More on pain rating scales, xkcd weighs in

Following up on Hyperbole and a Half's critique of the Wong-Baker Scale, xkcd weighs in on anchors of common assessment scales.

His mouseover caption presses the point: "If it were a two or above, I couldn't answer because it would mean a pause in the screaming."

This reminds me of a conversation with a friend about the pragmatics of rating the pain which brought you to the doctor's office. Our consensus: Rating the pain a 6 is high enough that the doctor will take you seriously, but not so high that they think you're lying or make the wrong diagnosis.

Preferring more pain to less

In his recent Why feeling more pain may be better for you, Tom Stafford reminds us of the classic Kahneman study which yielded both the Peak End rule and succor to sadistic proctologists.

If that description didn't tempt you to go read the column, here's the super short version: Kahneman found that when asked how bad a painful experience was, people recall (roughly) the average of how bad it was at it's worst --the 'peak'-- and how bad it was at the end --the, uh, 'end'. This, Kahneman claims, raises a real ethical dilemma:

Imagine a physician conducting a colonoscopy; the patient is in intense pain. The examination is complete and the physician could terminate the procedure now, providing instant relief --and a permanently negative evaluation of the whole episode. Should the physician seek the patient's consent to extend the pain for a while in order to form and retain an improved opinion of the procedure….a patient who has had two otherwise identical procedures that differ in the abruptnees of relief will prefer [the one with] more total pain but provides a better end….When the experiencing self and the remembering self disagree, whom are we to believe? (1994, p.21)

Stafford doesn't answer this question. Rather he turns to the Peak-End Rule as a broader phenomena (as other research shows) to make a different point

"But I think the most important lesson of the Peak-End experiments is something else. Rather than saying that the duration isn't important, the rule tells me that it is just as important to control how we mentally package our time. What defines an “experience” is somewhat arbitrary. If a weekend break where you forget everything can be as refreshing as a two-week holiday then maybe a secret to a happy life is to organise your time so it is broken up into as many distinct (and enjoyable) experiences as possible, rather than being just an unbroken succession of events which bleed into one another in memory."

I have to politely demur on what's the most interesting lesson. I've spent the last 10 years ---my entire professional career thus far--- thinking about some of the deep philosophical issues Kahneman's question raises.

Presumably, as Kahneman notes, none of us as patients would agree (while in pain) to the physician prolonging our pain. But we would then look jealously upon our friend whose doctor didn't ask her permission and whose colonoscopy was (as she recalls it) easier than our own. From our deathbed perspectives, my life contained more suffering. It was in that respect worse than hers.

Of course, we're both mistaken about how our total suffering compares. Arguably, in some cases, our lives can be better or worse than we believe them to be. If your loved ones' affection had been a cruel facade behind which they constantly ridiculed you, even though you never found out, your life was still worse than you thought it was. But are mistakes about how much we suffered like this?

Look at what's going on here. We need to decide what makes pain bad. We need to figure out how to aggregate goods (e.g., do we simply add up the good and bad?). We need to understand what constitutes human well-being ---to decide what makes a life as a whole good. We need to deal with organic unities (i.e., whether the arrangement of a good and a bad may yield an overall value that's different from the simple sum --schadenfreude is a common example). We need to deal with the asymmetries of past and future pains. Indeed, this road takes us straight to fundamental questions about the nature of intrinsic value. (That's the road I followed to my dissertation)

John Broome took this issue up in his 1996 'More pain or less?' with the straightforward claim that the person's mistaken evaluations are irrelevant. Pains are intrinsically bad. There should be less of it.

Stephanie Beardman who was finishing up at Rutgers just as I entered, came up with a more sophisticated response in her The choice between current and retrospective evaluations of pain (here's a pdf). In it she sets out several alternative interpretations of Kahneman's results and articulates some ways in which our preferences about past experiences may be more sophisticated than they at first seem.

Since she does a lot of what philosophers do best ---laying out the conceptual territory--- some of you empirically-minded folks may find it a useful source for developing uninvestigated hypotheses. It's also just a very nice gateway to some of the deep philosophical issues lurking just beneath the surface of seemingly easy questions. (Though be forewarned, it's a gateway drug too. A few early conversations with Stephanie definitely played a role in my getting hooked). In any event, you should read it.

What's bad about masochistic pain?

Here's the video from the talk I gave back in April about whether masochistic pain is good:

http://www.adamswenson.net/HSG/HSG1.html

But since it's just me reading the paper aloud, you'll probably want to skip ahead and just watch the discussion:

Part 1 http://www.adamswenson.net/HSG/HSG2.html
Part 2 http://www.adamswenson.net/HSG/HSG3.html

The paper and powerpoint slides are available on the website.

Warning: This is totally unsafe for work, and most definitely not for the squeamish. The talk proper may cause mild reactions in those allergic to analytic philosophy. Such reactions are less common with the discussion alone.

Confusing 'ameliorating' with 'obliterating'

I've seen several authors make this point, but in an email to me, reader SV put it in a very nice way:

"We physicians are called upon to "ameliorate" pain, which often is considered synonymous with "obliterating" pain."

This is a very important flip-side to the incredible advances that have been made in pain medicine and public expectations about treatment.


The way 'ameliorate' and 'obliterate' have gotten run together in the public's (and even in many physicians') expectations has a significant downside: In addition to being annoying and disappointing to all involved, there's a case to be made that this sometimes (often?) leads to worse treatment outcomes.

For example, if a patient expects complete relief from her pain, partial relief might leave her depressed, frustrated, and resigned. Attitudes like those can be some of the biggest factors in determining how bad a pain is.* This is especially the case with many chronic pain conditions.

Of course, we've come a long way from seeing pain as an inevitable concomitant of disease and treatment, and thus not a direct concern for the physician.

And, we've to a large degree gotten over the invidious tendency to heap moral condemnation upon those who don't suffer in silence, and to see all pains, including medical pains, as deserved (the words 'pain' and 'punishment' both have their roots in 'poena').

On that note, this story in the Boston Globe is important: The Day Pain Died: What Really Happened During the Most Famous Moment in Boston Medicine

So, I suppose its worth keeping some perspective on how much attitudes and expectations have come in a very short amount of time. Still, there's still a long way left to go.

--

*As always: These attitudes are not merely responses to the pain, they can become part of the pain itself.

It is a serious conceptual mistake to think of a patient who feels helpless and resigned in the face of her pain as (necessarily) being in two bad states:

(a) Her pain is bad to degree x

and

(b) Feeling helpless and resigned is bad to degree y.

Rather, these feelings are themselves parts of the pain. Their treatment is just as much a treatment of the pain itself as is the administration of morphine.

Whose problem is the diversion of opioids?

Okay. In the last post I mentioned that I get annoyed when concerns about opioids being diverted pop up in discussions about when opioids are indicated treatments. It's not that I don't think diversion is an important concern in drug policy. It's just that I feel like it shouldn't be part of discussions of when opioids are good treatments.

Anyway, I was annoyed by not knowing I feel this way.* So, the following is some off-the-cuff noodling about when concerns are relevant in decisions about the use of opioid drugs. I'm not at all sure about how much of it I want to stand behind. But hopefully it might be useful for sparking some discussion.

*I remember someone once telling me that philosophy starts with a sense of wonder. I have since found that, for me, it usually starts with annoyance; it ends in wonder.

-------------

In general, I tend to think that the dangers of opioid diversion --opioids ending up outside of the patient's hands-- get too much weight in discussions of drug policy (although some recent statistics on overdose and death rates involving opioids are giving me some pause in my beliefs about the severity of diversion's harms).

But in addition to questions about how severe the consequences of diversion are, we also need to know whose problem it is. A comprehensive drug policy spans many different areas including, inter alia, the law in its criminal, civil, and regulatory forms; professional determinations of best clinical practices; and individual clinicians' decisions about how to treat individual patients. Thus we need to know whether preventing diversion should have the same importance for everyone involved in the prescription drug arena.

I'm going to suggest that preventing diversion can be a legitimate concern at the more general levels. And they may inform doctors practices in a general way. But, I suspect, the potential harms resulting from diversion should not factor into a doctor's decisions about what medications to prescribe a patient.

My claims here will rest on the supposition that a clinician's ethical responsibilities arise from her patient's individual welfare. Her professional obligation is not the promotion of the general welfare via her interactions with a certain individual. The clinician's responsibility is to alleviate her patient's suffering in the safest and most effective way available.

A rough analogy may help bring out this distinction between duties based in the promotion of the general welfare and duties based in the promotion of an individual's welfare. In an adversarial system of criminal justice like we have in the United States, the role of a defense attorney is to advocate for her clients interests as best she can. Even if she recognized that her client's conviction may benefit the public at large, she is obligated to ignore that fact in doing her job. This doesn't mean that the job of defense attorney is entirely removed from the enterprise of promoting the public good. It's that a system in which a party is assigned to look out only for the interests of the defendant is more likely to be better overall. (One major disanalogy here is that my supposition about the source of the doctor's duties need not appeal to claims about what would best promote the general welfare.)

If we a clinician's duties as tied her patient's welfare in this way, concerns about the welfare of others are thus (nearly always) irrelevant to decisions about what substances to prescribe her patient. This suggests that even though the clinician may foresee that others may be harmed through diversion if she prescribes an opioid to a patient, this possibility should have no weight in her decision about what to prescribe. Her duty arises from and is directed at the health of her patients, not the health of people in general.

Obviously, this has its limits. Massive harms to others may trump this obligation. And it may be that if two treatments were exactly equal in their efficacy and safety, then considerations of the general good or other effects on others may break the tie.

Nor does this mean that the doctor must completely ignore the possibility that the drug will be diverted. Other public entities' interests in preventing diversion are based in their obligation to protect public health overall. But given the source of her professional obligations, the clinician's concerns about diversion should be limited to its effects on her patient's health.

Clearly, a responsible clinician must be attuned to the possibility that the patient herself will divert the drug. But her vigilance is not demanded by the need to prevent harms to the recipients of the diversion. It comes from her responsibilities to the patient. The clinician's treatment decisions must be based on the supposition that the patient will comply with the prescribed regime. She cannot aim to promote an individual's welfare by prescribing her a substance that she believes that the patient will not take. Therefore, the belief that the patient will take the drug as prescribed is a necessary condition of justifiably prescribing an opioid.

Suppose that a patient is accompanied by a stoned adolescent whose T-shirt reads "I love drugs!" Does this necessary condition imply that she ought to take into consideration the likelihood that the son will divert the drugs?

The answer seems to be yes. She cannot prescribe a medication to benefit her patient if she believes that the patient won't take the drug because someone else will steal it. Of course, it's unlikely that the suspicion in this case would justify her refusing to prescribe an otherwise indicated opioid Much will hang on the strength of her conviction that the drug will be diverted. In the drug diverting adolescent case, the clinician may be required to put special emphasis on the need to keep control of the medication in counseling the patient. But as long as she can be satisfied that the patient will be reasonably vigilant, she will be justified in writing the prescription. Her uncertainty about the likelihood of diversion combined with the need to respect the patient's autonomy will set the bar for reasonable vigilance pretty low.

Cases in which she should altogether refuse to prescribe on these grounds will likely be rare. But they are easy to imagine. Suppose that a disabled patient is completely dependent on her caretaker for all of her medications. If the clinician was convinced that the caretaker would divert a significant portion of the prescribed opioid, then she should not write the prescription. Indeed, doing so would be tantamount to writing the prescription for the caretaker. Though, she may have some obligation to seek other ways of getting the indicated treatment to the patient (e.g., recommending at home nursing visits, and patient treatment).

What's important is the way concerns about diversion are figuring in here. A clinician should be cautious of diversion insofar as it would interfere with her patient's treatment. Her responsibilities do not depend on how the recipients of the diverted substance may be affected. Those dangers of diversion give her reason to, for example, keep her cabinets locked. But they should be irrelevant to her decisions about patients' treatments.

This is not to say that a comprehensive drug policy should not be concerned about the harms to non-patients who gain access to opioids through diversion. It is a fact that the availability of opioids in legitimate channels will involve some diversion and some non- patients will be harmed. While the clinician's responsibility is based in her individual patient's welfare, government policies are properly attuned to protecting welfare across the board. Thus entities (in the US) like the FDA, the Department of Justice and the DEA are justified in creating policies and enforcement practices which will minimize the amount of diversion.

But this picture of the clinician's obligations does create tension between the government's proper aims creating drug policy and the duties of clinicians. We should thus want a principled way of resolving these kinds of inevitable conflict. One possibility is that one set of considerations will always trump the other (that is, the first set is lexically prior to the other).

To see the implications of a lexical ordering of these considerations suppose that the paramount consideration in shaping drug policy was ensuring clinicians' abilities to carry out their duties to their patients. This would have implications for how we decide conflicts. Such a partial lexical ordering would entail that the protection of access to safe and effective drugs cannot be trumped by considerations about diversion. More generally, this might mean that any proposed policy that would promote the general good could be vetoed if it unreasonably affected the ability of clinicians to treat their patients.

This ordering of concerns would be unlikely to undermine reasonable restrictions on the use and prescription of opioids. For example, this is compatible with a well regulated and organized system for inventory control in the manufacturing, shipping, and distribution of opioids. The same is true for methods of verifying the legitimacy of prescriptions and the identity of patients. But some apparently relatively mild restrictions on prescribing ability may not be compatible with this set of drug policy priorities.

For example, the FDA is presently considering requiring all clinicians who prescribe powerful long-acting opioids to have a special certification. Many general practice clinicians who currently prescribe such medications may be unwilling to go through the hassle of obtaining and maintaining the certification. If the certification process was unduly difficult, many clinicians would be unable to prescribe the medications that they thought were best indicated for their patients conditions. Such a regulation would likely decrease the number of deaths from diversion. But no matter how many diversion related deaths would be prevented, it should be rejected if we believe that the clinician's abilities to treat their patients should always trump any other consideration.

So, in sum, here's what I've suggested: If we think about the source and nature of clinicians' professional obligations in a particular way, then concerns about diversion should not play a role in determining whether to prescribe an opioid (outside of diversion undermining the treatment regime). Direct focus on preventing diversion is instead the job of regulatory agencies whose mission is the common public good.

I haven't given any argument in favor of the further idea that concerns about diversion should always be subordinated to clinicians ability to prescribe opioids as they see fit. Though I am definitely attracted to this view. We can leave that a subject for another post.

Opioids often preferable to NSAID's in the elderly

This is important.

The NYT reports that in light of findings that

[in elderly patients] The risks of Nsaids include ulcers and gastrointestinal bleeding and, with some drugs, an increased risk of heart attacks or strokes. The drugs do not interact well with medicines for heart failure and other conditions, and may increase high blood pressure and affect kidney function, experts said.

The American Geriatrics Society

removed those everyday medicines, called Nsaids, for nonsteroidal anti-inflammatory drugs, from the list of drugs recommended for frail elderly adults with persistent pain. The panel said the painkillers should be used “rarely” in that population, “with extreme caution” and only in “highly selected individuals.”
[....]
“We’ve come out a little strong at this point in time about the risks of Nsaids in older people,” said Dr. Bruce Ferrell, a professor of geriatrics at U.C.L.A. who is chairman of the panel. “We hate to throw the baby out with the bathwater — they do work for some people — but it is fairly high risk when these drugs are given in moderate to high doses, especially when given over time.

“It looks like patients would be safer on opioids than on high doses of Nsaids for long periods of time,” he continued

Link (My italics; I've interpolated the order of the paragraphs)

Editorial comment: I'm unhappy that the reporter chose to use this quote in emphasizing that opioids have their own dangers:

“We’re seeing huge increases nationwide of reports about the misuse and diversion of prescription drugs and related deaths,” said Dr. Roger Chou, a pain expert who was not involved in writing the guidelines for the elderly but directed the clinical guidelines program for the American Pain Society. “The concerns about opioids are very real.”

Diversion of opioids is a real problem. But it really annoys me to see it used as a counterpoint in discussions of their clinical usefulness.

I almost feel like these claims are saying something like: Advil might kill Grandma, but we might not want to give her a safer treatment because her grandson might steal it and kill himself.' (I don't think the reporter or Dr. Chou intended it this way --that's just how I take it)

Update: I was bothered by not knowing why the stuff about diversion annoys me so much. So I've posted some very rough thoughts here.

ABC story on FDA Acetaminophen overdose report

With every changing of the seasons comes a new set of cautions about acetaminophen use.

Like the changing of the leaves, experts call for better public education and packaging practices.

And, like the migration of the butterflies^, the pharmaceutical industry tells them to go f*** themselves:

McNeil Consumer Healthcare, a Johnson & Johnson subsidiary and the manufacturer of Tylenol, said in a statement Thursday that they fear the [FDA report's] recommendations could have the effect of steering consumers away from an appropriate and safe drug.

"While we share the FDA's mutual goal of preventing and decreasing the misuse and overdose of acetaminophen, we have concerns that some of the FDA recommendations could discourage appropriate use and are not necessary to addressing the root causes of acetaminophen overdose," the statement reads. Link

See this show again in a few months and a couple thousand more deaths.

^Sorry for the bad simile

Pain in animal slaughter

Newsflash!

Cutting calves throats hurts, study says...

A re-evaluation of the need to stun calves prior to slaughter by ventral-neck incision : An introductory review.: "

N Z Vet J. 2009 Apr; 57(2): 74-6
Mellor DJ, Gibson TJ, Johnson CB

Commercial slaughter of farm livestock usually employs an extensive incision that severs the soft tissues of the neck including the major blood vessels supplying and draining the brain. It is intended to cause a catastrophic decrease in cerebral blood flow with rapid onset of unconsciousness or insensibility. The tissues of the neck are innervated with nociceptive nerve fibres and their transection will cause a barrage of sensory impulses. Consciousness, and therefore the ability of the animal to feel pain and experience distress after the incision, may persist for 60 seconds or longer in cattle. These observations suggest that livestock may experience pain and distress during the period before they become unconscious (insensible). Psychological shock and fear may also be associated with the extensive tissue damage and blood loss. Pre-incision stunning has been adopted as a precautionary measure to prevent suffering. However, the question remains: How intense and noxious are these experiences? Recent methodological developments related to quantitative analysis of the electroencephalogram (EEG) allow the experience of pain to be assessed more directly than has hitherto been possible. This methodology has now been applied to the question of the slaughter of calves by ventral-neck incision. The new information demonstrates clearly for the first time that the act of slaughter by ventral-neck incision is associated with noxious stimulation that would be expected to be perceived as painful in the period between the incision and loss of consciousness. These data provide further support for the value of stunning in preventing pain and distress in animals subjected to this procedure."

(Via HubMed - pain.)

Palliative care for a patient with anorexia nervosa

Pallimed brings up a very hard case. I'm honestly not sure what I think about much of this:

Palliative care & eating disorders: "The International Journal of Eating Disorders has a case report and discussion of a patient with refractory anorexia nervosa who died receiving hospice care. This is one fascinating case report. The case, to summarize briefly, involved a young woman with a long history of anorexia nervosa, refractory to all attempts at treatment (including involuntary/forced treatment) who apparently also was not deemed a candidate for forced guardianship (the hospital's legal counsel advised she would not meet requirements to be declared incompetent).

This is how they describe the ethics committee's response to the case:

The committee’s members struggled to understand how one could die from a psychiatric illness (other than by suicide or unintentional overdose) and were not sure how to proceed. Although they could delineate the differences between acute mental health risks such as suicide, drug overdoses, psychosis or self-neglect, they had no points of reference regarding how to manage a patient who was chronically a danger to herself, unwilling to engage in further treatments, and unresponsive to all prior attempts to treat her involuntarily. The only examples the committee raised for comparison concerned drug users who received heart valve replacements, yet continued to use, knowing that such ongoing use would kill them. In such cases, if a high risk of ongoing subsequent IV drug use was suspected ahead of time, the decision was often made not to provide valve replacements, but there was no forced treatment.

This is how they presented what palliative care for anorexia nervosa would look like to the patient (italics mine):

If she chose to pursue treatment she would be assisted, but the staff would not force her into any involuntary placements or impose any treatment she did not want. There would be no weigh-ins, no calorie or exercise monitoring, no IM medications and no required therapy sessions. She would be offered outpatient therapy only as she felt desirable and necessary. Psychiatric medications would be prescribed as the patient deemed necessary to help manage depression, anxiety and insomnia. The patient would receive weekly visits from a palliative care nurse, who would work with her to manage her symptoms and keep her comfortable. The patient agreed to no further hospitalizations, but did not fully agree with the plan for ‘‘palliative care’’ since she did not believe she was going to die.

The patient basically continued her illness behaviors, got weaker/sicker, and was eventually enrolled in an inpatient hospice where she died.

Some observations.

1. AN is clearly at times a terminal illness, refractory to all attempts to reverse it.
2. In this case it was clear that the patient's life could have been prolonged although only with forced treatment. It was the opinion of her physicians that such forced treatment, while life-prolonging, would not 'cure' her AN (for some patients a trial, or many trials, of forced nutritional treatment along with psychiatric care gets them to the point at which they are willing to continue with voluntary treatment and can have a durable response; it was felt this would never happen with this patient). Thus the decision came down to trying to force further involuntary treatment vs. letting the disease run its natural course with her inevitably dying.
3. I found it interesting that they did not feel there was enough of a chance she'd be considered incompetent that they didn't even put her through the court process. Her statement that she did not think she would die (and it seems she continued that belief until the end, and persisted at least until she was enrolled in hospice in saying that she in fact wanted to live) seems to me to indicate such a fundamental lack of insight into her condition that I'm not sure I believe that. Granted, I'm not too familiar with criteria for declaring someone incompetent on psychiatric grounds, but I assume it has something to do with one's mental illness being such that one cannot even take in basic medical information.
4. That said, and even if she was legally stripped of her decision-making rights, for situations in which even involuntary treatment would not work long-term, is it right to force patients to do that? In this situation they concluded No, and made plans accordingly, which seemed to work as well as could be expected under the circumstances.

[A very interesting discussion follows in the rest. Definitely give it a read]

(Via Pallimed: A Hospice & Palliative Medicine Blog.)

Guide to torture justifications

Having trouble keeping up with the lines of justification for the US torture regime? Digby brings you a handy chart:


Go here for a larger version.

Another new paper by me: Privation Theories of Pain

Yep. More from me. This time in a philosophy of religion journal --guess I'm branching out.

Privation Theories of Pain

Most modern writers accept that a privation theory of evil should explicitly account for the evil of pain. But pains are quintessentially real. The evil of pain does not seem to lie in an absence of good. Though many directly take on the challenges this raises, the metaphysics and axiology of their answers is often obscure. In this paper I try to straighten things out. By clarifying and categorizing the possible types of privation views, I explore the ways in which privationists about evil are—or should or could be—privationists about pain’s evil.

International Journal for Philosophy of Religion (2009)
DOI: 10.1007/s11153-009-9202-4
http://www.springerlink.com/content/644751l635n21r71/

Super awesome paper: Pain's Evils

Okay. I'm lying. It isn't really super awesome. But it is a new paper by me in the latest issue of the journal Utilitas:

Pain's Evils

The traditional accounts of pain’s intrinsic badness assume a false view of what pains are. Insofar as they are normatively significant, pains are not just painful sensations. A pain is a composite of a painful sensation and a set of beliefs, desires, emotions, and other mental states. A pain’s intrinsic properties can include inter alia depression, anxiety, fear, desires, feelings of helplessness, and the pain’s meaning. This undermines the traditional accounts of pain’s intrinsic badness. Pain is intrinsically bad in two distinct and historically unnoticed ways. First, most writers hold that pain’s intrinsic badness lies either in its unpleasantness or in its being disliked. Given my wider conception of pain, I believe it is both. Pain’s first intrinsic evil lies in a conjunction of all the traditional candidates for its source. Pain’s second intrinsic evil lies in the way it necessarily undermines the self-control necessary for intrinsic goods like autonomy.

Utilitas Vol. 21 No. 2 June 2009
doi:10.1017/S0953820809003550

More drugs, please: Italian edition

May I have your attention please?

Ahem.

STOP DENYING CANCER PATIENTS THE MEDICINE THEY NEED.

Thank you for your attention

Pattern and quality of care of cancer pain management. Results from the Cancer Pain Outcome Research Study Group.: "

Br J Cancer. 2009 Apr 28;
Apolone G, Corli O, Caraceni A, Negri E, Deandrea S, Montanari M, Greco MT

Most patients with advanced or metastatic cancer experience pain and despite several guidelines, undertreatment is well documented. A multicenter, open-label, prospective, non-randomised study was launched in Italy in 2006 to evaluate the epidemiology, patterns and quality of pain care of cancer patients. To assess the adequacy of analgesic care, we used a standardised measure, the pain management index (PMI), that compares the most potent analgesic prescribed for a patient with the reported level of the worst pain of that patient together with a selected list of clinical indicators. A total of 110 centres recruited 1801 valid cases. 61% of cases were received a WHO-level III opioid; 25.3% were classified as potentially undertreated, with wide variation (9.8-55.3%) according to the variables describing patients, centres and pattern of care. After adjustment with a multivariable logistic regression model, type of recruiting centre, receiving adjuvant therapy or not and type of patient recruited (new or already on follow-up) had a significant association with undertreatment. Non-compliance with the predefined set of clinical indicators was generally high, ranging from 41 to 76%. Despite intrinsic limitations of the PMI that may be considered as an indicator of the poor quality of cancer pain care, results suggest that the recourse to WHO third-level drugs still seems delayed in a substantial percentage of patients. This delay is probably related to several factors affecting practice in participating centres and suggests that the quality of cancer pain management in Italy deserves specific attention and interventions aimed at improving patients' outcomes.British Journal of Cancer advance online publication, 28 April 2009; doi:10.1038/sj.bjc.6605053 www.bjcancer.com."

(Via HubMed - pain.)

Pain in infants and very young children

Interesting. Though, as always, these neurological facts don't by themselves entail any ethical conclusions. Of course, it would be nice to see standard practice err on the side of preventing as much pain as is clinically feasible.

"Pain, Hurt, and Harm: The Ethics of Pain Control in Infants and Children" in The New England Journal of Medicine (Vol. 331.8):

Many myths about pain in children have been discredited. One myth was the belief that very young infants do not have the neurologic capacity to experience pain. Neuroanatomical studies, however, have shown that by 29 weeks of gestation, pain pathways and the cortical and subcortical centers involved in the perception of pain are well developed, as are the neurologic systems for the transmission and modulation of painful sensations 15. Behavioral16,17 and physiologic18 studies have shown that even very young infants respond to painful stimuli. Premature infants undergoing surgery with minimal anesthesia, which was once standard practice, have significantly higher stress responses (by hormonal and metabolic measures) and significantly higher rates of complications and mortality than those given deeper anesthesia.19,20

A related misunderstanding is the belief that even if very young children experience pain, they have no memory of it, and therefore it has no lasting effect. However, recent studies have concluded that pain and distress, such as those associated with circumcision, can endure in memory, resulting, for example, in disturbances of feeding, sleeping, and the stability of the state of arousal.21 Preliminary data even suggest that early experiences of pain may produce permanent structural and functional reorganization of developing nociceptive neural pathways, which in turn may affect future experiences of pain.22

Awesome.

Was torture part of the pep talk?
Suit alleges waterboarding used as motivational technique
By Erin Alberty
The Salt Lake Tribune
Salt Lake Tribune

A supervisor at a motivational coaching business in Provo is accused of waterboarding an employee in front of his sales team to demonstrate that they should work as hard on sales as the employee had worked to breathe.
In a lawsuit filed last month, former Prosper Inc. salesman Chad Hudgens alleges his managers also allowed the supervisor to draw mustaches on employees' faces, take away their chairs and beat on their desks with a wooden paddle "because it resulted in increased revenues for the company."
Prosper President Dave Ellis responded that the allegations amount to "sensationalized" versions of events that have gone uncorroborated by Hudgens' former coworkers.
"They just roll their eyes and say, 'This is ridiculous . . .. That's not how it went down,' '' Ellis said.
The suit claims that Hudgens' team leader, Joshua Christopherson, asked for volunteers in May for "a new motivational exercise," which he did not describe. Hudgens, who was 26 at the time, volunteered in order to "prove his loyalty and determination," the suit claims.
Christopherson led the sales team to the top of a hill near the office and told Hudgens to lie down with his head downhill, the suit claims. Christopherson then told the rest of the team to hold Hudgens by the arms and legs.
Christopherson poured water from a gallon jug over Hudgens' mouth and nostrils - like the interrogation strategy known as waterboarding - and told the team members to hold Hudgens down as he struggled, the suit alleges.
"At the conclusion of his abusive demonstration, Christopherson told the team that he wanted them to work as hard on making sales as Chad had worked to breathe while he was being waterboarded," the suit alleges.
Ellis said the exercise was a dramatization of a story in which a young man asks Socrates to become his teacher. Socrates responds by plunging the student's head underwater and telling him he will learn once his desire for knowledge is as great as his desire to breathe.
However, Ellis said Christopherson explained the exercise before Hudgens volunteered, no one held Hudgens down and Hudgens was free to get up if he was uncomfortable.
"It was meant to be a team-building exercise," Ellis said. "Everybody was . . . involved and enthusiastic."
Hudgens claims he complained to Prosper managers about the exercise, but no action was taken against Christopherson until Hudgens left Prosper.
Prosper attorney George Brunt said Hudgens lodged the complaint six weeks after the exercise; in the meantime, Hudgens joined his team on a water skiing retreat and drove the boat, Brunt said. Ellis said Christopherson was suspended for two weeks while managers investigated Hudgens' complaint. Christopherson returned to work and remains the sales team leader, Ellis said.
"It's incredible to even suggest that he would put anyone under a level of discomfort," Ellis said. "He's a really nice, pleasant, polite young man. He's very dedicated and takes his job very seriously."
However, the suit claims Christopherson "intentionally engaged in physically and emotionally abusive conduct" to punish workers who did not meet company performance goals.
"Prosper's management passed by and through Christopherson's team area and was able to see mustaches on its employees, missing chairs and Christopherson's paddle," the suit alleges. Ellis said no managers have said they saw the activities described in Hudgens' suit, and the employees reported they are "more along the lines of fun."
"It's voluntary, it's humorous, it's team and camaraderie-building," Ellis said.
Hudgens left Prosper because of sleeplessness, anxiety and depression he experienced after the waterboarding, the suit claims. He required psychological counseling for emotional trauma, the suit claims.
The suit accuses Christopherson and Prosper of assault and battery, intentional infliction of emotional distress and wrongful termination. It accuses Christopherson of interfering with Hudgens' employment relationship with Prosper.
Prosper "provides executive-level coaching for individuals," according to its Web site. Personal coaches offer mentoring that focuses on business and finance.
"Our mission is to provide our students with the education and hands-on experiences they need to achieve their personal and professional goals," the Web site claims. "We strive to make the road to personal achievement meaningful, rewarding, and enjoyable."
Link
H/T TPM

Might it be that the normalization of torture in our culture has not really been a good thing?

The Catholic Church on torture

Also from the same Harpers article, the official Catholic Church position on torture:

Respect for bodily integrity.

[2297.] Kidnapping and hostage taking bring on a reign of terror; by means of threats they subject their victims to intolerable pressures. They are morally wrong. Terrorism threatens, wounds, and kills indiscriminately; it is gravely against justice and charity. Torture which uses physical or moral violence to extract confessions, punish the guilty, frighten opponents, or satisfy hatred is contrary to respect for the person and for human dignity. Except when performed for strictly therapeutic medical reasons, directly intended amputations, mutilations, and sterilizations performed on innocent persons are against the moral law.

[2298.] In times past, cruel practices were commonly used by legitimate governments to maintain law and order, often without protest from the Pastors of the Church, who themselves adopted in their own tribunals the prescriptions of Roman law concerning torture. Regrettable as these facts are, the Church always taught the duty of clemency and mercy. She forbade clerics to shed blood. In recent times it has become evident that these cruel practices were neither necessary for public order, nor in conformity with the legitimate rights of the human person. On the contrary, these practices led to ones even more degrading. It is necessary to work for their abolition. We must pray for the victims and their tormentors.

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Scalia on torture

Sometimes its obvious why I'm not cut out for the judiciary. My little mind is not capable of such genius:

From Harpers:

Justice Scalia said it was “extraordinary” to assume that the ban on “cruel and unusual punishment”—the US Constitution’s Eighth Amendment—also applied to “so-called” torture. “To begin with the constitution… is referring to punishment for crime. And, for example, incarcerating someone indefinitely would certainly be cruel and unusual punishment for a crime.”

Justice Scalia argued that courts could take stronger measures when a witness refused to answer questions. “I suppose it’s the same thing about so-called torture. Is it really so easy to determine that smacking someone in the face to determine where he has hidden the bomb that is about to blow up Los Angeles is prohibited in the constitution?” he asked.

“It would be absurd to say you couldn’t do that. And once you acknowledge that, we’re into a different game. “How close does the threat have to be? And how severe can the infliction of pain be?”

Just so we're clear. We've now learned that the 8th Amendment is only about punishment. It does not cover what the state can do to you before they get around to punishing you.

The subjective experience of punishment

Friend of PFP has an intriguing article on sensitivity to punishment and punitive practices here.

Abstract:
Suppose two people commit the same crime and are sentenced to equal terms in the same prison facility. I argue that they have identical punishments in name only. One may experience incarceration as challenging but tolerable while the other is thoroughly tormented by it. Our sentencing policies seek to equalize the duration of their incarceration, yet largely ignore the differences in their experiences of isolation, stigma, and confinement. In this article, I argue that, according to our prevailing theories of punishment, the subjective experience of punishment matters. There is, therefore, a disconnect between our punishment practices and our best attempts to justify those practices.

There are three possible responses. First, we could try to modify or expand our theories to avoid the obligation to calibrate punishment. I show why this approach is unlikely to succeed. Second, we could conclude that, even though we ought to calibrate our punishments, doing so would be too costly or difficult to administer. This response is too hasty. In civil litigation, we do make subjective assessments of damages. Advances in neuroscience may someday make these assessments more accurate and less expensive. Even if we cannot individually calibrate punishments, we can surely enact sentencing policies that are more subjectively-sensitive than the policies we have now. We are left, then, with only the third response: to recognize that subjective experience matters in assessments of punishment severity and to take at least modest steps toward calibrating punishment, either through individual measurement or, more feasibly, by enacting punishment policies that are subjectively sensitive.

Krauthammer: The Truth about Torture

Remember this little bit of sunshine and rainbows?

The Truth about Torture
It's time to be honest about doing terrible things.
by Charles Krauthammer
12/05/2005, Volume 011, Issue 12


DURING THE LAST FEW WEEKS in Washington the pieties about torture have lain so thick in the air that it has been impossible to have a reasoned discussion. The McCain amendment that would ban "cruel, inhuman, or degrading" treatment of any prisoner by any agent of the United States sailed through the Senate by a vote of 90-9. The Washington establishment remains stunned that nine such retrograde, morally inert persons--let alone senators--could be found in this noble capital.

Now, John McCain has great moral authority on this issue, having heroically borne torture at the hands of the North Vietnamese. McCain has made fine arguments in defense of his position. And McCain is acting out of the deep and honorable conviction that what he is proposing is not only right but is in the best interest of the United States. His position deserves respect. But that does not mean, as seems to be the assumption in Washington today, that a critical analysis of his "no torture, ever" policy is beyond the pale.

Let's begin with a few analytic distinctions. For the purpose of torture and prisoner maltreatment, there are three kinds of war prisoners:

First, there is the ordinary soldier caught on the field of battle. There is no question that he is entitled to humane treatment. Indeed, we have no right to disturb a hair on his head. His detention has but a single purpose: to keep him hors de combat. The proof of that proposition is that if there were a better way to keep him off the battlefield that did not require his detention, we would let him go. Indeed, during one year of the Civil War, the two sides did try an alternative. They mutually "paroled" captured enemy soldiers, i.e., released them to return home on the pledge that they would not take up arms again. (The experiment failed for a foreseeable reason: cheating. Grant found that some paroled Confederates had reenlisted.)

Because the only purpose of detention in these circumstances is to prevent the prisoner from becoming a combatant again, he is entitled to all the protections and dignity of an ordinary domestic prisoner--indeed, more privileges, because, unlike the domestic prisoner, he has committed no crime. He merely had the misfortune to enlist on the other side of a legitimate war. He is therefore entitled to many of the privileges enjoyed by an ordinary citizen--the right to send correspondence, to engage in athletic activity and intellectual pursuits, to receive allowances from relatives--except, of course, for the freedom to leave the prison.

Second, there is the captured terrorist. A terrorist is by profession, indeed by definition, an unlawful combatant: He lives outside the laws of war because he does not wear a uniform, he hides among civilians, and he deliberately targets innocents. He is entitled to no protections whatsoever. People seem to think that the postwar Geneva Conventions were written only to protect detainees. In fact, their deeper purpose was to provide a deterrent to the kind of barbaric treatment of civilians that had become so horribly apparent during the first half of the 20th century, and in particular, during the Second World War. The idea was to deter the abuse of civilians by promising combatants who treated noncombatants well that they themselves would be treated according to a code of dignity if captured--and, crucially, that they would be denied the protections of that code if they broke the laws of war and abused civilians themselves.

Breaking the laws of war and abusing civilians are what, to understate the matter vastly, terrorists do for a living. They are entitled, therefore, to nothing. Anyone who blows up a car bomb in a market deserves to spend the rest of his life roasting on a spit over an open fire. But we don't do that because we do not descend to the level of our enemy. We don't do that because, unlike him, we are civilized. Even though terrorists are entitled to no humane treatment, we give it to them because it is in our nature as a moral and humane people. And when on rare occasions we fail to do that, as has occurred in several of the fronts of the war on terror, we are duly disgraced.

The norm, however, is how the majority of prisoners at Guantanamo have been treated. We give them three meals a day, superior medical care, and provision to pray five times a day. Our scrupulousness extends even to providing them with their own Korans, which is the only reason alleged abuses of the Koran at Guantanamo ever became an issue. That we should have provided those who kill innocents in the name of Islam with precisely the document that inspires their barbarism is a sign of the absurd lengths to which we often go in extending undeserved humanity to terrorist prisoners.

Third, there is the terrorist with information. Here the issue of torture gets complicated and the easy pieties don't so easily apply. Let's take the textbook case. Ethics 101: A terrorist has planted a nuclear bomb in New York City. It will go off in one hour. A million people will die. You capture the terrorist. He knows where it is. He's not talking.

Question: If you have the slightest belief that hanging this man by his thumbs will get you the information to save a million people, are you permitted to do it?

Now, on most issues regarding torture, I confess tentativeness and uncertainty. But on this issue, there can be no uncertainty: Not only is it permissible to hang this miscreant by his thumbs. It is a moral duty.

Yes, you say, but that's an extreme and very hypothetical case. Well, not as hypothetical as you think. Sure, the (nuclear) scale is hypothetical, but in the age of the car-and suicide-bomber, terrorists are often captured who have just set a car bomb to go off or sent a suicide bomber out to a coffee shop, and you only have minutes to find out where the attack is to take place. This "hypothetical" is common enough that the Israelis have a term for precisely that situation: the ticking time bomb problem.

And even if the example I gave were entirely hypothetical, the conclusion--yes, in this case even torture is permissible--is telling because it establishes the principle: Torture is not always impermissible. However rare the cases, there are circumstances in which, by any rational moral calculus, torture not only would be permissible but would be required (to acquire life-saving information). And once you've established the principle, to paraphrase George Bernard Shaw, all that's left to haggle about is the price. In the case of torture, that means that the argument is not whether torture is ever permissible, but when--i.e., under what obviously stringent circumstances: how big, how imminent, how preventable the ticking time bomb.

That is why the McCain amendment, which by mandating "torture never" refuses even to recognize the legitimacy of any moral calculus, cannot be right. There must be exceptions. The real argument should be over what constitutes a legitimate exception.

Let's Take An Example that is far from hypothetical. You capture Khalid Sheikh Mohammed in Pakistan. He not only has already killed innocents, he is deeply involved in the planning for the present and future killing of innocents. He not only was the architect of the 9/11 attack that killed nearly three thousand people in one day, most of them dying a terrible, agonizing, indeed tortured death. But as the top al Qaeda planner and logistical expert he also knows a lot about terror attacks to come. He knows plans, identities, contacts, materials, cell locations, safe houses, cased targets, etc. What do you do with him?

We have recently learned that since 9/11 the United States has maintained a series of "black sites" around the world, secret detention centers where presumably high-level terrorists like Khalid Sheikh Mohammed have been imprisoned. The world is scandalized. Black sites? Secret detention? Jimmy Carter calls this "a profound and radical change in the . . . moral values of our country." The Council of Europe demands an investigation, calling the claims "extremely worrying." Its human rights commissioner declares "such practices" to constitute "a serious human rights violation, and further proof of the crisis of values" that has engulfed the war on terror. The gnashing of teeth and rending of garments has been considerable.

I myself have not gnashed a single tooth. My garments remain entirely unrent. Indeed, I feel reassured. It would be a gross dereliction of duty for any government not to keep Khalid Sheikh Mohammed isolated, disoriented, alone, despairing, cold and sleepless, in some godforsaken hidden location in order to find out what he knew about plans for future mass murder. What are we supposed to do? Give him a nice cell in a warm Manhattan prison, complete with Miranda rights, a mellifluent lawyer, and his own website? Are not those the kinds of courtesies we extended to the 1993 World Trade Center bombers, then congratulated ourselves on how we "brought to justice" those responsible for an attack that barely failed to kill tens of thousands of Americans, only to discover a decade later that we had accomplished nothing--indeed, that some of the disclosures at the trial had helped Osama bin Laden avoid U.S. surveillance?

Have we learned nothing from 9/11? Are we prepared to go back with complete amnesia to the domestic-crime model of dealing with terrorists, which allowed us to sleepwalk through the nineties while al Qaeda incubated and grew and metastasized unmolested until on 9/11 it finished what the first World Trade Center bombers had begun?

Let's assume (and hope) that Khalid Sheikh Mohammed has been kept in one of these black sites, say, a cell somewhere in Romania, held entirely incommunicado and subjected to the kind of "coercive interrogation" that I described above. McCain has been going around praising the Israelis as the model of how to deal with terrorism and prevent terrorist attacks. He does so because in 1999 the Israeli Supreme Court outlawed all torture in the course of interrogation. But in reality, the Israeli case is far more complicated. And the complications reflect precisely the dilemmas regarding all coercive interrogation, the weighing of the lesser of two evils: the undeniable inhumanity of torture versus the abdication of the duty to protect the victims of a potentially preventable mass murder.

In a summary of Israel's policies, Glenn Frankel of the Washington Post noted that the 1999 Supreme Court ruling struck down secret guidelines established 12 years earlier that allowed interrogators to use the kind of physical and psychological pressure I described in imagining how KSM might be treated in America's "black sites."

"But after the second Palestinian uprising broke out a year later, and especially after a devastating series of suicide bombings of passenger buses, cafes and other civilian targets," writes Frankel, citing human rights lawyers and detainees, "Israel's internal security service, known as the Shin Bet or the Shabak, returned to physical coercion as a standard practice." Not only do the techniques used "command widespread support from the Israeli public," but "Israeli prime ministers and justice ministers with a variety of political views," including the most conciliatory and liberal, have defended these techniques "as a last resort in preventing terrorist attacks."

Which makes McCain's position on torture incoherent. If this kind of coercive interrogation were imposed on any inmate in the American prison system, it would immediately be declared cruel and unusual, and outlawed. How can he oppose these practices, which the Israelis use, and yet hold up Israel as a model for dealing with terrorists? Or does he countenance this kind of interrogation in extreme circumstances--in which case, what is left of his categorical opposition to inhuman treatment of any kind?

But let us push further into even more unpleasant territory, the territory that lies beyond mere coercive interrogation and beyond McCain's self-contradictions. How far are we willing to go?

This "going beyond" need not be cinematic and ghoulish. (Jay Leno once suggested "duct tape" for Khalid Sheikh Mohammed. See photo.) Consider, for example, injection with sodium pentathol. (Colloquially known as "truth serum," it is nothing of the sort. It is a barbiturate whose purpose is to sedate. Its effects are much like that of alcohol: disinhibiting the higher brain centers to make someone more likely to disclose information or thoughts that might otherwise be guarded.) Forcible sedation is a clear violation of bodily integrity. In a civilian context it would be considered assault. It is certainly impermissible under any prohibition of cruel, inhuman, or degrading treatment.

Let's posit that during the interrogation of Khalid Sheikh Mohammed, perhaps early on, we got intelligence about an imminent al Qaeda attack. And we had a very good reason to believe he knew about it. And if we knew what he knew, we could stop it. If we thought we could glean a critical piece of information by use of sodium pentathol, would we be permitted to do so?

Less hypothetically, there is waterboarding, a terrifying and deeply shocking torture technique in which the prisoner has his face exposed to water in a way that gives the feeling of drowning. According to CIA sources cited by ABC News, Khalid Sheikh Mohammed "was able to last between two and 2 1/2 minutes before begging to confess." Should we regret having done that? Should we abolish by law that practice, so that it could never be used on the next Khalid Sheikh Mohammed having thus gotten his confession?

And what if he possessed information with less imminent implications? Say we had information about a cell that he had helped found or direct, and that cell was planning some major attack and we needed information about the identity and location of its members. A rational moral calculus might not permit measures as extreme as the nuke-in-Manhattan scenario, but would surely permit measures beyond mere psychological pressure.

Such a determination would not be made with an untroubled conscience. It would be troubled because there is no denying the monstrous evil that is any form of torture. And there is no denying how corrupting it can be to the individuals and society that practice it. But elected leaders, responsible above all for the protection of their citizens, have the obligation to tolerate their own sleepless nights by doing what is necessary--and only what is necessary, nothing more--to get information that could prevent mass murder.

GIVEN THE GRAVITY OF THE DECISION, if we indeed cross the Rubicon--as we must--we need rules. The problem with the McCain amendment is that once you have gone public with a blanket ban on all forms of coercion, it is going to be very difficult to publicly carve out exceptions. The Bush administration is to be faulted for having attempted such a codification with the kind of secrecy, lack of coherence, and lack of strict enforcement that led us to the McCain reaction.

What to do at this late date? Begin, as McCain does, by banning all forms of coercion or inhuman treatment by anyone serving in the military--an absolute ban on torture by all military personnel everywhere. We do not want a private somewhere making these fine distinctions about ticking and slow-fuse time bombs. We don't even want colonels or generals making them. It would be best for the morale, discipline, and honor of the Armed Forces for the United States to maintain an absolute prohibition, both to simplify their task in making decisions and to offer them whatever reciprocal treatment they might receive from those who capture them--although I have no illusion that any anti-torture provision will soften the heart of a single jihadist holding a knife to the throat of a captured American soldier. We would impose this restriction on ourselves for our own reasons of military discipline and military honor.

Outside the military, however, I would propose, contra McCain, a ban against all forms of torture, coercive interrogation, and inhuman treatment, except in two contingencies: (1) the ticking time bomb and (2) the slower-fuse high-level terrorist (such as KSM). Each contingency would have its own set of rules. In the case of the ticking time bomb, the rules would be relatively simple: Nothing rationally related to getting accurate information would be ruled out. The case of the high-value suspect with slow-fuse information is more complicated. The principle would be that the level of inhumanity of the measures used (moral honesty is essential here--we would be using measures that are by definition inhumane) would be proportional to the need and value of the information. Interrogators would be constrained to use the least inhumane treatment necessary relative to the magnitude and imminence of the evil being prevented and the importance of the knowledge being obtained.

These exceptions to the no-torture rule would not be granted to just any nonmilitary interrogators, or anyone with CIA credentials. They would be reserved for highly specialized agents who are experts and experienced in interrogation, and who are known not to abuse it for the satisfaction of a kind of sick sadomasochism Lynndie England and her cohorts indulged in at Abu Ghraib. Nor would they be acting on their own. They would be required to obtain written permission for such interrogations from the highest political authorities in the country (cabinet level) or from a quasi-judicial body modeled on the Foreign Intelligence Surveillance Court (which permits what would ordinarily be illegal searches and seizures in the war on terror). Or, if the bomb was truly ticking and there was no time, the interrogators would be allowed to act on their own, but would require post facto authorization within, say, 24 hours of their interrogation, so that they knew that whatever they did would be subject to review by others and be justified only under the most stringent terms.

One of the purposes of these justifications would be to establish that whatever extreme measures are used are for reasons of nothing but information. Historically, the torture of prisoners has been done for a variety of reasons apart from information, most prominently reasons of justice or revenge. We do not do that. We should not do that. Ever. Khalid Sheikh Mohammed, murderer of 2,973 innocents, is surely deserving of the most extreme suffering day and night for the rest of his life. But it is neither our role nor our right to be the agents of that suffering. Vengeance is mine, sayeth the Lord. His, not ours. Torture is a terrible and monstrous thing, as degrading and morally corrupting to those who practice it as any conceivable human activity including its moral twin, capital punishment.

If Khalid Sheikh Mohammed knew nothing, or if we had reached the point where his knowledge had been exhausted, I'd be perfectly prepared to throw him into a nice, comfortable Manhattan cell and give him a trial to determine what would be fit and just punishment. But aslong as he had useful information, things would be different.

Very different. And it simply will not do to take refuge in the claim that all of the above discussion is superfluous because torture never works anyway. Would that this were true. Unfortunately, on its face, this is nonsense. Is one to believe that in the entire history of human warfare, no combatant has ever received useful information by the use of pressure, torture, or any other kind of inhuman treatment? It may indeed be true that torture is not a reliable tool. But that is very different from saying that it is never useful.

The monstrous thing about torture is that sometimes it does work. In 1994, 19-year-old Israeli corporal Nachshon Waxman was kidnapped by Palestinian terrorists. The Israelis captured the driver of the car used in the kidnapping and tortured him in order to find where Waxman was being held. Yitzhak Rabin, prime minister and peacemaker, admitted that they tortured him in a way that went even beyond the '87 guidelines for "coercive interrogation" later struck down by the Israeli Supreme Court as too harsh. The driver talked. His information was accurate. The Israelis found Waxman. "If we'd been so careful to follow the ['87] Landau Commission [which allowed coercive interrogation]," explained Rabin, "we would never have found out where Waxman was being held."

In the Waxman case, I would have done precisely what Rabin did. (The fact that Waxman's Palestinian captors killed him during the Israeli rescue raid makes the case doubly tragic, but changes nothing of the moral calculus.) Faced with a similar choice, an American president would have a similar obligation. To do otherwise--to give up the chance to find your soldier lest you sully yourself by authorizing torture of the person who possesses potentially lifesaving information--is a deeply immoral betrayal of a soldier and countryman. Not as cosmically immoral as permitting a city of one's countrymen to perish, as in the Ethics 101 case. But it remains, nonetheless, a case of moral abdication--of a kind rather parallel to that of the principled pacifist. There is much to admire in those who refuse on principle ever to take up arms under any conditions. But that does not make pure pacifism, like no-torture absolutism, any less a form of moral foolishness, tinged with moral vanity. Not reprehensible, only deeply reproachable and supremely impracticable. People who hold such beliefs are deserving of a certain respect. But they are not to be put in positions of authority. One should be grateful for the saintly among us. And one should be vigilant that they not get to make the decisions upon which the lives of others depend.

WHICH BRINGS US to the greatest irony of all in the torture debate. I have just made what will be characterized as the pro-torture case contra McCain by proposing two major exceptions carved out of any no-torture rule: the ticking time bomb and the slow-fuse high-value terrorist. McCain supposedly is being hailed for defending all that is good and right and just in America by standing foursquare against any inhuman treatment. Or is he?

According to Newsweek, in the ticking time bomb case McCain says that the president should disobey the very law that McCain seeks to pass--under the justification that "you do what you have to do. But you take responsibility for it." But if torturing the ticking time bomb suspect is "what you have to do," then why has McCain been going around arguing that such things must never be done?

As for exception number two, the high-level terrorist with slow-fuse information, Stuart Taylor, the superb legal correspondent for National Journal, argues that with appropriate legal interpretation, the "cruel, inhuman, or degrading" standard, "though vague, is said by experts to codify . . . the commonsense principle that the toughness of interrogation techniques should be calibrated to the importance and urgency of the information likely to be obtained." That would permit "some very aggressive techniques . . . on that small percentage of detainees who seem especially likely to have potentially life-saving information." Or as Evan Thomas and Michael Hirsh put it in the Newsweek report on McCain and torture, the McCain standard would "presumably allow for a sliding scale" of torture or torture-lite or other coercive techniques, thus permitting "for a very small percentage--those High Value Targets like Khalid Sheikh Mohammed--some pretty rough treatment."

But if that is the case, then McCain embraces the same exceptions I do, but prefers to pretend he does not. If that is the case, then his much-touted and endlessly repeated absolutism on inhumane treatment is merely for show. If that is the case, then the moral preening and the phony arguments can stop now, and we can all agree that in this real world of astonishingly murderous enemies, in two very circumscribed circumstances, we must all be prepared to torture. Having established that, we can then begin to work together to codify rules of interrogation for the two very unpleasant but very real cases in which we are morally permitted--indeed morally compelled--to do terrible things.

Charles Krauthammer is a contributing editor to The Weekly Standard.

© Copyright 2007, News Corporation, Weekly Standard, All Rights Reserved.

The Truth about Torture

Tasers are safe? Oh. Never mind then...

I take it all back. Nothing bad about Tasering people. Just a few good natured 50,000 volt tickles and you're on your way.

Taser stun guns used by the police for law enforcement are safe - the injury rate is low and most injuries appear to be minor, a US study finds.

The electric disablers that hit their target with 50,000 volts are commonly used by US police and are increasingly being used by UK forces.

Human rights experts have expressed concern about the use of the stun gun.

But a Wake Forest University review of 1,000 US cases suggests the risk and severity of injuries is low.

Most injuries were mild, such as scrapes or bruises.

Three of the subjects suffered injuries severe enough to need hospital admission - two had head injuries suffered in falls after Taser use. The third was admitted to hospital two days after arrest with a medical condition of unclear relationship to the Taser.

Two subjects died but autopsy reports suggested neither death was related to the Taser.

Interim results on 597 of the cases were published in Annals of Emergency Medicine in September.

Lead researcher Dr William Bozeman, who received funding from the US National Institute of Justice for the work, said: "This is the largest study to date and the first to detail the medical effects of Tasers under real-world conditions.

"These results support the safety of the device. The injury rate is low and most injuries appear to be minor."

He stressed, however, that the Taser was a weapon and could clearly cause injuries and even deaths.

Amnesty International says Tasers have been linked to more than 70 deaths in America.

When Tasers are fired, two metal barbs connected to the weapon by a thin wire pierce the skin before the charge is delivered.

In the UK, police officers who carry guns have also carried Tasers since 2004. In September 2007, the Home Office extended permission to non-firearms officers in pilot areas.

Amnesty International's Arms Programme Director, Oliver Sprague, said: "Let's not be misled here. Tasers are dangerous electro-shock weapons.

"This is why we are urging the Home Office to review its decision and to ensure that only specialist firearms officers use the Taser in very limited circumstances and only as an alternative to shooting a lethal weapon."

A Home Office spokesman said: "The risk of life-threatening and other serious injuries is considered to be low.

"Tasers have contributed to resolving incidents without injury where otherwise there would have been a real possibility of someone being shot and killed.

"In some cases they have not needed to be fired: drawing them or arcing the Taser has been enough of a deterrent."

In England, a Taser has been used (drawn or fired) in service by the police 851 times, since April 2003.
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