Thoughts and Prayers

Last month marked the five year anniversary of the shooting at Sandy Hook elementary school in Newtown, Connecticut.  Newtown has become a word loaded with political implications.  Gun control, left vs right, state's rights, 2nd Amendment rights, NRA, concealed carry laws, assault rifles, semi-automatic, ammunition limits, etc etc.  Time passes and the word Newtown is sheared of any connection to real life events.  It becomes something abstract and conceptual, a nagging insolvable that one wearies of wrestling with and so we quietly put it to rest, close the lid, forget the events that gave meaning to the word.  We allow a word to function as a signifier for vague gauzy notions.  It stops being an actual place.  It loses its link with the living.  Newtown means tragic.  Newtown means aberrational horror.  Newtown means unpredictable and unpreventable.  Newtown is in the past. Newtown.  Newtown was.  Never again, we promise.  Remember Newtown.  Newtown was a thing that happened.  Newtown becomes a word one uses to signal one's political stance, a cultural projection, a transparent bravado. Newtown was a moment for collective outrage.  Newtown Newtown Newtown.

If you say a word over and over it starts to lose its function as language, as signifier of a particular meaning.  Newtown.  Look.  Newtown.  Say it again.  Say it one more time.  Mourn for Newtown.    A time when, all too briefly, we came together to express our thoughts and prayers for the victims. Millions of good intentions and earnest entreaties released into a quiet void by decent, hard working [patriotic Americans.

We say "thoughts and prayers" a lot now, in this age of social media and 24 hour news cycles.  This is how a modern man or woman communicates an identification with social norms.  With each new horror, whether mass shooting or terrorist attack, we post to Facebook or pin Tweets expressing our solidarity.  Look at me, we seem to be saying, look at me identifying with a collective moral outrage.  Look at me as I mark my spot on the moral continuum.  I am just as appalled as all of you.  But now is not the time for public debate, for a national reconsideration of current gun policy.  That would be tacky and gauche.  It is enough to express our thoughts and our prayers.  And those thoughts and prayers are cast into the ether like spells, like magical incantations that, deep down, we know do nothing at all.  Because for thousands and thousands of years, when we are afraid, when we feel utterly powerless to change anything, mankind has resorted to the transmission of thoughts and prayers.  Divine intervention and supplications.  When overcome with fear, when the darkness blots out all forms of light, we have always been an animal that bows its head and prays to be saved by abstract higher powers.

It is worth re-visiting what Newtown actually meant on a particular day.  To get beyond the abstractions and review the tangible actuality of a day in the life of America.  On December 14th, 2012 a disturbed young man killed his mother and then broke into Sandy Hook elementary school, the same school he had once attended as a child, and there proceeded to execute 20 children and 6 adults.  Before he could be apprehended he committed suicide by putting a bullet inside his own skull.  The children were all either 6 or 7 years old.  Some were hiding under desks or in bathrooms when murdered.  The carnage lasted about ten minutes.  Within ten minutes 20 children were dead.  These were not mythical deaths like Achilles or Hector or Iphigenia, mere stories to tell future generations, symbols of man's eternal unsolvability.  These were real live children, suddenly gone silent forever.  It's worth re-visiting these children.  Looking at them.  Remembering them not as abstractions but as sentient beings, as living flesh.

This was Daniel Barden:

This was Charlotte Bacon:

This was Noah Pozner:

This was Jack Pinto:

This was Jesse Lewis:

This was Grace McDonnell:

This was Jessica Rekos:

This was Ana Grace Marquez-Greene:

This was Madeleine Hsu:

This was Olivia Engel:

This was James Mattioli:

This was Chase Kowalski:

This was Catherine Hubbard:

This was Josephine Gay:

This was Emilie Parker:

This was Caroline Previdi:

This was Avielle Richman:

This was Ben Wheeler:

This was Allison Wyatt:

This was Dylan Hockley:

Others killed that day included Rachel D'Avino, Dawn Hochsprung, Anne Marie Murphy, Lauren Rousseau, Mary Sherlach, and Victoria Leigh Soto.

The perpetrator had arrived at the school with a .223 caliber Bushmaster XM-15 ES2 rifle, 10mm Glock 20SF semi-automatic handgun, and a 9mm SIG Sauer P226 handgun.  Within the span of 5-10 minutes he had squeezed off 156 rounds.

This is what a Bushmaster XM-15 semi-automatic rifle looks like:

It belonged to the shooter's mother.  It had been purchased legally.  All the paperwork was in order.  This was a legally owned, legitimately possessed semi-automatic firearm belonging to an American adult in a small city in random Connecticut.

Since then, 3 of the 5 deadliest mass shootings in American history have occurred.  In Sutherland Springs, 26 people were killed by a lone gunman who opened fire inside a small church with a semi-automatic AR-15 style rifle.  In Orlando, a lone gunman opened fire in a crowded nightclub wth a SIG Sauer MCX semi-automatic rifle and killed 49 people.  This past October, a lone shooter set up a sniper's perch in a Las Vegas hotel with an arsenal of weaponry and unleashed a hail of bullets on a crowd of people attending an outdoor country music concert, killing 58 and wounding over 500.

But those are just the mass shootings, an extraordinarily rare event.  The vast majority of firearms-related deaths are not mass shootings.  Most never make the front page of a local newspaper, let alone go viral on social media.  Firearms cause 30,000-35,000 deaths every year in the United States.  Two-thirds of these deaths are from self inflicted gunshot wounds.  Another 8,000-11,000 homicides are the direct result of firearms.

Compared to other wealthy developed countries, the United States is far and away the most violent country on earth in terms of firearms-related deaths.  There are also, surely a coincidence, more firearms per capita in America than any other country on earth.

A paper in the American Journal of Medicine from last March studied the epidemic of firearms-related deaths in the United States compared to other high-income OECD countries.  The data was rather chilling:

The United States has an enormous firearm problem compared with other high-income countries. Americans are 10 times more likely to die as a result of a firearm compared with residents of these other high-income countries. In the United States, the firearm homicide rate is 25 times higher, the firearm suicide rate is 8 times higher, and the unintentional gun death rate is more than 6 times higher. Of all firearm deaths in all these countries, more than 80% occur in the United States.

The United States has a serious homicide problem. The overall homicide rate in the United States is 7 times higher than in these other countries. Men in the United States are approximately 9 times more likely to be a homicide victim than their male counterparts in these other high-income countries, and women are 4 times more likely to be a homicide victim than women in these other countries. The homicide rate is fueled by the firearm homicide rate in the United States. More than two thirds of the homicides in the United States are firearm homicides; by contrast, firearm homicide accounts for less than 20% of homicides in the other high-income countries.

But hey, what is data?  What are numbers in a world of real  bullets and bump stocks and drones and cluster bombs?  Figures on a page.  Tangentials.  Binomial functions.  Asymptotes verging in the infinite distance.  Numbers become abstractions.  Like thoughts and prayers.

Somewhere in Newtown, a classroom full of boys and girls are now reduced to thoughts in the dark recesses of the minds of grieving parents.  Ghostly recipients of prayers whispered by the living in the sleepless nights and lonesome dawns.  Prayers hoping to collide with little thoughts in the netherworld of inexplicable loss.  We all reach for our children in the night when awakened by the ancient fear, clutching for their warm bodies, their pale faces, their smallness beneath the covers; but for too many their trembling fingers find only the cold steel thoughtlessness of a gun.  And our prayers stutter to a halt, become wordless.

Birth Control is Essential

Listen, birth control was never "free". This is a fucking lie.  Since Obamacare became law, no one with standard employer-based health insurance got their monthly oral contraceptive prescription for free.  If you have health insurance, that means you pay a premium every month.  You pay money.  Actual real live currency.  In fact, you don't even get a chance to decide; it just comes directly out of your paycheck before the federal government can tax it.  That's employer-sponsored health insurance.  It has been that way since WWII.

What changed with Obamacare was the creation of the concept of "Essential Health Benefits".  EHB's are a list of ten categories detailing basic, essential services that all health insurance policies (employer, individual and small group plans) now have to offer.  By law, the category of EHB's deemed to be "preventive care services" have to be offered free at the point of delivery, i.e. without an additional co-pay.  All American adults get 15 preventive care services.  Women get 22 and children 26.

And what are these services?  Basic medical shit: colorectal cancer screening, cholesterol blood work, tobacco and alcohol abuse screening.  You goddam yearly mammogram.  Your kids' freaking vaccines.  And, holy mother of god, contraception prescriptions for all women.  Because contraceptives are actual medications.  Not just some proxy signaling  device in the wider culture war.  Being able to determine when one wants to have children in an era when it costs $250,00 to send your kid to goddam state school is a critical advance in modern medicine.  And some women use contraceptive for non-procreative reasons.  Conditions like Poly Cystic Ovarian Syndrome, PMS, heavy and irregular cyclic uterine bleeding are managed solely with oral contraceptives.

The benefit of preventive care is such that you make up on the back end any lost revenue from forcing patients to pony up with a co-pay.  Catching a breast or colon cancer early in the game is a lot cheaper than surgery and expensive adjuvant chemotherapy.  Not to mention opportunity costs of early deaths of working age Americans.

This is obvious and intuitively good medicine and reasonable public health policy.  People who argue the moral side?  That companies should be able to pick and choose which medicines they want to pay for based on some phony, archaic religious rationalization?  Fuck them.  Hobby Lobby can go to hell.  These women have paid for the right to get these medications via exorbitant monthly premiums.  Taking that away is an unnecessary and vindictive kick in the crotch.

This is infuriating.  Allowing this benefit to lapse would be self defeating and, in the long term, more costly.

Politically Correct or Just Correct?

Recently the staid, establishment surgical journal, Annals of Surgery, attracted some undesirable attention regarding a Presidential Address to the European Surgical Society they published in last month's issue.  The transcribed speech---- "Modern Surgeon: Still a Master of His Trade or Just an OPerator of Medical Equipment? ---by Polish surgeon Marek Krawczyk MD was roundly vilified on Twitter and elsewhere for the alleged crime of only using male pronouns when referring to surgeons.

Following the backlash, Annals took the extraordinary step of retracting the entire piece.  Their statement on the retraction is below:

In an era of expected gender equality and, furthermore, in a medical field (surgery) where women are increasingly closing the disparity gap (for the past 5 years, women have represented 40% of all general surgery residents) the idea that such an august surgical publication would perpetuate gender stereotypes is certainly unacceptable.  But a deeper dive into this episode raises some questions.  

The speech by Dr Krawczyk was a rather lumbering, anodyne review of the relationship between surgical excellence and evolving technology, i.e. can a surgeon be truly great or is greatness contingent on having the right tool at the right time.  He does a pretty standard historical overview of surgical innovation, from the Napoleanic Wars through the era of transplantation and robotics.  His conclusion is what you expect: the truly great surgeons would have been great in any era.  Cue applause at dimly lit hotel conference room in Bucharest.

The j'accuse of the matter is that Dr Krawczyk uses exclusively male pronouns when referring to surgeons in general (i.e. no one can get angry if "he" is used in reference to Dr Starzl or Dr Buchler).  I don't want to get into the minutiae of "micro-aggressions" or the "violence of discourse" but we can all certainly agree that using "he" or "him" every time to refer to "surgeon in general" is belittling and crude, especially when potentially half the audience identifies with the other gender.  It trivializes and diminishes the actual role that women play in modern surgery.

So does Dr Krawczyk actually do this?  

Well, for starters, the title of the piece is absolutely garbage.  How that slipped by the editors of Annals is head scratching.  Simply substituting one word would render much of the controversy moot.  How does this sound:  "Modern Surgeon: Master of the Trade or Just an Operator of Medical Equipment".  Better?  Less demeaning?  More inclusive?  

How about the body of the piece?  In how many instances does Dr Krawczyk flout acceptable pronoun norms?  To find out I went through the speech and counted.  (I'm a ridiculous OCD bastard when it comes to things like this.)  And I found 5 pretty clear cut instances when "him" or "he" is used to refer to a non-specific surgeon.  I also found 22 instances when he uses a term like "surgeon" (i.e. "surgeon's errors" or "assessment of surgeon performance" or "when a surgeon uses laparoscopy") instead of using "him" or "he".  He even uses the unwieldy "his or her" one time!  I mean, if Dr Krawczyk really wanted to be a cartoonish incarnation of misogyny he could have done so in a far more ostentatious and obnoxious manner.  

Further, Dr Krawczyk, in a response to Annals editor Dr Keith Lillemoe, averred that he meant no gender offense, that in Polish, the pronoun he used is gender neutral and can refer to men and women.  Apparently this was not good enough for Dr Lillemoe and, in a statement to RetractionWatch, he said:

In Polish, ‘his’ is not a gender specific term, but it is in this country, and we wanted to make it right….We didn’t want to make the suggestion that we were not sensitive to gender issues, so we wanted to jump on it quickly.

Well ok.  And jump on it, they did, retracting the piece 3 days after initial publication. That's fine I guess.  But I sort of feel bad for Dr Krawczyk.  His transgression, such as it was, seems to have been amplified by the translation process.  Retraction is one of the worst things that can happen to a scientist or researcher.  The stigma attached to having had a paper or piece retracted by a reputable medical or scientific journal can pollute a hard earned reputation and compromise future attempts to get papers published.

And so now Dr Kramczyk is known by those in the international surgical community with cursory knowledge of the whole affair as that Euro-surgeon who had an article retracted from Annals because of "gender insensitivity".  It doesn't seem fair.  Is he a misogynist?  Or just syntactically challenged?  Or perhaps neither?

Instead of going straight to DEFCON 2 and retracting the piece, perhaps the editorial staff of Annals could have simply taken down the on-line version for the 47 minutes or so that it would have taken to clean up the title and switched out a couple of the "he" and "hims" for "a surgeon" or "his/her" and then posted an explanation for why it was altered.  I don't know, that's just me.

The corrected version remains unposted at Annals.

This is America

In America, we have millions uninsured (even after the ACA), high deductible plans and ten thousand dollar per month chemotherapy treatments for desperate patients with stage IV disease.  In America, alone among western democracies, medical bills represent the leading cause of personal bankruptcy.  In America, we choose to commodify the health care sector, transform it into a vast, complex money generating machine.  This is the American way: free markets, personal responsibility, distrust of government interference.

And so it ought to surprise no one that some private companies (from Bloomberg) see opportunity in the misery of others.  Crowdfunding websites like GoFundMe are seeing remarkable growth in the category of medical expense fund raising.  And why wouldn't they?  What else are people to do when you get a bill from a hospital for 12 grand or your company's "insurance plan" carries a $6000 deductible?  It's the 21st century: you go on line and ask for money from strangers.

Of the $2 billion in money raised on GoFundMe last year, nearly half was for medical expense campaigns.  This is both commendable and abhorrent.  Commendable in the sense that it suggests a widespread philanthropic spirit running through our nation.  But is this really the best we can do?  A 21st century version of a spare change jar at the check-out counter of your local diner, proceeds of which to be used for "Jenny Miller's cancer pills"?  It's utterly absurd.  And most of these crowd funded endeavors don't raise nearly enough to cover the outstanding remittances. One study suggested that over 90% of medical expense campaigns on GoFundMe came up short of the requested goals.  In fact, the average fundraiser for medical bills got only 40% of what was needed.  So an American citizen, drowning in debt, gets the double ignominy of having broadcast his financial troubles for all to see, only to come up short anyway.    

But at least GoFundMe makes out all right.  Shed no tears for them.  For every donation, they take 5%.  That's a nice round number when you're talking about billions.

Dr Ferrari

Kevin Williamson wrote a piece last month in the National Review bemoaning the hand wringing he sees occurring across America surrounding the threat of millions of Americans losing their health coverage with the intended repeal of the ACA and its replacement with TrumpCare.  He calls this piece:  The "Right" to Health Care, with the scare quotes performing the task expected.  (What? Did you think you had a "right" to health care when you get sick, silly boy?) appended with the self-answering subtitle There isn't one boldly patched in the space before the opening lede.

He then goes on to construct a thought experiment utilizing children and apples to demonstrate that health care is a just scarce good and that all the nail biting over making sure all the kids get an apple is just cheap moralizing and coastal elite performative antics when, in the end, you only have 3 apples for 4 kids.  Market forces, you see.  Supply and demand.  What is needed is not a national reckoning--- the likes of which every other advanced western democracy has done--- with the idea that health care is a service/good that ought to be made available to all Americans, like schools and public safety and national interstate highways, but rather we just need to empower laissez-faire super entrepreneurs to plant a few more apple trees. This is thought-experimenting in its most primitive form, using the bare minimum of neurons.  Maybe 3 or 4 synapses get traversed at this cognitive level of "thought experiments".  This is like turning around and going home hungry because someone has placed a medium sized stone in the middle of the sidewalk on the way to the store.  The inability to conceptualize the apples as a totality, to be divided and sliced in such a way to ensure that everyone gets a fair nutritional share is punditry malpractice.  But Williamson doesn't care.  He has followed his thought bubbles to the terminus of his own choosing.

Rationing is posited as the true villain in this piece.  For Williamson, universal coverage is not worth the price we might have to pay in consequence; longer wait times for elective non-life threatening procedures, cost effectiveness barriers for new treatment approvals, lower profits for the holders of Capital etc etc.  This is his true dystopia, not the recent American past of a sparsely insured population wracked by medical bill induced bankruptcies.  For Williamson, health care is just another good on the market.  And the more it increases in demand, the higher its price ought to be.

And so we get this hopefully career defining quote:  "Rich people always get better stuff.  That's what it means to be rich." Let them take aspirin for their cancer, indeed.  Because hey, if you live in Africa and have HIV, that's all you get.  That's life.  Deal with it.

Meanwhile back in the world of Kevin Williamson, when a head cold just won't seem to run its course, he usually just struts into his fancy doctor's office in the suburbs, brandishing his American Express Platinum card, to see a doctor who is "always pleased to see me because I paid him out of pocket".  His insurance plan, you see, is called "American Express".  Cash is best.  What is wrong with all you dolts?  Are you plebeians not able to just whip out some plastic or peal off a couple hundies when it comes time to settle up with ol Doc Blowhard?  Not mentioned is the "thought experiment" of what might happen if Kash-man Kevin didn't need just a little Z-pack and, instead, came down with viral meningitis or perforated diverticulitis that resulted in a 12 day ICU stay and a charge master hospital bill of $79,850.  Even elite credit cards have maximums.

As Kevin gazes around at the opulent setting of his favorite doctor, he notices several pictures of Ferrari sports cars on the walls.  He kiddingly, nudge-nudge wink-wink, queries Dr Wonderful about the Ferrari's, suggesting that maybe he might be paying him too much.  And the good doctor replies: "Do you really want a doctor who can't afford a Ferrari?"  Yes, that groaning you hear is not some pipe swelling with the temperature change in your basement.  Kevin Williamson is the one person out of 100 who is impressed by a guy bragging about his luxury car.  I mean, I can just smell the overly administered Drakar Noir cologne emanating from my laptop as I read that.  This is either a doctor who does not exist or he is a guy who obtained a medical degree from the boardwalks of Jersey Shore, undid the top two buttons of his contrast collared Oxford, perfected his best shit-eating grin and went about the business of marketing himself to insecure but healthy dunces like Kevin.  It's a good gig if you can stand it.

Somehow, in a very short piece, Kevin Williamson of the National Review was able to accomplish more than even a well written parody could ever hope to achieve.  Parody works best when the target is limited and precise.  Nuance and complexity are the enemies of successful satire.  Somehow Kevin is able to be both obtuse (not understanding how health care is not a "good" like, say, lawn chairs or sausages to be purchased on the open market) while also revealing himself to be the embodiment of the crass materialistic John Galt elitist superman, so easy mocked by second rate late night talk show hosts.  He is the guy who thinks the dude with the muscle car revving at a stop light is the coolest person on Myrtle Beach.  He is the guy who thinks the tank-topped meat head grunting and squelching at the Gold's Gym must be "really strong and masculine".  He is the guy who notices when other men wear cuff links, and what kind.  He is the guy who must find out what car you drive within 10 minutes of meeting you in order to more properly form a judgment of your character and usefulness.  

Not to mention the complete lack of moral imagination that would prompt most intellectuals, from both the right and the left of the spectrum, to wrestle with the discordance of finding ourselves living in the richest nation in the history of human civilization while still somehow being unable to provide affordable, accessible healthcare  to 100% of its citizens......

Executioner/Doctor

There was a very bad op-ed published in the NY Times Saturday by the writer/cardiologist, Dr. Sandeep Jauhar.  It's called "Why It's OK for Doctors to Participate in Executions" and that pretty much tells you all you need know.  If you were to  read something online entitled "Why It's OK for Rapists to Babysit Your Child" you would feel the same filthy layer of scum descend upon your skin as I felt when I read Dr Jauhar's inexplicable ode to Doctors of Death.

The piece comes on the heels of a recent decision by the good ol' state of Arkansas to execute 8 men on death row over the next 11 days--- not because their crimes were particularly heinous or irrefutable, or just from sheer coincidence, or some other fluke of timing in the sentencing--- but rather because the state's supply of IV drugs used in executions is due to expire by the end of the month.  There's enough in that last batch, apparently, to knock off 8 inmates.  So...while the iron is hot....

Dr Jauhar makes the error of assuming that capital punishment will never go away, that all we can do as a society is to figure out ways of rendering it in a less mendacious, less barbaric, more telegenic fashion.  And who better to assure that a lethal drug cocktail will be administered with elan and efficacy than a practicing physician?  After all, medical errors are the 3rd leading cause of death in our great country! Allegedly.

I need to break Dr Jauhar's piece down paragraph by excruciating paragraph.  It's the only way to do this with any justice.  Here's one paragraph:

The three drugs in Arkansas’s execution protocol — midazolam; vecuronium bromide, a paralytic used during surgery that halts breathing; and potassium chloride, which stops the heart — are administered intravenously. The execution procedure therefore requires the insertion of catheters, controlled injection of lethal drugs and monitoring of a prisoner’s vital signs to confirm death. This makes it important that a doctor be present to assist in some capacity with the killing.

What is it about "insertion of catheters, controlled injection of lethal drugs, and monitoring of a prisoner's vital signs" unequivocally necessitate the presence of a physician?  The next time I witness an actual real live doctor place a peripheral IV in a patient, inject a medication all by himself, and then check a set of vital signs will be the first in at least a decade of practice.  There is nothing about the act of lethal injection that is inseparable from physician presence.  The idea that basic procedures performed every day by nurses and EMT personnel cannot be duly done without a physician watching over their shoulders is both condescending and ill-informed.

Here's another paragraph:

 The American Medical Association, however, strongly opposes physician participation in executions on ethical grounds. Selecting injection sites, starting intravenous lines and supervising administration of lethal drugs, the association says, violate a doctor’s oath to heal or at least to do no harm. Doctors who defy the association’s guidelines face censure and the threat that a state medical board might revoke their license, though it is doubtful such punishment has ever been carried out. I disagree with this view. Though I oppose capital punishment as a matter of principle, as a doctor I believe physician presence at executions is consistent with our mandate to alleviate suffering.

Who edited this piece? Here we have a physician outlining the American Medical Association's firm stance opposing any physician participation in lethal injection executions and then, blithely, distancing himself from that view while still claiming to hold a higher moral ground---- he only wants to alleviate suffering!  That's obnoxious, man.  You want to stick a doctor in a death chamber with vials full of instant death and call yourself a hero because you are allowing for the state to eradicate a human in a way that seems quiet and unobtrusive and clean.  Even the kids can come out to watch.  Watch the bad man go to sleep, Johnny.  See?  See how peaceful he looks?  Is that a smile on his lips?  He's happier now!  His sin has been purified! Christ has smited him!.  Satan has him now!

I have to go to another paragraph before I start writing 3000 words in the voice of a Evangelical Christian from Little Rock talking to his kid at a state sanctioned execution:

A lot can go wrong during lethal injections. In 2014 in Oklahoma, to cite just one gruesome example, a 38-year-old convicted murderer named Clayton Lockett writhed in pain at his execution, clenching his teeth and straining to lift his head off the pillow, according to witnesses, after a botched injection into a vein in his groin.

A lot can go wrong?  Even with lethal injection?  State sanctioned murder for more civilized and  sophisticated tastes?  You don't say!   You mean that when dangerous drugs are given off label for purposes they weren't meant for that sometimes things can "get a little hairy"?  That's some wild and wacky shit.  Short side tangent here: Do you know why vecuronium is always included in lethal injection cocktails?  Because it is a strong paralyzing agent.  My anesthesiologist colleagues often use it to render a patient completely still when I perform abdominal surgery.  The purpose of the drug in a death chamber is pure optics.  The third drug administered, the actual killer, is generally a lethal dose of potassium chloride.  Once injected it causes a massive myocardial infarction--- which is excruciating.  Even the injection of KCL into the veins itself will make it feel like your arm has been lit on fire.  So to spare us the "theatrics" of a condemned man writhing and groaning in agony while strapped to a gurney, we give the paralyzing agent as cloak; to hide the unsavory awfulness of what an execution actually entails.

Here's 2 paragraphs in a row: