The Ends of Life

Many aspects of life have become undiscussable by anyone with power, especially in the USA. Criticise the military and your career may be over. Argue for a tax increase and you are on thin ice.

This is a shame, and it has contributed to paralyzing progress in many areas of life. Nowhere is this more true than in health, especially end of life health.

This applied in the UK too, and probably elsewhere, though I have less knowledge. Perhaps, with their approach to euthanasia, the Dutch and Belgians have helped to lift the taboo.

At the root of the issue are trade offs over healthcare. One consequence of progress is that people are living longer. This is not unrelated to a wide availability of cures and treatments for diseases. The problem is that these cures cost money. And our progress is not yet so complete to render that irrelevant.

This leads to dilemmas. When should a treatment be attempted? Is it sometimes better to leave nature to take its course? Should this decision ever have anything to do with money? Doctors have to make these trade offs every day. It seems to me that there is very little consistency in how the decisions are made, and society loses out as a result.

There a few fixed starting points to the debate and a few generally recognized practices.

The first fixed point is the Hippocratic oath. Doctors must always try to do their best for patients. In practice that means using all weapons at their disposal to cure a patient. Quite rightly, doctors take this very seriously. It goes to the heart of their profession.

Another fixed point is the treatments generally available. This is regulated, in the UK by an organization called NICE. New drugs and treatments get assessed against criteria of reliability, effectiveness and cost. Without NICE the NHS costs would be even more out of control than they are. But NICE doesn’t look so nice if you have a disease, a drug is available in another country and yet it is denied to you.

It gets a bit murkier with the practices. There is a trade off between patient comfort and the likelihood of cure. If someone is very sick, it may be possible to continue to try aggressive treatments. But these are often painful, and the best outcome might be to prolong life by a few days. So a doctor will choose instead to put the patient on morphine and wait for them to die.

All of us will have to face this for loved ones sooner or later. Doctors are generous and usually make the choice themselves, because involving the family only causes worry. Often the patient will give some sort of indication about how reconciled they are to death, and doctors become good at seeing those signals.

Even in this seemingly obvious case doctors take risks. Are they strictly following their oath? They are subject in the US to lawsuits. It is all very murky.

Add in money as a factor and it gets murkier still. Say the treatment is not especially painful, but would cost $100,000? What about $1,000,000? If the patient is 20 years old, we would probably all want to give it a try. But what if the patient is 95?

It is difficult to even consider such trade offs. It would be harder still if it were our own mother we were talking about. Or, later on, it was our life partner, or even us.

But the fact is such trade offs are necessary, and currently the results are haphazard and arguably plain wrong. That $1,000,000 used to keep ninety year-olds alive for a month could fund a lot of pre-school classes. It could also improve the quality of care available for lonely people of eighty. Or fund some paternity leave so dads could start to play their role better. All of these alternatives could have lasting societal benefits – I read recently that inequality of opportunity was locked in within the first year of a child’s life, based on their learning environment from birth.

Next, what does the ninety year-old really want? Ask most of us at sixty, and we would say we don’t want to live over ninety. We might then qualify it by talking about quality of life, so if we were still independent and clear of mind we could stagger on for a few more years, but if the prospect was dementia in a home we would rather die. When we get to eighty, we might stretch the cut of to ninety-five. When we got there, we might change our mind again.

I watched my Mum grow old, and have seen a few others as well. Mum was petrified of the shame of a nursing home and the humiliation of losing basic faculties. She wrote a living will asking for care to be minimal. But she swung wildly on the matter. When depressed, she often said she wished she were dead. But on other days she had a lot of fun, and she cherished time with her grand children.

Mum died two years ago, and in the end I feel she was blessed by good fortune. She died quickly and painlessly, at a time when her dementia was on the cusp of leading to levels of shame and humiliation that would have reduced her life quality below what she would have wanted were she able to be completely detached about it.

But how lucky she was and we were and the state was. She is the exception. In many cases she would have lived on for a further few years, miserably, painfully, expensively, even pointlessly.

We read that cancer is set to double in society, and that we can’t afford the care involved. As I understand it, this is not about cancer, it is about longevity. If you restrict statistics to people under eighty, most cancers are becoming rarer, thanks to advances in medicine. But, just because there is an explosion of people over eighty and they have to die of something, many contract a cancer.

There are, of course, no easy solutions. But what I say is it is a pressing problem deserving of the full attention of society. The victims include most old people themselves, suffering a horrible final year or two. It includes their families, given vile choices and robbed of better memories. It includes, doctors, acting as masters of life or death every day of their lives without real guidelines. But the main victims are those who could benefit from the alternative use of funds. Health spending exceeds 10% of GDP in developed countries (18% in the USA), and my guess is that more than 25% of that goes on end-of-life care. These percentages are only going to increase over time.

For this critical area, decision-making today is woeful. Politicians avoid it. Doctors are stuck with it – while much of the medical profession is driven by maximizing activity so prolonging all life. Families and patients deny the issue until the last minute, and then will usually be cautious, and in some cases may even be manipulative. Richer people have more choices than poor ones. Euthanasia is a headline issue and I applaud the bravery of Dutch and others, but it still only covers a tiny proportion of cases.

Better criteria might include patients stated wishes (long in advance), and statistical evidence of costs, discomforts and quality years earned. These are tough to even start to consider, but must be better than the status quo and its inevitable worsening as we all stagger towards our century.

Now, here is the big question. Would I want someone to wave this article at me on my ninetieth birthday? On balance, the answer is yes. It is just like having a will or being clear on things like being an organ donor, it is distasteful and we defer it, but we are better for it. I am better for it. Ask yourself the same question. Maybe this is one of those issues that can only be progressed bottom up by all of us.      

When Democracy gets stuck

There was an excellent essay in the Economist last week about democracy. It acknowledged many issues with where democracy has failed its subjects over the last few years, and also recognizes that China has challenged the notion that other systems are doomed to fail eventually. But the main point was to take a longer perspective, and see these as cyclical rather than fundamental. Democracy has had ups and downs before, but tends to win out in the end.

I found that message reassuring, for at times I do despair of the current state of large democracies. Still, perhaps the conclusion that all will end well is a little complacent. So perhaps there is value in having a rant, looking at what may have changed to cause the problems, and seeking possible solutions.

We might characterize democratic failings as falling into two opposite camps, the Do-too-much camp and the Do too little camp.

Do-too-much tends to happen when one party manages to grab all the power levers at once, and, often slowly, starts to damage the institutions that offer checks and balances. South Africa, Turkey and Hungary are good examples. I could also quote Russia and other quasi-democracies, but I find it better not to classify these as democracies at all. Of course, the end state for a Do Too Much democracy can turn out to be a quasi-democracy, so the distinction can be moot.

This type of failure has always existed. Nazi Germany is an example from an earlier time. On this type, I am quite optimistic, since globalisation and technology tend to make sustaining such abuse harder than before. Mr Erdogan in Turkey, initially a benign and effective leader but perhaps with a dark side, seems to be finding life a bit tough just now. Even thirty years ago, he would have had it easier for longer.

I am more interested in the opposite problem, that of Do-too-little, for I think I live in the prime example, the USA. This is a newer phenomenon, and I am concerned that it is less likely to self-correct than Do-too-much.

At the federal level, the US congress passed almost no laws of note in 2013, and it looks like it might repeat the feat in 2014. Since 2009 only two bills of note have been passed. The first was the stimulus package to respond the financial crisis of 2008. The second was Obamacare. It is instructive to look at both, and also at bills that have not been passed.

The stimulus bill gets a good press, as a solid response to a crisis. Here, congress had the advantage of an obvious and immediate crisis to galvanise it. It was clear action was required, and the urgency prevented too many vested interests having time to get in the way.

Obamacare got through because essentially it had the mandate of a referendum to carry it over the line. It was the centerpiece of Obama’s first election campaign. But what passed in the end was a pretty ugly compromise. The bill was supposed to deal with two massive pressing issues – the uninsured and spiraling costs. In the end, it did some good in both cases, but did not fully solve either.

Budgeting has been a disaster. Brinkmanship led to the closing of the federal government and almost to a debt default. Before that an “impossible” “too horrific to contemplate” sequestration provision came into effect and is still operating. All agreements have been minimal. Last week Obama and the Republicans made budget proposals ignoring most key issues and with zero chance of enactment.

Meanwhile, on other issues no laws have emerged at all. Despite periodic massacres, gun control cannot make progress. Immigration is stuck. Unaffordable welfare trends go unaddressed. Crime policy is a generation out of date. Everyone can see it yet nothing is achieved.

These are just the visible and obvious issues. What about the truly complex and difficult ones? Euthanasia? Transitions from work to retirement? Climate change? Forget it! Democracy in the US has got stuck.

How has this happened? There are a few causes. Some are to do with the political system. Scandalous gerrymandering has meant few congressional districts are competitive between the parties, so the real goal of a congressman wanting to stay in power is to avoid being outflanked by one’s own party. And “citizens united” and other rulings have spawned lobbyists and interest groups of enormous power.

A recent example in Florida (also from the Economist) is telling. Many elderly Canadians like to winter in Florida. It would make sense to change the law to offer an extra month or two per year. No-one objects. The economy overall would benefit, and lives would be improved. But getting a law approved seems to be impossible. Why? It is because no lawmaker wants to be associated with increased immigration.

Here is the rub. Lobby groups have managed to make many areas toxic. Many negative ads lead with something like “In power, X voted to increase taxes for ordinary Americans Y times”. There is no context, no recognition that choices are always required, just a destructive statement. Taxes in the statement could be replaced by jobs (destroying), regulation (bad for business and jobs), immigration, welfare, guns (freedom), our military, American allies (usually meaning Israel), and nowadays Obamacare (it is not clear why this is bad, nothwithstanding its botched implementation, but it has become toxic anyway), and even just Obama.

All these issues are complex. All involve trade offs, pros and cons. Yet each is reduced to toxic sound bites. The result is that congressmen avoid passing any laws at all.

Of course, money makes this much worse. Even before a lobby group gets you with the voters by smearing you, they capture you by cutting off the funds, or reminding you where the funds came from in the first place. They might as well wear sponsored shirts these days.

Now here is the sad part. We, ordinary people, let this happen. Despite the wealth of information available through better education and the internet, we choose to accept this rubbish. Our attention spans are so short, our apathy so great, our desire for simplicity so overwhelming that we lap up this claptrap.

We can blame Fox News, and I do. We can blame the Koch brothers, and I do. But in the end these groups only succeed because the people let them. In Hungary, the people vote for an active dismantling of democracy out of fear and bigotry. In the US, they disable democracy too, but passively.

Who benefits? Well, that is obvious. Reactionaries throughout history have tried to slow down progress. Elites and special interests are the beneficiaries. Nothing suits them better than a disabled democracy. Each year, inequality becomes a little worse, the old steal a little more from the young, and the advantaged avoid yielding to the rest.

It is worth pointing out that in some ways the US does well. Wherever lack of legislative action can be a good thing, the US gets in the way less and progress is quicker. It also manages to devolve more issues to states, who compete with each other and sometimes make sensible law. But neither of these advantages excuse the tragedy of lack of federal progress.

The Economist argues for patience, saying the democracy usually gets it right in the end. I am not so sure. It also argues for commonsense reforms to the systems – but of course these will not happen except in genuine crises (look at what happened to poor Nick Clegg and his eminently sensible systemic reform proposals in the UK). Usually I come with my own solutions, but here I am bereft. I fear that the US will only become more stuck and that other mature democracies will soon become stuck too (Italy?). I don’t like to think of the long-term consequences. And it is all our fault.

The Power of Goals

Recently, I was asked to give a workshop to a team to improve their effectiveness. Thankfully the task was presented to me with a lot of latitude as to how to do it, so I started by talking to members of the team. Quite soon, I came to the conclusion that the best way to use the time would be to focus on goals.

The team certainly had other challenges besides clarity of goal, as would be true of most teams. Trust within the team was mixed, there were some absent skills and some behaviours present that damaged performance. The structure of the team was not ideal, nor was its processes, and the interfaces with clients, suppliers and others could have been improved.

But many of the challenges above would have been difficult to tackle in a short time. People can change, but only slowly and with a lot of help. Many team difficulties lay outside of their control. And the simpler things to fix, like meeting protocols, would not have had a significant affect on performance.

Goals, however, can be very powerful, and are not difficult to put in place, so they seemed a good area for the workshop. I read up lots of material, formed my own judgments, and built a workshop around the theme.

It is not difficult to see how goals are often a good thing. A team only needs a couple of things to be considered a team: a common goal and some opportunity to deliver it. If the goal is not clear, the effectiveness is bound to be limited.

With well-defined goals, a team can unify. It can prioritise, at team and individual level. It has a framework to help in resolving disputes. It has something it can commit to, again as a team and as individuals supporting to a leader. It has something to measure progress. And it can celebrate success.

This is all pretty obvious. My research discovered a claim that 80% of problems within a team stem from a lack of clear goals that everyone is committed to.

Then there was another research finding. Seemingly 80-85% of us have not defined personal goals. And only 3% of us have actually written them down. Seemingly, the 3% ends up earning five times as much as the middle group, and ten times as much as the goal-free majority.

When I read that, the skeptic inside me came alive. Firstly, there is probably some cause and effect issue here. High earners probably have the opportunity for plenty of training, personal coaches, and also demanding bosses. Also, who is to say that high earnings are a good proxy for success or happiness? We cannot conclude that the diligent 3% are happy, can we?

Anyway, putting that to one side, I think most of us can agree the logic that setting goals is a worthwhile thing to do. So for me the interesting question becomes – why don’t we? What stops us?

Like many of our failings, probably the biggest cause for a lack of goal setting is fear or denial. Setting goals means facing up to reality. Perhaps we have less influence than we pretend. Perhaps we don’t want to face the yawning gap between the most we can reasonably aspire to and the least we would not feel ashamed of. Perhaps, deep down, we know that there are unresolved issues with a life partner or teammates that would be exposed by the exercise. Perhaps we are just too depressed to look forward at all.

None of these reasons are to be glossed over – I know from my own experience that confronting deep issues can lead to gut-wrenching outcomes – but of course they only strengthen the case for goals. Every day of denial makes the ultimate recovery tougher.

Then there are arguments about loss of flexibility. Many of us like to keep our options open, especially those of us with a P in our Myers Briggs profile. Team leaders also can be averse to sharing goals since they might equate the activity with a loss of power or control. After all, if we don’t set goals, we can change our priorities as we wish and can expect subordinates to do the same. And we fear that we will lose our credibility if we miss targets or keep changing them.

Again, there is some seriousness to these objections. The main way to deal with them is to understand that goals are there to be changed, perhaps even frequently. At any point, a stated goal is our best guess at where a sensible target lies. External factors can change, so can internal ones, and goals should change with them. There is nothing worse than a stated goal that everyone can see has become unattainable – that does suck credibility. But a regular process of reviewing goals actually builds credibility if done well. It also helps partners and subordinates buy in and understand what lies behind the goals, enabling stronger accountability, prioritization and decision-making. So this kind of objection should also be resisted and overcome, along with an understanding about a flexible process for review.

Another block of reasons to avoid goals has arisen from their abuse. The worst examples come from performance related pay, led by my (not) good friends in finance. Skewed goals create skewed incentives and unearned rewards. This has percolated outwards and downwards. Of course the best way to get a good performance review is to achieve a set of soft targets, or even to avoid real targets at all beyond “supporting”, “enabling” or the like. We have all seen it, by governments, dictators, CEO’s and humble bosses, and it has made us suspicious and cynical.

We can probably all see that abuse by others does not invalidate a good principle. But then comes the real problem. We often have surrendered power over our own goal setting to the corporate monster, and thrown away a lot of its benefits by doing so.

Most of us equate goal setting with our company annual target setting exercise. I do not argue against these, indeed they are great, as long as the abusers are kept away. But by their nature, they tend to be negotiations, and to follow too much of a formula.

The negotiation aspect can be overcome by a good line manager and a reasonable process. The real issue is that a formal process is so inflexible. It ties everyone to a timetable, usually an annual phasing with an often overlooked mid year review. And it imposes all sorts of rules, from the number of goals to their nature to the inclusion of a whole shopping list current corporate fads.

A whole industry has shot up around designing such inflexible processes. Kaplan and others have promoted the balanced scorecard, a good thing but not a panacea. Someone came up with the acronym SMART (for Specific, Measurable, Attainable, Relevant, Time-bound) to try to improve goals, again a good thing but not always easy or even sensible.

If we are in a corporation, we need to comply with the set process. But that should not stop us working on goals outside that process too (though if we are honest there should always be an explicit link). If you lead a team, think about what makes sense for that team, and apply it.

Often good goals come in three distinct time horizons. There should be something that looks like a vision, maybe for a year or two ahead. There should be short list of key definitions of success for a time maybe 2-4 months ahead. And there should be a longer list, more like an action list, with a horizon of a week or two. Each should be linked to the other, and each reviewed and amended by a clear process. Maybe your team only needs two horizons (or four) or should have horizons nearer or further away – so be it, that is the point, make it work for you.

So reclaim goals for yourself. Feed the corporate monster but don’t then think that finishes the task. Suspend your cynicism. Understand that the flexibility of a lack of goals is a chimera. And be ready to face up to fear or denial.

Finally, remember that your work is only a small part of your life, and should only represent a small share of your goals. Personal goals, especially non-work related ones, are very powerful. I wrote some down as I was turning fifty. I still remember them and refer to them every so often. But it is time for a review.

My guess is that you would benefit from a personal goal-setting exercise, or at least a review, as well. So do it. Goal number one for the shortest horizon – set goals and write them down. Once you’ve made your millions in the ranks of that 3%, don’t forget it was me who set you on your way!