“Enhancement” and Moral Development

Oxford ethicist Julian Sevulescu and Swedish philosopher Ingmar Persson argue in their book Unfit for the Future: The Urgent Need for Moral Enhancement that now is the time to introduce neurological and genetic changes in people so they are willing to go along with various agendas.  They note that climate change is a big issue, but when a number of people are apathetic about the cause, it might be helpful to change their thinking by altering their biology.  In their words in a 2012 article in the Sydney (AU) Morning Herald:

”Our knowledge of human biology–in particular genetics and neurobiology–is beginning to enable us to directly affect the biological or physiological bases of human motivation, either through drugs, or genetic selections or engineering,”

It is rather common in both scientific and philosophical circles to find proposals for altering the biology of people as a good way to change people and their thinking.  Tom Garigan recently addressed these technologies in “What Should We Forget?” on Sept. 9th as they relate to modifying memories:

“To argue that memories should be “extinguished” or excised is also to forget the purpose of memories. We need memories, even the bad ones. In the research cited above, the memory extinguished was that of an electric shock repeatedly received in a specific chamber. How “therapeutic” is it to the mice to forget that they should not venture there again?”

Indeed, it might be helpful to remember that someone is administering an electric shock.  This comment emphasizes that the deeper issue at hand is the concept that being human is more than just the aggregate of brain processes.  I would say there is very much an immaterial, spiritual part of each human being, an aspect which interfaces with the brain chemistry and processing which we examine in the medical sciences but which cannot be wholly contained or defined by physical analysis or terminology.  This is what many religions have termed the soul, or the spirit, and I believe it is the realm of the particular discipline we know as theology.

Classic, Christian concepts of moral development emphasize that morality and ethics stem from the character of God Himself and therefore a person’s moral development is dependent on a human being’s relational activity with the Deity.  In turn, relationships with other human beings who are also soul-ful (likewise bearing the Imago Dei) are essential.  For instance, these types of interpersonal relationships are at the heart of the university experience, specifically that which is commonly termed as liberal arts education.  These disciplines are liberal in that they are freeing, allowing graduates to pursue the profession of their choosing.  It is an education of the human being so as to produce mature persons who not only are equipped to acquire technical skills for jobs but also possess the moral development of adulthood so as to be spouses and parents, citizens and neighbors.

To think we could take a pill and achieve Huxley’s “Soma” bliss or plug in a cerebral flash drive in order to acquire a semester’s coursework is wrongheaded to begin with.  The great learning of higher education is in the development of the person.  This includes the wisdom and insight of colleagues, the difficulty of trials and obstacles, the mentorship of a professor, and the calling of God in Heaven (the vocatio of vocation).

There are real brain diseases out there.  Perhaps we should save our expensive MRI machines and tailored pharmaceuticals for the neurologists working on those problems.  Let’s leave the social engineering to the annals of history.

For Further Study

de Brito, Sam. “Maybe It’s Time for a Little Human Enhancement.” Sydney Morning Herald (AU), December 23, 2012.

Heller, Nathan. “Poison Ivy: Are Elite Colleges Bad for the Soul?” New Yorker, September 1, 2014.

Scott, O. A. “The Death of Adulthood in American Culture.” New York Times, September 11, 2014.

Moral Enhancement, Uehiro Centre, Oxford University

Transcendence starring Johnny Depp (2014)

 Lucy starring Scarlett Johansson and Morgan Freeman (2014)

 

 

 

 

What Is Driving Our Health Care?

Katie Jennings recently wrote in Politico Magazine of the American Medical Association’s role in American health care policy, particularly concerning pricing for services (see “The Secret Committee Behind Our Soaring Health Care Costs”).   Since the 1990s, an AMA committee has been in charge of determining the value of services provided by physicians, including determining Medicare prices.  Jennings points out that the committee serves as “a de facto federal advisory committee” but is not subject to the transparency requirements of the 1972 Federal Advisory Committee Act.

Discussion of unfair pricing within American medicine is nothing new.  The New York Times reported in 2013 on the unreasonable costs of hospital care highlighting more murky arrangements concerning medical care pricing:

”It is no secret that medical care in the United States is overpriced.  But as the tale of the humble IV bag shows all too clearly, it is secrecy that helps keep prices high: hidden in the underbrush of transactions among multiple buyers and sellers, and in the hieroglyphics of hospital bills.”

Many people complain about how a simple stay in a hospital is a risky financial venture, especially when bags of saline can run into the hundreds of dollars.  This is far removed from the Christian origins of the hospital and its role as a place of respite and refuge for the stranger or the poor.  However, I think Jennings’s article is particularly important because it seeks to get at the root of the problem and expose the misguided philosophy behind it.

In the article, Jennings states that while over half of physicians in most industrialized nations are primary care practitioners, only 30% of doctors in the United States work in primary care.  Dr. Nancy Snyderman of NBC reported this week on Walmart’s foray into medical consumer clinics, which are designed to provide a cheap alternative to visiting a physician’s practice for minor ailments.  It looks like we are continuing the trend away from family practitioners, with on one end the million-dollar specialist and on the other end the physician assistants and nurse practitioners serving up retail medicine.  One thing is for sure:  The idea of a physician being first and foremost a person’s caregiver fostering a relationship over time is pushed out of the American medical equation.

In many areas of American society we suffer from a lack of a sense of fairness.  Words like “dysfunctional” are used to describe our leaders in Washington, but a simple development of one’s character so as to be able to see something other than one’s own self-interest would go a long way toward addressing our problems.

For Further Study

Jennings, Katie, “The Secret Committee Behind Our Soaring Health Care Costs,” Politico Magazine, August 2014.

Bernstein, Nina, “How to Charge $546 for Six Liters of Saltwater,” New York Times, August 25, 2013.

Snyderman, Nancy, “What You Need to Know About Walmart’s Walk-In Health Clinics,” NBC Nightly News,  August 29, 2014.

 

 

 

 

 

 

 

Attending to Attention

It’s hard not to notice that the idea of “attention” is on a lot of people’s minds. In just one week my desk received a copy of The Hedgehog Review,, the monthly Turning Points Magazine & Devotional, and an e-mail message from a parent all dealing with this subject.

Since the advent of a DSM diagnoses involving deficits of attention (initially linked to hyperactivity), the number of children diagnosed has risen sharply, along with the number of prescriptions written to treat them. Many have carried this diagnosis, and treatment, well into adulthood. There are claims from opposing sides—that the claim that medical advancements have made produced an appropriate clarification and treatment of a previously undertreated problem, versus the claim that this a classic example of medicalization and promotion of a disease for the purpose of creating a market for a product.

Those interested in bioethics would appreciate the breadth and depth of analyses by the editors in the Summer 2014 edition of The Hedgehog Review, who call for a “metaphysics, aesthetics, and ethics of attention, as well as a political economy, and an ecology of attention.” In other words, something other than biochemical treatment. We can start with asking what we mean by “attention,” and therefore what would be a “disorder” of it? For example, attention can be viewed as active engagement with the surrounding world, as well as the dedicated focus on a particular subject, as in the inward contemplation required by academic studies. Invariably such discussion leads to our modern culture and its burgeoning distractions and alterations of values; from there it is no surprise that some would walk us back through the evolution of philosophical beliefs over the centuries, in combination with the advancements and effects of technology.

Emerging from all articles is a clear concern for the ethics of attention, with the recognition that a commercial and technologically saturated culture is not just providing options for our attention but demanding it. Thomas Pfau states that “to pay attention is not simply a matter of increasing, seemingly at will, one’s computational processes, but, first and foremost, to recognize and assent to what deserves our attention and why.” Pfau cites Aquinas as regarding attention as “indispensable to an education in the virtues.” With this argument we can see that the coarsening of our culture and the loss of attention are not simply coincident, but linked.

David Jeremiah in his August edition of Turning Points Magazine & Devotional also speaks to the ethics of attention, but is more specific in highlighting what we should and should not attend to. Indeed, if we are to declare there is an ethics of attention, it would be a hollow gesture to simply aver that attention or focus is good without then answering on what should we focus.

Such discussions are difficult to imagine in the environment of the clinical encounter, constrained as it is by time, abbreviated relationships, and various expectations. And as much as I would like to steer all patients away from medication, and have them and their families address the more profound and fundamental personal and social concerns, I also recognize how many patients and families I have seen who have managed to hold it together and succeed with the benefit of medications. But as a profession we ought to appreciate the depth of concern in our society as represented in these publications, and find ways to work along the lines of discussion to address the deeper problems in society, families, and patients.

A “diagnosis” a physician can no longer make?

If you were to follow the trends on gender identity discussion you would be unsurprised to see this article in The Slate:
“Don’t Let the Doctor Do This to Your Newborn”

The author begins by portraying a physician taking a newborn away from a worried mother for a “procedure,” which turns out to be gender “assignment.” This physician, described as stern, masked, dismissive, knuckle-cracking, paternalistic, and judgmental, is charged with executing a “brutal” act within some “power structure.” It is essentially a charge of malpractice.

I am, unfortunately, not surprised that it is necessary today for a physician to justify what is blindingly obvious: calling a boy a boy and a girl a girl. The first step in helping to clarify reality is to refute the author’s narrative. I am usually not the first, second, nor even third person to declare the child’s gender. In the majority of pregnancies the mother and the ultrasound technician have already made the “diagnosis” in the second trimester. In the delivery room, I am often attending to the many details of delivery while observers such as family members and nurses declare the gender before I even notice.
But perhaps what is most instructive in this article is how well it exemplifies six devices of deception commonly used in modernity to undermine confidence in those aspects of society so long taken for granted that we have forgotten their quite logical origin and purpose:

1. Assigning false (and evil) motive;
2. Claiming that human actions can only be the result of collusion within some fantasized power structure instead of the logical result of human nature (that is, reality);
3. Turning a blind eye to the benefits of traditional social arrangements for human flourishing (while relying on a general inability of others to articulate them);
4. Claiming no harm in deviation from traditional social arrangements, perhaps out of willful ignorance that the very existence of society depends upon them;
5. Relying on lack of scrutiny of misleading terms;
6. Relying on hidden presuppositions that actually depend on a reality that disproves the existence of that which they try to describe.

Each of these provides ample basis for future blog discussions. Perhaps one must first decide if there is a reality that exists independent of our own design. If not, then it is pointless for a physician to make any diagnosis before checking with the patient to find out if he or she has already done so.

Jimmy Savile and the Hospitals

This week, a report released by the British government details sexual abuse by Jimmy Savile and its relationship to NHS hospitals.  Remarkably, the blockbuster entertainer went decades escaping investigation.  Even in his later years when he faced some scrutiny, Savile was never prosecuted for any crime.  However, in the three years since his death in 2011 at the age of 84, a ghastly picture of abuse has been uncovered.  And much of it is tied to his charity work with hospitals.

Most notably, Savile’s abuse appears to be tied to that of doctors at Stoke Mandeville, a British hospital which benefited from £40 million of fundraising from Savile.  One doctor, pediatrician Michael Salmon, served three years in jail after admitting to assaulting two girls.  Another doctor said of Savile:

“We all knew [Savile] because he was such a presence at Stoke Mandeville.  I personally had no inkling about Savile’s behavior.  This was all as much as a surprise to me as anyone else.  He wasn’t a person I was mad about but he was a philanthropist and he was responsible for getting an enormous amount of money for the hospital.  He would come into the wards, and I never saw a problem with him doing so—all the doctors knew him.  I am absolutely shocked by all of this.”

For Further Study

Laura Smith-Spark, “Rapes, abuse, possible necrophilia: DJ Jimmy Savile’s hospital horrors detailed,” CNN, June 26, 2014.

Sandra Laville and Lisa O’Carroll, “Jimmy Savile inquiry looking at alleged sexual abuse by three doctors,” The Guardian, October 24, 2012.

“NHS and Department of Health Investigations into Jimmy Savile,” Department of Health, Government of the United Kingdom, June 26, 2014.

Edward Malnick, “Jeremy Hunt Apologises for Jimmy Savile’s ‘Sickening’ Abuse in Hospitals,” The Telegraph, June 26, 2014.

The Fountain of Youth

 “Since by man came death, by man came also the resurrection of the dead. For as in Adam all die, even so in Christ shall all be made alive.”

Two weeks ago, family physician Joe Gibes wrote on the shaky medical footing of low testosterone treatment.  This week, Brian Williams reported on the NBC Nightly News that the FDA has issued warnings about thrombotic events associated with “Low T” treatment.  Dr. Bill Reilly, owner of an expanding chain of “Low T Centers” around the country and a user of testosterone treatment himself, says testosterone treatment is worth the risk.  According to Reilly:

“Once I got on testosterone, boy, it was just back like I was in college.”

At the conclusion of Dr. Nancy Snyderman’s story on Low T and Dr. Reilly’s testosterone centers, Dr. Reilly stated:

“You can age, but you don’t want to grow old as you age.”

I don’t understand that last statement.  I think part of aging is getting older.  Though it is hard for some Americans to imagine, aging, at one point in time, was thought to be accompanied by honor, as younger people looked to their elders as sources of wisdom.  Take the words of the book of Proverbs:

“Gray hair is a crown of glory; it is gained in a righteous life.” – Proverbs 16:31

Of course, today we would use hair-coloring long before “old age” and the proverb would be a moot point.  Gray hair would be a sign of a problem.  We would need a treatment for that.

Low T Tx is one of many maladies in American medicine due to our loss of our Christian context.  There is no need for every physician to be well-schooled in Christian theology, but when a culture becomes removed from its Christian background, well, then we really are left o our own devices (in a very literal sense).  Thus, aging, with its organic decay and immobility, is of no use to us and must be “treated” as a pathology.  What we really lack is the context of a resurrection.  It is completely normal to be dismayed at our own mortality.  However, within the context of a Resurrection we understand that God is good enough to even restore the decaying body.  In the words of the apostle Paul:

“But in fact Christ has been raised from the dead, the firstfruits of those who have fallen asleep.  For as by a man came death, by a man has come also the resurrection of the dead.  For as in Adam all die, so also in Christ shall all be made alive.  But each in his own order: Christ the firstfruits, then at his coming those who belong to Christ.  Then comes the end, when he delivers the kingdom to God the Father after destroying every rule and every authority and power.  For he must reign until he has put all his enemies under his feet.  The last enemy to be destroyed is death.  For ‘God has put all things in subjection under his feet.’”  — 1 Corinthians 15:20-27

Aging reminds us that death is real.  However, in Christ, the new Adam, there is hope of resurrection.

 

 

Strengthening from the Supper

I’d like to follow up on a recent post I made on the Lord’s Supper (see “The Body and the Blood” on May 11, 2014).  One of the important things to remember about Communion is that it is for our nourishment.  In fact, it was specifically instituted by Christ for our nourishment.  Baylor professor and Texas pastor of 100 years ago B.H. Carroll preached an interesting sermon on this fact, “The Relation Between the Lord’s Supper and Temptation.”  While I do not know exactly the circumstances surrounding this sermon, Carroll mentions near its conclusion that he sought desperately the Supper that very day because he had been suffering from a “dangerous illness” for at least six weeks.[1]

In this sermon, Carroll mentions that he cannot recall hearing a pastor make the connection between temptation and the Supper as seen in 1 Cor. 10:

“There hath no temptation taken you but such as man can bear: but God is faithful, who will not suffer you to be tempted above that ye are able; but will with the temptation make also the way of escape, that ye may be able to endure it. … The cup of blessing which we bless, is it not a communion of the blood of Christ?” — 1 Cor. 10:13, 16

I can’t either, but it does appear that Paul is making the connection.  And it makes sense.  When we are facing trials and temptations, we need strength.  And if Christ has specifically set aside something for our strengthening, we ought to take advantage of it.  Carroll makes this important point by way of analogy:

“If you knew that a child of yours had before him an arduous duty, requiring toil and persistence, you would want him, before he commenced it, to be well, to be strong, to go out nourished. … That is the precise point of failure in most of the Christian life, the indifference to the great doctrine of the nourishment of the soul, and the soul must draw that nourishment day by day from God.  It is the great teaching of the Lord’s Supper.”[2]

In this day and age, when we are suffering from illness or emotional trauma, our first move is to seek the best medical specialist or spend hours with a psychotherapist.  While the knowledge and skills of medical science and counseling are resources from which we should draw, let us first look to Christ in faith.  He has provided ample means for our help: the preaching of the Word by those called to the pulpit; the Scripture for our own private study as well as its reading among our brothers and sisters in the congregation; prayer, especially as we are led along by His indwelling Spirit; and the sacraments of baptism and His Supper.

Let us especially draw near to His table as we celebrate the Supper together for our nourishment.

For Further Study

Carroll, B.H., “The Relation Between the Lord’s Supper and Temptation” (Chapter V.) from The Supper and Suffering of Our Lord: Sermons.  Compiled by J.W. Crowder, Fort Worth: J.W. Crowder, 1947, pp. 56-71.

 


[1]Page 69.

[2] Pages 67-8.

International Research Ethics

More and more research funded by high-income countries (HICs, e.g. the US) is taking place in low- and middle-income countries (LMICs). For example, colleagues at my institution have received grants of over $64 million to do research in Ghana. A search of ClinicalTrials.gov shows that 20 of 29 open studies in Ghana involve women, children, and persons with HIV—all considered vulnerable populations. The obvious concern is how to protect human subjects of research from exploitation. For example, the pregnant woman with HIV who is approached by a US-funded researcher who offers to pay for all her prenatal care if she agrees to be randomized into a trial. How can she best be protected from coercion?

Therefore,  HICs are now taking the responsibility of exporting research ethics to LMICs. The question then comes up: Whose ethics? A cynical view is to look at the effort to teach research ethics in LMICs as a form of missionary work: to proselytize those who haven’t heard the good news of the Georgetown mantra and to help them build research ethics committees that can function like a Western IRB. Certainly many of these countries have been colonized by Western countries and have seen missionary work in their borders. Is this just adding insult to injury as rich countries continue another form of imperialism in South America, Africa, the Middle East and Asian sub-continent? Many authors think so, or at least warn against this approach.

But even if we all agree that exporting a Western IRB framework is the ideal, implementation still has a long way to go. A recent survey of research ethics committees in LMICs (that will be published next month in the Journal of Medical Ethics) showed that only 40% of these committees had a budget and only 50% included women on the committee—certainly a few stumbling blocks to effective research regulation.

An ideal model would be to facilitate the articulation of ethical guidelines for research in LMICs that are based on local interpretations of the concept of respect for human dignity. What that looks like and how to sustain protections of human subjects of research in LMICs is still a work in progress.

The Men of Atalissa

Originally, it was a progressive idea that sought to give mentally retarded men a place to earn their own pay.  Eventually, it became a system of servitude where men with intellectual disabilities lived in squalor and barely took home $65 per month.

Please take a moment to watch “The Men of Atalissa,” a short New York Times documentary made as a summary of a larger investigative project.  It traces the history of the Henry Turkey Service, the venture of a two Central Texas ranchers used to get “boys” out of state institutions and provide poultry companies with inexpensive labor.  “The Men of Atalissa” chronicles the story of a group of men from Texas who were moved to Atalissa, Iowa, where they suffered for many years with little notice from their fellow townspeople.

One man’s recollection of “they kicked us around” reminded me of a woman I met in the E.R. one night during a clerkship.  A woman with an intellectual disability and scratches on her arms was brought to the hospital by one of the caregivers at the group home where she lived.  I was the first on the scene, and as I began to talk to her she looked me straight in t he eye and said, “I want to talk to you alone” and gestured for the caregiver to leave.  Taking this as a possible indication of abuse, I notified the resident on call concerning the situation.  We did indeed conduct the interview with her alone and a separate interview with the caregiver out in the hall.  The social workers down the hall were contacted, but it was unclear to me later how well they followed up on the case.

We know what we are to do in the procedural sense.  The right questions are asked.  The right boxes are ticked off.  The chart is handed off to the next healthcare professional.  But do we see the person who is the patient?  Or is he nothing more than Ralph Ellison’s invisible man passing before us?

Maybe we are hurrying to our cubicle in order get our quota of sales calls in for the day.   Or maybe we are rushing to our townhome sandwiched between the families whose members don’t even have first names (to us).  Or maybe accounting or billing is breathing down our throats and there’s just not the time (or money) to speak to the patient in that manner.

Listen to the words of the father in Luke 9 who brought his suffering child to Jesus:

“And behold, a spirit seizes him, and he suddenly cries out. It convulses him so that he foams at the mouth, and shatters him, and will hardly leave him. “ (v.39)

Perhaps this is not the most heart-wrenching part.  Listen to his next sentence:

And I begged your disciples to cast it out, but they could not.” (v.40)

Let us not be called a “faithless and twisted generation” (v.41) and miss the patient in need or neglect to prayerfully consider how we might best treat him.

Ukrainian Bioethics

I returned from Kyiv, Ukraine, last week as part of a team that is working to strengthen a partnership with a Christian seminary there. As we met with various program heads within the school, I asked a few questions about how ethics are taught, and what bioethical issues the Ukrainian people face. Some of the answers were surprising.

Ukraine, of course, is the long-suffering nation to the west of Russia, most often remembered as the breadbasket of the former Soviet Union, as the nation where millions starved to death in Stalin’s effort to break the farmers that resisted collectivization, as a nation where much of the fighting—and death—from World War II occurred, and as the location of the horrific Chernobyl nuclear disaster of 1986, some seventy miles north of Kyiv. Ukrainians know what it means to endure; their national anthem is “Ukraine Is Not Yet Dead.” Ukraine’s history has witnessed many affronts to human dignity, perhaps one most chillingly on display at the “Museum of the Great Patriotic War” (a.k.a., World War II) where gloves made of human skin and a bar of soap made from human fat show just what human beings are capable of doing to each other. The Ukrainian people were saved from the atrocities of the Nazis to be dominated by the Soviets, exchanging one form of tyranny for another.

Years of communist rule still leave their mark on Ukraine. Something especially notable when out and about in Kyiv is the utter absence of physically-challenged people, the handicapped, on the city’s streets. It isn’t that they don’t exist. But communism in the Soviet Union served to create an “ideal society,” free of suffering and disability, filled with “perfect” people. In reality, this meant warehousing the mentally and physically-handicapped—and orphans—into hidden-away institutions. This mindset has been slow to change. Handicapped access is limited, to be charitable, and it is hard to imagine that a shopping trip would be anything but excruciating for anyone in a wheelchair. As much as I groan at some of the excesses, as I perceive them, in our “Americans with Disabilities” Act, I’ll probably now more gladly accept its quirks and demands as a way of affirming the dignity of those who suffer challenges I have yet to face in my own life.

It is easy to criticize the post-Soviet outlook, this vestigial communist view of human beings, as an American. But how much do we sanitize the pursuit of perfection here? What are enhancement technologies but a reflection that we have a need to be free of problems, to be our “best selves?” We tuck away our dying elders in nursing homes so that the inevitability of decline and death don’t confront our pursuit of happiness.

A member of our team wryly reflected that, in Ukraine, their faces are from the West but their minds are from the East. As I mentally checked off the list of bioethical issues we face in the West—challenges with assisted reproductive technologies and pre-implantation genetic testing, with use of technologies for human enhancement, and with limitation of burdensome treatment at the end of life—it became clear in discussing bioethics with the seminary faculty in Kyiv that most of these issues are completely off the radar of the vast majority of Ukrainians. Abortion is still hideously common as a method of birth control in Ukraine, as it is in Russia and elsewhere in the former Soviet Union. But the idea that we would use medicine to end life with physician-assisted suicide or euthanasia, or spend scandalous amounts of financial treasure on cheating the aging and dying process, seem arcane in Ukraine. One director even noted that the people of his country don’t have time to be depressed (even as they have faced generations of addictions) because they are too busy just surviving. A study in contrasts, this nation, where children are forgotten in orphanages and old women, the babushkas, may beg for money to supplement their meager pensions, but where children are bundled for warmth with the smallest hint of chilly air and people give up their seats on crowded buses for the elderly and for women with small children. These are a people acquainted with suffering and sorrow, and they have a certain respect for those who have suffered for more years than most (the elderly) and for those who hold the eternal promise of a better future (the children). A rather elegant ethic there: respect and promise.

Wiser minds than mine have delved into the mystery that, within the crucible of suffering, we may be best equipped to find evidence of grace in daily life. It was a visit to a church in Kyiv that I could best see this illustrated. There is, in Ukraine, a national church that had been suppressed, harassed, and persecuted at every turn, one that has survived communism and the economic anarchy that followed, and today sends workers into other former Soviet republics. It is, in fact, a joyful and beautiful place. It is a church that is ministering to orphans and the mentally and physically handicapped, bringing them out of the shadows to which communism relegated them. Ukrainian bioethics is more, forgive the awful word here, “primitive” in a sense, because the technologies that are such qualified blessings in the West have yet to meet this part of the world. But it is the church that is leading the way toward negotiating the ethical issues in a society in transition and embracing the notion of human dignity, a church that just may impact the course of a nation that is, indeed, not yet dead.