Should the Irish Giant be Buried at Sea?

On December 20 the British Medical Journal published a fascinating and important article by ethicist Len Doyal and law professor Thomas Muinzer - "Should the skeleton of 'the Irish Giant' be buried at sea?"

Charles Byrne was born in County Londonderry in Ireland in 1761. It was clear from early in his life that he had a growth disorder. He ultimately grew to approximately 7' 7". Charles, who was from a poor peasant family, became relatively wealthy from being exhibited as a freak. In 1780 he went to London where he entertained audiences and was described as "civilised" and "amiable." But his health deteriorated, and he died in 1783.

Charles was terrified that Dr. John Hunter, the famous surgeon, who was known for collecting corpses to dissect, would lay hold of his body after death. He requested that he be placed in a lead coffin and buried at sea. After his death friends set out to do as he wished, but Hunter bribed them, and his body was removed and replaced with stones. Hunter boiled the body to reduce it to a skeleton, which he exhibited in his own museum, which is now part of the Royal College of Surgeons.

The video that accompanies the article provides a brilliant opportunity for moral deliberation. The authors argue persuasively that Charles Byrnes's clearly expressed wishes ("advance directive" in current parlance) should be respected, albeit belatedly, by burial at sea. But Brendan Holland, a man with acromegaly (Byrnes's condition) from the same area of Ireland, whose pituitary tumor was successfully treated, persuasively argues that if Charles Byrne understood how study of his skeleton has benefited others (by identification of a genetic mutation that predisposes to acromegaly) he would want his skeleton to remain in the museum where further therapeutic research could be done as new methodologies emerge.

The BMJ posed a poll along with the article. As of today, with 700 votes having been cast, 54.3% favor burying Byrnes at sea, 13.4% favor keeping the skeleton for further research but not exhibiting it, while 32.3% would leave it on display.

The video pits Doyal and Muinzer's "respect-for-the-individual" argument against Holland's "respect-for-the-good-of-others" position. Holland imagines that Byrne would have been persuaded by his perspective, a move that - if accepted - undermines Doyal and Muinzer's conclusion. But as they point out, his conclusion about what Byrne would have wanted is purely speculative.

This contest between rights of the dead and welfare of the living came up for me in a consultation many years ago. A clinician whose patient had committed suicide had been approached by his patient's family with a request for information. Their underlying question was - "did X love us?" X had given no guidance about his wishes. I asked what my colleague inferred X would have wanted him to do. He felt that while X knew that suicide would hurt his family, he would not have wanted them tortured by the question of whether he loved or hated them. I suggested that my colleague follow his best sense of what X would have wanted.

But suppose X had expressed hatred of his family and a wish that his suicide would punish them? What then?

I don't believe this question can be answered without much more detail about the circumstances. But in my view the analysis should attend to the wellbeing of the living as well as the wishes of the dead. With regard to Charles Byrne that perspective leads me to favor (a) retaining the skeleton for its further potential for research that would help the living, thereby respecting the welfare of the living, but at the same time (b) using Doyal and Muinzer's argument as the basis for prodding moral reflection, thereby respecting the dignity of the dead.

(Disclosure: Len Doyal was very helpful to me when I was a fellow at the King's College Centre of Medical Law and Ethics in 1992. I haven't seen him for more than a decade, but I think of him as a friend.)

Hospital Ethics Committees

Hospital Ethics Committees, the most important organizational structure in health care ethics, are a decidedly mixed bag, as measured by skill, reputation, and utilization of the consultation process. Kevin O’Reilly’s excellent article in the current American Medical Association News provides a very full update.

Almost all hospitals with more than 200 beds offer ethics consultation. But the median use is approximately 3 consults per 100 beds per year. Anyone who has worked in a hospital and seen the conundrums that emerge so regularly knows that 3 per year is very low.

O’Reilly cites multiple articles and interviews for concluding that (a) consultants are often under prepared for their role, (b) physician attitudes towards the consultation process are often negative, and (c) evidence for the effectiveness of the consultation process is weak. Howard Brody, director of the University of Texas Medical Branch Institute for Medical Humanities, commented that "if ethics committees were a drug, they would not be approved."

For two reasons, however, I expect that in the next 5 – 10 years we will see an upturn for ethics committees and the consultation process.

First, systematic research on the consultation process, combined with quality improvement interventions, will lead to enhanced consultation techniques and outcome monitoring. The Veterans Affairs IntegratedEthics program, initiated in 2007, is an example of the kind of systematic development that is needed.

Second, the change of language in the 2004 Federal Sentencing Guidelines for Organizations from “compliance” to “compliance and ethics” combined with the statement that organizations should “promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law” creates a strong push for strengthening ethics activities.

Hospital ethics committees are at the end of their entrepreneurial phase. They are up and running and widely disseminated. The phase we are entering now is managerial. The primary challenge is getting more mileage from the time, energy, and (limited) dollars that have been invested in launching them.

Adapting to Chronic Illness

I'm at a Vermont country inn for a few days of family holiday. Today a freezing drizzle deterred us from cross country skiing or snowshoeing, and I sat by the fireplace with Oliver Sacks's most recent book - The Mind's Eye. The book is a collection of Sacks's distinctive stories about people who have experienced neurological disasters. Sacks uses the stories to probe how the mind functions and how we frail but resilient humans adapt to dramatically altered circumstances such as losing the ability to speak, read, or recognize objects.

Pat, an active, sociable woman, suffered a massive stroke in her sixties that left her paralysed on the right side and unable to speak. Sacks describes how over the course of several years Pat learned to express herself by way of gestures and use of a list of words she could point at to name a topic or make a request:

Every so often, Dana [Pat's daughter] related, her mother would make a gesture that seemed to say, "My God, what happened? What is this? Why am I in this room?" as if the raw horror of her stroke hit her once again. But Pat was aware that she had, in a sense, been very lucky, even though half of her body remained paralysed. She was lucky that her brain damage, though extensive, did not undermine her force of mind or personality...

Pat's story, and others, reminded me how patients of my own had adapted to psychiatric ailments that, in the current state of the art, we couldn't cure. (I've disguised the vignettes.)

John had schizophrenia, but luckily not with any deterioration of underlying intelligence or other mental functions. When his symptoms acted up he channeled voices. To him the experience was real, but he knew that walking down the street conversing with hallucinatory companions struck people as odd. Since he liked to be out and about, he carried a cell phone, to look like others chattering with presumably non-hallucinatory conversational partners.

I was impressed with John's practicality, and passed on his technique to others.

Janet, in her forties, also suffered from schizophrenia. She was tormented by the conviction that she spoke in her sleep, accusing herself of deviant sexual acts. Her husband assured her that she slept soundly and said nothing, but she didn't believe him. She insisted on keeping all the windows closed so that passers by wouldn't hear her self accusations and think badly of her.

Closed windows made the house stuffy in the summer. This made for conflict with her thirteen year old son Alex. He persisted in opening his window and Janet persisted in blowing her top.

We held a family meeting. I said to Alex - "you know your mother has beliefs she can't shake that make her feel the windows have to stay shut." Janet nodded in agreement. "But if you're too hot in your room and sneak your window open, she'll understand and won't get too mad in the future." I was sure that Janet, who loved Alex and who had a sense of realism alongside her delusions, would agree. She did.

It was as if Janet lived on two planes. On one, her delusions were in charge. On the other, she could accept Alex's need to open his window. I was never sure whether that meant that at some level she saw her delusions as "unreal," or if, as a loving mother, she was willing to risk condemnation from her neighbors for the sake of her son.

I'd asked a patient who came from France what a French psychiatrist would say at the end of an appointment to a patient struggling to stay well. First she mentioned "continuez sur le bon chemin" ("continue on the same good path"). Then she cited, as more helpful to her, the single word - "courage." That rang true.

Clinicians who care for people with chronic conditions need to be skilled at rehabilitation as well as their own specialty. We need to respect and support our patients' capacity for courage.

Another of Sacks's patients made the point well: "The problems never went away, but I became cleverer at solving them!"

Spicy Lima Bean Soup & Zesty Sprout Salad

The Zesty Sprout Salad shown below was created with my own fresh grown sprouts and taste so delicious!  You can have a sprouting kitchen all winter long and it is a lot of fun, not to mention the nutritional value you gain.  Seeds, nuts and grains remain dormant until you give life to them. Inside they are full of potential just waiting to happen.  Unfortunately most people are eating them in their dormant and more difficult to digest stage.  Unlocking their potential by soaking in water and then sprouting is easy and will do wonders to improve digestion and health. Sprouts abound with antioxidants, they are full of protein, chlorophyll, vitamins, minerals and amino acids and in some cases reduce cholesterol.

     Phytic acid (or phytate when in salt form) is a substance found in many foods, but especially soybeans and soy products, oatmeal, corn, peanuts, kidney beans, whole wheat and rye. In the human gut, it acts as a chelater and an anti-nutrient. It reduces the absorption of valuable vitamins and minerals such as niacin, calcium, iron, magnesium, and zinc.

     Soaking, fermenting or sprouting beans, seeds, nuts and grains will neutralize much of the phytic acid.  A high consumption of improperly prepared phytate heavy foods can result in mineral and niacin deficiencies. This is particularly true for those with low mineral intakes, including children and people in developing countries where grain based foods make up the majority of the diet.

     Sprouting wheat for wheat bread makes it easier to digest. Sprouting wheat berries encourages them to make enzymes that break down starches, fats and proteins, which makes it easier to digest the grain. Sprouting tends to break down many of the substances, such as gluten, that may cause allergies in some people. Sprouting assists in making nutrients more available and can increase the absorption of calcium, iron and other minerals. To create healthier breads, muffins, pancakes, etc. soak your wheat kernels overnight, drain and let sprout for 1 or 2 days.  Dry the wheat kernel sprouts in a dehydrator.  When completely dry, grind into wheat and use in your recipes. 

     I also created a delicious Spicy Lima Bean Soup where I soaked the beans overnight and sprouted for a few days. Sprouting is the point where the bean is providing energy to create a plant. To facilitate this process, the bean’s nutrients are made as available as possible, and this coincidentally makes those nutrients more available to us. You won't actually see sprouts on the Lima Beans, but they will be ready to use in your soup after a few days. Large beans: Anasazi, Black, Fava, Kidney, Lima, Navy, Pinto, etc.-must be cooked to be digestible and are not to be eaten raw. These beans are actually unhealthful raw. To see a list of edible & non-edible sprouts - see Sprout People . After soaking and sprouting beans overnight or for a few days, you cook them with NO salt. Salt will interfere with the cooking process, and the beans will not fully soften if it is added too early. A piece of kombu (or other seaweed) in the cooking water while they boil helps improve digestibility and adds minerals to the beans.

Spicy Lima Bean Soup
Printable Recipe
Serves 4

Soaking, sprouting & cooking lima beans:
Ingredients
1 pound bag of lima beans (soak overnight & sprout for 2 days)
1 cup chopped onions
1 tomato, chopped fine
2 ½ tsp sea salt
1 tsp ginger, grated
2 cloves garlic, minced
1 tsp cumin
1 tsp coriander powder
1 tsp curry powder
1/2 tsp chili powder
1-2 large handfuls of fresh basil chopped (add before serving)
Method:
Soaking, sprouting & cooking lima beans:
1.) Soak 1 pound of lima beans overnight, drain and rinse well. Place 4 or 5 wet paper towels on top of plastic tray. Place wet, well drained lima beans on top of paper towels and spread them out. Cover with more wet paper towels and then a wet dish cloth. Let sprout for 2 full days (you will not see a sprout shoot at this point). Keep lima beans moist during the sprouting process.
2.) Rinse lima beans well after 2 full days of sprouting and pick out any small little hard lima beans and toss out. Place the nice plump beans in a crock pot (should equal around 5 cups plump beans). Cover with 5 cups no-salt vegetable broth and 1 sliced onion. Cook on low for 8 hours. (you can do this overnight)
3.) Add remaining ingredients in crock pot and cook on low until ready to serve.
4.) Right before serving add fresh chopped basil.
5.) This soup is very thick and is best served over rice or potato. ENJOY!!

Sprouted Wheat, Sprouted Pro-Vita Mix, Soaked Lima Beans

Zesty Sprout Salad

ZESTY SPROUT SALAD
Printable Recipe
Sprout 1 cup (Pro-Vita-Mix) Organic adzuki beans, peas, lentils, mung beans, triticale, wheat, fenugreek
Sprout 2 tsp (Alfa-Plus-Mix) Organic alfalfa, clover, cabbage, raddish
1 cucumber (chopped into small pieces)
2 carrots (shredded)
2 tbsp sesame seeds (raw or toasted)

Dressing:
¼ cup maple syrup (grade B)
¼ tsp salt 1 Tbsp dried onion or 1/8 small onion chopped finely
1/3 cup olive oil
3 tbsp apple cider vinegar

Place 1 cup (Pro-vita-Mix) in glass bowl and cover with warm water. Place 2 tsp (Alfa-Plus-Mix) in a separate glass bowl and cover with water. Soak overnight. Place sprouts in the Sprout Masters. Thoroughly rinse 2 times per day (morning/night) with a gentle spray of warm water. Note: This step is needed to keep the seeds from drying out and to wash away natural toxins (like giving your sprouts a bath). Drain well after each rinse. Sprout Pro-vita-Mix 2 days and the Alfa-Plus-Mix for 3-5 days. Place Alfa-Plus-Mix in sun on the last day of sprouting to have them green up.

Place sprouts in bowl and add chopped cucumber and carrots. Mix with zesty dressing and sprinkle with sesame seeds.

2 Seed Pack & Mini Sprouter

Getting Patients to Think About Cost

Harvard Pilgrim Health Care (HPHC), the not-for-profit regional health plan (Massachusetts, New Hampshire and Maine) where I direct the ethics program, is introducing a rewards program - "SaveOn" - to encourage patients to have procedures like colonoscopy, mammogram, and MRI at facilities that provide the service at lower cost. Patients who use lower cost facilities will receive a check for 10$ to $75. Here's how HPHC CEO Eric Schultz explains the rationale:

"It’s the kind of decision patients aren’t making today because they don’t have the information. Doctors are still referring patients for diagnostics based on the way they’ve always done it, without regard for the cost. But we can’t sit around and accept behavior that drives costs up with little or no impact on quality."

I respect and admire Eric Schultz, and think of him as a friend. But here's what Dr. Rick Lopez, chief medical officer for the group I practiced with for 35 years, and who I also respect and admire, and think of as a friend, has to say about SaveOn:

"I do have concerns about this. When I refer a patient for a test or an imaging, I’m taking into account what the patient needs and I’m referring the patient to a place where there’s quality. And I know that from experience. And, [if something goes wrong with a patient’s care] the doctors are liable."

I understand where Rick is coming from. SaveOn is a disruptive innovation. Rick knows and trusts the radiologists who do imaging studies for his patients and the gastroenterologists who do the colonoscopies. Of course he prefers to use them.

If I'm a lower cost radiologist I'm motivated to do a good job with Rick's patients and to communicate with him. If I succeed everyone wins. I build my practice, the patient gets a direct financial reward, and the referring physicians are happy with my services. And if the specialists Rick prefers are losing referrals on the basis of cost, they may decide to lower their fees.

But who benefits from the savings? Here's what Richard C. Lord, president of Associated Industries of Massachusetts, a trade group representing 6,000 businesses, has to say about SaveOn and the savings it may produce:

"Conceptually, it’s a move in the right direction. We’ve been talking about getting consumers more engaged in making their own health care decisions. Up until now, there’s been no incentive to a consumer to shop around. [But] ultimately the savings should be reflected in premiums employers pay."

For the past 25 years I've thought, talked, and written about the ethical imperative to contain health care costs. Unlike health care, words are cheap, and reams of articles and exhortations have not slowed down the cost curve. Innovations like SaveOn have the potential to be more educative than learned articles. If I see that the MRI I'm referred for may cost $1,000 at facility A and $3,000 at facility B, I'll be prodded to think about value. Perhaps B offers $2,000 worth of additional value, but perhaps not. The crucial thing is for the U.S. population to see questioning health care costs as an ethically appropriate activity, not a moral crime!

(The quotations come from a Boston Globe article. To learn more about how the SaveOn program works, see the website of Tandem Care, the subcontractor who provides the service.)

Why Patients Should Have Easy Access to their full Medical Records

Two articles in today's issue of the Annals of Internal Medicine present research on patient attitudes towards access to their doctor's notes: do they want to read the notes? do they think reading notes could be harmful? and, would they share the material with others? The articles and the accompanying editorial put some flesh onto the often vacuous buzzword "patient-centered care."

One article discusses OpenNotes, a year-long test of giving patients ready access to their primary care physicians' notes at sites in Boston, rural Pennsylvania and Seattle. The other describes a VA survey of patients who use My HealtheVet, the VA personal health record system.

Virtually all respondents believe that having access to their doctors' notes would help them. A minority (fewer than 1 in 6) was concerned that the notes would confuse them or cause worry. In the VA survey, 4 of 5 would want to share aspects of their record with family caregivers and other physicians.

The editorial described of how the M.D. Anderson Cancer Center has given patients and their referring physicians access to the Anderson electronic medical record. Since May 2009 more than 40,000 patients have viewed their records over 605,000 times, and 1,300 referring physicians have accessed the records of their patients over 28,000 times. 84% of Anderson's active patients have obtained access to their records. The editorial concludes:

Any health care organization with an electronic medical record and a secure Internet portal can provide patients and referring physicians with real-time access to medical records from anywhere in the world, opening the door to levels of patient engagement and care coordination not previously possible.

I believe that ready access to our own medical records is an important piece of what patient-centered care will mean in the future. The group I practiced with for thirty five years was using an electronic record when I joined. By the good fortune of having been forced to learn touch typing in middle school, I kept the keyboard on my lap and could look at my patient while making notes. I often consulted them about what we should put into the record. In the future I hope that in addition to having real time access to their records there will be ways for patients to make entries of their own. That's collaborative care!

The OpenNotes team compares the innovation they are testing to a new drug. OpenNotes is approaching a potential policy change in an admirably empirical manner. There's lots of reason to be optimistic about the benefits the intervention will offer, but my optimism is a hypothesis, not an established truth.

A Personal Experience with Consumer Directed Health Care

I'm agnostic about how effective Consumer Directed Health Care (CDHC) will turn out to be in prodding us patients into acting like discerning, value-oriented consumers. But I'm a total believer in the goal.

As a psychiatrist whose work is now largely in ethics and health policy, I'm interested in the psychological side of how we not-always-rational human beings respond to policy innovations like CDHC. So when I had a little interaction with my own CDHC plan last week, I paid attention.

In the last couple of weeks a longstanding mild medical problem had acted up such that my primary care physician and I decided that a specialty consultation would be a good idea. As a physician I knew it wasn't a medical emergency, though it had preoccupied me enough so that I didn't do any blog posts between December 1 and December 18.

In terms of CDHC, I knew that I'd met my deductible for 2011, so the sure-to-be-pricey specialty consultation would only cost me a $20 copayment, not an arm and a leg, but only if it took place this year. But I doubted that a "routine" appointment would be available before January at best, when the new deductible would kick in.

I was pretty sure I could get an appointment in 2011 if I said it was "urgent." But from a medical perspective it wasn't urgent, and I didn't want to (a) lie or (b) take away an appointment from someone else for whom it would be truly urgent. But at the same time I was peeved at the idea that the consultation would cost me $20 or several hundred dollars (especially if tests were added on, which they may well be), depending on the vicissitudes of schedule. Since I could afford the difference, even if grudgingly, I determined to take the first non-urgent appointment that was available, expecting it to be in 2012.

Still, it seemed odd that "better service" (an appointment in December) would cost much less than "worse service" (an appointment in January or later). That would be like Amazon offering next day delivery for a lower price than routine delivery!

The personal side of the story has a happy ending - the specialist had time later this week.

But I was interested in the way the financial incentive built into CDHC created a potential artifact. It wasn't a big deal, but these real world behavioral impacts are the kind of thing we need to understand and evaluate in assessing policy innovations.

(For an example of research I did with colleagues on the behavioral impact of CDHC see here. And see here for a blog post about how CDHC can work exactly as hoped for!)

The Reform Medicare Really Needs

Between now and the elections in November 2012 we're going to hear a lot about Medicare vouchers - or, in the prettied up term, "premium support." We're finally at the point where no responsible politician denies the need to curtail Medicare costs. And, in recent weeks, Democrats as well as Republicans have been floating different forms of voucher proposals for reining in Medicare costs. "Guaranteed Choices to Strengthen Medicare and Health Security for All," the hot-off-the-press proposal from Senator Ron Wyden (D-Oregon) and Representative Paul Ryan (R-Wisconsin) will get the most attention.

The Wyden-Ryan proposal opens with an on-target diagnosis of how virulent Medicare politics has led to the morass we're in:

Few issues draw more heated partisan rhetoric than the future of Medicare. Seniors are a reliable and powerful voting bloc, and both Republicans and Democrats are guilty of exploiting Medicare concerns to frighten and entice voters..In fact, the more the national conversation about the future of Medicare deteriorates into partisan attacks that our opponents will “cut Medicare” versus superficial campaign pledges to “make no changes” to a 45-year-old program, the harder it gets to have a serious debate about the best way to ensure that seniors can rely on a strengthened Medicare program for decades to come.

The debate about Wyden-Ryan and other voucher proposals is predictable. Republicans and a few Blue Dog Democrats (foreign readers - "Blue Dogs" are conservative Democrats) will fight for vouchers on the basis of free market theology of choice and competition. Yellow Dog Democrats (foreign readers - "Yellow Dogs" are so loyal they would vote for a yellow dog if it was called a Democrat) will fight to keep fee-for-service Medicare as it is, with tweaks to reduce costs.

Both positions are wrong. They ignore the two most important constituents - Medicare beneficiaries themselves and the improvement-minded clinicians who care for them.

We Medicare beneficiaries (I say "we" even though I'm only a Medicare "eligible," since I still have employer insurance) don't want to mortgage opportunity for future generations to pay for the bloated system we have now. The 77% of us with traditional Medicare like the government-run insurance program. The 23% of us with Medicare Advantage plans are happy with private insurance. But we're not happy with the discoordinated care system in which tests are repeated unnecessarily, doctors don't communicate with each other, we get readmitted to the hospital too quickly, and, at the end of life, too often die surrounded by monitors and tubes in the ICU rather than by our loved ones at home. And our physicians and nurses are frustrated by many of the same things.

To get real Medicare reform three things must happen:

1. Medicare beneficiaries must speak out about improving care and protecting future generations by reducing costs. Politicians imagine that we're all "greedy geezers" like the folks who threaten them in the recent AARP advertisement. Some of us are, but it's a minority. Our political leaders won't get serious until they hear from us - their constituents - about what most of us believe and want.


2. Improvement-minded physicians, nurses, other health professionals, and administrators are the ones who know how to wring the waste, estimated to be as high as 30%, out of the care system. Competition won't do it. Vouchers won't do it. Only motivated health professionals can. If you want to understand why this is so, read Don Berwick's recent address to the Institute of Health Improvement.


3. Medicare needs a budget. Creating a budget by adding up the bills for our care won't do the job. If there's a true budget we can work with out caretakers to do what's needed within fair limits. Most of us are on fixed incomes. We know there's no pie in the sky!

For 35 years I practiced and got my own care at a not for profit HMO where clinicians and patients lived within a budget and made the system work. I'd rather see us use patient-physician collaboration as the basis for Medicare reform rather than hope that financial pressure will turn Medicare beneficiaries into health care shoppers who drive costs down. But quite apart from the prevailing conservative faith-based belief that "skin in the game" will inevitably fuel the needed reforms, it's not irrational to fear that politicians won't have the gumption to create and stick to a true budget for Medicare, or to allow CMS to apply sensible management strategies like centers of excellence instead of unbridled fee-for-service. It's that perspective that leads Democrats like Senator Wyden to take up the voucher concept.

But with or without vouchers, with or without either single payer Medicare or multiple competing insurers, the key ingredients of Medicare reform are (1) strong beneficiary demand for positive change, (2) leadership from improvement-minded clinical leaders, and (3) an overall budget for the program. Without this triad we're just whistling into the wind.

Ethics of Physician Self-Disclosure

Shara Yurkiewicz, an enterprising second year student at Harvard Medical School, edited the December issue of the American Medical Association Journal of Ethics, an on-line publication targeted to medical students, residents and fellows. Shara developed a short case that raised questions about physician self-disclosure and asked me to comment on it. It's a fascinating part of clinical practice. You can read the piece here if you're interested.

Shara writes a great blog about her experiences at medical school. You can see it here.

P.S. I didn't choose the title ("Is Physician Self-Disclosure Ever Appropriate?"). It would seem nonsensical to argue that self-disclosure is never appropriate. The important questions are - when is it appropriate and how should we decide?

Spicy Carrot-Celery Juice

If you have never juiced before, here is a recipe that does a great job of improving your health and the veggies are really easy to juice.  I have an Omega Juicer and I really like several things about it.  First, it is super easy to clean up. Second, with this juicer you can make enough juice to last you for 3 days without compromising the nutrients. It lasts longer because it doesn't rip your vegetables at high speed causing fast deterioration of the juice.  The slow rpm's of this juicer, at just 80 rpm's, allow the juice to hold its nutritional value longer. Slower machines produce less friction and less heat, preserving enzymes that can be destroyed by heat. Low RPM machines “masticate” or virtually chew the food to squeeze out the juice. High RPM centrifugal juicers spin juice through the air causing exposure of juice to lots of air and thus oxidizing the juice. Low RPM juicers don’t expose the juice to lots of air, reducing oxidation and preserving more of the nutrition in the juice Some juicers spin and shred at 14,000 rpm's-YIKES!! I also like my juicer because I can make soft serve ice cream out of my frozen fruits.  You can also make nut butter and homemade pasta. 

Juicing the greens with orange carrots makes an interesting color of juice. Matter of fact, if you google what color orange and green make it says a "Poopy" color-LOL. Well, you can decide for yourself what color it turned out to be.  If you double up on the carrots it will take on the orange color.

SUPERFOOD CUISINE - Cooking with Nature's Most Amazing Foods - BOOK REVIEW

SUPERFOOD CUISINE - Cooking with Nature's Most Amazing Foods is a beautiful hardcover book by Julie Morris, a natural food chef, writer, educator and advocate of whole, plant-based foods and superfoods for optimal health.  Julie includes 100 recipes, a vivid description of each superfood (including history, benefits, use and taste), and a convenient "pantry list" of what you need and where to find these special foods. She uses Navita Naturals 100% organic superfoods. I found I already had a lot of these superfoods in my pantry since I am a huge fan of Navita Naturals Raw products. If I counted correctly, about 46 of the 100 recipes are raw. The recipes I tried were easy, full of nutrients and super satisfying. Superfood Cuisine is the perfect Christmas gift. Get your holiday shopping finished early with the healthy gift that keeps on giving!!!

In chapter three Julie talks about 'The Need for Nutrient Density'.  She states that for the very first time in history, a yonger generation is showing signs of a shorter life expectancy than its parent generation.  Epidemic rates of terminal diseases such as heart disease, diabetes, cancer, osteoporosis, obesity - to name just a few - are at an all-time high, and rising.  She states the problem stems largely from our current Western diet.  We demonstrate a profound dependence on processed and refined (nutrient-void foods, which inundate our bodies with empty calories; a habitual craving for animal protein, with its high cholesterol-forming saturated fats and destructive acidic impact on our blood chemistry; and the almost unconscious consumption of refined sugars (such as high fructose corn syrup and excessive white cane sugar), whose omnipresence on supermarket shelves has contributed to the alarming spike in diabetes, among many other disease.  Our addiction to these foods is literally destroying us.  Because they often require more resources from the body just to digest than they give back in benefits, these foods can be classified as "antinutrients"  Instead of building us up, they actually break us down:  robbing our body of energy.  Modern studies point to the utilization of a whole-food, plant-based diet as one of the most promising ways to keep these serious - yet largely preventable - chronic disease at bay.  The World Cancer Research Fund has stated that simply by eating the right diet, a person can cut his or her cancer risk by up to 40% (a number thought to be on the conservative side by many estimates).

Superfoods are one of the easiest, most efficient ways to make significant beneficial changes to even the most risky of lifestyles, Small, powerful changes really do add up, and superfoods are one of the best ways to make an impact.  Superfoods are also super delicious! 

The recipes I created were: Mediterranean Vegetable Pizza, Kale & Black-Eyed Pea Stew, Pure & Simple Green Smoothie, Tater (Like) Tots and Hot Chocolate.  They all turned perfect and tasted so delicious. One superfood I used in the Green Smoothie was Lucuma Powder and it was so delicious. It is made by freeze-drying the Lucuma fruit, which is native to South America.  It has a sweet, maple-like taste, but is very low in sugars. Julie considers it her "secret ingredient" and I agree.

Below I have posted the recipes I created, a video where Julie shares her No Bake Brownies and an additional link so you can download 3 more recipes from her book + the introduction chapter from the book on her FACEBOOK page.  The 3 recipes you can download are Asian Tempeh Lettuce Cups, Cheesy Kale Crisps and Sacha Inchi Buckeyes - YUMMY!!
You can also purchase an autographed copy of her book at juliemorris.net.

 There's something about a pot of good stuff bubbling away on the stove that's always exciting.  Especially when that "good stuff" includes powerful ingredients providing a balanced array of minerals, protein and fiber.  Adding the kale at the very end of the cooking ensures that it's softened enough to be enjoyed, without destroying all of its nutrition through heat.  This is the kind of stew that eats like a meal.

KALE & BLACK-EYED PEA STEW

Printable Recipe

Makes 6-8 Servings

1 tablespoon coconut oil

2 cups white onions, diced (about 1 medium)

6 cloves garlic, minced

3 stalks celery, diced

1 red bell pepper, diced

1 tablespoon fresh oregano leaves, chopped

1/2 tablespoon fresh thyme leaves, chopped

1/4 teaspoon chipolte powder

1 tablespoon smoked paprika

3 cups vegetable broth

3 cups water

2 tablespoons wakame flakes, ground/crushed into fine pieces

3 cups cooked black-eyed peas

1 head kale, stems discarded and leaves chopped

1/2 lemon, juiced

fresh parsley, chopped, for garnish

In a large pot, melt the coconut oil over medium heat.  Add the onions and garlic and cook for 2 minutes, stirring occasionally.  Add the celery and bell pepper and cook for a few minutes loner.  Stir in the herbs and spices, cooking for about 30 seconds.  Add the vegetable broth, water, wakame flakes, and black-eyed peas.  Bring to a gentle simmer, and cook uncovered for 30 minutes, add more water if needed.  After the soup is cooked through, stir in the kale and keep over the heat for a minute longer - just enough to wilt the kale.  Add the lemon juice and turn off the heat.  Top with parsley and serve.

SUPERFOOD TIP:

Using smoked ingredients like chipotle powder and smoked paprika add an impressive depth of flavor to recipes without compromising nutrition through overcooking. 



Pure & Simple Green Smoothie, Pg. 221
(made with frozen mango chunks, banana, lucuma powder, spinach leaves, chlorella powder, water and stevia)



Hot Chocolate, Pg. 230
 (made with cacao powder, mesquite powder, maca powder, palm sugar and either cashew or almond milk)

Mediterranean Vegetable Pizza, Pg. 136

(This is a pizza more by architecture than by detail.  The crust is a high-protein, cracker-like flatbread boosted with super seeds; the sauce is a savory olive spread rich in minerals and healthy fats; and the vibrant topping boasts copious amounts of flavorful cooked vegetables)

 

                          No-Bake Brownies (By Julie Morris)

Download 3 free recipes + the introduction chapter from the book via Superfood Cuisine on  facebook
@greenjules on twitter
Website juliemorris.net (can purchase signed copy here)

A Controversial Proposal about Complementary Medicine

A controversial proposal about complementary and alternative medicine (CAM) will be the hot item today and tomorrow at the annual meeting of the College of Physicians and Surgeons of Ontario. Since the College regulates medical practice in Ontario, this isn't a Mickey Mouse discussion!

The College felt it had to create a policy because patients in Canada, like those in the U.S., were voting with their feet - and money - for CAM:

In increasing numbers, patients are looking to complementary medicine for answers to complex medical problems, strategies for improved wellness, or relief from acute medical symptoms. Patients may seek advice or treatment from Ontario physicians, or from other health care providers.

The proposed policy explicitly recognizes a patient's right to decide on the course they want to follow:

Patients are entitled to make treatment decisions and to set health care goals that accord with their own wishes, values and beliefs. This includes decisions to pursue or to refuse treatment, whether the treatment is conventional, or is CAM.

In my psychiatric practice, I heard more than once from patients that their other physicians pooh-poohed psychiatric treatment, especially psychotherapy, with terms like "magic," "witch doctor" and "rent-a-friend." From that experience, I especially liked the way the Ontario College insists that physicians conduct themselves with civility:

The College expects physicians to respect patients' treatment goals and medical decisions, even those with which physicians may disagree. In discussing these matters with patients, physicians should always state their best professional opinion about the goal or decision, but must refrain from expressing personal, non-clinical judgements or comments...about the therapeutic options, or the patient's health care goals or preferences unless those are explicitly requested by the patient.

The fact that many physicians and physician organizations complained bitterly that this standard would "muzzle" them demonstrates the need for making civility and common courtesy an ethical expectation!

The Canadian medical community was especially vehement in its criticism of the way the original draft discussed standards of evidence for CAM. In the eyes of the critics, the College was setting a lower bar of evidence for CAM compared to allopathic medicine. Here's the key passage from the original draft:

Reasonable expectations of efficacy must be supported by sound evidence. The type of evidence required will depend on the nature of the therapeutic option in question, including, the risks posed to patients, and the cost of the therapy. Those options that pose greater risks than a comparable allopathic treatment or that will impose a financial burden, based on the patient’s socio-economic status, must be supported by evidence obtained through a randomized clinical trial that has been peer-reviewed.

To my reading, this statement was entirely reasonable. It's a small percentage of medical practice that's based on rigorous randomized controlled trials. The term "sound evidence" requires explication, but it's the best we can claim for much of what we physicians do. The wording of the revised proposal being discussed in Toronto today makes it clear that the same standard of evidence should be applied to "conventional" and "complementary" medicine. But to my reading it retains an appropriately skeptical view of just how solid the evidence is for what is conventionally done:

Any CAM therapeutic option that is recommended by physicians must be informed by evidence and science, and it must:

• Have a logical connection to the diagnosis reached;
• Have a reasonable expectation of remedying or alleviating the patient's health
condition or symptoms; and
• Possess a favourable risk/benefit ratio based on: the merits of the option, the potential interactions with other treatments the patient is receiving, the conventional therapeutic options available and other considerations the physician deems relevant.

Physicians must never recommend therapeutic options that have been proven to be ineffective through scientific study.

I applied these standards to myself with regard to my treatment many years ago of a patient with trichotillomania (compulsive hair pulling). The literature recommended medication and stated that hypnosis did not work. But my patient didn't want to take medication, and liked the concept of hypnosis, despite what the literature said. We agreed that it seemed relatively risk free, and tried it.

It worked. I didn't see the patient again until 20 years later, when the symptoms recurred. A brief repeat of the hypnosis did the job again. (For a more extensive discussion of the case, see here.) I believe the Ontario College would conclude that the treatment met their standards. I had done the hypnosis, but I hadn't recommended it!

If I were in Toronto today I'd vote to approve the College's proposal. Without demeaning "conventional" medicine it implicitly recognizes the degree to which conventional practice rests on uncertainties. And without using the term "placebo effect" it allows for the provision of interventions - "conventional" and "complementary" - that may well derive their efficacy from the placebo mechanism.

(The proposal being considered by the Ontario College of Physicians and Surgeons can be found on pages 248-275 of the agenda for today's meeting. If you're especially interested in the topic, you can read the original policy statement draft here. A summary of the Canadian Medical Association's criticism of the original draft is here.)

Learning from Massachusetts Health Reform

The Blue Cross Blue Shield Foundation of Massachusetts has just published a report on the first five years of Massachusetts health reform. The report provides valuable lessons about how U.S. society can learn to improve access and set limits on costs. It's crucial for us to understanding the learning curve for health reform. Reforming the health system isn't primarily an intellectual challenge. The difficulties are mainly in our own psyches, and among the different players on the health care chess board.

As I see it, the key aspect of Massachusetts health reform is the process by which it came about. Prior to passage of the 2006 law, there were several years of discussions, reports, conferences, committee meetings, and more. From this combination of education, argument and deliberation, what emerged was a consensus that government, employers, and individuals had to share responsibility for making things better. And, at least as important, all that interaction created some trust among the key parties and a culture of civility that is all-too-lacking in the pathetic national non-dialogue on federal reform. The term "Obamacare" is a symptom of the lack of dialogue and civility.

In terms of shared sacrifice: individuals accepted a mandate that we be insured; employers accepted a requirement that they provide insurance or pay into a state pool; and the state accepted responsibility for subsidizing low income folks and for creating a mechanism - the Connector - to administer the new forms of insurance that were made available.

Massachusetts has reduced its uninsured population to 1.9%, compared to the shameful national average of 16.3%. The cost of the subsidized insurance has gone up 3% per year, significantly lower than the national average. Approval of the 2006 law has remained steady at two thirds of the adult population.

Massachusetts explicitly chose to tackle coverage before squaring off with cost. The five year report documents that coverage is relatively "solved." Now the state is turning its attention to cost.

It looks to me as if we're approaching the cost problem the way we approached coverage - with LOTS of talk. We've had multiple reports, all of which say much the same thing - that providers with market clout get paid high prices without delivering comparably superior outcomes, that the entire system has a great deal of waste, and that cost escalation is strangling the businesses, public agencies, and individuals, who pay for care. As I wrote back in March, Massachusetts is the jawboning capital of the western world (see here).

Wise psychotherapists understand that dealing with the resistance to change is the hard part of the work. Once resistances have been dealt with, things get easier. And the late management guru Tony Athos described Japanese management style in the same way - LOTS of process to bring about consensus and then much smoother implementation than we see with our "process-lite" U.S. approach.

I believe, and hope, that what we're seeing in Massachusetts now with with regard to health care costs is creating the human and social infrastructure we need to get a grip on costs. The next report, five years from now, will reveal whether this is true or not.

(The five year report, written by my former colleague Alan Raymond, is very readable. If you're interested in learning more about Massachusetts health reform, take a look.)

Zeke Emanuel on Health Reform

Zeke Emanuel provides an excellent piece of public education about the potential for improved quality of care and cost savings in a recent New York Times blog post. The piece will be especially informative for folks who don't understand how fragmented the U.S. care system has become and how fee-for-service reimbursement promotes the fragmentation. Emanuel concludes, correctly, that there's substantial potential for improving care for patients with chronic illness, and that these improvements can achieve savings for the health system.

But I think Emanuel makes two mistakes in the piece. Both come from misinterpreting the psychological underpinnings of health reform.

First, after describing very lucidly how bundled payments provide financial support for coordination among caretakers, he explains that "the idea is to force all of a patient's care providers to work together." But "force" is the wrong verb here, and it reflects a mistake medical managers make all too often.

Collaborating with colleagues actually makes practice more enjoyable as well as more effective. Working together in ways that help our patients is intrinsically satisfying. When those in charge assume we clinicians have to be "forced" to do something, we buck them. When they facilitate what good clinicians want to do, we do it with pleasure. The idea of global payments is to "allow" and "support" collaboration, not to "force" it!

Second, Emanuel correctly notes that improved care coordination can produce much more savings than malpractice reform. But apart from the question of how much savings a reduction in defensive medicine might produce, the climate of litigation has a corrosive impact on the psychology of medical care and the doctor-patient relationship. In ethics discussions with medical students, residents, and practicing physicians, the first question is typically - "what does the law say - what happens if I'm sued?"

The spectre of malpractice litigation creates a sense that patients and society are potential enemies. Health reform requires collaboration between doctors, patients, and the wider public. Malpractice reform is crucial not just for whatever money it might save for the health system, but for the potential that reform will reduce the degree to which physicians feel under attack.

Heart-Healthly Plant-Based Thanksgiving Recipes

I want to wish you all a very happy and healthy Thanksgiving!!  I hope you enjoy my holiday recipes. The menu is Holiday Wellington, Wild Rice Cornbread Stuffing, Mashed Potatoes with Mushroom Gravy, Sourdough Bread, Tender Green Bean with Mushroom & Lemon Peel, Spinach Almond Salad, Homemade Whole Cranberry Sauce, Vegan Pumpkin Pie & Sparkling Cranberry Juice. This meal is designed to keep your heart healthy, your energy up, taste fabulous and be packed with delicious plant-based nutritious ingredients like kale, sweet potatoes, spinach, apples, green beans, pecans and cranberries just to mention a few.  What a yummy feast of thanksgiving. I have a lot to be thankful for, and one is that I can share my food and nutrition ideas with all of you. You can do a lot of the preparation for this meal ahead of time and finish on Thanksgiving day. Have an absolutely wonderful time with your family and friends.  Please email me if you have any questions at all on the recipes. Stay happy and healthy:)

Holiday Wellington
Adapted from Morgan's Holiday Wellington  Little House of Veggies
Printable Recipe
(Serves 8)

(2) Homemade pastry dough recipes (see recipe below)
1 bunch of kale, washed, trimmed & chopped
8 oz. sliced baby Bella mushrooms
3 yellow onions, sliced
1 large sweet potato or Yam, peeled &amp sliced
1 ½ cups vegetable broth
1 recipe for sage quinoa (see below)
Red pepper flakes

To Make:
• Start the caramelized onions first. Peel and slice all 3 onions. In a skillet or pot, heat 1 Tbsp of coconut oil over medium high heat. Add the onions, along with a pinch of salt and pepper. Sauté for about 3-4 minutes, stirring occasionally. Add in 2 Tbsp. vegetable broth and continue to cook until the onions are darker in color (slightly brown) and have a sweet taste and very tender texture. While the onions are caramelizing, preparing the rest of the ingredients for the Wellington.
• Start by prepping all of your different ingredients keeping them all separate from each other. Heat a large skillet over  medium heat.
• Start with the kale. Heat 1 Tbsp. vegetable broth in the pan. Add the chopped kale, and a pinch each of salt, pepper, and red pepper flakes. Sauté until softened, about 5 minutes. Remove the kale from the pan and set aside on a plate.
• Add another 2 Tbsp. of vegetable broth to the pan. Add the sliced mushrooms, and a pinch of salt and pepper. Sauté about 5 minutes until the mushrooms are softened. Remove from the pan and set aside on a plate.
• Add 2 Tbsp. of vegetable broth to the pan, and add the yams/sweet potatoes. Add a pinch of salt and pepper and sauté 5 – 10 minutes until tender, but not mushy. Remove from pan and set aside on a plate.

To Assemble the Wellington:

Using a rolling pin, roll out dough on parchment paper to a 17” x 14” rectangle. Begin layering the ingredients on the pastry dough. Once all ingredients are layered, roll up very gently and fold and close up all open ends. Put in a baking dish and bake at 350 degrees for about 1 hour. Brush with olive oil when you have about 10 minutes left to help brown. Remove from oven and allow to cool for 10-15 minutes before slicing.

Sage Quinoa
1 cup uncooked quinoa
2 cups vegetable broth
½ Tbsp poultry seasoning

Put all ingredients in a pan and bring to a boil. Simmer with lid for 25 minutes until all liquid is well absorbed.

Pastry Dough (For Wellington & Pie)

Printable Recipe
(Makes 1 pie)

1 1/3 cups unbleached white flour, whole wheat pastry flour or white whole wheat
¼ cup coconut oil
Dash salt
¾ cup water

Put flour and salt in bowl and stir. Spread pieces of the coconut oil around on top of the flour and cut into flour with either a pastry cutter or a fork. Add water all at once and stir into a ball. Dough will be a bit sticky. Flour board and top of pastry ball. Roll into desired shape.

Wild Rice Cornbread Stuffing
Printable Recipe

Wild Rice Cornbread Stuffing By Rachel Spurr, posted on The Kind Life

Serves 6-8

Ingredients
• 2 tbs olive oil
• ¼ onion
• 1 rib celery, cubed small
• ½ apple
• 1/2 tsp rubbed sage
• 1/8 tsp black pepper
• 1/8 tsp sea salt
• 3 cups vegan corn bread, pre-cooked
• 1/2 cup wild rice, pre-cooked
• 2 tbs pecans
• 2 tbs fruit sweetened dried cranberries
• 1/2 tsp poultry spice
• 3/4 tsp sea salt
• 2 tbs parsley
• ½-1 cup vegetable broth

Steps
1. Add the first 7 ingredients to a sauce pan and cook 10-15 minutes or until apples and celery begin to soften.
2. Meanwhile, crumble precooked vegan cornbread into a large bowl.
3. Add wild rice, pecans, dried cranberries, poultry spice, sea salt and parsley.
4. Mix in sauteed mixture, stirring well.
5. Adjust seasonings as desired.
6. Add vegetable broth.
7. For a moisture dressing, more vegetable broth can be added.
8. Place in a well oil pyrex dish or casserole.
9. Bake covered at 350 for 1 hour, uncovering in last 20 minutes of cooking.

Wild Rice
1 cup wild rice
3 cups water

Bring to a boil and simmer until all liquid is gone about 40-50 minutes. Remove lid and fluff with fork. Simmer longer if there is still any additional liquid. Keep lid off until use.

Vegan Cornbread for Stuffing
1 cup cornmeal
1 cup white whole wheat flour
½ tsp. sea salt 4 tsp baking powder
1 Tbsp maple syrup
1 flax egg (make with 1 Tbsp ground flax seed & 3 Tbsp water)
1 cup almond or cashew milk  (make cashew milk by blending 1/4 cup cashews with 1 cup water)

Preheat oven to 425 degrees. Sift together all dry ingredients. Stir all liquid ingredients together and add to dry ingredients. Beat until smooth, but do not overbeat. Bake in a greased 8-inch square pan for 20-25 minutes. Cool and break into pieces to use for stuffing.

Mashed Potatoes & Mushroom Gravy
Printable Recipe

Mashed Potatoes
6 Russet potatoes scrubbed well (leave skins on)
1 recipe cashew cream
Salt and pepper to taste

• Cut up potatoes and place in pan. Cover with water and bring to a boil. Lightly salt water. Boil until potatoes are soft.

• Drain potatoes and place in bowl in preparation for mashing.
• Add 1 cup cashew cream (recipe below) and salt and pepper to taste.
• You can top with a little Earth Balance Butter if desired before serving.

Cashew Cream
½ cup cashews (soak in water for 30 minutes and then drain)
Enough water to make 1 cup with the cashews

After soaking cashews, drain water and then add enough water with the cashews to equal 1 cup. Blend well until smooth and creamy.

Mushroom Gravy
Makes 3 1/2 cups

3 ½ cups vegetable broth, divided
1 cup chopped white onion
4 cloves garlic, finely chopped
 8 oz. sliced mushrooms
2 tsp. dried thyme
1 tsp. dried rosemary
¼ cup apple cider vinegar
2 tbsp Coconut Aminos, Bragg’s Liquid Aminos or Tamari
3 tbsp nutritional yeast
 2 tbsp arrowroot powder or flour
¼ tsp ground black pepper

• In a large skillet over medium-high heat, bring ½ cup broth to a simmer.
• Add onion and garlic and cook for about 4 minutes or until onion is translucent.
• Stir in mushrooms, rosemary and thyme and continue to cook about 2 minutes or until mushrooms release their liquid and start to become tender.
• Add apple cider vinegar and cook 1 minute, stirring constantly. Stir in remaining 3 cups broth and bring to a simmer.
• Meanwhile, in a small bowl, whisk together coconut liquid amino or Bragg’s, yeast and arrowroot powder.
• Add mixture to skillet about 1 tsp at a time, whisking constantly to make sure paste dissolves.
• Bring to a boil and boil 1 minute, stirring constantly. Add pepper and serve.
Mushroom Gravy adapted from Whole Food Market

Whole Cranberry Sauce
Printable Recipe

1 (12 oz.) bag fresh whole cranberries
6 packets stevia (1 1/2 tsp.)
1/3 cup maple syrup (grade B)
½ lemon (juiced)

Add all ingredients to sauce pan. Simmer 10 minutes. Add juice of ½ lemon. Refrigerate to thicken.

Tender Green Bean with Mushroom

& Lemon Peel

Printable Recipe

1 Portobello mushroom sliced
2 tbsp yellow onion diced
¼ tsp oregano
1 tsp olive oil
Salt & pepper

Steam:
1 pound green beans
¼ cup water

Sauce:
Juice of ½ lemon
2 tbsp Vegenaise (grape seed oil)
1/8 tsp dried dill
Rind of 1 lemon (use a lemon zester to produce long thin slices)

• Cook mushroom, onions and oregano in olive oil and season with salt and pepper. Cook until mushrooms look soft and turn color. Remove from pan.
• Add ¼ cup water to pan you cooked the mushrooms in. Add green beans and simmer with lid until all water has disappeared. Remove green beans and place in bowl.
• Mix sauce well and blend with green beans.
• Add mushroom mixture. Add rind of lemon and enjoy.

Spinach Almond Salad
Printable Recipe

1 (10 oz.) bag fresh baby spinach
1 medium Granny Smith Apple
¾ cup toasted slivered or sliced almonds
1 cup fruit juice sweetened dried cranberries

• Place spinach in bowl.
• Slice apple very thin and add to spinach.
• Toast almonds in oven for 300 degrees for around 8-10 minutes and cool. Stir several times while cooking.
• Add cooled toasted almonds to spinach.
• Add cranberries and toss.

Dressing:
¼ cup maple syrup (grade B)
1/3 cup olive oil
¼ tsp salt
3 Tbsp apple cider vinegar
1 Tbsp dried onion or 1/8 small onion chopped finely

Place all ingredients in a blender bottle and shake well. Just before serving, pour dressing over salad mixture and toss.

Sourdough Bread

Adapted from: The Complete Bread Cookbook by Kaufman
Printable Recipe

1 cup sourdough starter (see recipe below)
½ cup lukewarm water
2 tbsp maple syrup (grade B)
3 Tbsp soft Earth Balance Butter
1 cup white whole wheat flour
1 cup unbleached white flour
1 tsp sea salt

• In a large mixing bowl, combine 1 cup starter, water. Maple syrup and butter. Beat well with a wooden spoon until thoroughly blended.
• Add 1 cup whole wheat flour. Mix well. Then gradually add remaining flour until a soft but firm ball is formed. Turned out onto a floured board and knead for 10 minutes until the dough is smooth.
• Turn into a warm greased bowl. Cover and set aside in a warm place until doubled in bulk, about 1 hour.
• Punch down with a wooden spoon, cover and let rise again until doubled in bulk.
• Turn out onto a floured board and knead for 5 minutes. Shape into a ball. Place in a well-greased and lightly floured ovenproof 1½ quart round bowl, or if desired, shape into a loaf and bake in a well greased 9-inch loaf pan.
• Cover and set aside in a warm place until doubled in bulk.
• Make a crisscross on top of round loaf.
• Bake in a preheated 400 degree oven for 35 to 40 minutes or until done. Tap loaf; when it sounds hollow it is done.
• Cook on wire rack.

Sourdough Starter
2 tsp instant yeast
1/3 cup lukewarm water
1 cup lukewarm water
2 tsp maple syrup (grade B)
1 cup unbleached white flour or white wheat flour

• Sprinkle dry yeast over 1/3 cup lukewarm water. Add maple syrup and stir.
• Cover and let stand for 5 minutes until the mixture begins to foam. Add 1 cup lukewarm water, and flour. Beat well with a whisk or beater until well blended.
• Pour into a large wide-mouthed jar. Cover lightly with lid and let stand in a warm place for 2 to 3 days until the starter is a bubbly foaming mass.
• After a day or two the liquid will rise to the top, mix gently with wooden spoon to blend. Use 1 cup of the starter at a time for your sourdough bread recipe.
• After using 1 cup replace with ½ cup flour, ½ cup water and let sit at room temperature for a few hours and then place back in refrigerator with lid on. You can pour off the liquid if it has been sitting in the refrigerator for days without use.
• When ready to use again, add ½ cup flour, ½ cup water, and stir with wooden spoon.  Let sit to warm up and get bubbly. Use 1 cup for recipe and replace with ½ cup flour and ½ cup water. Let sit at room temperature for a few hours and then place back in refrigerator with lid on.
• Repeat this process and you will continually have a sourdough starter ready to use.
• If the sourdough starter ever stops creating bubbles, begin with step 1 in a new jar and repeat process.. Enjoy!!
Adapted from: The Complete Bread Cookbook by Kaufman

Vegan Pumpkin Pie

Printable Recipe
(Makes 1 pie)

1 (14 oz.) can 100% Pumpkin
½ tsp sea salt
1 tsp ground cinnamon
½ tsp ground ginger
¼ tsp ground cloves
1 cup cashew cream (see recipe below)
½ cup maple syrup (grade B)
1 tsp vanilla
4 packages stevia (1 tsp)
2 tsp (Orgran) No-Egg (natural egg replacer) plus 4 tbsp water
1 pastry dough pie crust

• Mix pumpkin, salt, and spices together. Add cashew cream, maple syrup, vanilla and stevia.
• In a small bowl mix 2 teaspoons of the (Orgran) No-Egg replacer with 4 tbsp water. Mix well and then add to pumpkin mixture.
• Place in whole wheat pastry and cook at 425 degrees for 15 minutes. Then turn oven down to 350 and continue to cook for an additional 40-50 minutes. Watch carefully to not over-brown the crust.
• Top with non-dairy whipped topping.

Cashew Cream
½ cup cashews (soak in water for 30 minutes and then drain)
Enough water to make 1 cup

After soaking cashews, drain water and then add enough water with the cashews to equal 1 cup. Blend well until smooth and creamy.

Non-Dairy Whipped Topping
Printable Recipe

1 (13.66 fl. Oz.) Coconut Milk-refrigerate overnight
3 packets stevia (3/4 tsp)
¼ tsp xanthum gum (optional)
2 tsp maple syrup (Grade B)
1 tsp vanilla

Open coconut milk and scoop out all the solid portion and place in whipping bowl. Discard liquid portion. Add stevia and xanthum. Whip until fluffy. Add maple syrup and vanilla. Continue to whip. Store in refrigerator until ready to use.

Public Altruism about Health Care is Alive and Well

Four days ago I discussed Medicare beneficiaries who think about Medicare in terms of future generations and the common good, not just in terms of their own care. That post was triggered by my reaction to hearing this aphorism:

The true meaning of life is to plant trees under whose shade you do not expect to sit.

This morning's Boston Globe included an obituary that made the same point. It told about Paul White, who died at 61 of kidney cancer, after eight years of illness. Here's the relevant passage:

In a life curtailed by cancer there was much to curse, but Mr. White was more apt to speak optimistically about how chemotherapy gave him more time with his five granddaughters and how experimental treatments would provide a foundation for patients he would never meet.

"He just felt he was doing his part," his daughter said. "He kept talking about, 'I'm doing this for the next generation.' I can hear him saying that: 'I'm the guinea pig for the next generation.'"

I've been looking to see if any surveys of Medicare beneficiaries suggest what proportion is moved by concerns about the commons. I haven't yet found what I'm looking for, but I'd predict that it's a substantial number.

The Globe also included this letter to the editor:

Five ways to cut spending on Medicare - from a beneficiary

WHEN SPENDING less on Medicare is suggested, it seems that many people, especially Democrats and those over 65, protest loudly. However, there are ways that Medicare could spend significantly less money without denying anyone medical care that is of value. As a Medicare beneficiary myself, I offer five concrete proposals.

1) Make generic drugs the default for covered prescriptions.

2) Let Medicare negotiate with drug companies on the cost of drugs.

3) Let the Medicare Independent Payment Advisory Board identify medical services that provide little or no benefit, and let Medicare refuse to pay for them, or require significant copayments.

4) For surgery or other major interventions for which there are medically reasonable alternatives, do not pay for those interventions unless patients are fully informed about their alternatives, including no intervention at all.

5) Give providers significant protection from malpractice claims if they can document that patients were well informed before a treatment decision was made.

Congress has made if difficult or impossible for Medicare leadership to take any of these reasonable steps to control Medicare costs. Enacting these reforms could significantly cut Medicare costs with no downside for patients or their doctors.

Jack Fowler

Brookline

The writer is senior scientific adviser for the Foundation for Informed Medical Decision Making. His views here are his own.

Voices like Paul White and Jack Fowler can make an important contribution to our national political dialogue. There's no way to deal with the country's long-term economic health without dealing with Medicare. If enough Americans speak as Paul White and Jack Fowler did it will become harder to argue for the politics of selfishness that our anti-tax zealots are so eager to promote.