Four months ago I wrote an essay for this blog (Oct. 22, 2011, "Measuring Quality and Value?") about the government telling us how to practice medicine in the guise of improving the quality and value of medical care in the United States. In that essay I mentioned a new rule they want us to follow in deciding whether patients who come to the emergency department with headache should have a CAT scan of the brain to look for a serious cause.
As I have said before, when folks from the government talk about quality and value, they're really focused on dollars spent. Value is defined in terms of the relationship between quality and cost. When you improve quality while holding cost constant, or reduce cost without compromising quality, you increase value. Even better would be improving quality and reducing cost at the same time.
So the feds (meaning bureaucrats at the Centers for Medicare and Medicaid Services, CMS) told us we do too many CAT scans of the brain in our evaluation of patients with headaches (that were not the result of an injury). They said we should use certain criteria, which they delineated for us, in making these decisions. By doing so, they claimed, we could improve the quality of care by sparing patients needless and potentially harmful radiation, while simultaneously reducing cost. This is just the double bonus we should be looking for in the calculus of value. What a deal!
The problem with the new CMS rule was that the National Quality Forum (NQF), the highly respected body that reviews and recommends measures of quality, rejected this one. And the American College of Emergency Physicians (ACEP) said the CMS criteria were fundamentally flawed. And now my esteemed colleague, Dr. Jeremiah (Jay) Schuur, has published a study in the Annals of Emergency Medicine demonstrating the unreliability of the CMS measure. Dr. Schuur is the Director of Quality, Safety & Performance Improvement in Emergency Medicine at one of Harvard's major teaching hospitals. He knows his stuff.
There's someone else in this story who should know his stuff but apparently doesn't. And that is Dr. Michael Rapp. Dr. Rapp is the Director of the Quality Measurement and Health Assessment Group at CMS. Dr. Rapp believes emergency physicians are less than competent when it comes to evaluating headache patients and rely on CAT scans far more than they should. Rapp pushed forward with this "quality measure" despite the NQF's rejection and over the emphatic protestations of ACEP. Now, I must go off on a bit of a personal tangent here. I find this disagreement especially vexing because I have known Dr. Rapp for many years. He was president of ACEP a dozen years ago, and I first met him several years before that, when he was a candidate for election to the ACEP Board of Directors. What a grievous example of going over to the dark side!
I am a staunch proponent of the cost-efficient practice of medicine and as willing as anyone else to embrace a clinical decision instrument that allows us to avoid expensive testing without missing important diagnostic findings. Over the years I have learned a bit about the process of developing such aids to our practice.
Don't worry, I am not going to try to turn you into an expert on evidence-based medicine (EBM) by the end of this essay. But it's not that complicated. Let's start with a large group of headache patients. This is a group that has been thoroughly evaluated, and we know which patients turned out to have something bad and which ones didn't. We'll make a list of characteristics, things about patients that we can see when we interview and examine them, that we think might help distinguish those with something serious from all the rest. We'll look at our population of headache patients and see who has what from our list. Then we'll do some fancy statistical modeling to come up with a list of low-risk features, such that patients who have all of them were extremely unlikely to have anything serious causing their headaches. That is how we derive a clinical decision instrument. Then we have to validate it by using it prospectively, on a new group of headache patients, and see how well our prediction rule performs in identifying the ones with something bad. What we're really looking for is simple: if a patient meets all of the low-risk criteria, that should reliably predict that the patient will turn out to have a non-serious cause of his headache. If it works, we have a sound method of identifying a group of patients for whom we don't need to order CAT scans.
(In case you were wondering, yes, there are other tests we sometimes do for headache patients, like a spinal tap if we think a patient's headache might be from meningitis, but the focus here is on whether headache patients need CAT scans.)
At this point you should be wondering the same thing I was when I learned last year about the new CMS quality measure. Was it based on a well-validated clinical decision instrument for determining which emergency department patients with non-traumatic headache need CAT scans? And by now you can guess the answer: a resounding no.
So Dr. Schuur, my colleague at Harvard, did an excellent study to examine this new CMS rule, and he concluded: "The CMS imaging efficiency measure for brain CTs ... is not reliable, valid, or accurate...." I will not attempt to summarize his findings here, but if you really want to read it and do not have a subscription to the Annals of Emergency Medicine, drop me a line and I will e-mail you a pdf.
Those of you who have come to recognize the statement "I'm from the government, and I'm here to help you" as one that should strike fear in your heart will find none of this the least bit surprising. I'm sure you can now surmise what happens to me every time I think about CMS. Yes, I know. It's just a headache.
Friday, February 24, 2012
Saturday, February 18, 2012
Is Santorum the Anti-Romney the Mitt Doubters Want?
Rick Santorum was my congressman in the early 90s and then my senator when he won that election in 1994. So I've been following his public career for more than two decades. Santorum was a partner in the same law firm with my personal attorney, who was also a good friend, so I got a bit of the insider's view of him along the way.
I was surprised when Santorum won election to the U.S. Senate from Pennsylvania. The Commonwealth has a long tradition of electing moderate Republicans in statewide elections, and the list of office holders who fit that description, governors and senators, includes many who remain highly regarded in the state's political history. But Santorum was no moderate Republican.
He did, however, have the good fortune to be running for the U.S. Senate in 1994, a year when the Republicans turned the usual advantage of the mid-term election after the other party wins the presidency into an overwhelming victory, taking control of both houses of Congress for the first time in several decades. And he was running against a fellow who, while an incumbent, had won just three years earlier in a special election. That was Harris Wofford. Wofford had been appointed by the governor to fill the senate seat vacated by the tragic death of John Heinz in a helicopter crash. He then won a special election against former PA governor Dick Thornburgh, one of those moderate Republicans. That surprised the heck out of me, but Wofford was claiming to have special expertise in health policy at a time when interest in health care reform among the electorate was high. Wofford, however, turned out to contribute essentially nothing to the Clinton health care reform effort, which went down in flames. (That ill-fated endeavor, labeled "Hillary Care," may get an essay of its own in this blog some day.)
And so Santorum's timing, in 1994, was most fortunate. Then, in 2000, the Democrats put up Ron Klink, a liberal Democrat, four-term congressman, and former television journalist as their Senate candidate. Although in 1994 I thought Santorum was too conservative for Pennsylvania voters, and in 2000 I thought that was still true, his opponent was probably too blue in a purple state.
In 2006 it was Democrats' turn to take advantage of a mid-term election and the increasingly unpopular war in Iraq, and Santorum was soundly thrashed in his bid for a third term. The fact that voters had finally figured out just how far right he was probably played a role, too.
So how far right is he? Certainly enough to satisfy those in the Republican party who don't like Romney's flip-flops on core issues. Santorum can be criticized for not being enough of a fiscal hawk, because he is not ashamed of having supported earmark spending so he could "bring home the bacon" to Pennsylvania. But aside from that, he is a true-blue (or should that be true-red?) conservative across the board. He wants to cut spending and taxes and reduce the size of government. He has ultra-right views on issues that matter to social conservatives, most notably abortion. His perspective on health system reform is free-market, clearly the diametric opposite of the socialist leanings of the Affordable Care Act (aka Obamacare) - in contrast to the program Mitt signed onto in Massachusetts, which has much in common with the ACA.
In contrast with Romney, when one peruses Santorum's record, it's really difficult to find flip-flops, or even much in the way of inconsistencies. Those who believe in open-mindedness and a willingness to allow one's thinking to evolve like to quote Emerson on consistency of thought. But Emerson said, "A foolish consistency is the hobgoblin of little minds" (emphasis added), and foolish is definitely in the eye of the beholder. If you like Santorum's rock-ribbed brand of conservatism, you find nothing foolish about it.
So is he the anti-Romney the conservative faithful have been seeking? After dwelling in the single digits - low teens at best - in the national Republican polls for many months, why is Santorum finally now apparently being taken seriously as a contender for the nomination?
Look at the heartland. That means all that territory the folks on the coasts think of as "flyover country." It took a while for the vote counts from the Iowa caucuses to be finalized, but Santorum won there. And then look at its next-door neighbor, Missouri, where Gingrich, also seeking the mantle of the anti-Mitt, was not on the ballot. Santorum trounced Romney, something no one thought Gingrich could do in a one-on-one contest with Mitt. The current polls show a Santorum surge: strong leads over Romney in Ohio and Michigan. Every time a new state or national poll comes out I shake my head in wonderment. Is this the conservative the Republican faithful really want?
With emphasis on the word faithful, the answer may well be yes. If you're looking for a candidate with strongly traditional religious values who has lived his life accordingly, Santorum is your man. In a party whose religious conservatives are constantly talking about family values, everything we know of Santorum tells us that's what he is all about, in deed as well as word.
As the campaign has progressed, and he has participated in debate after debate after debate ... sorry, I lost count ... his public presentation has acquired polish at the same time that his brash, in-your-face explication of his views has lost none of its intensity.
I'm still not at all sure this is the conservative the conservatives are seeking for November. But I've seen enough in this race so far that I now will not be surprised if it turns out that way. If they want someone who will provide a stark contrast with Barack Obama in every imaginable way, Santorum is most definitely that guy.
I was surprised when Santorum won election to the U.S. Senate from Pennsylvania. The Commonwealth has a long tradition of electing moderate Republicans in statewide elections, and the list of office holders who fit that description, governors and senators, includes many who remain highly regarded in the state's political history. But Santorum was no moderate Republican.
He did, however, have the good fortune to be running for the U.S. Senate in 1994, a year when the Republicans turned the usual advantage of the mid-term election after the other party wins the presidency into an overwhelming victory, taking control of both houses of Congress for the first time in several decades. And he was running against a fellow who, while an incumbent, had won just three years earlier in a special election. That was Harris Wofford. Wofford had been appointed by the governor to fill the senate seat vacated by the tragic death of John Heinz in a helicopter crash. He then won a special election against former PA governor Dick Thornburgh, one of those moderate Republicans. That surprised the heck out of me, but Wofford was claiming to have special expertise in health policy at a time when interest in health care reform among the electorate was high. Wofford, however, turned out to contribute essentially nothing to the Clinton health care reform effort, which went down in flames. (That ill-fated endeavor, labeled "Hillary Care," may get an essay of its own in this blog some day.)
And so Santorum's timing, in 1994, was most fortunate. Then, in 2000, the Democrats put up Ron Klink, a liberal Democrat, four-term congressman, and former television journalist as their Senate candidate. Although in 1994 I thought Santorum was too conservative for Pennsylvania voters, and in 2000 I thought that was still true, his opponent was probably too blue in a purple state.
In 2006 it was Democrats' turn to take advantage of a mid-term election and the increasingly unpopular war in Iraq, and Santorum was soundly thrashed in his bid for a third term. The fact that voters had finally figured out just how far right he was probably played a role, too.
So how far right is he? Certainly enough to satisfy those in the Republican party who don't like Romney's flip-flops on core issues. Santorum can be criticized for not being enough of a fiscal hawk, because he is not ashamed of having supported earmark spending so he could "bring home the bacon" to Pennsylvania. But aside from that, he is a true-blue (or should that be true-red?) conservative across the board. He wants to cut spending and taxes and reduce the size of government. He has ultra-right views on issues that matter to social conservatives, most notably abortion. His perspective on health system reform is free-market, clearly the diametric opposite of the socialist leanings of the Affordable Care Act (aka Obamacare) - in contrast to the program Mitt signed onto in Massachusetts, which has much in common with the ACA.
In contrast with Romney, when one peruses Santorum's record, it's really difficult to find flip-flops, or even much in the way of inconsistencies. Those who believe in open-mindedness and a willingness to allow one's thinking to evolve like to quote Emerson on consistency of thought. But Emerson said, "A foolish consistency is the hobgoblin of little minds" (emphasis added), and foolish is definitely in the eye of the beholder. If you like Santorum's rock-ribbed brand of conservatism, you find nothing foolish about it.
So is he the anti-Romney the conservative faithful have been seeking? After dwelling in the single digits - low teens at best - in the national Republican polls for many months, why is Santorum finally now apparently being taken seriously as a contender for the nomination?
Look at the heartland. That means all that territory the folks on the coasts think of as "flyover country." It took a while for the vote counts from the Iowa caucuses to be finalized, but Santorum won there. And then look at its next-door neighbor, Missouri, where Gingrich, also seeking the mantle of the anti-Mitt, was not on the ballot. Santorum trounced Romney, something no one thought Gingrich could do in a one-on-one contest with Mitt. The current polls show a Santorum surge: strong leads over Romney in Ohio and Michigan. Every time a new state or national poll comes out I shake my head in wonderment. Is this the conservative the Republican faithful really want?
With emphasis on the word faithful, the answer may well be yes. If you're looking for a candidate with strongly traditional religious values who has lived his life accordingly, Santorum is your man. In a party whose religious conservatives are constantly talking about family values, everything we know of Santorum tells us that's what he is all about, in deed as well as word.
As the campaign has progressed, and he has participated in debate after debate after debate ... sorry, I lost count ... his public presentation has acquired polish at the same time that his brash, in-your-face explication of his views has lost none of its intensity.
I'm still not at all sure this is the conservative the conservatives are seeking for November. But I've seen enough in this race so far that I now will not be surprised if it turns out that way. If they want someone who will provide a stark contrast with Barack Obama in every imaginable way, Santorum is most definitely that guy.
Saturday, February 4, 2012
Keep Right Except to Pass
It's different here. The slower drivers seem to spread themselves out among all available lanes, as if there is some vast, middle-of-the-road conspiracy to slow everyone else down. Somehow they have never learned the rule that slower traffic should keep right. Or that passing should be done on the left. Or that passing on the right violates convention and is thereby less safe.
One of the things all of us want when we're driving is for the behavior of all the other drivers to be predictable. And, to the greatest extent possible, we'd like it to be fairly uniform. And this is where the notion that "speed kills" is misleading.
Then along came the Arab oil embargo of the 1970s and a federal 55 mph speed limit. All of a sudden there were millions of miles of highway with a well-established record of safe driving with a speed limit of 70 mph that now had a 55 mph limit. And that introduced greater variability. Some drivers fearfully going 55. Others, accepting the stress of having to keep a sharp eye out for the highway patrol, and aided by radar detectors, going 75. Not good.
So what is happening in those places where the limit is still 55? You guessed it: more variability than ever. Lots of people who feel compelled to stick close to 55, and lots of others who think it's ridiculous and go 70-75. And, as if that isn't bad enough, many in the first group seem to prefer the left lanes.
Friday, February 3, 2012
Vegans for Veal
Several years ago, on a trip to Boston to visit one of my daughters, a college student at the time, I saw a group of demonstrators in a public square. They were holding signs. I have no recollection what they said, except that they were in the format "X" (group of people connected by some common interest) for "Y" (the cause or person they were supporting). So it could have been "College Democrats for Ron Paul," but I'm pretty sure it wasn't. While I cannot recall what it was, I do recall that the "X" and "Y" didn't seem an obvious match.
I was seized by a mischievous impulse, the sort of impulse by which I am seized many times a day. I usually manage to resist, but sometimes they seem irresistible. I began thinking of "X for Y" combinations that were improbable but somehow ultimately plausible. The one flitting across my cerebral cortex that most appealed to me was "Vegans for Veal."
I was a vegan myself for about five years, having decided to follow that diet to lose weight and lower my cholesterol. I didn't stay with it permanently, though, as it presented too many lifestyle challenges. But it had nothing to do with religion or animal rights. So I could be a vegan while still supporting the rights of those who want to eat veal, or foie gras, or anything else the production of which is anathema to animal rights activists. And I could be a vegan while staunchly supporting the use of animals in medical education and research.
Facebook offered the temptation to go public with my mischievous impulse, and I started a Facebook group with that name. In one of Facebook's mysterious moves, all of the nearly 100 members of the group have been purged. All, in fact, except me. Oh, well. It was fun while it lasted.
When my first child, who is now a school teacher, was a newborn, my dad came to visit. One day we went out to lunch, and we were approached by two young women asking us to sign an animal rights petition. My dad, never one to beat around the bush, said the idea that animals have rights was absurd. I was intrigued and wanted to know what the young ladies really thought about the value of an animal's life relative to that of a human. I posed a hypothetical situation. Suppose, I asked the one holding the petition, you were in a car crash and were brought, seriously injured, to the emergency department at the hospital where I work. You have two choices. First, I have been trained in a surgical skills laboratory, using dogs, to perform procedures that make it possible for me to save your life. Second, I have received no such training (because humans have no right to use animals for their own selfish purposes), and, because I lack the requisite knowledge and skill, you die. She said she would choose option two. That occasion provided my first real insight into the mindset of animal rights activists - and was the last time I tried to have a serious discussion with one of them.
In August 2008 my daughter Diana and I spent part of a day driving across South Dakota. As she put it, we were in the land of cattle, wheat, and 75 mph speed limits. The number of sleek, fat, black Angus cattle visible just from the highway was astonishing. There was a time, before the upper plains states were settled, that the considered opinion of that part of the country was that it was completely useless and uninhabitable. But Americans like a challenge. So now those lands are used for grazing millions of cattle, and in late summer and early fall the fields are dotted with large collections of baled hay to feed the livestock during the winter. As you might imagine, PETA is not popular in those parts. Americans in that sector of our nation hold in very low regard those who tell them their very way of life is immoral, unethical, and unjustifiable. In pondering this, I found myself falling back on my libertarian musings about how there are so many people in this world who are sure they know how others should live their lives and have no compunctions in making pronouncements about such matters.
I recall an episode of Law & Order in which the character portrayed by S. Epatha Merkerson was engaged in a conversation about a shooting in which the victims were members of a party of deer hunters out in the woods in upstate New York. She wondered - apparently as a matter of general principle regarding deer hunting - whether the deer were armed. It was certainly no surprise that this sort of anti-hunting remark would find its way into a TV script. But it got me thinking about how many people who are opposed, in some measure, to hunting are animal rights activists and vegetarians who are philosophically opposed to the killing and eating of any sentient being. On the other hand, how many are just people who could not bring themselves to shoot an animal and so think no one else should, either, but they're perfectly happy to eat meat, poultry, and fish that they can buy in a supermarket or order in a restaurant, safely insulated from the reality that there was someone else who killed the animal for them?
"What caused the wreck?" I asked.
"I swerved to miss a deer."
"Next time hit the deer."
"Really?"
I see people all the time who swerved to miss a deer and lost control of the car and wrecked. I almost never see people who hit a deer.
"I brake for animals," says the bumper sticker. Do you? All animals? As long as they are big enough to see? No matter what the road conditions or traffic patterns? As a blanket policy, this seems a bad idea. I try to avoid animals if I am confident that I can do so safely. This is more of an issue for some animals than others. I would probably take my own advice and hit the deer if I could not easily avoid it. But one winter I was in Vermont, on my way back from Stowe, where I was lecturing at a conference, to the airport in Burlington. A road sign said, "Moose Crossing Next 15 Miles." Moose are big. Very big. I think I would try harder to avoid a collision.
People who are in single-vehicle crashes at 2 or 3 in the morning are, more often than not, inebriated. But they rarely admit that, saying instead that someone ran them off the road or that they swerved to miss a ... fill in the blank. One imaginative fellow told me he swerved to miss a water buffalo.
"A water buffalo? You mean the tanker truck that hauls water?"
"No! The animal."
"Really? They're not indigenous to the Upper Ohio Valley." (OK, maybe considering the other participant in this dialogue I didn't actually use the word indigenous.) "Except in zoos, they are not found on this continent."
"I'm telling you, there was one in the road."
Well, I would swerve to miss a water buffalo, but I think around here they appear in the road only when a driver has been hitting the sauce - the same stuff that draws vehicles off the asphalt and causes them to crash into trees and utility poles and bridge abutments.
Would you rather not have to worry about swerving to miss a deer? Then at every opportunity thank a deer hunter - and encourage them all to get out there during the season and bag the limit.
So "Vegans for Veal" was an attempt to capture the notion that whatever we choose for ourselves in life, we should recognize that others must remain free to make choices of their own.
I was seized by a mischievous impulse, the sort of impulse by which I am seized many times a day. I usually manage to resist, but sometimes they seem irresistible. I began thinking of "X for Y" combinations that were improbable but somehow ultimately plausible. The one flitting across my cerebral cortex that most appealed to me was "Vegans for Veal."
I was a vegan myself for about five years, having decided to follow that diet to lose weight and lower my cholesterol. I didn't stay with it permanently, though, as it presented too many lifestyle challenges. But it had nothing to do with religion or animal rights. So I could be a vegan while still supporting the rights of those who want to eat veal, or foie gras, or anything else the production of which is anathema to animal rights activists. And I could be a vegan while staunchly supporting the use of animals in medical education and research.
Facebook offered the temptation to go public with my mischievous impulse, and I started a Facebook group with that name. In one of Facebook's mysterious moves, all of the nearly 100 members of the group have been purged. All, in fact, except me. Oh, well. It was fun while it lasted.
When my first child, who is now a school teacher, was a newborn, my dad came to visit. One day we went out to lunch, and we were approached by two young women asking us to sign an animal rights petition. My dad, never one to beat around the bush, said the idea that animals have rights was absurd. I was intrigued and wanted to know what the young ladies really thought about the value of an animal's life relative to that of a human. I posed a hypothetical situation. Suppose, I asked the one holding the petition, you were in a car crash and were brought, seriously injured, to the emergency department at the hospital where I work. You have two choices. First, I have been trained in a surgical skills laboratory, using dogs, to perform procedures that make it possible for me to save your life. Second, I have received no such training (because humans have no right to use animals for their own selfish purposes), and, because I lack the requisite knowledge and skill, you die. She said she would choose option two. That occasion provided my first real insight into the mindset of animal rights activists - and was the last time I tried to have a serious discussion with one of them.
In August 2008 my daughter Diana and I spent part of a day driving across South Dakota. As she put it, we were in the land of cattle, wheat, and 75 mph speed limits. The number of sleek, fat, black Angus cattle visible just from the highway was astonishing. There was a time, before the upper plains states were settled, that the considered opinion of that part of the country was that it was completely useless and uninhabitable. But Americans like a challenge. So now those lands are used for grazing millions of cattle, and in late summer and early fall the fields are dotted with large collections of baled hay to feed the livestock during the winter. As you might imagine, PETA is not popular in those parts. Americans in that sector of our nation hold in very low regard those who tell them their very way of life is immoral, unethical, and unjustifiable. In pondering this, I found myself falling back on my libertarian musings about how there are so many people in this world who are sure they know how others should live their lives and have no compunctions in making pronouncements about such matters.
I recall an episode of Law & Order in which the character portrayed by S. Epatha Merkerson was engaged in a conversation about a shooting in which the victims were members of a party of deer hunters out in the woods in upstate New York. She wondered - apparently as a matter of general principle regarding deer hunting - whether the deer were armed. It was certainly no surprise that this sort of anti-hunting remark would find its way into a TV script. But it got me thinking about how many people who are opposed, in some measure, to hunting are animal rights activists and vegetarians who are philosophically opposed to the killing and eating of any sentient being. On the other hand, how many are just people who could not bring themselves to shoot an animal and so think no one else should, either, but they're perfectly happy to eat meat, poultry, and fish that they can buy in a supermarket or order in a restaurant, safely insulated from the reality that there was someone else who killed the animal for them?
"What caused the wreck?" I asked.
"I swerved to miss a deer."
"Next time hit the deer."
"Really?"
I see people all the time who swerved to miss a deer and lost control of the car and wrecked. I almost never see people who hit a deer.
"I brake for animals," says the bumper sticker. Do you? All animals? As long as they are big enough to see? No matter what the road conditions or traffic patterns? As a blanket policy, this seems a bad idea. I try to avoid animals if I am confident that I can do so safely. This is more of an issue for some animals than others. I would probably take my own advice and hit the deer if I could not easily avoid it. But one winter I was in Vermont, on my way back from Stowe, where I was lecturing at a conference, to the airport in Burlington. A road sign said, "Moose Crossing Next 15 Miles." Moose are big. Very big. I think I would try harder to avoid a collision.
People who are in single-vehicle crashes at 2 or 3 in the morning are, more often than not, inebriated. But they rarely admit that, saying instead that someone ran them off the road or that they swerved to miss a ... fill in the blank. One imaginative fellow told me he swerved to miss a water buffalo.
"A water buffalo? You mean the tanker truck that hauls water?"
"No! The animal."
"Really? They're not indigenous to the Upper Ohio Valley." (OK, maybe considering the other participant in this dialogue I didn't actually use the word indigenous.) "Except in zoos, they are not found on this continent."
"I'm telling you, there was one in the road."
Well, I would swerve to miss a water buffalo, but I think around here they appear in the road only when a driver has been hitting the sauce - the same stuff that draws vehicles off the asphalt and causes them to crash into trees and utility poles and bridge abutments.
Would you rather not have to worry about swerving to miss a deer? Then at every opportunity thank a deer hunter - and encourage them all to get out there during the season and bag the limit.
So "Vegans for Veal" was an attempt to capture the notion that whatever we choose for ourselves in life, we should recognize that others must remain free to make choices of their own.
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