The exceptional state of the union

Perhaps the President has been stung by Republican accusations that he does not believe in American exceptionalism: the belief that America is unlike, and superior to, every other nation on earth. Perhaps he was simply using good communication skills to keep his audience cheering at the nation's annual pep rally. Whatever his motivation, American exceptionalism was a recurring theme in last night's State-of-the-Union speech.

What helps to set us apart as a nation, according to Mr. Obama? Well, there's our remarkable diversity, and our willingness to fight for our beliefs, and our successful businesses and world-renowned universities, and our creativeness and eagerness to do big things. We are inspired by the American Dream: our belief that each of us deserves the chance to shape our own destiny, that anything is possible no matter who we are or where we come from. And because we're so outstanding, we are a light to the world: we provide a moral example of freedom, justice, and dignity, and we influence other nations to move toward peace and prosperity. That's why, the President said, "there isn't a person here who would trade places with any other nation on Earth."

Not, of course, that we don't have problems. As Mr. Obama pointed out, our educational system continues to lag: many schools have low expectations and low performance, a quarter of our students drop out of high school; other nations surpass us in math and science and have a higher percentage of young people earning a college degree. Our infrastructure is crumbling: South Korea has better internet access than we do; Russia and many European countries invest more in roads and railways; China has faster trains and newer airports. Our finances are in trouble: we have a mountain of debt along with one of the highest corporate tax rates in the world.

But we can get past these problems and stay Number One! We can, in Mr. Obama's words, "out-innovate, out-educate, and out-build the rest of the world"! We did it 50 years ago when we thought the Russians might surpass us in space exploration. Let's do it again, this time by improving education, government, business, the infrastructure! (Oh, and by the way, sustaining the American Dream has always demanded sacrifice and struggle. We're going to have to take responsibility for the deficit. We'll need to make painful cuts to decrease debt. But enough with the gloom ... ) If we can dream it, we can do it!

I appreciate the President's faith in our country's traditional ideals. I am grateful that he appealed to Democrats and Republicans to work together to achieve them. I agree that the government needs to encourage innovation, reform education, and rebuild the infrastructure. I understand why he invoked American exceptionalism - national self-esteem - to motivate us.

But I am sorry he did not say more about the sacrifice and struggle we will all soon be facing.

By freezing spending, he told us, we can reduce the deficit by more than $400 billion over the next decade. Good start, Mr. President, but our national debt is over $14 trillion - that's nearly $130,000 per taxpayer - and growing larger every second. Our exceptional country has already mismanaged its finances so badly that, no matter what the government does now, most of us are going to have to seriously trim our lifestyles in the coming years. Some of us will face real poverty. At nearly 10 percent, our unemployment rate already surpasses that of most European Union countries. Housing prices appear to be falling yet again. State governments are deeply in debt. Our largest generation is starting to apply for Medicare. Yet Mr. Obama spoke only passingly of  sacrifice, and his two Republican responders mentioned it not at all.

American exceptionalism is good when it increases our love for our country, when it reminds us of our founders' vision, when it drives us to increase opportunity and respect human dignity. It is dangerous when it allows us to ignore reality and hope for magical solutions where only sacrifice and hard work will do the job. Our world has seen many proud nations and empires; today most of them lie in ruins. In "Four Preludes on Playthings of the Wind," American poet Carl Sandburg paints a bleak picture of those forgotten places, now overrun by rats, lizards, and crows. Once, like us, they were powerful and rich. Once, like us, they sang:

We are the greatest city,

the greatest nation,

nothing like us ever was.

Health-care policy: 10 wishes

Republicans in the U.S. House of Representatives have voted to dismantle the health-care bill, whether by directly repealing it (which they can't do without the approval of the Democratically controlled Senate) or by chiseling away at its funding. They think they can improve on it. Fine. It's a flawed bill. Let the improvements begin.

If we're going to start from scratch, here are my 10 wishes for health-care policy. I want a system that

• provides health care for every citizen and legal resident in the country
• raises the number of physicians per capita
• raises the number of hospital beds per capita
• allows patients to choose their own doctors
• lowers per capita spending on health care
• lowers the health-care percentage of the GDP
• raises life expectancy at birth
• lowers adult mortality
• lowers maternal mortality
• lowers infant mortality

In other words, I want health care that is universal and widely available, allows free choice, saves money for the government as well as for individuals, and - of course - improves our health.

Are you waiting for pigs to fly? If so, check the skies above the following countries. Every country on this list has a health-care system that surpasses ours in all ten areas:

• Austria
• Belgium
• Denmark
• Finland
• France
• Germany
• Ireland
• Italy
• The Netherlands
• Norway
• Spain
• Sweden
• Switzerland

Three other countries - Canada, the U.K., and Japan - surpass us in nine of the ten categories, even though they have fewer doctors per capita than we do.

What do they know that we don't know? Perhaps we should ask them. How about we send our members of Congress on an extended Western European fact-finding tour?

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If you enjoy looking up data on health-care systems, you can amuse yourself for hours at the World Health Organization's detailed database search.

Murder by metaphor

Edward Hicks, Peaceable Kingdom

A public figure is shot. School children are shot. A building explodes. A package explodes. And immediately we look for someone or something to blame: Republicans? The Tea Party? Democrats? Muslims? The National Rifle Association? White Supremacists? The devil? Mental illness?

As Congresswoman Giffords fights for survival, perhaps we'll turn our soul-searching into a collective resolve to practice civility in both public and private discourse. But since we seem to be looking at others' souls rather than at our own, radical transformation seems unlikely.

The sad fact is that all of us are awash in violence.

I believe that political ads featuring targets and crosshairs - whether produced by Republicans, Democrats, or independents - are evil. I also believe, however, that they are metaphorical, not prescriptions for action. Alas, most of us voluntarily surround ourselves - and our children - with metaphors far more potent and pervasive than anything ever produced by a political committee.

The level of violence in even our PG-13 movies would have been unthinkable a generation or two ago (and back then, the special effects weren't nearly so gory, either). Movie previews - supposedly screened for general audiences - feature intrepid heroes and occasionally heroines gunning down the opposition (while driving like maniacs). Video games let adolescents go on imaginary killing rampages. Smaller kids buy action figures. Violent lyrics are common in popular music. TV violence outdoes TV sex. Popular books feature - and often describe in gruesome detail - murder, dismemberment, and rape - and all of these horrors are avenged by - you guessed it - violence.

It would be good if we could conduct debate without resorting to vitriolic ads and talk shows, of course. It would be good if automatic and semi-automatic weapons were available only to military and law enforcement personnel. It would be good if all mentally ill people had access to medical treatment (although, according to a report by the World Psychiatric Association, most acts of violence are committed by sane people, and most mentally ill people are non-violent).

But if we really want to stop the violence, we also need to pay close attention to our daily metaphors - the violent stories that change us for the worse while we think we are merely being entertained.

End-of-life planning - don't stop thinking about tomorrow

My daughter and her grandmother

"The Obama administration, reversing course, will revise a Medicare regulation to delete references to end-of-life planning as part of the annual physical examinations covered under the new health care law, administration officials said Tuesday." Thus begins a New York Times article citing "procedural reasons" and "political concerns" as factors leading to the change. Clearly the administration does not want a resurrection of "death panels" hysteria. Alas, a widely misunderstood but sensible provision has bitten the dust.

Some people think the term end-of-life planning means "planning to end life." Not at all (though cleverer politicians might have come up with a less confusing term). End-of-life planning is not about euthanasia (illegal in all states) or physician-assisted dying (currently legal in Oregon, Washington, and Montana). Rather, it seeks to answer this question: When you come to the end of your life, what kind of medical treatment do you want?

Why should end-of-life planning be part of an annual physical?

1. All of us - even Boomers and politicians - are going to die.
If we are fortunate enough to have living parents, they are going to die too. Some of us will die too soon. We will have a fatal accident or contract a killer disease or succumb to the sudden failure of an essential body part. Some of us will die too late. We will continue to breathe long after our minds and bodies have shut down, or we will endure unspeakable pain for weeks, months, even years (and no, despite the advances in pain medication, not all pain can be removed). Unless we and our loved ones die suddenly, with no warning, all of us will eventually have serious decisions to make.

2. It is better to start thinking about end-of-life decisions before we have to face them.
If we are in pain, or terrified, or unconscious, or demented, or in a hospital bed, it is hard to research and consider our options. If we are willing to think about death before we're actually staring it in the face, however, we can consult not only with our physicians, but also with our clergy, our family members, and our friends.

3. If we don't write down our wishes in advance, someone else may make our decisions for us.
If we have a health-care power of attorney, that person will be a relative or friend we have chosen. If we do not, it may be a health-care worker that we don't even know or a relative that we wouldn't trust with our lives. If we have written down our wishes regarding end-of-life care, our agent is likely to follow them. If we have not, our care will depend on state law and our doctor's or agent's philosophy.

4. If we don't regularly review our advance directives, they may stop reflecting our wishes.
As people age, their attitude toward death may change. Twenty years ago, I was helping my parents fill out a form required by their nursing home. In case their hearts stopped beating and/or their breathing stopped, did they want (a) to spare no effort or expense in order to prolong life, (b) to be given life-sustaining treatment as long as they were not in an irreversible coma, or (c) no intervention if burdens would outweigh benefits? Without a second's hesitation, both of my parents said, "No intervention." Startled, I gently suggested that life-sustaining treatment might be the better option. "You are speaking as a person in her forties," said my father. "We are speaking as people in their eighties."

In addition, as medical science advances, new interventions may make our final days more comfortable - or less bearable. A yearly conversation with our doctor about end-of-life planning could help us make wiser decisions in light of continually evolving options.

5. End-of-life planning is about free choice, not rationing.
Advance directives are not about people who, with proper intervention, would return to health. They are about people who are going to die soon no matter what intervention is offered - people who are too ill, too injured, or too worn out to ever return to health. With intervention, they may prolong the dying process, adding a few days or weeks to their lives; but they may also add pain, the discomfort of being in hospital, and the possibility of being kept alive by machinery after their brains have ceased to function. Some people want all possible intervention; some prefer to let nature take its course. In the absence of an advance directive, health-care providers tend to opt for intervention. This can be very expensive - and why take money out of the Medicare pot to hospitalize those who would rather die naturally, perhaps at home or in a hospice, when that same money could be used to treat the dying who want those extra weeks?

*   *   *   *   *

Well, the health-care law was going to make it easier for Medicare recipients (and their children) by asking them to think about these things once a year. Now we're back on our own, and most of us will continue to pretend that we (and our parents) are immortal. While we nestle our heads in the comforting sand, some people will be getting state-of-the-art but ultimately futile treatments that they do not want, and other people won't be getting the heroic end-of-life measures that they urgently desire - and all so we can be free from the unbearable intrusion of having our personal physicians ask us if we'd like to talk about our wishes.

What you can do today

Fill out and sign a health-care power of attorney, listing the people you trust to make decisions for you if you are incapacitated; and an advance directive, specifying the degree of medical intervention you want if you are dying. In some states, the power of attorney includes a section on advance directives.

You can get these forms from doctors, hospitals, nursing homes, or attorneys. You can also download them right now, at no cost, from a variety of sites on the Internet. State laws differ, so be sure to get forms from your own state. For example, Illinois residents can get the combined health-care power of attorney and advance directives here and a living will (an advance directive for people who do not want intervention that prolongs dying) here.

Give copies of your signed forms to your doctor and to each person listed on your power of attorney.

Keep copies at home. Take copies to the hospital or emergency room when you or a loved one goes for treatment. Review your documents yearly, on your birthday or when you go for a physical exam.

Even if nobody reminds you.