Big Think Interview With Jacob Appel
Jacob M. Appel is a bioethicist and fiction writer. He holds a B.A. and an M.A. from Brown University, an M.A. and an M.Phil. from Columbia University, an M.D. from Columbia University's College of Physicians and Surgeons, an M.F.A. in creative writing from New York University, and a J.D. from Harvard Law School. He has most recently taught at Brown University in Providence, Rhode Island, and at the Gotham Writers Workshop in New York City. He publishes in the field of bioethics and contributes to such publications as the Journal of Clinical Ethics, the Journal of Law, Medicine & Ethics, and the Bulletin of the History of Medicine. His essays have appeared in The New York Times, The New York Daily News, The Chicago Tribune, and other publications.
Appel has also published short fiction in more than one hundred literary journals. His short story, Shell Game With Organs, won the Boston Review Short Fiction Contest in 1998. His story about two census takers, "Counting," was shortlisted for the O. Henry Award in 2001. Other stories received "special mention" for the Pushcart Prize in 2006 and 2007.
He is admitted to the practice of law in New York State and Rhode Island, and is a licensed New York City sightseeing guide.
Appel contributed a Dangerous Idea to Big Think's "Month of Thinking Dangerously," advocating that we add trace amounts of lithium to our drinking water to help reduce the suicide rate.
Appel is a Big Think Delphi Fellow.
Jacob Appel: I'm Jacob M. Appel, and I'm a professional bioethicist as well as a short story writer.
Question: How do you balance bioethics, psychiatry, and writing?
Jacob Appel: Sure. I try to wake up every morning and get several hours of writing done before I go to the hospital, which can range between 5:00 in the morning and 7:00 in the morning. So, I could, in theory, be writing as early as 3:00. Do a few hours of writing; see my patients during the day. Intermittently during the day I do some phone interviews. If I'm on call at the hospital I can write a bioethics column and then I come home and do probably a couple of hours of bioethics work in the evening.
Question: What does your work as a psychiatrist and bioethicist entail?
Jacob Appel: Sure. Well, until recently, I was teaching bioethics at Brown University and NYU. So, there I would have my full class of either undergraduate or graduate students and I would do some consulting work on the hospital floors as well. Now, since I'm practicing medicine nearly full time at Mt. Sinai in psychiatry, I do occasional bioethics consultancy inside the hospital at Mt Sinai, but far more often, I'm consulting people outside, giving them advice on issues relating to the beginning of life, end of life.
Question: What is bioethics, and what is the role of a bioethicist within a hospital?
Jacob Appel: Absolutely. I think 30 years ago, there were no bioethicists. It is one of the new occupations of the technological age that we live in. And it takes traditional moral questions about when life begins when life ends, and sees them through the prism of modern technologies. And as we've developed, for example, ways of keeping life going beyond its natural parameters, the question arises; how far should we keep life going? And a bioethicist inside the consultant setting of the hospital doesn't offer people answers, it sets out parameters for people to think about answers. So that a family on their own can make decisions based upon different ways other people have handled these situations in the past.
Question: Should bioethicists perceive themselves as arbiters of right and wrong?
Jacob Appel: I think it's far better to think of bioethicists as guides. I think there is a cottage industry now of people who have made a living or a career out of criticizing bioethicists because they view bioethicists as these plutonic guardians on high who step into the fray and say, "this is how we will do things." I know no professional bioethicists who actually operate that way. Far more bioethicists show people the signposts, show people different alternatives and let them make their own decisions. And I think that's important. I think that in the same way you wouldn't want your medical or legal decisions made by someone else; you will want to be consulted on an expert and then make the decision on your own. A bioethicist is an expert who shows you different parameters and then let you make your own decision.
I should add, before the 1970's, philosophy as a field had branched far away from moral thought. It delved into questions of epistemology, the five-year olds age old question, when my parents leave the room do they still exist? And it's bioethics that in addition to working inside the hospital with families has also brought back morality back into the field of philosophy.
Question: Should bioethicists take stances on issues of politics and social justice?
Jacob Appel: I do think they should, and I do. But I think that it is important to distinguish the different hats that a bioethicist wears. When I'm in a classroom at Brown or NYU or Columbia, I make a point of not telling the students how I feel about topical, or hot-button issues. They can certainly go online or find a journal with my viewpoints, but few of them do and you really want to be an arbiter. You want to be an impartial judge letting them come to their own conclusions.
In the same way, in the hospital. You want to let families reach their own conclusions and you want to show them viewpoints you don't agree with as well as the ones you do. In contrast, as a public intellectual, or a public figure engaged in the discourse, you should be advocating for a particular position. What I like to tell the students at Brown, and this derives, it's not my idea, it's something Vartan Gregorian, the former President of Brown said in a, I believe, the commencement address about 10 years ago. He said, the problem with modern universities, paraphrasing, "On the problem with modern universities is that they breakdown all of the student's preconceived notions, but don't give them any new ideas, and they leave the university believing that all ideas have equal value and hence, in some sense, believing in nothing.” I think it is important to have all **** ideas broken down, to be able to see that people who disagree with you aren't idiots, they simply start with different premises and have different value sets and come to logical conclusions based on them. But once you do that it's also important to operate in the world with a deeply held set of beliefs that you can fight for and that you are not mutually exclusive.
Question: Is there ongoing friction between bioethicists and doctors who see them as meddlesome?
Jacob Appel: I think historically, there was much more friction then there is today. Historically, physicians lived in a fairly **** of the world and the bioethicists were often clergymen, or philosophers who came in with moral judgments that were often detached from the field of medicine. As the brilliant ethics thinker and clinician, Ken Frager at Columbia University says, "All good ethical decisions should stem from the facts of the case.” As we have more physicians who become bioethicists and as the bioethics field now increasingly is a field populated by physician/clinicians who happen to practice ethics, that conflict is largely evaporating. We're all on the same page, I think.
Question: Is euthanasia for human patients ever morally justified?
Jacob Appel: Well, I think we need to distinguish both physician-assisted suicide, or assisted suicide in which the individual actively makes this choice. The patient says, "I have capacity, I want this done," and euthanasia, where the individual no longer has capacity and the state or doctors make this decision for them. I always favor the right to physician assisted suicide. Under limited circumstances I favor euthanasia. I think that we've accepted patient autonomy in virtually every other area of decision-making, but for some reason probably because of the change and somewhat irrational change of Judeo-Christian, we're afraid to let patients end their lives. There are people who are legitimately concerned that the system will be abused, but when we've actually implemented the system in Holland, in Oregon, now in Washington, we don't have a long track record of people abusing the system. Few people use it. The few people who used it we've seen from reports from their families, use it wisely, do use it at the last moment when they want to, they are not coerced into doing it.
Equally importantly, I think on the one hand, we want to guarantee that the system is used reasonably, but we also want to reduce suffering. For many people, the worst enemy is not death. The worst enemy is suffering. And opponents of the position of assisted suicide don't take that into account. Also, there is a vast number of people out there who are interested in physician assisted suicide as an option who will never use it. For these individuals, knowing they have an out somewhere, even though it’s not an out they're going to buy into, gives them an enormous amount of relief. I imagine some day, I will be one of those people who may not choose to end my life, but will know that if I ever have a terminal illness that the option exists and will take comfort in that.
In contrast, I think euthanasia should be used very sparingly. And I can think of two particular cases. One are infants who don't have the capacity to make their own decisions, but who have horrific terminal illnesses that cause them to suffer, who are unlikely to live to adulthood, or even into childhood. So, a child, for example, who is born with disease like Kasac’s where the children go blind and are paralyzed by the age of three or four, never develop full cognition. It seems to be reasonable for parents or doctors to say, we know this child is not going to live and is going to suffer, we're going to end their life earlier.
And similarly, people who are trapped in states of permanent paralysis without communication. The Ron Halben case in Belgium comes to mind, where a man who has been trapped for 30 years in a body may or may not have consciousness. Now it seems he does not have consciousness. He can't communicate his wishes as to whether he’d want to be in this state or not. I think the vast majority of people, given the choice between living their lives permanently trapped in a body in a hospital back room somewhere without an ability to communicate, or being euthanized, would choose euthanasia. And in those circumstances I would also favor it, even though we don't know for sure what the patient's wishes were.
That being said, if for some reason we did know this patient didn't want to be euthanized, we would honor their request and not force this upon them.
Question: Can we distinguish between death and death-like states, and should we?
Jacob Appel: Well I think, unlike the beginning of life, which is highly politicized, in which there are in some sense two camps; those who think that for all practical purposes life begins at birth, or sometime in the third trimester. And those people who think that life begin at conception. And really not that many people in between. In relation to the end of life, there are a lot of people who stand at different places on this continuum and different states in fact stand at different places on this continuum. The old test of holding a mirror up to someone's face to see whether they've breathed on it, no longer works for us.
In Japan, they have a much more constricted, or much stricter rule for when life ends and therefore organ donation is far more limited as a result. For me, when talking to a patient, or talking to a patient's family, I think there are two very important questions to ask when making end of life decisions. In addition obviously to how this person would have felt in this situation. One is, will this patient ever leave the hospital again? A patient who has no prognosis of ever leaving the hospital again should be treated differently, I think, than a patient who might leave the hospital again.
And the second question is, will this patient ever regain consciousness? And if the patient is never going to regain consciousness, one probably wants to impose a much more conservative form of management. Wants to restrict care as much as possible in the context of reducing suffering, unless one has a compelling reason not to. If, for example, the patient has left a long written record that says, even if I'm never going to regain consciousness, I still want care; we might still provide full care. But in the absence of that, I personally, and most bioethicists I know would encourage families, and in some sense permit families because families, even though they make the decision are often looking for the blessing of the bioethicist to give them license to say, "We know that our grandfather, our mother, our father is never going to recover and we can step back and just do the minimum necessary.
Question: How should bioethicists think about abortion, and where do you stand on the issue?
Jacob Appel: Well, I think the two questions that a bioethicist has to ask in the abortion debate are; one, is it a question of when life begins, or is it a question of either permitting or prohibiting abortion based on independent phenomena. If you are interested in the question of when life begins, then the motivation for the pregnancy should be utterly irrelevant to your decision-making. If you believe that a fetus attains a personhood past a certain age, even if that fetus is the product of rape or incest, it wouldn't make sense to allow someone to terminate a pregnancy if you believe that fetus is personary.
In contrast, there are other reasons one might oppose abortion rights independent of when the fetus begins -- when the life begins. One might say, I acknowledge that fetuses aren't human beings. Life doesn't begin until birth. But if we ban abortion, we reduce the likelihood of teenage pregnancy, sexually transmitted disease; we can reverse the social and sexual revolution of the 1960's. Which many people do advocate and do believe, and from their point of view, whether or not the fetus is a human being isn't a relevant question.
I think as a society today and bioethicists particularly have largely focused on the question of when life begins. I am fairly radical in my views in the sense that I would permit abortion up to the point of birth. I think that the arbitrary distinction that fetuses apply or personhood at a certain point is simply too grey an area, a too uncertain premise to enforce in law. The example always use, and it's somewhat trivial, but at the same time evinces the question well, I think, is small children making Jello. If you have a small child making Jello, they put the colored water in their refrigerator, they run away, they come back 30 seconds later, they put their finger in the Jello, is it colored water or is it Jello. And they do this over and over again until suddenly and miraculously it becomes Jello. The development of a fetus operates the same way. Birth is an easy guideline. The truth is, since I believe that sentience and cognition, or consciousness define life, there probably are infants in the first few days of life who don't really have cognition. Who don't have in this sense, sentience, but for a practical, realistic way of running the world, we couldn't live in a world where we euthanized them, or allowed infanticide.
That being said, I would also add as a bioethicist, I have written extensively on treating infanticide, and particularly mothers with post-partum depression and post-partum psychosis, as distinct from other murderers and other criminals. I think we should grant great latitude to women who kill or euthanize their infants at birth and treat them with kindness as someone who suffers from illness.
Question: Why make birth the dividing line and not a certain phase of pregnancy?
Jacob Appel: I think that is fairly simple. The ancient Romans, for example, didn't view birth as the cutoff point. They had a certain number of days, and it varied where in Rome you were before a child gained full personhood. The ancient Spartans certainly didn't view infants at birth as having human capacity or human value. We have a very hard time distinguishing whether a child once born is three days old, or seven days old, or two months old. And you don't want to have a system that has courts engaged in the process of figuring out exactly how many days old the baby was. And having people's lives and their prospect of going free or spending time in jail dependent on exactly how many days they were post-birth.
So, my actual philosophical drawing line would be far past birth in terms of days or weeks. But there's no practical way to implement that. You could easily figure out how many days before birth, or how many trimesters, how many weeks a fetus was by ultrasound, but there is not a point along that parameter where I would feel that a child or a fetus has enough capacity and enough sentience to be considered a human being.
Question: Should buying and selling human organs be legal?
Jacob Appel: Sure. I've actually written about a legal market in fetal organs, which I think is somewhat different from a legal market in organs of post-born adults. And I would strongly favor legalizing the market in fetal organs because I don't feel that fetuses are people and therefore the risk of exploiting them is minimal and I feel that women are capable of making reproductive choices in relation to their fetuses particularly people who abort may want to save the lives of other individuals by making their organs available. And I think they should be able to profit from this.
In contrast, for adult organs, I think there should be a financial mechanism for allowing people to sell their organs. But I don't necessarily think there should be a market. I think a market opens itself up to abuse and will likely have the organs go to the highest bidder and make it most available to the wealthy.
In contrast, you want to create financial incentives so there are enough organs available for all 70,000 people who need kidneys, for example, in the United States. But then you don't want to distribute them based on economic opportunity, or economic -- based on assets, you want to distribute them based on need. So, I would have a system where the government bought up organs for people, let's say $10,000 for a kidney and then distributed them using the same system we have now, on a first-come, first-served, or need based approach. I think to tell people they can make other economic decisions in their lives, they can choose to be a laborer at $7.00 an hour for 40 hours a week, but they can't choose to avoid three months of work by selling a kidney is an unnecessary involvement, or an unnecessary intervention in the individual decision-making of people.
I will add, and I think this is often lost in the debate over organs. We focus excessively on the risk of exploitation of people who would sell their organs. We don't focus on the passion of people who die every year because they don't get organs. And if you are one of those individuals, or one of their relatives, you may see the question from a very different light.
Question: How difficult is it to obtain a life-saving organ in America today?
Jacob Appel: Oh, it's extraordinary difficult. I don't have the numbers in front of me, but there are approximately 115,000, 120,000 people on the waiting list for different life-saving organs in the country and with kidneys, we do have dialysis, so we can prolong the lives of these people a number of years. But the people who need heart transplants, or liver transplants, the majority of them, I believe die while waiting. Certainly a good plurality of them dies while waiting. Unlike kidneys where you can have a live donor make a donation, these people have to wait for cadavers. So the question arises, why not pay people who know they're going to die, or people to make their organs available in a pool if they are going to die to harvest their organs as soon as they do die, which would also reduce the risk of exploitation. These people are at death's door and are dying anyway.
As for kidneys, while dialysis is life prolonging, dialysis is not always life saving. It also substantially reduces the quality of life of individuals involved. In contrast, not having a kidney has no impact if you have one kidney of your own on the life quality or life expectancy of the individuals that give a kidney, on a virtually zero risk. Extremely low risk procedure. The real question that arises is, do we have an ethical obligation as healthy individual with two kidneys to give one to a stranger? And it's a challenging question. Maybe we do. We don't have the mechanism in place to make that happen. In fact, in the rare cases where people have tried to do that in this country, hospital ethics committees have often stepped in and questioned the capacity, or sanity of the individual who is seeking to. Which to my way of thinking is somewhat perverse. If someone is willing to, not sacrifice their life, or quality of life, but make a great altruistic **** for a stranger and we say this person must be crazy.
Question: Why do you advocate pre-implantation genetic diagnosis of babies fertilized in vitro?
Jacob Appel: I think we make an arbitrary distinction between embryos before they are implanted, or fetuses before they are born, and children once they're born. There are certain conditions you could never enforce upon a child once it was born. You could never, for example, say I have a child who hears, but I am deaf and deaf culture is important to me, so I'm going to puncture my child's ear drums. Child Protective Services would show up at your doorstep tomorrow and take that child away.
However, under our current system, you can go to a fertility clinic and ask the doctor to screen your embryos to make sure that you have a deaf embryo, rather than a hearing embryo implanted. To me doing that is just as much child abuse as puncturing your child's ear drums.
Question: Does such screening create a slippery slope toward the engineering of “designer babies”?
Jacob Appel: I think if the slope is slippery there are far more level places on it. I think that once simple distinction between the procedures we would require or strongly encourage and those really to remain neutral on, or oppose, would be if there are conditions that modern medicine currently tries to cure. If they are, for example, conditions that Medicare or Medicaid would cover gives us a fairly bright line distinction. There is no Medicare or Medicaid reimbursement for getting a nose job to look more handsome, or having your eye color changed. In contract, few people would say that cystic fibrosis or sickle cell anemia aren't sufficiently handicapping diseases that if we could prevent them in utero, or in vitro, we should do.
That being said, I have no particular qualms with designer babies. I think the reality is that even if designer babies, so to speak, were available, not many people would make that choice, and the result would only be enhancement for those individuals who chose them and no harm to anybody else. It seems to me there isn't that much difference between getting your child and SAT tutor and getting him into a good college, making him a little bit more intelligent before they're born. In some ways you can save money in SAT tutoring if you put the effort in early on.
Question: Should we worry that engineering some genetic traits in babies might deprive them of others?
Jacob Appel: Well, I think it's no different than child rearing the introduction of one trait, or just be the child's ability to do other things. We, for example, give children anti-depressants if they're depressed. You want them to be happy. And they may be happy, but they might be less creative, and that's a trade off we let parents make. I think we want to maximize the autonomy individual parents have. The one caveat would be if we're going to induce some kind of birth defect or some kind of severe handicap in these children, we would want to intervene and stop that from happening. We do want to make sure they don't step below a certain floor. The advantage we have is both parents and fertility clinics are deeply vested in keeping whatever we create as a result of these interventions from stepping below that floor. Moreover, the overwhelming majority of parents who are embracing these new technologies are also parents who are willing to terminate a pregnancy if it doesn't work out the way they want. People who embrace one technology tend to embrace most modern technologies. So the risk of producing severely impaired children is actually far lower.
Question: Why have you spoken out against electronic medical records?
Jacob Appel: I'm concerned about electronic medical records. I think you could develop a system where electronic medical records work, and in theory, it would be a wonderful system. The paramedics would show up at your doorstep when you have a heart attack, they would press a button and they would instantly know your entire medical history, they would know what medicines you were allergic to, they would know whether you had had a heart attack in the past. They would be able to see your last 10 EKG's.
The downside of that, if you create that system, is any paramedic in the country pushing a button can see what medicines you are allergic to, your past EKG's, whether you'd ever had an abortion, a psychiatric hospitalization, the estimates are it would be between 12 and 15 million people that would have to have access to your medical records to have a successful interoperable system. The example you can use is when a celebrity checks into the hospital. For example, when Bill Clinton checked into Columbia Presbyterian several years ago, even though the hospital sent out stern warnings to all of its employees, if you look at his records, you will be fired, a substantial number of employees, it was 30 or 40, looked at his records and a number of them were fired. The hospital had a way for catching that because they were on the look out for people looking at Bill Clinton's records. Nobody in the hospital is looking at your records to make sure somebody else isn't looking at them.
Right now because it's just one hospital, and we don't have an interoperable system, where all healthcare providers can see all healthcare providers records, the risk of someone knowing you and working in the hospital is fairly low, particularly if you are from out of town. If you have the entire system connected, then a pharmacist in Alaska can look at the records of his daughter's fiancée in Florida to see if the guy has a cocaine problem, and there’s no way the system right now can track that down.
There are things we can do to change that. We could use, for example, the same mechanisms the credit card companies use to pick up unusual or illogical interventions or access to records, and we could use those unusual interventions to flag people. Or, as Medicare or Social Security do, we could send people a list every year not of your benefits, but a list of people who have seen your healthcare records. And if you see, wow, my father-in-law's been looking at my records, you could check that box and act accordingly. We aren't doing that right now.
The other downside of these methods is once the genie is out of the bottle, it doesn't do you any good to put it back in. Once your father-in-law knows that you had a cocaine problem, it really doesn't do you much good to say, "Okay, now I'm going to sue my father-in-law for breach of privacy," because your marriage or your future marriage is a wreck and everybody he has spoken to already knows this.
Question: How do you pursue creative writing on top of two other careers?
Jacob Appel: Well, I think part of it is the importance of viewing them as separate careers. I think there are some writers who view writing and practicing medicine are very much interrelated and they write short stories about medicine or **** by medicine, some of them are very talented. Perri Klass comes to mind, Ethan Canin comes to mind, for me they're two very separate animals. And I view my occupation as being a bioethicist. And any extra benefits or extra blessing I get from being a writer, I'm very happy to have but if it doesn't work out, I'm not devastated by it. And in some ways that makes it easy to do, I know I can step back from it and go to the hospital and do my job and I haven't abandoned something that is essential to my well being.
I don't have to earn a living as a writer, which makes being a writer both more interesting and more pleasurable. That being said, my wisdom to anybody out there who is thinking about become a writer, and I tell all my writing students, is that the vast majority of success as a writer comes just not from persistence, but relentlessness.
I have recently reached a point where I have now more than 20,000 rejection letters. I don't know if 20,000 rejection letters is a record for people submitting small journals, but it shouldn't be because anybody else out there who wants to be a successful writer should also accumulate 20,000 rejection letters. The most successful writers I know, even those who are doing well who have several good books out still submit to small journals, still submit articles and reviews, get rejected, pick themselves off of the ground and fight back again.
Question: How do you persist in spite of so much rejection?
Jacob Appel: Well it's interesting, I actually did an interview a couple of years ago where 11,000 was the number, and I have a nice little journal where I keep track of every submission I have made, and if I ever do become a more successful writer, which is not a guarantee, but if I do, some day somebody will have my journal and be able to see exactly every submission I have made. And I've gotten some horrifically discouraging rejections. I've gotten rejections that say things like, "Not only will we not accept this story, but please never submit to us again." Or, "Consider this a preemptive rejection of anything you might write in the future." And the way you deal with that, on the one hand, is to know that writing is very much a matter of taste. And once you have a certain number of acceptances, you can say to yourself, I know I've gotten 20,000 rejections, but I've gotten over 100 acceptances, so somebody must like what I'm doing. And the other half of it is to realize that the same story that may be rejected by numerous journals, or numerous periodicals can then be accepted, which shows that someone else shares your sensibility.
One example I cite frequently is, I had the honor and privilege of a story of mine called "Shell Game With Organs" receiving an award from the Boston Review about a decade ago; my first significant literary honor, actually more than a decade now. It was rejected by more than 75 journals before I finally placed it; some of them rather unceremoniously, which suggested that it wasn't the shortcoming of the story, but simply a failure of the story to match the taste of a particular writer. I also urge people submitting stories to write a cover letter that convinces whoever the intern or college student first reading your work that you are somebody important enough that they shouldn't pass up on passing this letter on to the next stage.
The story I always tell, I was once a screener, at one point, I worked for Congressman Ted Weiss down here in lower Manhattan back in 1980’s. And I screened all of his phone calls, and the poet, Allen Ginsberg called to congratulate him on a recent election and I didn't believe it was Allen Ginsberg the poet, so I told him to write a letter and hung up on him. And about 10 minutes later he called back on the Congressman's private line and I nearly lost my job. Your goal is to convince whoever has the role like mine at a literary agency that you are important enough to get through to the boss.
Question: Should writers change their work based on rejections, or have faith in it as it stands?
Jacob Appel: I think you just have to have faith. I often make changes to the work based on acceptance. The editor who will call me and say, "We loved your story, but we had trouble with the ending." We are still thinking about publishing it, will you change the ending. Now, that's someone who is invested enough in the story, but I'm willing to say, maybe this person has a point and I'll go back and take a look at it and often, I will make changes. I think one story that comes to mind was a story of mine, "Grappling," that appeared in Stories South a couple of years ago about alligator wrestling. And the editors there, Jason Stanford particularly, were excellent advisors who said, "We loved your story, but you should really change the order of the scenes. And they were dead on. The advice I give young writers is never take advice from anyone that doesn't have a vested interest in your future. Once an editor says, we might publish the story; they have a vested interest in your future. The editor that sends you a note that says, we're not publishing your story and it's no good for the following reasons, has no vested interest in you and you take their wisdom with a grain of salt.
Question: In stories like “Hazardous Cargoes,” how do you create a voice that’s radically different from your own?
Jacob Appel: Well, it's interesting. Hazardous Cargoes is actually a story, for those in your audience, about a man whose job it is to drive a flock of penguins across the country. And in the course of the story, the truck of penguins overturned. This was actually a real incident. I cobbled out of a newspaper a number of years ago and it sat in my desk for a long time. And walking to work every day, or living my life, periodically these penguins would come back into my mind and the challenge was to capture the voice of the man who drives penguins. And part of the challenge of that is, there is a famous writer, who I won't mention here, who says you should never write stories about truck drivers unless the truck drivers think like Proust. And I think there's a lot of wisdom in that.
I am not a fan of stories about ordinary people who think in ordinary ways. I am deeply devoted and a big fan of people's stories, but ordinary people who think in extraordinary ways. Not because there are millions of people out there leading ordinary lives because ordinary lives don't make interesting stories. Your challenge is to find the extraordinary person who matches the extraordinary facts of a situation that you're going to explore. And often it's not just a matter of coming up with that voice, but match that voice to the facts of the situation.
Question: As a writer and bioethicist, do you believe writers should consciously dramatize modern ethical issues?
Jacob Appel: Well, I think on the one hand, fiction is a very powerful tool to show us the issues and writers should not be afraid to explore these questions. On the other hand, you don't want to write issue-driven stories. And the thing you most don't want to do is you don't want to write issue-driven stories in which you've solved the problem, or offer an answer to the issue.
The distinction I make, and this is purely a matter of case, but I think if you compare probably the two great African-American male novelists in the 20th century, Richard Wright, and Ralph Ellison, Richard Wright is, in some sense, a more didactic writer, if you look at "Native Son," the first of the three **** of "Native Son" is a beautiful lyric work, the second is a lyric work that is driven by issues, and the third is somewhat propagandic and give you an answer to the question.
In contrast is Ralph Ellison who shows you in its full panorama the challenges of African-Americans in the early 20th century, but doesn't give you any answers. And I think history will show that Ellison's "Invisible Man" is a far better and more lasting work than "Native Son." I think for writers out there, you want to show people the issues, or show people the questions, but you don't want to offer them answers, let them come to the answers on their own.
Question: As a New York City Sightseeing Guide, what’s your favorite sight to see in the city?
Jacob Appel: What I like to tell people is, of all the exams I have taken over the years, I've taken the Bar Exam in New York and Rhode Island, I've taken the Medical License Exams, I've taken the GRA's to get into graduate school, I've taken a Notary Public Exam in New York State, the hardest exam by far was the New York City's Tour Guiding Exam. So, if you were planning on becoming a New York City Tour Guide, get your blue book and study hard. It was also the one I was most proud to have passed.
That being said, I’ve given some walking tours in New York. One of my dreams is that some day, when I retire, I will be on one of those red double-decker buses sharing my love of New York because do love New York and I think it is the greatest city in the world, at least for me to live in.
My favorite monument is a rather obscure monument that few people even know of. I've written about it in the past, is the Amiable Child Monument at Riverside Drive and 133rd Street. It's a little grey marker that's been there for about 250 years -- 300 years, excuse me, that marks the place where a child in the late 18th century fell off the cliff and died. Back when it was rural farm land and it was a strawberry field. Not much is known about the child, but over the centuries, people from the neighborhood, and increasingly people from the city come to that site to pay tribute to things they've lost in the city, or to share their own experiences, and there's a little museum, so to speak, around this gravesite of trinkets, and Christopher's medals and heirlooms, and after 911, people from the neighborhood came there and you can still sense the smell of the burning buildings from downtown wafting up the Hudson, and people left tributes there and pinned letters there, and it's a truly haunting site that if you're ever in Morningside Heights, it's worth seeing.
Recorded on March 1, 2010
Interviewed by Austin Allen
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The COVID-19 pandemic is making health disparities in the United States crystal clear. It is a clarion call for health care systems to double their efforts in vulnerable communities.
- The COVID-19 pandemic has exacerbated America's health disparities, widening the divide between the haves and have nots.
- Studies show disparities in wealth, race, and online access have disproportionately harmed underserved U.S. communities during the pandemic.
- To begin curing this social aliment, health systems like Northwell Health are establishing relationships of trust in these communities so that the post-COVID world looks different than the pre-COVID one.
COVID-19 deepens U.S. health disparities<p>Communities on the pernicious side of America's health disparities have their unique histories, environments, and social structures. They are spread across the United States, but they all have one thing in common.</p><p>"There is one common divide in American communities, and that is poverty," said <a href="https://www.northwell.edu/about/leadership/debbie-salas-lopez" target="_blank">Debbie Salas-Lopez, MD, MPH</a>, senior vice president of community and population health at Northwell Health. "That is the undercurrent that manifests poor health, poor health outcomes, or poor health prognoses for future wellbeing."</p><p>Social determinants have far-reaching effects on health, and poor communities have unfavorable social determinants. To pick one of many examples, <a href="https://www.npr.org/2020/09/27/913612554/a-crisis-within-a-crisis-food-insecurity-and-covid-19" target="_blank" rel="noopener noreferrer">food insecurity</a> reduces access to quality food, leading to poor health and communal endemics of chronic medical conditions. The U.S. Centers for Disease Control and Prevention has identified some of these conditions, such as obesity and Type 2 diabetes, as increasing the risk of developing a severe case of coronavirus.</p><p>The pandemic didn't create poverty or food insecurity, but it exacerbated both, and the results have been catastrophic. A study published this summer in the <em><a href="https://link.springer.com/article/10.1007/s11606-020-05971-3" target="_blank">Journal of General Internal Medicine</a></em> suggested that "social factors such as income inequality may explain why some parts of the USA are hit harder by the COVID-19 pandemic than others."</p><p>That's not to say better-off families in the U.S. weren't harmed. A <a href="https://voxeu.org/article/poverty-inequality-and-covid-19-us" target="_blank" rel="noopener noreferrer">paper from the Centre for Economic Policy Research</a> noted that families in counties with a higher median income experienced adjustment costs associated with the pandemic—for example, lowering income-earning interactions to align with social distancing policies. However, the paper found that the costs of social distancing were much greater for poorer families, who cannot easily alter their living circumstances, which often include more individuals living in one home and a reliance on mass transit to reach work and grocery stores. They are also disproportionately represented in essential jobs, such as retail, transportation, and health care, where maintaining physical distance can be all but impossible.</p><p>The paper also cited a positive correlation between higher income inequality and higher rates of coronavirus infection. "Our interpretation is that poorer people are less able to protect themselves, which leads them to different choices—they face a steeper trade-off between their health and their economic welfare in the context of the threats posed by COVID-19," the authors wrote.</p><p>"There are so many pandemics that this pandemic has exacerbated," Dr. Salas-Lopez noted.</p><p>One example is the health-wealth gap. The mental stressors of maintaining a low socioeconomic status, especially in the face of extreme affluence, can have a physically degrading impact on health. <a href="https://www.scientificamerican.com/index.cfm/_api/render/file/?method=inline&fileID=123ECD96-EF81-46F6-983D2AE9A45FA354" target="_blank" rel="noopener noreferrer">Writing on this gap</a>, Robert Sapolsky, professor of biology and neurology at Stanford University, notes that socioeconomic stressors can increase blood pressure, reduce insulin response, increase chronic inflammation, and impair the prefrontal cortex and other brain functions through anxiety, depression, and cognitive load. </p><p>"Thus, from the macro level of entire body systems to the micro level of individual chromosomes, poverty finds a way to produce wear and tear," Sapolsky writes. "It is outrageous that if children are born into the wrong family, they will be predisposed toward poor health by the time they start to learn the alphabet."</p>Research on the economic and mental health fallout of COVID-19 is showing two things: That unemployment is hitting <a href="https://www.pewsocialtrends.org/2020/09/24/economic-fallout-from-covid-19-continues-to-hit-lower-income-americans-the-hardest/" target="_blank" rel="noopener noreferrer">low-income and young Americans</a> most during the pandemic, potentially widening the health-wealth gap further; and that the pandemic not only exacerbates mental health stressors, but is doing so at clinically relevant levels. As <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413844/" target="_blank" rel="noopener noreferrer">the authors of one review</a> wrote, the pandemic's effects on mental health is itself an international public health priority.
Working to close the health gap<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDc5MDk1MS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxNTYyMzQzMn0.KSFpXH7yHYrfVPtfgcxZqAHHYzCnC2bFxwSrJqBbH4I/img.jpg?width=980" id="b40e2" class="rm-shortcode" data-rm-shortcode-id="1b9035370ab7b02a0dc00758e494412b" data-rm-shortcode-name="rebelmouse-image" />
Northwell Health coronavirus testing center at Greater Springfield Community Church.
Credit: Northwell Health<p>Novel coronavirus may spread and infect indiscriminately, but pre-existing conditions, environmental stressors, and a lack of access to care and resources increase the risk of infection. These social determinants make the pandemic more dangerous, and erode communities' and families' abilities to heal from health crises that pre-date the pandemic.</p><p>How do we eliminate these divides? Dr. Salas-Lopez says the first step is recognition. "We have to open our eyes to see the suffering around us," she said. "Northwell has not shied away from that."</p><p>"We are steadfast in improving health outcomes for our vulnerable and underrepresented communities that have suffered because of the prevalence of chronic disease, a problem that led to the disproportionately higher death rate among African-Americans and Latinos during the COVID-19 pandemic," said Michael Dowling, Northwell's president and CEO. "We are committed to using every tool at our disposal—as a provider of health care, employer, purchaser and investor—to combat disparities and ensure the <a href="https://www.northwell.edu/education-and-resources/community-engagement/center-for-equity-of-care" target="_blank" rel="noopener noreferrer">equity of care</a> that everyone deserves." </p><p>With the need recognized, Dr. Salas-Lopez calls for health care systems to travel upstream and be proactive in those hard-hit communities. This requires health care systems to play a strong role, but not a unilateral one. They must build <a href="https://www.northwell.edu/news/insights/faith-based-leaders-are-the-key-to-improving-community-health" target="_blank" rel="noopener noreferrer">partnerships with leaders in those communities</a> and utilize those to ensure relationships last beyond the current crisis. </p><p>"We must meet with community leaders and talk to them to get their perspective on what they believe the community needs are and should be for the future. Together, we can co-create a plan to measurably improve [community] health and also to be ready for whatever comes next," she said.</p><p>Northwell has built relationships with local faith-based and community organizations in underserved communities of color. Those partnerships enabled Northwell to test more than 65,000 people across the metro New York region. The health system also offered education on coronavirus and precautions to curb its spread.</p><p>These initiatives began the process of building trust—trust that Northwell has counted on to return to these communities to administer flu vaccines to prepare for what experts fear may be a difficult flu season.</p><p>While Northwell has begun building bridges across the divides of the New York area, much will still need to be done to cure U.S. health care overall. There is hope that the COVID pandemic will awaken us to the deep disparities in the US.</p><p>"COVID has changed our world. We have to seize this opportunity, this pandemic, this crisis to do better," Dr. Salas-Lopez said. "Provide better care. Provide better health. Be better partners. Be better community citizens. And treat each other with respect and dignity.</p><p>"We need to find ways to unify this country because we're all human beings. We're all created equal, and we believe that health is one of those important rights."</p>
The rites we give to the dead help us understand what it takes to go on living.
As the coronavirus pandemic hit New York in March, the death toll quickly went up with few chances for families and communities to perform traditional rites for their loved ones.
Shannon Lee shares lessons from her father in her new book, "Be Water, My Friend: The Teachings of Bruce Lee."
- Bruce Lee would have turned 80 years old on November 27, 2020. The legendary actor and martial artist's daughter, Shannon Lee, shares some of his wisdom and his philosophy on self help in a new book titled "Be Water, My Friend: The Teachings of Bruce Lee."
- In this video, Shannon shares a story of the fight that led to her father beginning a deeper philosophical journey, and how that informed his unique expression of martial arts called Jeet Kune Do.
- One lesson passed down from Bruce Lee was his use and placement of physical symbols as a way to help "cement for yourself this new way of being, or this new lesson you've learned." By working on ourselves (with the right tools), we can develop the skills necessary to rise and conquer new challenges.
Philosopher Nick Bostrom's "singleton hypothesis" predicts the future of human societies.
- Nick Bostrom's "singleton hypothesis" says that intelligent life on Earth will eventually form a "singleton".
- The "singleton" could be a single government or an artificial intelligence that runs everything.
- Whether the singleton will be positive or negative depends on numerous factors and is not certain.
Want to Retain American Jobs? Stop Blaming Globalization<div class="rm-shortcode" data-media_id="oxK8j1xN" data-player_id="FvQKszTI" data-rm-shortcode-id="2cf425d7b91ed2a6fc4fe19d065f3408"> <div id="botr_oxK8j1xN_FvQKszTI_div" class="jwplayer-media" data-jwplayer-video-src="https://content.jwplatform.com/players/oxK8j1xN-FvQKszTI.js"> <img src="https://cdn.jwplayer.com/thumbs/oxK8j1xN-1920.jpg" class="jwplayer-media-preview" /> </div> <script src="https://content.jwplatform.com/players/oxK8j1xN-FvQKszTI.js"></script> </div>
How to deal with "epistemic exhaustion."