Chapter 45: A Potentially Problematic Situation

October 5, 1988, McKinley, Ohio

After putting Rachel to bed on Wednesday evening, I called Kris and described my day to her, though I left out the details about the condition of the young girl's body.

"Are you OK?" Kris asked

"I'm upset and outraged," I replied. "I cuddled Rachel for close to an hour after dinner, and that helped."

"You said the guy was arrested, right?"

"Yes. He's in the County Jail, and there ought to be sufficient evidence to hold him without bond. The DNA testing will take several days, but a rush was put on it, as you can imagine would be. The blood type match will be quicker, but all that can do is rule him in or out. DNA is as close to definitive as you can get, with accuracy that would limit the perpetrator to 1 in a million or so, and when combined with other physical evidence, would give absolute certainty. The courts haven't fully accepted DNA results, but I think this would be a good case to have them accept those results."

"What would be his sentence?"

"Murder in commission of a rape is a capital crime," I replied. "So he could be executed. That wouldn't surprise me, given the victim was only fourteen, and the acts committed."

"François Mitterrand pushed through the elimination of the death penalty in France in 1981. It really is uncivilized."

"I remember Jocelyn telling me about the last execution, in 1977, for the torture-murder and rape of a twenty-two-year-old girl, which is not unlike the current case. As for me, I object on theological grounds and I prefer a life sentence."

"What about parole?"

"I think that depends on the crime and the individual. In a case such as this, I don't think society would ever feel safe in letting him out of prison. I'm not even sure how you would judge rehabilitation."

"What about the man who murdered your friend?"

"I think, in his case, penitence and rehabilitation would be possible, and that releasing him after an extended period in prison would be possible. In thirty years, he'd be almost eighty, so if he's still alive, and has shown remorse, I think he could be released."

"What happened to the boys who raped your sister?"

"Lengthy prison sentences," I replied. "Some of them are already eligible for parole, so they might be out. I haven't kept track, and I don't believe Liz has, either."

"Anything else happen today?"

"Nothing interesting. How about you?"

"Just another day in High School. I did get asked to the Homecoming Dance, but I politely declined. The guy was surprised to hear I was betrothed!"

"The ring on your right hand didn't give him a clue?"

"No! He saw it, but didn't understand the implication because it was on the opposite hand. Not to mention, most girls who get engaged here traditionally have a diamond ring, not a plain band."

"True. Speaking of school dances, would you like to come to the Goshen Harvest Ball on October 28th when Code Blue plays?"

"Yes, I'd like that!"

"Actually, if you're ready to sing Endless Love with me, we could do that."

"I think so, because we'll have three more practices before then, right?"

"Yes."

"Then yes, I'd love to sing with you! What time are you home on Friday?"

"Barring a surprise autopsy, which is rare, around 4:30pm because we have the afternoon off, so to speak, for the M & M conference and a lecture."

"OK. Mom is home by 3:00pm on Fridays, so I'll be able to be there by 4:30pm."

"Sounds great! See you then!"

We said our 'goodbyes' and I sat down to read and listen to music before going to bed.

October 7, 1988, McKinley, Ohio

On Friday, we had just one autopsy, and after lunch, I met up with Clarissa to head to the M & M conference. Doctor McKnight presented a case of medical error, which, fortunately, had not resulted in death, but which had required emergency surgery to resolve. A surgeon had, during a hernia repair, nicked the large bowel and hadn't realized it, resulting in peritonitis.

It was a fairly common surgical error, but a totally avoidable one. The repair was made via an open procedure, and an antiseptic lavage was used to treat the peritonitis. Doctor Cutter spoke afterwards, reinforcing proper surgical procedures, as well as properly diagnosing the condition post-surgery, and the appropriate treatment procedures which included immediate IV antibiotics.

"How do you make that kind of error?" Lauren asked as she, Clarissa, Debbie, and I left the M & M conference.

"Trying to rush through the procedure and not running the bowel," Clarissa declared. "That's why Doctor Cutter emphasized that as part of the procedure. The Resident claimed to have run the bowel, but clearly he didn't do a proper job, and the Attending didn't notice."

"At least it was caught in time and the patient survived," I said.

"After an extra surgery!" Debbie declared.

"Which is better than being dead!" I retorted. "I think the key takeaways are not to rush and not to make assumptions."

"And keep an eye on your Residents!" Clarissa declared.

"I heard that!" Doctor Keller, an endocrinology PGY1, declared.

"I'm not going to apologize for speaking the truth!" Clarissa declared.

"As well you shouldn't!" Doctor Rajaswaran, the Chief of Endocrinology, stated firmly.

"Guess who's doing scut for the next two months?" Doctor Keller asked.

"You, if you think Clarissa is mistaken!" Doctor Rajaswaran said with a smile.

Several other doctors laughed, but I was careful not to even crack a smile, as were the other medical students.

"Are you going to the lecture?" Debbie asked.

"Yes," I replied. "While I won't be involved in treatment of AIDS, I feel it's important to understand it, as there is no doubt I will see patients with HIV infections in the ED."

"Have you?" Debbie asked.

"During my Preceptorship we had a young man come in with Kaposi's sarcoma, which is one of the AIDS-defining illnesses. I don't know what happened to him, obviously."

We sat through the lecture which provided the most current information on AIDS, including reports on the success of azidothymidine, or AZT, antiretroviral medication, which inhibited HIV's reverse transcriptase, an enzyme used by the virus to replicate. The problem was that the cost of the drug was insanely high at something on the order of $10,000 per year. That was a third of the median income in the entire country, and just under half the median income of Hayes County, which meant it was, in effect, unaffordable.

"The cost is outrageous," I said when Clarissa, Debbie, Lauren, and I left the auditorium.

"But isn't that based on the cost of developing and producing the drug?" Kylie, who had joined us, countered.

"I'm sure it is," I replied. "But that doesn't make it not outrageous. Nobody can afford that, and insurance companies are going to balk, or they'll have to raise overall premiums significantly to cover the cost of the drug. That said, I know that the development costs include all the failed attempts, not just the specific development of AZT. And before you ask, I don't have a solution, except perhaps to review the patent system."

"Why that?" Kylie asked.

"When I was in Internal Medicine, Doctor Collins made the point that it's a double-edge sword. In one sense, it allows generics to be made when the patent expires, but the expiration of the patent means the company has to recoup their costs during the patent period before they face lower-cost competition. And patents are from the date of issue, not first use of the drug, so if clinical trials take years, it shortens the recovery period. I don't know enough about the patent system to comment, other than to report what Doctor Collins said, but that does make sense."

"What about universities doing research?" Debbie asked.

"I read that the University of California System, MIT, Stanford, and the University of Texas System all control significant numbers of patents," Lauren said. "And they have to cover their research costs as well. And I'm sure they make a profit."

"But nothing like the major pharmaceutical companies, I'm sure," I countered. "Not to mention they have limited resources, just as every research group has. I think a bigger problem is drugs for which costs can't be recovered except from governments."

"Such as?" Debbie asked.

"Malaria drugs," I replied. "You can't sell those to well-off Europeans and North Americans, and the countries where malaria is a major problem are relatively poor. About the only way a drug like that could be developed and manufactured would be through a university or charitable organization, and then produced in the country where it was needed at near zero profit."

"That sounds like only a government could do it," Lauren observed.

"More specifically, a Western European, American, or Japanese government," I said. "One with sufficient GDP to cover the development, production, and distribution costs."

"Taxpayers would balk at that," Kylie observed.

"Taxpayers often balk at things which are for the 'greater good' with no individual benefit," I replied.

"Because we aren't socialists!" Kylie declared.

I chuckled, "And neither are countries like Sweden, which everyone claims is socialist! Did you know they have no minimum wage and you cannot be forced by the government to join a union? And most means of production are privately held? In other words, they're like us, only at a different place on the curve, though firmly on the side of capitalist."

"Socialized healthcare?" Kylie asked.

"Medicare and Medicaid?" Clarissa countered. "Mike's point is correct in that it's just different places on the curve. Do you consider police and fire protection to be 'socialist'? After all, they are public services funded by taxes, not private corporations."

"We tried 'company towns' and look how THAT turned out!" Lauren declared.

"Our medical system is entirely socialized," I said, "except in rare circumstances. Insurance pools premiums and socializes costs. It's just a matter of which bureaucrat and which non-practicing doctor makes decisions about what treatment and procedure costs can be socialized, and in what amounts."

"Oh, come on!" Kylie protested. "Insurance is not socialist!"

"Oh yes it is!" Clarissa countered. "What else is it except what Mike said? I mean, what's the real difference between an insurance premium and the payroll tax?"

"One is voluntary," Kylie said. "The other is theft."

Debbie groaned, "Not the whole 'taxation is theft' argument!"

"It is," Kylie said firmly. "It's immoral for me to take money out of Mike's bank account. Similarly, it's immoral for me to organize a group of people with guns and take Mike's money from his account. But vote on it, even with only a tiny portion of the population voting, and suddenly it's moral?"

"Well," I chuckled, "a famous revolutionary and accused insurrectionist once said 'Render unto Caesar what belongs to Caesar'. Last I checked, our coins and notes have equivalent images to those on Roman coins, which was the trap the Pharisees were laying for that radical itinerant preacher!"

"Oh, come on!" Kylie protested. "Do not steal? Do not covet thy neighbor's goods?"

"Or wife," I chuckled. "First of all, Jesus said there were only two commandments — 'You shall love the Lord your God with all your heart, with all your soul, and with all your mind', which is the first and greatest commandment. And the second is like it: 'You shall love your neighbor as yourself'. He stated, quite clearly, that on these two commandments hang all the Law and the Prophets."

"But he wasn't abrogating the Ten Commandments?"

"No, he was making them stricter," I replied. "He turned them from prohibitions to exhortations. It is much, much easier to follow the Ten Commandments than to follow the two commandments Jesus gave, which was the entire point. If you do as Jesus said, the Ten Commandments are basically the Cliff Notes version of what not to do, as opposed to a command to actively love your neighbor, which would preclude doing any of the things proscribed by the Ten Commandments, and a whole lot more, as well as requiring positive action.

"And my second point is that both Jesus and the Holy Apostle Paul made it quite clear that we should be subject to the governing authorities, insofar as it does not involve a denial of our faith. Paying taxes does not deny the truth of the Christian faith, and as I noted, Jesus made it clear both in the incident we're discussing, and with the Temple Tax, they were to be paid. And before you raise him driving the moneychangers from the Temple, that was about them making a profit by taking advantage of the proscription on making 'graven images'."

"Your church uses icons!"

"Which are not 'graven images', as they are neither 'carved', which is the technical meaning, nor are they 'idols', which is what was actually being proscribed. Icons are due respect, not worship, as they manifest the reality behind them. And if you're truly opposed to 'graven images', you're going to have one heck of a problem being a physician."

"Why?"

"The Staff of Asclepius, which represents the asclepieia, or healing temples of ancient Greece. They were dedicated to Asclepius, a hero and the god of medicine."

"That's different! I'm not worshiping the medical symbol!"

"And I'm not worshiping icons!" I retorted. "But, here's one for you from the Old Testament, specifically in Exodus and Numbers. I'm sure you remember, either from the Bible or from the movie, that the staff of Moses transformed into a snake and then back into a staff. But do you remember from the Bible that God instructed Moses to put a copper image of a snake on a pole for the purposes of healing?"

"What?!" Kylie gasped.

"The name of the snake is Nəḥuštān, which is revealed in 2 Kings. But in Numbers, Yahweh instructed Moses to erect a staff with a copper snake on it so that the Israelites who saw it would be cured and be protected from dying from the bites of the 'fiery serpents', which Yahweh had sent to punish them for speaking against him and Moses."

"Leave it to the Old Testament God to save people from his own punishment!" Lauren declared, shaking her head.

"Welcome to Calvinism 101," I chuckled. "We reject Calvinism as heresy and blasphemy. But the point remains that images were used throughout the Old Testament, including images of the Seraphim in the tent which held the Ark of the Covenant. But that's not my point here. My point here is that Asclepius and Moses were on the same page about snakes and staves and their relationship to medicine!"

"Do you think they're related?" Debbie asked.

"Possibly," I replied. "The scholarly date for 2 Kings is around 550BC, while the cult of Asclepius developed around 350BC. Given that the oral tradition behind the story of Moses is even older than 2 Kings, by at least five hundred years, if not as much as two thousand or more, it's entirely possible that some kind of cultural exchange happened, given that Alexander the Great conquered the Levant in around 330BC. Of course, it's also possible that it developed both places independently, though I suspect, as with the flood myth, it is much, much older."

"Flood myth?" Kylie asked. "You don't think it happened?"

"I think something happened, but the exact details are unimportant, as the point is always about spiritual truth, not about literal word-for-word truth. The reason I say 'myth' in this case is that there are similar stories told in Mesopotamian mythology, Hinduism, Chinese mythology, Greek mythology, Norse mythology, Polynesian mythology, Mayan mythology, Native American mythology, and a whole bunch of African and Australian Aboriginal mythology. Something obviously happened, and almost everyone knew about it. A good example from outside the Scriptures is Plato's 'Atlantis' myth."

"So what happened?" Debbie asked.

"Good question," I replied. "When I did some research on it, mainly to counter the bogus 'young earth creationism' argument, I discovered two viable theories. One, which I think is most likely, is that the end of the last glacial period, which was around 12,000 years ago, caused significant inundation. Interestingly, that's close to Plato's assertion about Atlantis being about 9,000 years before his time, or about 12,000 years ago."

"Whoa!" Debbie exclaimed.

"The second theory, which would account for local flooding in the Middle East is that a meteor or comet crashed into the Indian Ocean around 3000BC, creating an undersea crater whose name escapes me at the moment, and generated a giant tsunami that caused severe flooding. I think that's possible, but it doesn't explain the global reach of flood myths."

"Neither of those killed everyone except Noah and his family!" Lauren protested.

"I wasn't addressing the theological or cultural ramifications of the flood, just the origin stories. And it is possible that entire villages were wiped out, similar to what Plato says about Atlantis, and in a time with no communication infrastructure and when a horse was considered high-speed travel, 'everything I know about was destroyed' is not unreasonable, and by extension, if you don't know about it, it doesn't exist, so you can just say 'everything'."

"Weasel words!" Debbie declared.

"So sue me," I chuckled. "But it does explain it, and I've never once argued for literal word-for-word understanding of the Scriptures. I'll leave that to the twenty-thousand or so different Protestant churches who can't agree with each other on every single interpretation of Scripture. And I'm using Protestant in the generic sense of not being Orthodox or Roman Catholic, not in the technical sense of the groups who formally broke with Rome in the sixteenth century."

"OK, now I have to ask," Debbie said. "Noah and his ark?"

"Some dude saw the waters of the Tigris and Euphrates rising, so he put his family and mating pairs of his farm animals on a raft and moved them to higher ground. End of story. As REO Speedwagon sang, 'the tales grow taller on down the line'!"

"Seriously?" she asked, laughing.

"Seriously. That has zero to do with the theological significance. And I'm sorry, but I need to get Rachel and head home to meet Kris."

Clarissa walked with me to daycare, where I retrieved my daughter from Jackie.