On medicine and public money in Australia

Recently I was at a meeting organised by a community pharmacist to “remind” myself and other general practice doctors about a scheme available to patients that not only can help patients, but just also happens to be remunerated quite well by Australia’s federal health care system, Medicare. And I mean it pays general practitioners (GPs) well, and it pays pharmacists well. Suddenly another GP in the room asked just why are we being paid extra to do this when as GPs we have little to actually contribute to this patient’s particular health care encounter. The room fell silent. I couldn’t believe that finally someone had said what I had suspected for some time but didn’t have the courage to admit: that in some instances, the government does misspend money allocated for health care. I know, it seems so counterintuitive, so out of place, to suggest this at a time when the Australian government is saying that health care funding is becoming unsustainable, that the need for it has made it such a drain to government funds that it’s become unaffordable to fund alone on public money.

So where are the holes in the bucket with public health care funding? Well, in the interest of open disclosure I will admit that it’s been years since I worked in the public hospital system. I work in private practice, but as most doctors in private practice, still work under Medicare rules and (federal) funding. What I mean by this is, although we work in medical clinics that are privately owned, we receive Medicare money for part or all of the work we do. The choice to accept Medicare funding as the whole payment for services provided (i.e. “bulk-billing”) or only as part of the total fee is each practitioners choice. And the choice is not as simple as “some doctors are greedy and some aren't”.

I’m not a greedy person, but I refuse to accept the inadequately-low fees Medicare offers as payment for most general medical consultations. Let me explain this with a simple everyday example. Seeing a patient for a general medical complaint in a consulting room for 15 minutes costs the medical centre about $65-$71. That is what it’s going to cost to pay the doctor, administration staff, building running costs, etc. Now, Medicare Australia only pays $36.30 for this service. The federal government pays that not because they have calculated that that is what it actually costs for the medical centre to actually fund this consultation. No, this has been a federal budgeting decision that says that that is all the government is willing to pay for this service. It does not take into consideration the medical needs of the patient, the individual patient’s financial situation, and it certainly does not take into account the real costs of medical practice today. So, the government has essentially given the Australian public Medicare cards that you could roughly equate to “50% discount” cards (when used in private general medical practice), but they have unfortunately gone and told them that they are “100% discount” cards. And what’s more frustrating than patients not realising this, is that they expect this, politicians tell them they have a right to receive healthcare from private practitioners that are 100% subsidised (what is commonly called bulk-billing) using their 50% discount cards. What happens then is that medical centres have to charge individual patients the difference of what it actually costs to fund their healthcare and what the government is willing to pay on their behalf – or you go to a medical centre that has adjusted their practice not to suit the patient’s medical needs, but to try to make the smaller money from bulk-billing stretch (I won’t go into their practices, but there’s a reason I refuse to work in that system). But that’s not the story the governments tells the general public, honesty doesn't win votes, what they tell the public is that doctors are charging them more because they are greedy, not because governments are not funding their healthcare adequately.

Having said that, let me now discuss instances where I feel funds are not best justified. Some years ago, it was brought to the government’s attention that there is a high incidence of mental illness in the community. This affects a large proportion of people’s health, and ultimately it also becomes a drain on the social welfare system. It was identified that psychotherapy could help a lot of these patients with mental health problems. So it was then decided to allow Medicare to fund psychologist visits if it was deemed by a doctor that this was likely to benefit a person’s mental health. In order to encourage GPs to asses patient’s mental health and subsequently refer them to psychology services, Medicare offered substantial funding to GPs to provide this service. Considering the high incidence of mental illness, the cost of paying GPs and subsequently also funding psychology visits, this resulted in a massive new/extra expenditure for Medicare. So although the government wanted to encourage extra referrals to psychologists, they wanted to make sure that people weren't being unnecessarily referred who perhaps didn't require it. To ascertain this, Medicare introduced clauses that referring GPs had to obey, things like how long the consultation  must last, what must be covered in the consultation, what things had to be recorded in patient’s charts and in referring letters, etc. As time has passed, these things came to lose their function: most GPs could take less than 20 minutes (one of the initial clauses) to identify that a patient likely was suffering a mental illness that may benefit from psychotherapy and write a simple referral for this. In fact, I would argue that were it not for trying to meticulously (and unnecessarily?) follow all Medicare clauses, this could all be done in the course of a single standard medical consultation. Remove the clauses, respect doctor’s clinical judgement more, and get rid of special extra incentives to GPs. I know, I know, how dare I suggest a “pay-cut”? I’m not, really, all I’m suggesting is a redistribution of public funds within healthcare.

I could raise a similar argument about other general practice activities that are all clunked up with a lot of Medicare clauses, that pay a lot money (and I say this only comparatively to other general practice activities like consultations [which are underfunded]), and that could be just as well performed by doctors without either the extra clauses or the extra money. I mean things like home medication reviews where it is acceptable that pharmacist are paid for, but it is hard to justify why doctors should also receive an extra reimbursement when we are already expected to review patient’s medications as part of a normal consultation. A lot of people also seek ‘care plans’ to be eligible for some Medicare-funded allied health services. Why not just trust that GPs can make an assessment in a general consultation that a patient has a chronic illness and would benefit from allied health assistance? And while we’re on Medicare-subsidised allied health referrals, why is Medicare funding referral for therapies whose benefit’s on people’s health is not widely accepted and tested as beneficial? Medicare offers subsidised consults with osteopaths and chiropractors for patients with chronic illnesses (on a care plan) who have been referred by a GP. Why? Even some private health funds refuse to subsidise this (due to their unproved benefits) and the Australian government thinks it is worthwhile throwing precious health care dollars at it?!

To maintain my focus on what I have more personal experience with, I haven’t commented on how public health care money can be misdirected in public hospitals. However, you can speak to many public health employees in Queensland and they’ll all be able to tell you that a lot of public health care money is directed to bureaucrats and purely bureaucratic processes. Now, I will give you a simple example of how I have noted this happening more and more – even from my end as a private practitioner in the community.

Remember how one of the “perks” of private health insurance in Australia is said to be that the patient can nominate which specialist they are to see? Well, the opposite of this is that if you attend a public hospital, there is no choice given and people are triaged on clinical need, etc. as to which practitioner they see and in what relative time frame. Well, a few years ago I could refer a patient to a public hospital outpatient clinic for review with doctors of a particular specialty and exactly that happened: the patient received a letter to attend an appointment to the outpatient clinic of a particular specialty. Do you know what happens now? That when I send a referral for a patient to see a general surgeon, for example, in a few days’ time myself and the patient receive the first of a series of letters. This first one says this clinic is heavily booked, reconsider the referral, and go back to your GP to discuss this further (I tell patients to expect this letter and to ignore it). The second letter is just for me, and  it says that the patient has been given an appointment with a specialist (but they don’t state who) but because of Medicare rules, could I please tick the name of the specialist on the form, rewrite my referral, sign this new referral form, and then fax it back to them. But the patient already has an appointment booked with a particular specialist so that’s the specialist’s name I need to tick (I have to call them to ask them who this is before I can fax it back to them), and they obviously already know the clinical details I had on the original referral or the appointment would not have been booked. After I return the form to this hospital booking department, the third letter (and the only one that needed to be sent, really) arrives giving details of when the appointment is booked for. I ask myself why all this bureaucracy? And more importantly, which of my hospital colleagues in clinical roles lost their income so that this crazy bureaucracy  could be funded?

On global warming

I  haven’t written in a little while because I have been quite busy with organising things for a change in job (location, not career) and also some personal difficulties which I won’t go into just yet. But I have managed to give myself 2 weeks off work to just settle the pace in the last few months, and I have been watching some mostly mind-numbing television but also some interesting stories. One that particularly surprised me was a debate on nuclear versus fossil fuel derived energy. Here’s the link if anyone is interested in watching it.

What I found particularly interesting about the debate on fossil fuels versus nuclear energy are the premises and assumptions the debate (for both sides) are founded on. You see, every debate argues that one “thing” is better than the opponent’s “thing”, but there is also common ground – there has to be. So one opponent may say, for example, “I’m trying to do the most just thing for everyone and this ‘thing’ I represent is better for justice than the thing that my opponent is backing. The other opponent goes and makes the same argument, but proposes his thing is better for justice. The debate is interesting and relevant because it focuses on a common ground: justice. And you know what I found interesting in this fossil-fuel vs. nuclear energy debate? That the common ground that both parties were intent on protecting was climate change. Yes, here were big energy industry representatives arguing that they wish to protect the environment, prevent further climate change / global warming, and therefore nuclear energy is bad. On the opposite side of the debate were nuclear energy proponents arguing that they wish to protect the environment, prevent further climate change / global warming, and therefore fossil-fuel energy is bad (and also that other non-fossil-fuel energies are non-viable). I was fascinated not by the points of argument each team debated, but that suddenly global warming and climate change was a given, not the point of argument itself. No one was debating whether climate change was real in and of itself!

In political and legislative forums, the existence of this concept of global warming is negated by representatives of the fossil fuel industry. Now, in a debate whether on whether nuclear energy or fossil fuel energy is worse, global warming and climate change is taken as a fact – and the people arguing these both these things are almost the same people. That is what I find quite interesting. Environmentalists get invited to these events to present the debate on behalf of nuclear power companies, mining companies, and “green energy” companies (which are usually owned by the mining companies themselves). Of course, for the sake of arguments such as this, all the types of energy companies claim to have one thing at heart: the environment. In reality we all know that thing at the heart of any company are monetary profits. I mean, that is exactly the reason why mining companies invest heavily in “green energy”: because if the market happens to shift and “green energy” becomes more profitable than fossil-fuel energy, then you want to be the guy that owns this market already...

It’s all nice and interesting, but now I’m more confused. Is global warming considered a real thing or not in Australian politics? If so, then what are we (including the energy industry and other big carbon emitters) doing about it? If not, why not if even the energy industry can at times concede that it is a real thing?

On money and healthcare: Rights & Priorities - Part 3/3

As a doctor you often see people in a very vulnerable state of health walk into your room. Your job is to provide some sort of health care to that person. It is a paid job just like anyone else’s job for which they trained and invested time, effort, and money. Why any of us decided to become doctors and not hairdressers, teachers, politicians, carpenters, etc., is different for everyone and that is not the point. The point is we are workers same as anyone else doing any job. You do the job for a certain amount of hours, you get paid for doing that job, and then the money is yours to do as you wish. That’s the essence of working in a capitalist, democratic country like Australia and the U.S.A. regardless of what your job actually entails, right?

The doctor is a bit like a hairdresser or an accountant or a lawyer or a politician in that he doesn’t physically sell you a product, but rather a service. A patient walks in, you carry out an assessment, work out what he needs, and advice or give that treatment required. Patients don’t leave the room with a new bag filled with products they’ve purchased, but the same thing happens once you leave your hairdresser or accountant – and yet you are aware you need to pay for the service provided to you. And yet you could say that the service provided to you is at least a little more essential than a haircut or advice about things other than your health. One of these things could potentially be the difference between life and death. I have never heard of anyone who risked death by having long or unkempt hair…

So here is the dilemma I wanted to get to: health, or the access to health care is an essential human right; it is a right every human being regardless of who they are or what they possess deserves for the simple act of having being born human. In countries where there is widespread poverty and having no money really means having no money (i.e. none to spare on food or clothing or housing, and not just meaning poor as in having no money for a tv, a car, a haircut, a holiday, or entertainment, etc.), having a right to free access to health care is one of the great achievements of humanity.

So why am I singling out ‘poor’ countries as separate to developed countries like Australia? Because in developed countries like Australia, we believe that if we can’t afford a holiday or a car or costly entertainment that we are poor. And we don’t want to miss out on these things! To a person in a wealthy country like this, we believe that these things are our rights too - and God forbid that we miss out on these things to pay for what we now consider non-essentials, such as our health care. And that is the cause of the dilemma in wealthy countries: we have for the most part changed our priorities as to what is considered essential and non-essential. Yet we all have a sense of what our human rights are. I will tell you that in Australia we see time and time again people who hesitate and complain about having to pay an out-of-pocket fee to have their health tended to, but will without hesitation hand over large amounts of money for haircuts, for manicures, for holidays, for fancy cars, for video games, movies, etc. And yet, only one of these things could potentially be the difference between life and death…

I don’t know what the right answer is. And I don’t know what the best system of health care is. Surely everyone deserves the right to access health care regardless of what they have or who they are or what they do with their lives. Yet, surely, we have also come to some concerning conclusions when tending to our health is considered less of a priority than funding our non-essential commodities. Personally, I have only ever considered the doctor’s role as equivalent to the mechanic’s, to fix the machine so the machine can go where it chooses and do what it chooses. Doing our job doesn’t make us special people, we just do a special task. But it is a job same as being a mechanic is a job - and in this society, a job implies compensation. Doctors eat too and pharmaceutical companies are not charities, so the reality of it is that health care has become a business. It’s not ideal, but it is the reality.

On money and healthcare: Rights & Systems - Part 1/3

Rights

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services”  (Article 25, The Universal Declaration of Human Rights). The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. Of course, to the majority of the world’s population, complete attainment of our human rights and of health are only ideals and not reality. Nevertheless, they are ideals worthy of our consideration.

Ideals

In an ideal world every time someone fell into an unhealthy situation (physically, mentally, or socially), he should be able to access medical health care, mental health care, or social care and have his “health” restored. He should be able to access these things regardless of the amount of money he has, his sex or age, his political or religious affiliation, his ethnicity or language, his sexual identity or practice, his birthplace or site of residence, his employment status, etc. Basically, his right to health care is universal and his human right. That’s the ideal; reality is very different for a lot of reasons.

Reality

Every country has different health care systems, which impact on the way patients access health care. Some countries will have a health care system that is exclusively government-funded and all you may need to access it is proof of citizenship to that country. Usually that means that there is no cost to the patient for an “encounter” (i.e. every time you access health care) as funds are usually derived from a portion of pooled taxes payed by that country’s citizens. Other countries may have a system where accessing health care requires payment to a private health care facility or a private company that coordinates provision of health care (e.g. supplying and paying for the medical staff’s wages, the medical equipment, the facility fees, etc.). A lot of developed countries, Australia included, operate both of these public and private health systems concurrently where the public system is the default for all citizens unable to afford private health care. The private system exists and thrives because it promises certain perks and advantages like your choice of health care provider, faster access to elective surgery, more ready access to specialist medical reviews and allied health services, and often newer premises, medical equipment, and technologies. And yet other countries have a third system, like a lot in South and Central America, a “worker’s” health care system that provides health care services exclusively to that country’s citizens whose employers pay for access to this service. The worker’s health system is closer (or equivalent) to the private health care system than to the public system. I don’t intend to argue which system is better or which worse or which country does it best, but it’s interesting to consider what’s out there.

Australia

Australia has a dual system of public and private healthcare, the public system funded from federal money and managed (for the most part) at a state level. Medicare can be considered a pool of federal monies reserved for funding certain medical services (including surgical fees and the payment for medical staff), medicines, medical aids, etc. All citizens have access to those Medicare funds provided certain criteria are met, but generally it is a default system for everyone.

An often misunderstood peculiarity of the Australian government’s Medicare system has to do with the way a doctor bills his or her patients. The Australian government decides which medical services are worthy of a Medicare rebate, the amount of money allocated to it, and the conditions under which a service qualifies for a rebate. For example, anybody may approach a general practitioner for medical care and Medicare will provide a certain benefit to the patient to pay for that consultation. The patient may also approach a specialist doctor and pay for the full cost of seeing him in his private clinic; or he may present to his GP first and obtain a written referral to the same specialist and then become eligible for a rebate from Medicare to help pay for his medical specialist appointment. (A patient not wishing to access the private medical system at all for any reason may also be referred to a specialist in one of the state’s hospitals where it is available and obtain medical specialist review free of charge.) Importantly, the Australian government decides which medical services qualify for a Medicare rebate and how much money it allocates to each service – however, how much money Medicare allocates to a service does not always reflect how much money a service actually costs to provide. Medicare in fact operates as a rebate, a subsidy to the total cost of health care, not (at least not always) as the absolute cost to cover the service. Think of it as a discount voucher, not as a voucher for a “free” service.

On courageous conversations

Last week I attended an education session on Aboriginal and Torres Strait Islander cultural awareness. The intent was to help health professionals engage better with this subset of the Australian population, and as such “close the gap” between the health of non-indigenous and indigenous peoples (who fair terribly worse in morbidity and mortality). The session was run by a man who identified himself as an aboriginal man and he explained various aspects of what is culture from a psychosocial and semantic perspective. It was interesting and he spoke of a thing called “courageous conversations” – you know, all those touchy subjects on elements of our society which if we comment on we’ll be called racist or bigoted or misogynist or otherwise prejudiced. Racism and the history of Australia (or the U.S.A or South Africa or so many other nations) is one of those touchy subjects. So we all listened to the discussion he presented and he played Professor Michael McDaniel’sreconciliation speech and made passing reference to Kevin Rudd’s “Sorry”speech. The things spoken by these two men are along the same vein, but stated quite differently.

On the 13th of February, 2008, Kevin Rudd, the then Prime Minister of Australia gave a speech to acknowledge the past evils that had been afflicted systematically on the indigenous peoples of this nation. The other purpose of the speech was to apologize to aboriginal peoples of past, present, and future who had been (or will be) disadvantaged or hurt as a consequence of the shameful government policies that existed to purposely suppress aboriginal peoples. The speech was symbolic and groundbreaking, intent on paving the way to improving things in future and learning from past mistakes. This very loud gesture was meant to benefit not only the Australian indigenous people who for decades had had their history and rights suppressed, but also of benefit non-indigenous peoples by empowering them with knowledge and freeing them from the guilt of knowing that their ancestors had done something wrong but they now had the chance to right their wrongs. It was by all accounts a very admirable gesture by the leader of a nation.

Professor Michael McDaniel, an aboriginal man who is also Dean of Indigenous education at the University of Western Sydney, also gave a speech related to the reconciliation process that was occurring in Australia. He told one story of a non-indigenous solicitor who met some elders of an indigenous community and tried to tell them that he was aware of the unfairness and mistreatment indigenous peoples had suffered and he had a plan to propose some “reconciliation”, in this case something akin to acknowledging the land rights of the indigenous first occupants of that land. The aboriginal elders when he had finished his courteous and respectful talk, retold him the history of the Aboriginal people. They told him how his ancestors had raped, stolen, killed, desecrated, abused, and hurt their people in previous generations and how the current generation of their people is still suffering because of his people. The young solicitor was taken aback, surprised, and feeling blamed! What do you say to that? You say sorry. And when you say sorry the better man forgives, right? Right. That’s what we do in our culture, but not everyone’s culture is apparently the same in this respect.

Now, I have varying notions of what a sense of responsibility is, but for a while you have to consider yourself in the young solicitor’s shoes also. Prof. McDaniel explains that to the elders they were simply telling their story in their way, that they needed to do this, to vent, if you will. And at that second when the elders meet this young successful non-indigenous man, “For that moment you are Captain Cook. You are Arthur Phillip. You are the Mission Manager. You are the representative of everyone who did those things”. But you may wonder, why should he be designated the “representative of everyone who did these things”? The logic goes that it is because it is as an acknowledgement that the system and society we currently live in was built to ensure the success, exactly as he has, of a non-indigenous person like him and not of an indigenous person like the elders. So is he at fault because he is successful? Prof. McDaniel doesn’t state it quite like this, but he states that the systems that exist are at fault, they’re the “bad” ones. And yet in the middle of all this is a young man trying to do the right thing given what he has. Prof. McDaniel states he just has to “cop it, because it’s part of the healing process”. I know, I was outraged at his logic too. But you know what? Apparently it's hard for us to understand, he says, because (and I am paraphrasing here) ‘as a young non-Indigenous person, we’ve never had a sense of belonging to a society. We’ve never had “a collective sense of responsibility”’.

Honestly, I liked Kevin Rudd’s speech better. I liked it better for two reasons. As a Christian I always remember that scripture in Ezekiel 18:20 that says, “The one who sins is the one who will die. The child will not share the guilt of the parent, nor will the parent share the guilt of the child. The righteousness of the righteous will be credited to them, and the wickedness of the wicked will be charged against them”. Acknowledging our ancestors sins is one thing, we can even apologize for them and regret it on their behalf, but as for being “punished” or held accountable for it, I believe is a bit rich. My second reason can be summarised in this quote by Antoine de Saint-Exupery: “To be a man is to be responsible. It is to feel shame at the sight of what seems to be unmerited misery. It is to take pride in a victory won by one's comrades. It is to feel, when setting one's stone, that one is contributing to the building of the world”. Guilt is a useless thing unless it motivates forward action. It is honourable to take responsibility for righting wrongs even if they weren’t committed by us. It is not honourable to use punishment unless your aim is for retraining. If your camel is already walking to where you want it to go, it is only cruel to continue to beat it.

On propaganda

I was watching these Youtube videos on North Korea, which somehow led me to watching videos of Cuba and Soviet Russia. I’m very nerdy so I find watching documentaries fascinating. So after watching some of these videos and seeing them diss on the propaganda styles used by socialist countries, “communist propaganda”, I started to think that the videos themselves seemed like anti-communist propaganda. Now, I don’t know much about politics or governmental styles nor do I have any opinion on what’s good and what isn’t, but I found that it’s almost impossible to present a topic that is so fraught with emotive images and stories and not be biased. Because it is the mainstream media, the bias is usually pro-capitalist and anti-communist. Like I said, I don’t favour one way or the other.

One of the comments often made about these “communist” countries is their use of propaganda to idealize their nation’s system of government and also demonize that of capitalist/imperialist nations. Well, the videos and media most westerners have easy access to do the same thing in reverse direction: demonizing communism and glorifying capitalism. So I guess that’s just how the world works, to prove ourselves right and just we often attribute to others injustice and wrong.

The other comment often made about countries like North Korea and Cuba are their censorship or restriction of access to foreign media. This is proclaimed as an injustice because people only have access to biased information, skewed towards that of the current system of governance. They’re also denied access to what else is going on in the world, and –critically – to how much “better” than themselves capitalist countries are. Again, this is seen as bad by the leaders of countries like the U.S. because people should have the freedom to choose what to watch, hear, and believe. The so-called communist leaders give it a different spin: they believe they are protecting their people from materialism, from self-centeredness, and from greed. So on the one hand the argument is that some people are being denied their freedom, and on the other hand is the counter-argument that these same people are being protected from greater evils. What evils?

I remember reading once about methods of persuasion. One group of people really interested in methods of persuasion are commercial enterprises, and by inference also advertisers. Another very interested group are politicians. What both these parties do in order to achieve success (whether that be votes or money) is use propaganda to persuade others (consumers or voters or subjects) to buy their product, ideal, philosophy, etc. Of course, there are many different methods of persuasion or propaganda styles. You could, for example, reward a person for supporting your “product” (ideology, philosophy, or physical item) or punish them for using that of a competitor. Most nations use a system of governance that uses this method of “persuasion” to some degree in the form of legal systems and prisons. Another method, especially used by health promotion teams, is to demonize something, to make the consumer fear/dislike it in order to abhor a behaviour or consumption of a product. Politicians of communist countries are often noted to use this method, blaming all of a country’s woes on the enemy state and demonizing their way of living to ensure their voters/subjects are alternatively loyal to their own nation. In capitalist countries one of the major methods used by commercial companies to sell a product or a service is to first convince a person that they are lacking something or that their method of doing things is outdated before showing them a new product that will make their life so much better. Non-capitalist estates abhor this, calling this one of the greatest evils of capitalism because it is seen as a method by which a person is first sold dissatisfaction (usually towards their own person or their family or some other entity) before being offered a “solution”, the product being advertised.

Some time ago I read some criticism about the rising use of antidepressants in medicine. The story goes that going back some decades ago, rates of depression were much lower than they are today. The change can be attributed to a number of things: smaller family sizes, greater awareness about depressive states and suicide, more time dedicated to the workplace, breakdown in family structure, greater use of chemicals in the environment, pretty much anything that has changed in the past several decades. But is there one causative factor or is it a multifactorial phenomenon? The answer is almost always “multifactorial”. However, one thing about the increased awareness of depressive illnesses that is particularly interesting, is that the groups that were “raising awareness” about depression consisted mainly of pharmaceutical companies that had themselves developed the antidepressant medication to treat it. Some of the early public service announcements (advertisements?) about depression would go through a list of “symptoms” that if you identified with you should ‘talk to your doctor about’ to be prescribed treatment to ease you of your illness. Now, this is an extreme example were commercial companies are accused of selling you dissatisfaction, in this case it’s purported they convince you to believe you’re “sick”, so they can sell you their solution: a pill. Similarly, people are convinced their lives are somehow lacking if they don’t buy a certain drink, wear certain clothing, eat at a certain restaurant, drive a certain car, travel to a certain place, etc.

Now, my point is not to argue whether depression is a real or a commercially-created diagnosis, nor whether communist or capitalist systems of governance are better; my point is to remind us that we are human beings and not just consumers or voters or subjects or victims. Who was it that said that once you understand a thing you can’t be used by it? I don’t know, but he had a point. The one liberty no government or person or amount of persuasion can take away from us is the innate human ability to reason for ourselves.