enterprise software or education, that involves relatively few transactions that consumers are willing to spend a lot of time negotiating, price discrimination will run rampant and price transparency will be low.  The trick here is mostly to get uninsured people insurance, which is after all the primary goal of the ACA.  Single-payer or what have you might be even better in this regard (after all the Massachusetts system covers 97 rather than 100%) but that's again a question of political will rather than economics.  It might also be an ethical issue, in that charitable institutions should probably spend less time terrifying working class people who come to them for help, but this post isn't about ethics.

The second regard in which healthcare is said to cost too much is that it will soon amount to 20% of U.S. GDP.  But why is that a problem?  Would it be better if we went back to spending more money on houses instead?  Do we need more polluting cars, or more household gadgets we don't have space for?  More luxury goods?  It seems reasonable that sectors like healthcare and education should be more in demand than other sectors as incomes rise, and in sectors where value is identified as time with the provider, productivity gains are hard to realize.  But there's nothing inherently bad about any particular sectoral split.

Perhaps the issue arises when the previous two points are combined:  if the poor need to receive as much healthcare as the rich, and healthcare grows as a portion of the economy, then non-market (typically government) share of the economy will rise dramatically, which may be a political problem (or even an economic problem if government-managed sectors have lower productivity).  The options would be to either accept increasing consumption inequality or improve healthcare productivity, about which more below.  Of course, the instinct to care more about productivity and less about inequality could be summarized as "be less like Europe" and one of the key points of the Time piece is that we are paying 27% more than Europeans in total and 100% more in many non-Medicare areas:  in other words "be more like Europe."  The main problem with the "we're paying more than Europe" story is that their cost growth rates are the same as ours (and cost growth is a much more minor factor than demographics anyway) and of course we have higher-per-capita-GDP than they do now, so we can afford to pay somewhat more than they do now and neither of us will be able to pay what healthcare will soon cost if the trend continues to increase for very long.  Paying more than Europe also doesn't mean much absent a good causal story of why and what to do about it:  Europeans, after all, pay much more than we do for basically all consumer durables, especially electronics, and for housing and many services as well.  They'd obviously love to change this, but not at the cost of their own worker protections.

So in short, we are paying significantly more than Europe, but the bigger problem is cost growth on both continents that will create political trouble regarding government share of the economy over time.

Second, why do we pay more than Europe?

I've read dozens of different sensible-sounding theories, but the data say that it's because our doctors and hospitals have roughly twice the profit for the same procedures as ones in Europe.  So why is that?  Well, common law medical malpractice tort liability may explain 10% of the difference, but that's only 2% of the total costs.  A big part of the answer is that mixed models don't work well to control costs:  the U.S. has too much regulation and centralization for market discipline of costs in negotiation with insurers, but does not have a democratically accountable fully single-payer or price controlled system.  The rapid increase in doctor salaries corresponds to the introduction of Medicare, supporting this claim.  But why did doctor salaries continue to rise, rather than the supply of doctors increase?  Because the number of residency slots is capped (last full paragraph).  Rather than churning out doctors who can't get residencies, as law schools and PhD programs do, medical school has just gotten massively more competitive over time (last full paragraph).

Doctors used to work for less, and doctors in Europe do work for less.  The constraint on doctor supply combines with the elastic demand of a mixed payment system to increase prices.   Expanding residency slots costs a drop in the bucket compared to ACA and impedes no one's freedom--people want to be doctors!  The eighteen states which allow significant practice freedoms to nurse practitioners and physicians' assistants show such providers achieve the same or better health outcomes than doctors, so some attempts to increase supply are being made.  If medical schools couldn't admit more students because they weren't willing to pay or couldn't pass the USMLE needed to practice, non-doctor providers would indeed be the only reasonable method to increase supply.  But since the constraint is residency slots, which are directly controlled by the Federal government, increases would not only add to the supply of doctors but allow new medical schools and teaching hospitals to open, reducing cartelization at the same time.  This is a complete no-brainer.  Matt Yglesias favors straight-up price controls, which he demonstrates won't lead hospitals to lose money, but admits that will decrease supply.  Why not just increase supply?

Third, what to do about the health care cost curve?

Increasing the supply of providers is by far the best short-term measure to bend the cost curve, but won't likely make that much long-term difference because nations without similarly constrained supply are seeing similar annual price increases, even with direct price controls.  First, it's important to realize that the problem might just fix itself.  Long term, we're going to have to improve provider productivity, which means reducing provider patient time, which means drugs and devices.  The FDA is the major obstacle to that, so reforming the FDA would help.  Patent reform might also help decrease the problematic cost cliff between patent and generic drugs.  But the long-term problem is a technology problem, and technical innovation is hard and the social policy necessary to support it is often not obvious.

UPDATE:  Bryan Caplan has come up with an ingenious test showing that physician supply is capped by a strict quota.

UPDATE2:  If you're wondering why increasing residencies would decrease hospital profits, hospitals are better described as monopolistic competition than perfect monopoly. One piece of evidence for this is that most hospital "profits" are not quite profits but capital depreciation (the Time article equivocates a little too quickly on this). While true that capital depreciation is not a marginal cost and hence indicative of monopolistic behavior, it is indicative of real real capital expenditure rather than pure profit taking--the 'subtle quality differences' the wiki article talks about, e.g. facilities like Hopkins' new $2B building which do create quality differentiation but not proportional to their cost. Further, as the wiki article also makes clear, the main check on price increases in monopolistic competition is market entry: but with residencies capped, new teaching hospitals can't open at all, and new regional hospitals can only open by bidding up the price of doctors: such hospitals do have lower capital depreciation, but salaries destroy most of the advantage. An increase in residencies means more doctors and more hospitals, thus reducing the profits of both.

UPDATE3:  Of course hospital expansion may not have its full effect on pricing without reforming certificates of need and Federal anti-trust oversight.  Unfortunately these stipulations are staple dysfunctions  of half-regulated systems.

UPDATE4:  People are starting to get it (especially read the comments).

Wednesday, February 13, 2013

New Old Posts

So I finally managed to import all the philosophy posts from the previous incarnation of this blog, hosted on Drupal at reasonablereflection.net.  And I did it without spamming the RSS or Twitter feeds!  Yay!  I'll be importing selected old politics posts at a later date.  Since the posts are old, there are likely to be many dead links, a problem of which I am also a cause.  I've tried to clean up the self-links and any links really critical to understanding the arguments, but if you come across a dead link and you successfully find the original article in Google, please post a comment and I'll update the original.  Conversely, if you want to track down a citation and you can't find it, leave a comment and I'll try to be of assistance.

In any case, thirteen posts from 2005 and nine posts from 2004 are now again available on the internet for your reading pleasure.  They were obviously written while I was an undergraduate, but I think most of them hold up pretty well and I'd largely stand behind them.  I also imported all of the comments; in addition to my usual interlocutors Byron Borger and Richard ClearyBrian WeathersonJohn Turri, Jeremy Pierce, Stephen LenhartNancy PearceySean Purcell, and others stopped by to offer their insights.  All in all, my back catalog on critical realism has really expanded (though I wasn't any better at explaining phenomenology to analytic realists then than I am now), as has the history of my engagement with reformed (neocalvinist) philosophy.  Both are ongoing interests and I hope to have more posts in both categories as time goes on.  Perhaps more in the historical curiosity camp at this point, I also wrote a series of five contentious posts on intelligent design.  

Friday, February 1, 2013

Debate Tournament Instability

Palmer has some thoughts up on the decline of Emory in LD and IEs.  I can't quibble with his concrete suggestions and call for solidarity, but I think there are some underlying structural factors at work.

Once Upon a Time (tm) the debate community, especially the Lincoln-Douglas debate community, wasn't very well networked.  LD was often seen as an adjunct at speech or policy tournaments (a bit the way PF is often seen now).  The LD-L carried a lot of email traffic, but personal ties among members were weak and flame-wars common.  Airline tickets were expensive.  Computer tabbing was young, and judge assignments were largely random and/or at the will of the tabroom.  Tab errors were fairly frequent, rounds were few, lag-pairing was not uncommon, and breaks were often steep.  In short, most tournaments were local and regional, and luck was an important component of success.  Large college tournaments (Harvard, Villiger at St. Joe's, Wake Forest, etc) weren't run much better than local tournaments, but they were the only way to compete against a wider base of students for TOC bids and establish a national reputation.  Colleges drew based on their name and college forensics reputation, and made large amounts of money on their tournaments.

Gradually, with airline deregulation and the advance of the internet, high school debate coaches began to form a more cohesive and professional community.  The NDCA was founded.  As a consequence, the coaches who considered themselves part of that community began to hold each other to higher standards.  They ran reasonably priced tournaments with good hospitality and quality hired judges.  They tabbed with TRPC which reduced errors and downtime and eventually allowed the proliferation of mutual judge preferences.  Expectations for judges went up, with judges who weren't preferred no longer getting rounds.  The changes at Bronx were the flagship, but other tournaments like Lexington and Hendrick Hudson weren't far behind.  Coaches began to question why they were paying so much money to attend college tournaments, which were run less efficiently, frequently had less preferred judges, and funded already wealthy colleges.  Some college tournaments (Yale most notably, with Princeton and Columbia following, and Penn at a distance) brought on high school coaches for tabulation and implemented many of the reforms first made at the high schools.  Others like St. Joe's, Wake Forest, now Emory, and even Harvard failed to reform and began to feel pressure.

This, however, has led to an unstable situation.  A few tournaments, like Yale and Bronx, are indisputably on the strongest footing, due both to their natural advantages (good weekends, strong brands, obvious judge pool) and the hard work of their directors and tabulators.  The unreformed college tournaments are run by policy or I.E. directors who don't especially know or care about LD, but continue to attract competition because they're attractive destinations for teams more focused on policy or IEs, or who want to make one big trip a year.  Even the reformed college tournaments, like Columbia and Penn, have trouble matching the efficiency of the higher quality high school tournaments, because their rounds are necessarily more spread out, and their judge pool is more diverse without alumni to pull from.  They also don't have parents available to provide high quality hospitality at low cost.

The high school tournaments, however, have a different set of problems.  The larger ones (Bronx excepted, of course) will never have the number of rooms available at Harvard or Wake Forest, so they can't accept IE entries, and they obviously don't have the brand power of the major colleges.  So LDers from more marginal schools will always prefer the college tournaments.  To a certain extent, the improved efficiency and meritocracy are actually a negative for more marginal programs, who can no longer hope for a lucky break, or plausibly ascribe failure to others' incompetence.  The smaller high school tournaments have trouble pulling in varsity debaters who can always travel to a TOC bid tournament somewhere on a given weekend.  And so as has been noted many times, the debate Gini coefficient rises.

So as a life member of the NDCA, I'm quite convinced that the "NDCA model" of debate, with a strongly cooperative and professional group of coaches and high-efficiency, low-cost, and extremely meritocratic tournament model is the best one.  But if we want to have a stable equilibrium, we need to figure out how to keep debate workable for IE-focused schools.  

Thursday, January 31, 2013

Stuff EMTs Know

The national Department of Transportation Emergency Medical Technician curriculum is only 110 hours, which doesn't allow a lot of time for theory beyond Biology 101.  Most of what EMTs learn is how to be both quick and thorough (not easy in any profession, let alone with lives on the line) and how to function as professionals with difficult patients and within the incident command system during emergencies.  Despite that, there are some bits of medical knowledge that EMTs pick up that are worth sharing with the broader public.

Your chances of surviving severe heart problems depend strongly on the causes.

  1. Bradycardia (slow heartbeat, sometimes too slow to feel a pulse).  In this case, the heart has normal electrical activity, but (typically) has not received enough oxygen to continue beating normally.  Common causes are drowning, and narcotics overdose (which stops breathing).  In this case, CPR is extremely effective, since it provides oxygen and circulates it within the body while the causes are treated (liver processes the drugs hopefully assisted by Narcan, water is no longer in the mouth, etc.).  This is the basis for the increasing focus on compressions and de-emphasis on ventilations:  few or poor compressions (good ones must be 1/3 of the body thickness) never succeed in filling the heart and generating blood pressure, thus failing to actually deliver any oxygen.  Inadequate ventilations, however, still allow the (often substantial) oxygen available in the lungs (only a part of the oxygen is replaced with carbon dioxide in each respiration) and blood to circulate, and often just a brief period of CPR is sufficient to restore spontaneous circulation.  Basically everybody who gets CPR vomits, so be prepared to roll and clear immediately, rather than treating vomit as a remote possibility.  EMTs use advanced airways precisely to avoid this frequent repositioning   Hypothermia seems like it should fall under this category, but doesn't, for complicated reasons, and similarly lightning strike seems like it ought to be a very different category but CPR often works.  
  2. Ventricular fibrillation (chaotic heart contractions too uncoordinated to produce a strong pulse).  In this case, an AED can often provide a shock to restore heart function, and CPR is just a stop-gap measure of a few minutes until the AED arrives.  Prolonged CPR is highly unlikely to result in a good outcome, which is why a drop in AED prices and hence wider availability in schools, police cars, etc, is likely to be very good news for heart attack victims.
  3. Asystole (no electrical activity in the heart--the classic flatline on the monitor).  CPR and AEDs won't save you; and in fact they won't even shock you since there's no fibrillation to defibrillate. This includes nearly all trauma victims--it's worth a try, of course, but people whose hearts stop from trauma stay dead.
  4. Acute myocardial infarction (heart attack with a pulse, where a coronary artery is blocked).  Here cardiac drugs, often epinephrine, and blood thinners (take four baby aspirin ASAP), or nitroglycerin if you're prescribed it, keep the heart going until the hospital can insert a catheter to physically clear the blockage or graft in a bypass.
  5. Pulmonary embolism and pericardial tamponade.  These are cases where the heart is failing to pump blood not through any failing of its own but because it can't push the blood against a blockage of some kind.  Surgery and/or drugs are extremely effective; though they must be administered in a timely manner to avoid death.  Mostly what the EMTs will do is give you oxygen so your heart can work less hard on the way to the hospital.
After heart and respiratory problems, the next most common acute issue EMTs deal with is shock.  Many older first aid books are vague about what shock is, but we now know that shock is really simple:  hypoperfusion.  Not enough oxygen going around to keep cells alive.  So the acute circulatory problems above can basically be redefined as cardiogenic shock.  Leaving the rarer and more complex neuro/vasogenic shock aside for the moment, what EMTs worry about in trauma cases is hypovolemic shock--not having enough oxygen-carrying blood in the circulatory system to perfuse tissues.  
  1. The most common cause of hypovolemic shock is an exterior bleed, especially a pulsating arterial one moving too fast to clot on its own.  These can kill fast, but thankfully they're pretty simple to fix--push down hard and keep the pressure on until the bleeding stops.  Forget pressure points (no evidence that they work) and elevation (doesn't hurt, but doesn't make much difference, either).  Just push and hold until the bleeding stops.  If you have a limb with a wound too ragged to find one place to push, make a tourniquet out of anything and place it above the wound, and tighten it until the bleeding slows.  The concerns about tourniquets don't really hold up--they can be on for at least an hour without causing tissue damage, and there are no special rules about where to put them.  Just get it on before the person loses too much blood, so they don't die before they get a transfusion.
  2. The second most common is breaking a major bone like the pelvis or femur (not, interestingly enough, the narrower hip joint between the two).  Major blood vessels run through these bones, and without the compression strength of the bone, the muscles in tension will continually pull the sharp bone ends against the vessels, re-opening clots and causing potentially-fatal internal bleeds.  The solution for the pelvis is to use a belt to compress the bone back together, while in the case of the femur traction needs to be pulled on the leg to counteract the contracting muscles.  Smaller bones should be re-aligned with gentle traction in order to restore circulation, sensation, and motion in the affected limbs, but are not large enough to cause a fatality.
  3. Internal bleeding in the abdomen or chest are worse, since there's no direct way to encourage clotting.  Moving rapidly to surgery is critical for someone with signs of shock (pale, cool, clammy skin) who has swelling in these areas.  In general, EMTs can guess at the affected organ by the location of abdominal pain, but can't do much for abdominal problems beyond giving charcoal for some cases of poisoning.
  4. Penetrating chest wounds pose further complications.  First, you can't use tourniquets on large wounds, so a clotting agent may be required to stop the bleeding.  Second, they require an occlusive dressing so that pressure doesn't build up between the lungs and the chest, inhibiting breathing.
The next thing EMTs worry about is brain problems like stroke/aneurysm and traumatic brain injury (especially its emergent form with rising intra-cranial pressure).  Here there's not a lot we can do other than get you to the hospital quickly, but it's well-worth knowing the signs and symptoms so that you can get your loved ones into a doctor's care quickly.  Any unexplained decrease or loss of consciousness or awareness is significant and needs to be treated (diagnosed seizure patients and diabetics should know what's normal for them, but seizures are not normally life-threatening unless they continue for a long time without return of normal consciousness, and it's always safe to give a diabetic some sugar if they're conscious and can swallow but not fully alert--they can test themselves when their alertness increases).  

We also worry about systemic issues like dehydration/heat exhaustion/heat stroke (and hypothermia) and sepsis (systemic infection).  There are of course lists of signs and symptoms for these conditions, but the most important thing is to pay attention to the appearance (especially skin) and level of consciousness of those around you, and take departures from the norm seriously.  If someone looks like they're doing worse, they probably are, and that shouldn't be ignored.  These conditions are easily treated, but can be deadly when ignored, and frequently don't have unambiguous symptoms.

What we don't worry about (much) are unstable spines, anaphylaxis, and North American snakebites.  Most spinal damage happens at the time of impact if it happens at all; yes if we have suspicion of spinal injury and a board available we'll strap them on for safekeeping, but don't let somebody die of drowning, fire, hypothermia, shock, or some other hazard because you're worried about their spine!  Anaphylaxis from allergies is extremely unpleasant but rarely deadly, even when an epi-pen is not available (which is not to say you shouldn't carry one if diagnosed).  And North American poisonous snakes aren't very aggressive, rarely biting people who aren't intentionally handling them.  And when they do bite, they don't always inject venom, and their venom rarely causes major injury with timely emergency room treatment.  Even without it, death is extraordinarily rare in adolescents and adults.  These are all real threats, but they're ones people spend more time worrying about than is warranted.

The bottom line is that the most effective medical interventions are often the most basic.  Be aware of dangerous situations, and don't let alcohol (or other drugs) and adventure activities (including driving!) mix.  Keep warm and hydrated--being cold and thirsty doesn't make you a hero.  Don't take it lightly when people exhibit diminished levels of consciousness or judgment, or have a sickly appearance.  Control bleeds with direct pressure.  Clear airways with the Heimlich maneuver in conscious patients (it's spectacularly effective, with nearly 100% success rate) and by rolling unconscious patients so they don't choke on their own tongues and vomit.  Call 911 so the professionals can come quickly and thoroughly evaluate you or your loved one and get them to definitive care. 

Emergency Management

During my deployment with Team Rubicon on Operation Greased Lightning (Hurricane Sandy response in New Jersey) it came to my attention that while disasters and disaster response get a great deal of news coverage, most people are very unclear on how emergency management actually works, so here's my attempt to remedy that.

Assets
Assets for disaster response are local, regional, state, federal, and international, and encompass both professionals and volunteers.  The first, and frankly most important, assets are the existing local police, fire, and emergency medical systems.  If they are well funded, well trained, and well functioning, they can handle surprising difficult situations for brief periods (by a week after Sandy, the cops in Brick NJ were practically falling over from exhaustion), and other assets will have an easy time integrating with them.  Community Emergency Response Teams have an increasing role. Many important local assets will not initially be thought of as disaster-response assets:  in Ocean County NJ, the Little League (turned their snack bar into a major feeding station), Police Athletic League (same), churches (actively beating the streets handing out food and coffee and finding people in trouble), VFW (staging area for regional assets), American Legion (delivering food to the fire hall being used to stage mutual aid assets), and others were just as important as any organization nominally devoted to disaster relief or emergency preparedness.  What counts is a group of people with existing high-trust and organization levels who are willing to help.  Regional and state assets include the National Guard, VOAD (Volunteer Organizations Against Disaster), reserve medical corps, and state police.  Private companies like the telephone and electric utilities and even tree services deployed trucks from across the Northeast.   Active duty military personnel and the Red Cross operate foremost at the national level.  Assets from other states and localities are made available under the principle (sometimes codified) of mutual aid.

Command and Control
Command and control during disasters functions according to the incident command system/national incident management system.  The lowest level is that of the incident commander, sometimes the senior person from the first responding agency, but in some states legislated to be the fire chief or other official.  Any incident that involves more than six casualties or fire and police assets from multiple jurisdictions should have an incident commander to ensure coordination.  The incident commander is responsible for assigning tasks to responding assets and must additionally deputize at least the following:

  1. Safety officer:  any mass-casualty incident, whether an automotive accident, fire, hostage standoff, terrorist act, or natural disaster has important ongoing hazards.  Allowing first responders to become additional victims is deeply irresponsible, and someone must be focused on planning to mitigate those hazards and informing the incident commander if responses are unsafe.
  2. Triage/operations officer:  a mass casualty incident by definition includes more victims or potential victims than initially responding personnel.  Someone must decide which aspects of the problem must be confronted first, whether to minimize immediate loss of life or to contain the incident and thus minimize later threats to life and property.
  3. Liaison/logistics officer:  while the triage officer is identifying the most urgent problems, the liaison officer must be arranging for further appropriate assets sufficient to contain and eventually manage the entire incident, and ensuring that arriving assets contribute to the plan of the incident commander rather than clogging key ingress and egress routes.
At larger incidents, these roles might be further subdivided.  For disaster incidents which scale beyond a single site, the county-level office of emergency management should be activated.  This office can mobilize assets from other municipalities or volunteers not ordinarily available to 911 dispatchers, and request aid from the regional or state level if necessary.  The functions of incident commander, safety officer, triage/operations officer, and liaison/logistics officer must be duplicated at the county level in order to ensure that resources flow appropriately to and from the incident sites.  For disasters of larger scope, state offices of emergency management and the Federal Emergency Management Agency operate similarly.  

Due to the disproportion between disasters and normal police/fire/EMS incidents, most assets deployed in disasters will not be organic assets that routinely report to and train with the incident commander.  Thus in addition to being flexible and trained to common standards, it is important for assets to clarify their command relationship to the employing agency or incident commander, particularly whether the commander has operational control over the asset (and must release it before it can move to another incident) or is only being supported, subject to the triage decisions of the command level that does have operational control.  Similarly, assets' organic commanders must not depart operational control without authorization, and must not assume that they are entitled to logistics support as if they were attached assets.  

Despite the duplication of effort involved in running multiple supply chains, assets in disasters are rarely attached because their supply needs are not generally well understood by the controlling command, and its logistics resources are likely to be stretched already in supply of its organic assets.  Assumptions about command relationships need not be committed to paper (they may change rapidly as a disaster unfolds) but should always be verbally formalized so as to avoid dangerous misunderstandings.  Assets are often squandered in disasters by assigning them to low-level operational control at an incident where they are not most needed or by holding them in general support at a higher level of control where they have insufficient knowledge of and access to the incident in order to act effectively.  Understanding the capabilities and needs of various assets is thus a major goal of table-top disaster preparedness scenarios frequently conducted at the county level and above.  Volunteer organizations, especially those responding without many local contacts, will be vastly more effective if they are regularly included in such simulations.  Responding organizations which have not been assigned in at least direct support of a particular incident must expect to run their own reconnaissance and triage if they are to be effective, while continuing to be mindful of their resource consumption (fuel, road space, housing) and prepared to follow directives from their controlling agency if and when those are forthcoming.

In general, you can see the discipline of emergency management as an attempt to resolve the public choice issues inherent in a crisis, and I think the current methods are actually doing a remarkable job, perhaps because many of the practitioners reap strong-monetary rewards in adrenaline and altruism.