The Business of Shaving

Recently a friend (high school classmate, now a Facebook friend whom I've not seen since high school) posted a status update that afforded a glimpse into his exploration of the art of shaving (the straightforward meaning of that phrase, not the Website of that name).  I was intrigued.

Over the years I've used everything from the old fashioned safety razor, holding a single blade that, in my youth, cost 10¢ to the current high-tech cartridges that have five blades and cost upwards of $4.

I've also used electric shavers from all of the major manufacturers.

[I will briefly dispense with the electrics.  Battery

life, meaning how long the battery lasts until it will no longer hold a charge, meaning it's no longer a cordless rechargeable, is pathetic.  Keeping the blades sharp and lubricated, finding the right pre-shave conditioner to suit one's beard, and developing the technique needed to get the closest and smoothest possible shave are all far more trouble than it's worth.  Even if you are meticulous about all of that and spend $200 for a top model, you still cannot get a shave as close and smooth as you can with a blade.]

[I must also say a few words about the old-fashioned straight razor.  I go to a barber who is a traditional Italian practitioner of the art, and he assures me it's far more difficult to learn to use a straight razor on oneself than on a customer.  That, he says, is why the safety razor got its name - and why he uses one on himself.]

The post by Bill (my old friend, a talented writer) piqued my interest.  He was going old school, to the traditional wet shave with a safety razor and shave soap applied with a brush.  Gee, I wondered, was that back-to-the-basics approach economical?

Some prefer exotic materials for the handle
 other than wood, which might not
 stand up to moisture over time.

Well, that depends.  Blades for a safety razor can be had for as little as 25¢ apiece, although the fancy German steel versions cost more than a dollar.  That's still a lot cheaper than $4+ for the high-tech cartridges.  But then what about shaving cream or soap?  Again, you can spend a little or a lot.  You can buy a traditional cream that comes in a tube that costs less than $10 and claims to be enough for 100 shaves when applied in the recommended thin layer.  You can spend $50 for a similar amount of really fancy stuff.  And how are you going to apply it?  With your hand, or a brush?  A shaving brush made of synthetic material is cheap.  Boar bristles cost a good bit more.

Apologies to animal rights activists

The traditional material, introduced by the French centuries ago, is badger hair, and you can spend $200 for an elegant brush with an exotic handle. The aficionados say there is nothing like badger to prepare the beard for the best possible shave.

The most common choice for lathering is the stuff that comes in a can and that every supermarket and drugstore carries, and that will probably cost somewhere around 10¢ a shave, give or take, depending on how much you use.

So, at the cheap end, buy a handle for a few bucks, blades that cost 25¢ apiece in bulk, and the inexpensive shave cream or gel in an aerosol can, and you're probably going to spend about 15¢ a shave.  But so many of us spend so much more.  And big companies like Gillette put a lot of money into marketing to get us to do just that.  They are very successful in getting us to spend more than $4 apiece for their high-tech cartridges.  (The best online price I found for the Fusion Pro-Glide was about $3.50.)
Remember, Gillette is the company that brought us the original

double-edged safety razor blade, patented in 1904 and supplied to American troops in World War I.  But Gillette does a lot of research on design, and their engineers are quite convinced that each advance, adding blades up to their current five-blade design, has meant a better shave: smoother, closer, easier, faster, less dependent on perfect technique, and with less irritation.  If you shave every day and put in a new cartridge every week, which is a common pattern, you'll be spending 50¢ a shave just for the blades.  Some men use a cartridge far longer than a week, but I can tell the difference between shave #1 and shave #7, so I find the weekly routine sensible.

With a bit of guidance from my friend Bill, I learned that there are others selling competitive cartridges for less.  And that made me wonder: are they really as good?  How can that be?  If they are sacrificing nothing in quality of materials and manufacturing process, if they are attentive to quality control and spending enough on marketing to have a successful business model, how can their product be that much cheaper?  It has to be profit.  And my regular readers know how I am fascinated by profit and the profit motive.

In my online research I have found two companies making razors and cartridges clearly intended to compete with Gillette's top-of-the-line Fusion Pro-Glide model. Both of them cost about a third less.  I have tried out one of them and have judged it to be of comparable quality and performance.  That made me really keen to investigate profit.

An article published in 2009 gave me some answers.  The Gillette Fusion Pro-Glide cartridge costs less than 10¢ to manufacture.

Add another few cents for packaging.  Each cartridge brings about $2.50 in profit for Gillette and another 75¢ profit for the retailer.  Of course there are some distribution costs.

But even considering the cost of research and development, that per-cartridge profit for Gillette is eye-popping.  It's no wonder that Gillette is the most profitable division of parent company Procter & Gamble, with a profit margin upwards of 30%. Gillette makes Big Pharma look like pikers.

I was raised by parents who belonged to labor unions.
My dad was not quite a socialist,

but he was a staunch believer in workers' rights and the importance of protecting them. And he saw corporate greed almost everywhere he looked. Maybe he sometimes saw it when it really wasn't there, but there is so much of it in America that one really needn't use any imagination to see it around every corner or in every nook and cranny. I'm sure this is why, at least in part, I am always ready to believe that every manufacturer is engaging in price gouging. Very consistently, over the years, my willingness to believe has been supported by cold, hard facts.  This is one of those instances.

But hey, I thought, maybe the undercut-pricing competitors are making their blades overseas, where labor costs are lower, while Gillette's razors are manufactured right here in the good ol' US of A.  Sure enough, Dollar Shave Club, which started up early last year, makes its stuff in Asia.  So what about Gillette, the Goliath to such Davids?  Seven years ago Gillette opened a new facility, which is its largest manufacturing plant for razors and blades in ... Poland.  If you want to help the Poles and think the Asians are already quite sufficiently economically successful without any more help from exports to the US, then go ahead and stick with Gillette.  If you think manufacturing is now global and it really makes no difference, or that you're happy to buy American, but if it's not American it doesn't matter where it's from as long as it's not sweatshop labor, then have a look at the competitors.  (There's another one, called Dorco, for which I cannot vouch, because I have not tried their products, but they certainly deserve mention.)

For me the calculus is simple - so simple that it is not, of course, calculus, but mere arithmetic.  Sacrifice profit to give me a product of equal worth at a lower price, and I will be a customer.

One more thing: don't lie to me.  Last year, convinced - and I wonder what produced this epiphany - that men were dismayed about high prices, Gillette's marketing geniuses initiated a campaign to tell us the cartridges for the Fusion Pro-Glide need be changed only once every 5 weeks.  The obvious goal was to get us to think that the lower-priced alternatives weren't going to save us that much money over time, and that we could get real savings right away just by using the blades longer.  If we all did that, their sales could be cut in half overnight, but they knew that wouldn't happen.  They just don't want to see their two-thirds share of the market shrink.  But when I was using the cartridges for two weeks, I felt a big difference between shave #14 one day and shave #1 the next.  So don't tell me five weeks.

Gillette (and the other big boys) could get serious about the competition and lower their prices.  That's the American way.  Just ask the Walton family.  They could drive their competitors out of business in short order.  Or they could do it the other American way and try to buy them out.  It will be interesting to see how this story unfolds.

Biomedical Ethics & the Law

About six weeks ago the Supreme Court of the State of New York issued an opinion that reminded me of an old joke.

A young law student asks his father, an attorney in practice for decades, to give him some expectation of what he will learn in the upcoming course on ethics.  His father offers an illustrative example.  You and a classmate pass the bar and go into practice together.  A lady comes in to see you about a minor adjustment to her will.  She returns the next day to receive her papers and hands you a crisp, new $100 bill in payment for this little bit of work.  As she is leaving the office you discover that she actually gave you two brand new $100 bills stuck together. Now you have an ethical dilemma.  Do you tell your partner about the extra $100 you made?

A man sought treatment for alcoholism in a hospital emergency department.  He then changed his mind and decided to leave.  He was apparently quite intoxicated (and the record included a "very high" blood alcohol level).  He left, wandered onto a highway, was struck by a vehicle, and was left quadriplegic as a result of his injuries.  He sued, claiming he should not have been permitted to leave the ED.  The Court said the defendants (physician and hospital) had neither the authority nor the duty (under New York law) to detain the patient.

This decision has been hailed by some of my colleagues as a victory for common sense and for the principle that there is such a thing as personal responsibility. And I must admit to being pleased that the doctor and the hospital were not held legally responsible for this tragedy.  Further, I can easily imagine circumstances under which medical personnel could not possibly be responsible.  For example, if the patient seemed cooperative and fully desirous of treatment for his addiction and then slipped out of the building undetected, it would be quite unreasonable to hold them to account for subsequent events.

Nevertheless, this case offers an excellent example of how ethical and legal analysis can lead to quite different conclusions.

Often when we're trying to figure out the right thing to do, we can frame the question as an ethical dilemma.  Sometimes that means there are competing interests that must be weighed against each other. Sometimes, as in a case such as this, there are principles of biomedical ethics in conflict, and we must decide which takes precedence.

The two principles here are beneficence (the duty to help the patient) and autonomy (the patient's right to make his own decisions about what happens to him).  In the United States (and some other Western societies) autonomy is placed at the top of the hierarchy.  This means if one is going to do something that violates patient autonomy, there must be a very good reason.  The most common such reason is that the person is mentally ill and intends to harm himself or others.  In such a situation, there is agreement that the duty to protect the patient (and possibly others) from harm takes priority over the duty to respect his individual autonomy.

Another common situation is one in which a patient wishes to refuse treatment or to leave a hospital against medical advice.  Sometimes such a decision may place the patient in peril of serious harm.  So, for example, if someone is having a heart attack, there is a very real risk of sudden death or severe, permanent disability attendant upon a decision to refuse treatment and leave the hospital. But we do not violate the patient's autonomy and prevent him from leaving, except....

We make an exception for lack of decisional capacity.  And to do that we must understand what decisional capacity is and how to assess it.

Let us use the example of the heart attack.  If you are having a heart attack and decide to refuse treatment and leave the hospital, my first priority is to try to change your mind.  I will explain my treatment recommendations and the risks you are assuming by rejecting them.  I will enlist the aid of those whose opinions or feelings mean more to you than mine: your family or friends, or your personal physician.  (Maybe even your nurse, because she has impressed you as a warm and caring person, and you have no suspicion that anything she tells you is motivated by pecuniary gain.)  I will try to find out why you want to ignore sound medical advice and whether you have concerns that can be effectively addressed.  If you say you cannot stay in the hospital because there will be no one to feed your dog, I will try to figure out how we can get somebody to feed your dog.  I will point out that if you die, your dog will be worse off than going hungry for a little while and tell you that in the wild, dogs go for days without eating, and that's why even domesticated dogs typically eat like they've had nothing to eat for a long time, and don't know when the next meal is coming, every time a bowl of food is put in front of them.

One of the things I must do when someone is making a really bad (meaning high-risk) decision is assess decisional capacity.  Does the patient understand the reason for my recommendations?  Does the patient understand my explanation of the risks of not following those recommendations?  Is the patient genuinely willing to accept those risks?  Can the patient explain why s/he is rejecting the advice and why s/he thinks it makes sense to accept the risks?  It should be apparent that, at the same time this process enables me to assess decisional capacity, it also allows me to make sure there have been no misunderstandings of the information I've conveyed and to correct any there may be.

All of this requires significantly time-consuming verbal communication.  I must be satisfied that the patient really understands my advice, and the risks, and that requires that the patient explain them back to me in his own words.  I also need him to explain his reasons for rejecting the advice.  His reasons for rejecting the advice don't have to satisfy my sense of what is logical or rational or makes sense.  So, for example, if he gives me a list of recently deceased friends and relatives and tells me they all died in hospitals, and so there is no way he is going to stay in a hospital, and he rejects all my attempts to demonstrate the logical fallacies in his reasoning, that doesn't mean he lacks decisional capacity.  If, on the other hand, he tells me if he stays in the hospital, as soon as he falls asleep tonight, space aliens or demons from Hell will appear in his room and abduct or incinerate him, I will be inclined to think he is delusional and mentally ill and does not have decisional capacity.  (For the sake of clarity, I should note that a delusion is not a belief that is merely false.  Rather, it is a belief that could not possibly be true.)

If his decision is based on values that are different from mine, I must respect that. For example, he may be perfectly comfortable with the risk of death and prefer to take his chances and die at home rather than be hospitalized and subjected to modern medical technology.  I may then wonder (and even ask) why he came to the hospital in the first place, and my values may be completely different, because if I were similarly situated, I would want to live to see my grandchildren graduate from college and get married.  But those are my values, and I have neither the right to impose them on him nor any reason to allow that difference to cast doubt on his decisional capacity.  

Getting back to the particular case in New York, it is important to understand that a high blood alcohol level does not necessarily mean that a patient lacks decisional capacity.  People who are habitual drinkers are often lucid and able to carry on coherent and rational conversation with blood alcohol levels that would render me unconscious.  They are also often able to walk with a steady gait and cross streets carefully and safely.  So, when we are deciding when a person who has been brought to the ED drunk can be safely discharged, we base that on whether the person can "walk and talk" normally (among other things), not on any number.

So let us assume, for the sake of argument, that the man in the New York case made his intent to leave known to ED personnel rather than deceiving them and slipping out of the building unnoticed.  Did they consider his decision to be against medical advice?  Did they think it was unsafe for him to leave?  Did they assess his decisional capacity?  Did they consider restraining him (either with tranquilizing drugs or with physical restraints), thus violating his autonomy in order to protect him?  (Such decisions are not always straightforward, because restraints of either kind carry their own risks.)  These are all the questions I would ask if I were reviewing the case and judging it for its adherence to principles of biomedical ethics.

While I consider it important to avoid violating the law in my practice of medicine, I consider it even more important to avoid violating principles of biomedical ethics. If I obey the law but violate professional ethics - and I'm not saying that's what happened in the New York case, as I think should be clear by now - that will not help me to sleep at night if there is a tragic outcome.


[Note: the author has served on hospital ethics committees for 25 years and on the ethics committee of the American College of Emergency Physicians for 15 years.]

Is this the Pirates' Year?

Great game last night.

The Pirates have reached the end of July in an unfamiliar place.  For most of the last two decades, they haven't been above .500 beyond June.  Last year was a promising exception, when they were 16 games over .500 in early August, but that was followed by the most dramatic collapse in the final two months of a season in the history of Major League Baseball, and they finished yet again below .500, extending their streak of losing seasons to 20.

Now, at the end of July, they are 23 games above .500.  Heck, they're 2 games above .600!  They have won the first four games of a five-game series with the St. Louis Cardinals and, in so doing, have taken possession of first place in the National League's Central Division.  This is a match-up of this season's best hitting team (the Cardinals) against the season's best pitching team (the Pirates).  And the old adage - popular with pitchers, at least - is that good pitching beats good hitting.

So where is the dark cloud that might envelop this silver lining?

Well, you could say that the Pirates just happened to catch the Cardinals in a batting slump.  And you could say the real strength of the Pirates' pitching roster is in the bullpen, and it takes some pretty astute managing to make sure games don't get away from you before you go to the relievers.  And you could say all it will take is for the Pirates to hit their own rough patch, and the negative psychology built up over 20 losing seasons will take over, and we will see that, deep down, they still don't believe they are a contender - and they won't be.

But the Bucs have already hit a couple of skids this season and have pulled out of them.  And last night I saw examples of how to use a pitching staff - and a distinct lack of negative psychology.

Starting pitcher Jeff Locke was throwing strikes, but the Cardinals were able to connect, and they got some lucky hits, just out of reach of Pirates infielders who may have been feeling the effects of having played 20 innings the day before.  He gave up 4 runs in 4 innings.  But the Pirates' bats weren't silent, and after the Cardinals' 4th they were down only 2 runs.

Then Vin Mazzaro came in and shut the Redbirds down.  Four innings.  Four zeroes in the Cardinals' scoring line.  Meanwhile, the Pirates hadn't given up.  They kept plugging, getting two more runs in their half of the 4th and 5th innings to tie it up.

What I heard in the stands was promising, too.  There was no murmuring among the fans, no pessimistic predictions that the Pirates seemed to be trying to find a way to lose this game and put a damper on the enthusiasm generated by their sweep of the doubleheader the day before.  Just lots of noise.  The electronic scoreboard signs saying "Make Some Noise" were quite unnecessary.

The Buccos got their go-ahead run in the bottom of the 8th.  And the fans responded.  In every section of the ballpark I could see at least one person standing and waving a large "Jolly Roger" flag.

In the top of the 9th, Mark Melancon, back in his closer role with Jason Grilli on the disabled list, came to the mound from the bullpen to a cacophony of cheers.  And he performed like he was there to show the world that when he comes in with a lead and one inning to pitch, there can be no doubt of victory.

Two decades of losing seasons have made it difficult to be optimistic, especially after last year's August collapse.  But the team I watched last night does not seem to be the same team that crumbled last August.  The tying run in the bottom of the 5th was illustrative.  Starling Marte got a lead-off single.  He bunted.  This man can bunt.  And he has the speed to beat it out for a single.  Then he stole second. More speed.  He moved to third on a ground-out.  Then he scored on a sacrifice fly.  But it didn't look like a sacrifice fly.  It looked like a clean single, and Marte broke for the plate when the ball cleared the infield.  He had to run back to third to tag up, and this ball was not deep in the outfield.  There was no play at the plate.  More speed.  So that was the tying run.  Not the easy kind, like Neil Walker's homer in the third.  But it takes both kinds to win ball games.

And - pssst! - I have some inside information to share.  The Pirates won their division in 1990, 1991, and 1992.  They haven't had a winning season since then. Shortly after the 1992 season ended - in November of that year - my younger daughter, Rose, was born.  And I have teased her, since she was old enough to roll her eyes at me about it, that she is the reason the Pirates have strung together all these losing seasons.  But she has been spending this summer in California!  And she will be here for only a couple of days before returning to college in New England.  The Pirates will never know she's here.  So this is it: this is their year to end the losing streak.

I also have a recommendation.  Across the street from PNC Park is a place called the Beer Market.  It's a BYOF (bring your own food) establishment.  So we had excellent deli-style sandwiches from home and arrived at the Beer Market at 4:30. That gave us a couple of hours for a leisurely dinner before the game.  This place has more than five hundred beers to choose from, and more than five dozen on draft.  If you like variety, you can't beat it.  And you can order "beer flights," choosing anything from the draft menu in 4-ounce "shots," four of them on a little wooden tray.  I took advantage of this to try eight beers that I'd never had before, knowing that I'd have at least four hours afterward (it ended up being 5) for my blood alcohol level to approach zero before I had to drive home.

I am not a sports pundit.  And so no one expects me to make any predictions (or at least not stand by them) with two months to go in the season.  But what I watched last night made me think this will definitely be the year that the Pirates break the losing streak.  And it may well be the year they do what they haven't done since the year before the streak began: win their division.