Safe Biopsy: Validated Method for Staging Liver Fibrosis in Hep C

Study results in Hepatology indicate that safe biopsy is a rational and validated method for staging liver fibrosis in hepatitis C with a marked reduction in the need for liver biopsy. It is an attractive tool for large-scale screening of hepatitis C virus carriers.

The staging of liver fibrosis is pivotal for defining the prognosis and indications for therapy in hepatitis C. Although liver biopsy remains the gold standard, several noninvasive methods are under evaluation for clinical use. Researchers validated the recently described sequential algorithm for fibrosis evaluation biopsy. The safe biopsy detects significant fibrosis and cirrhosis by combining the AST-to-platelet ratio index and Fibrotest-Fibrosure, thereby limiting liver biopsy to cases not adequately classifiable by noninvasive markers.

The researchers enrolled hepatitis C virus patients in nine locations in Europe and the U.S. The diagnostic accuracy of safe biopsy versus histology, which is the gold standard, was investigated. The reduction in the need for liver biopsies achieved with safe biopsy was also assessed. Safe biopsy identified significant fibrosis with 90 percent accuracy, and reduced the number of liver biopsies needed by 47 percent. Safe biopsy had 93 percent accuracy for the detection of cirrhosis, obviating 82 percent of liver biopsies. A third algorithm identified significant fibrosis and cirrhosis simultaneously with high accuracy and a 36 percent reduction in the need for liver biopsy. The patient's age and body mass index influenced the performance of safe biopsy, which was improved with adjusted Fibrotest-Fibrosure cutoffs.

The team found that 10 percent of cases had discordant results for significant fibrosis with safe biopsy versus histology, whereas 8 percent of cases were discordant for cirrhosis detection. The research team also found that 71 of the former cases and 56 of the latter cases had a Fibroscan measurement within two months of histological evaluation. Fibroscan confirmed safe biopsy findings in 83 percent and 75 percent, respectively.

Please remember, as with all our articles we provide information, not medical advice. For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

For more health info and links visit the author's web site www.hookman.com

NHS decides not to make sorafenib, bevacizumab available

"In the United Kingdom, the National Health Service (NHS) has decided not to make two more cancer drugs available because of cost." According to the National Institute for Health and Clinical Excellence, [NICE] the use of "sorafenib (Nexavar) for liver cancer and...bevacizumab (Avastin) for metastatic colorectal cancer" is "not cost-effective." But, the decision on bevacizumab "is preliminary, and the manufacturer, Roche, has said that it will continue to work with NICE on making the drug available." The moves "have sparked headlines about cancer patients being denied life-prolonging drugs" as well as criticism from some oncologists. Karol Sikora, MD, medical director of Cancer Patterns UK, noted that "the British decision about sorafenib puts it 'hopelessly out of step with the rest of Europe,' because every other country within the European Union makes the drug available."
Commentary-Disseminate to those people who want us to emulate the British system of Healthcare-such as Roger Moore of “Sicko”

Please remember, as with all our articles we provide information, not medical advice. For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

For more health info and links visit the author's web site www.hookman.com

THE ABCs Of Colon Cancer [CRC] Screening

Involved organizations promote a message for adults: get screened if you are 50 or older.

It is predicted that if all individuals aged 50 or older had regular colorectal screening tests resulting in the removal of all precancerous polyps, up to 90% of deaths from colorectal cancer could be prevented. The premise for the utility of cancer screening, in general, is that early diagnosis may reduce cancer mortality, result in less radical therapy, and decrease costs. Colorectal cancer screening, in particular, is capable of detecting precancerous polyps in the colon or rectum for removal and can detect early-stage cancer so that treatment may be initiated when it is more effective, often leading to a cure.

Screening for colorectal cancer begins soon after an individual turns 50 years of age, then continues at regular intervals. People at higher risk for colorectal cancer should be tested at a younger age and/or more frequently, including individuals who 1) have a personal or close family history of colorectal polyps or colorectal cancer; 2) have inflammatory bowel disease; 3) have genetic syndromes such as familial adenomatous polyposis (FAP) or hereditary nonpolyposis colorectal cancer. Patients should speak to their health care provider to ascertain when they should begin screening and how often they should be tested.

A consensus guideline for colorectal cancer screening was released in March 2008 by the American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology (ACS/USMSTF/ACR), while the USPSTF updated its screening recommendations in October 2008. Ongoing studies drive the constantly evolving recommended screening schedules. For the latest in cancer screening point your medical professional to these articles. Ask your medical professional where you fit in.

Levin B, Lieberman D, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin. 2008;58:130-160. U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149:627-637.

Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

For more health info and links visit the author's web site www.hookman.com

POOR COMMUNICATION IN HOSPITAL READMISSIONS

Discharging and readmitting physicians communicated on only about half the patients who returned within 2 weeks.

When patients who are discharged from a hospital are readmitted, do the discharging and readmitting medical teams communicate with each other? To examine this issue, researchers at two Boston teaching hospitals surveyed residents and attending physicians about patients who required short-term readmission after being discharged from general medicine services.

Of 432 consecutive patients who were discharged and readmitted within the next 14 days, 123 had common providers on both teams, and 84 had planned readmissions; thus, 225 cases were analyzed. Discharging teams were aware that their patients had been readmitted in only 49% of cases, and communication occurred between teams in only 44% of cases. When communication did not occur, 61% of respondents believed that communication would have been beneficial.

Comment by Allan S. Brett, MD: These results won’t surprise physicians who work in systems in which hospitalist or resident-attending teams rotate every few weeks.
Better communication likely would enhance quality of care: In caring for hospitalized patients, we learn valuable medical and psychosocial information that doesn’t always appear in discharge summaries. Failure to communicate also results in lost learning opportunities: We surely learn valuable lessons when we see what happens to our patients shortly after hospital discharge. Creating systems to ensure communication between discharging physicians and readmitting physicians simply makes good sense.

Other articles on Hospital readmissions: physician awareness and communication practices.

Roy CL et al J Gen Intern Med. 2009 Mar;24(3):374-80. Epub 2008 Nov 4.Physicians are frequently unaware of patient readmissions and often do not communicate when readmissions occur. This communication is often desired and frequently results in the exchange of important patient information. Further work is needed to design systems to address this potential discontinuity of care.

Inform Prim Care. 2008;16(2):147-55.Design and implementation of a web-based patient portal linked to an electronic health record designed to improve medication safety: the Patient Gateway medications module.

Schnipper JL et al. This module allows patients to view and modify the list of medications and allergies from the EHR, report non-adherence, side effects and other medication-related problems and easily communicate this information to providers, who can verify the information and update the EHR as needed. Usage and satisfaction data indicate that patients found the module easy to use, felt that it led to their providers having more accurate information about them and enabled them to feel more prepared for their forthcoming visits.

J Gen Intern Med. 2008 Sep;23(9):1414-22. Epub 2008 Jun 19.Classifying and predicting errors of inpatient medication reconciliation.
Pippins JR et al.

Unintentional medication discrepancies are common and more often due to errors taking an accurate medication history than errors reconciling this history with patient orders. Focusing on accurate medication histories, on potential medication errors at discharge, and on identifying high-risk patients for more intensive interventions may improve medication safety during and after hospitalization.

J Am Med Inform Assoc. 2008 Jul-Aug;15(4):424-9. Epub 2008 Apr 24 A randomized trial of electronic clinical reminders to improve medication laboratory monitoring.
Matheny ME They identified high rates of inappropriate laboratory monitoring. Electronic reminders did not significantly improve these monitoring rates. Future studies should focus on settings with lower baseline adherence rates and alternate drug-laboratory combinations.

Could Doctors Today Have Saved Lincoln's Life?

Could Doctors Today Have Saved Lincoln's Life?
Memorial Day is a United States federal holiday observed on the last Monday of May (May 25 in 2009). Formerly known as Decoration Day, it commemorates U.S. men and women who died while in the military service. First enacted to honor Union soldiers of the Civil War (it is celebrated near the day of reunification after the civil war), it was expanded after World War I to include American casualties of any war or military action. Memorial Day, prior to the rest of the wars, was a day celebrated by Civil War veterans as a day special for them.

The most important casualty of the Civil War was Abraham Lincoln.On April 14, 1865, Lincoln was shot in the back of the head by John Wilkes Booth at Ford's Theatre in Washington, D.C. The bullet from Booth's derringer stopped behind Lincoln's left eye. Army assistant surgeon Charles Leale, who was at the theater, cared for Lincoln and found a blood clot at the back of the president's head.

Physicians used brain decompression, but within 10 hours, Lincoln was dead.

"The state of the art that they offered him was brandy, water and probing the wound," said a physician who reviewed medical records from Lincoln's physicians.

He added that Lincoln's frontal lobes were spared, preserving sections that handle emotions, language and problem-solving. Thus with rehabilitation, the president would have improved and may have been able to communicate.

If the shooting happened now, Lincoln would be airlifted to a trauma center for a CT scan and medications to reduce effects of brain swelling.

Surgery would be done to lessen pressure and remove accumulated blood.

Doctors also would work to prevent additional brain damage.

But Lincoln would have had a difficult time returning to a normal presidency."If Lincoln had survived, he would have been in such bad shape, says one doctor, that there would have been a long, long rehabilitation."

At the time, it should be noted; there was no provision for replacing a disabled president. It wasn't until 1967 that the 25th Amendment was ratified to address transfer of power from the president.

He would have had a long recovery and would have had to endure a long rehabilitation while in office to regain some of his abilities. Experts say Lincoln would be left with residual dyslexia and vision problems.

Could crucial post Civil War America survived the long rehabilitative period without a strong hand at the helm?

Doubtful.

But look what they got instead.

PART II OF II. ARE WE HEADING TO A US MEDICAL RATIONING SYSTEM?

Thus if the new Obama money on the health care scene will do more comparative studies to make sure current guidelines are appropriate, that’s great.

What we need most are evidence based outcome studies showing the benefits of quality metrics on mortality/morbidity in concert with the application of such studies rather than experts getting together to hammer out compromised clinical practice guidelines as exists today.

Groups representing African-American, Hispanic or elderly patients argue that they will be underrepresented in future clinical trials. Whether this is true or not, the whole point of comparative effectiveness is to move medical practice beyond the limits of ordinary randomized trials, by looking at a broader range of evidence that includes the actual experience of patients undergoing treatment. Comparative effectiveness is to see what works in practice, rather than over generalizing from a few unrepresentative studies.

However as I see it there is another bugaboo. Policymakers and research funders, such as the National Institutes of Health, often assume that the final steps in the translation of clinical research — the decision to act on new medical evidence and its implementation in routine care — are seamless and automatic. We clinicians know that changing the behavior of physicians and patients is difficult. Many of the assumptions regarding the most important aspect of such research — the ultimate implementation of its findings into health care — have had little empirical support.

The dominant White House voice on health policy is Peter Orszag, the budget chief who champions "comparative effectiveness research" -- studying the patterns of clinical practice to determine which drugs and treatments work best and therefore necessary and which treatments are un-necessary and therefore non re-imburseable.

The Obama Administration thinks it can use "comparative effectiveness research" analysis to weed out wasteful or unnecessary care. They say that by paying more "if the treatment has been shown to be effective and necessary and a little less if not," as Mr. Orszag recently was quoted, that un-necessary treatment will stop. He cites Dartmouth data that shows health-care spending varies wildly between regions, often with little or no correlation to “health outcomes.” Does anyone really believe that un-necessary treatment will eventually be reimbursed at all?

And haven’t we’ve seen “comparative effectiveness” before?

Under managed care in the 1980’s and 90’s, doctors and hospitals had to undergo prior "utilization review" by HMOs to reduce “unnecessary” hospitalizations, surgeries, tests, prescriptions etc. This cost-effectiveness gatekeeping was supposed to have disciplined health spending. “What happened next to this version of the dream is known to all,” says the WSJ. Administrative hassles led to a consumer backlash, with patients feeling they were getting inferior care in return for insurer profits. The political class eventually forced the HMOs to dilute or end most of their cost-control strategies.

Will the same course of events happen again?

It is for this reason that a shift is needed from the "science of recommendation to a science of implementation."

The creation of a CER initiative focused on developing and disseminating effectiveness reviews is an essential, but not yet a sufficient, step toward the routine provision of safe, high-quality health care to all Americans.

We also need evidence-based methods for discovering and describing how the findings of clinical trials and CER can be efficiently implemented and incorporated into routine practice.

An implementation research and development program designed for this purpose could fulfill three important objectives.

• It could accelerate the translation of evidence into everyday care.
• It could enhance the opportunities for doctors and patients to define value (balancing expected benefits with costs) on the basis of their understanding of local contexts and constraints.
• It could allow providers and patients to communicate with researchers and policymakers about clinically important issues earlier in the research process.

Local factors such as infrastructure, existing processes, the degree of buy-in by clinicians and administrators, and the costs associated with change may vary widely among hospitals and regions.

The Federal Coordinating Council must therefore remain mindful that the primary goal of CER is to enhance the translation of new medical discoveries into safe and high-quality health care for all Americans.

This goal can be achieved only if our investment in CER includes a commitment to implementation research.

This has not yet been done.

But a step in the right direction was taken by Sen. Arlen Specter, D-PA, who recently introduced legislation that would authorize the establishment of the Cures Acceleration Network (CAN). Under the bill, a new $2 billion agency would provide funds to translate research discoveries from the bench to the bedside, and would operate as an independent agency; it would not be part of HHS. The CAN would make awards outside of the traditional funding stream to accelerate the development of cures and treatments including but not limited to drugs, devices and behavioral therapies. The CAN would have a flexible expedited review process to get monies into the hands of the grantees as quickly as possible. These development funds would complement the research dollars provided to the NIH and would not compete or take monies away from the NIH.

Let’s hope bills like these don’t get stalled.

PART III of III: IN DEFENSE OF THE DOCTOR WITH A BAD REPORT CARD WHEN NOT ADHERING TO PAY FOR PERFORMANCE [P4P] GUIDELINES

PART III of III

The WSJ ran several letters received in response to Groopman and Hatzband alarming data- most from “quality professionals” pointing to 30 years of data in the Dartmouth Atlas showing widespread variation in the quality of care in many common chronic conditions. The Rand Corp statements that patients receive only about 56% of recommended care is also quoted. This widespread U.S. variation in healthcare is equated with low quality, injurious and costly medical care by these quality professionals instead of Groopman’s “what is best sometimes deviates from the norms.”

One letter writer from San Diego pathetically wrote that “Drs. Groopman and Hartzband state very well the dangers of general mandates in the practice of medicine. At our institution we are very concerned about the emergence of multi-drug resistant microbes, and we designed a treatment regimen for community acquired pneumonia to avoid certain antibiotics notorious for causing antibiotic resistance and Clostridium difficile infection. We were informed, however, that if we varied from the prescribed medication directive we would be out of compliance and suffer the consequences. Naturally, we caved to the pressure. Long-term consequences are not involved in the ‘metric.’"

But not answered adequately by these letter responses are the lack of outcome studies showing proof that the use of process quality measurements or metrics will improve morbidity or mortality in the real world. This unfortunately if addressed by the letter writers was not printed in the responses.

The devil in the details of “quality care” outlined by the letter-writing physicians is what the medical expert can use in his defense of the defendant physician “straying from the guidelines as we’ll see in a later chapter.

These devil in the quality details are:

• First, the federal incentive program entitled "pay-for-performance" is really "pay-for-process."
• Rather than measuring and rewarding improved outcomes, the program which is also being adopted by state and private insurers rewards adherence to practice guidelines.
• Second, there is little or no evidence the quality measures that comprise the guidelines correlate with improved outcomes, and
• If government and private insurers want to penalize and reward physicians for their practices they should measure those physicians' outcomes.
• This is dramatically demonstrated by the UCLA study mentioned above of over 5,000 patients at 91 hospitals published in 2007 in the Journal of the American Medical Association found that the application of most federal quality process measures did not change mortality from heart failure.
  

One must agree that using quality guidelines seems like good thinking superficially, but these rigid rules cannot fit the complexity of the human condition.

I spoke about this matter with my good friend Dr. Bernie Rosof, a pioneer in the Quality movement about this controversy on P4P guidelines. He replied that

• These guidelines must be nimble, i.e. they must quickly change as the profession believes in a new guideline prompted by an appropriate study.
• In addition he believes that more recent guidelines should based on both process and outcome studies.
• And finally the new money on the health care scene will drive us to do more comparative studies to make sure the guidelines are appropriate and to drive down the high variability that is now the current scene in medical care.
  

What we need most are evidence based outcome studies showing the benefits of quality metrics on mortality/morbidity in concert with the application of such studies rather than experts getting together to hammer out compromised clinical practice guidelines as exists today.

Until such time my opinion as a medical expert based on a reasonable degree of medical probability is that a good defense can be offered to a physician defendant on an individualized basis.

REFERENCES:

Book I - “Medical Malpractice Expert Witnessing: Introductory Guide for Physicians and Medical Professionals” (Hardcover) by Perry Hookman, MD (Author) : 592 pages.27 chapters. Publisher: CRC; Potomac Press; Language: English ISBN-10: 1420058959 ISBN-13: 978-1420058956; Dimensions: 10.1 x 7.1 x 1.4 inches; Shipping Weight: 2.6 pounds; price $239.95.
For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com


Book II –“Medical Expert Testimony: Advanced Syllabus for Physicians and Medical Professionals”
(Hardcover) by Perry Hookman MD (Author) 32 chapters; 936 pages. Proj.Pub date Spring 2009. Publisher: Potomac Press-CRC; ; Language: English ISBN: 978-0-9817570-0-1; ISBN:10:0-9817570-0-6 - Barcode (9780981757001.eps) Dimensions: 10.1 x 7.1 x 2.1 inches; Shipping Weight: 3.0 pounds; Price $289.95; includes CD-ROM. For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com

PART I of III: IN DEFENSE OF THE DOCTOR WITH A BAD REPORT CARD WHEN NOT ADHERING TO PAY FOR PERFORMANCE [P4P] GUIDELINES

Doctors suffer bad report cards by medical insurance carriers for not adhering to “quality of care guidelines.”

Doctors say these guidelines are more cost saving/profit making for the insurance companies than medical quality.

Who is correct?

Currently less than one tenth of 1% of the total. $2 trillion spent annually on health in the United States is spent on evidence based medicine to ascertain and establish competent medical clinical guidelines.

The demand for better evidence to guide healthcare decision-making is growing rapidly due to the variation of healthcare interventions, the frequency of medical errors, and the adverse consequences of care administered without adequate evidence.

The Roundtable on Evidence-Based Medicine in the office of the Institute of Medicine [IOM] have set a goal that, by the year 2020, ninety percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information, and will reflect the best available evidence on what works best for whom, and under what circumstances. http://www.iom.edu/CMS/28312/RT-EBM/55282.aspx.

To this end the American Recovery & Reconstruction Act of 2009 commits $1.1 billion to Comparative Effectiveness Research, and $19 billion to increasing health information technology.

Let’s look at an example of what such studies would look like in patients. --In this instance patients with Diabetes.

Almost 200 million people worldwide have type 2 diabetes. Coronary artery disease (CAD) is a major health concern and the leading cause of death in individuals with type 2 diabetes. CAD is often asymptomatic in these patients until the onset of myocardial infarction or sudden cardiac death. Type 2 diabetes is also widely recognized as a CAD risk equivalent. Thus endorsed by professional organizations screening of patients with type 2 diabetes and no symptoms of CAD were recommended in the absence of prospective outcome studies supporting its utility. Screening for CAD in patients with type 2 diabetes especially with 2 or more cardiac risk factors, though not an evidence based recommendation like many such guidelines had been also endorsed previously by an expert panel of the American Diabetes Association.

The strategy of routine screening for CAD in patients with type 2 diabetes is based on the premise that testing could accurately identify a significant number of individuals at particularly high risk and lead to various interventions that prevent cardiac events. However, in a study by Young L.H.et al, Cardiac Outcomes After Screening for Asymptomatic Coronary Artery Disease in Patients With Type 2 Diabetes;The DIAD Study: A Randomized Controlled Trial .JAMA. 2009;301(15):1547-1555 the results of the DIAD study would appear to refute this notion.

Although type 2 diabetes is considered to be a CAD equivalent participants had a low cardiac event rate (average, 0.6% per year) and the identification of participants with abnormal screening results did not serve to eliminate their risk over 5 years of follow-up.

The current standard of care for type 2 diabetes emphasizes the reduction of cardiovascular risk factors. However, there has also been substantial interest in the early detection of asymptomatic CAD by screening of patients with type 2 diabetes. Recent studies have shown that CAD can be detected noninvasively in a significant number of these individuals. Inducible ischemia and coronary artery calcium each have been shown to be associated with worse cardiac outcomes. However, the potential of routine screening to alter treatment and to prevent cardiac events in persons without clinically apparent CAD is largely unknown.

Thus, although endorsed by some professional organizations, screening of patients with type 2 diabetes and no symptoms of CAD remains highly controversial in the absence of prospective outcome studies supporting its utility.

In the light of the author’s findings, routine screening for inducible ischemia in asymptomatic patients with type 2 diabetes cannot be advocated for 4 reasons.

• First, the yield of detecting significant inducible ischemia is relatively low.
• Second, the overall cardiac event rate is low. Indeed, even our participants with moderate or large defects and the highest event rate would be conventionally assigned to an intermediate-risk category.
• Third, routine screening does not appear to affect overall outcome.
• Finally, routine screening of millions of asymptomatic diabetic patients would be prohibitively expensive.

Medical Ethics

The late Richard John Neuhaus, like the Catholic Convert he was, tied morality to natural law. In his “American Babylon” says Charles R. Morris [NYT 4/12/09] he also states his case for a natural-law approach to politics. Neuhaus insisted that politics and morals were inextricably linked. Neuhaus’s argument according to Morris proceeded as follows:

• Political entities come with a narrative and, usually, a sense of purpose.

• Neuhaus’s brand of natural law came from the Greeks, especially Aristotle, which was imported into Christian Europe in the 12th century and still the mainstay of Catholic moral teaching ala Pope Benedict.

• The common thread of natural-law models is that the “oughts” come not from inside the individual but from “out there.”

• Political dialogue is shot through with shared notions of right and wrong.
Others, however, like the “ironists” hold as did Gertrude Stein in California that there is no there “out there.” Things are relative. The ironist believes that we know nothing except our own vocabularies; and that “nothing has an intrinsic nature, a real essence.” The ionist believes that:

• Concepts like “just” and “rational” are simply “the language games of one’s time.”

• An ironist may worry “that he has been . . . taught the wrong language game,” but “he cannot give a criterion of wrongness.”

• The cultural assumptions we share with great philosophers are less likely to be “a tip-off to the way the world is in reality rather “than just a “mark of the discourse of people inhabiting a certain chunk of space-time.”

• Schools of philosophy or science are thus just different vocabularies.

• When an ironist works on developing a vocabulary, he is constructing himself.

• He is not getting in closer touch with some underlying reality — for even if there is one, it isn’t knowable..

But the danger is that politics without an anchor in an absolute morality from “out there” can quickly slip away in dark directions as was seen in Nazi Germany, Communist Russia and innumerable other polities.

Now comes political analyist David Brooks who also challenges the new atheists, who see themselves involved in a war of reason against faith. He attacks them as having an unwarranted faith in the power of pure reason and in the purity of their own reasoning. He quotes [4/7/09 NYT] Michael Gazzaniga in his 2008 book, “Human,” “it has been hard to find any correlation between moral [rational] reasoning and proactive moral behavior, such as helping other people. In fact, in most studies, no correlation has been found.”

But does that mean Brooks looks to God or an outside absolute as the source of morality? No.

“Today, he says, “many psychologists, cognitive scientists, and even philosophers embrace a different view of morality.” Brooks agrees that today “moral thinking is more like aesthetics.” Brooks also quotes Jonathan Haid of the University of Virginia “The emotions are, in fact, in charge of the temple of morality, and ... moral reasoning is really just a servant masquerading as a high priest.” “The rise and now dominance of this emotional approach to morality,”
Brooks also acknowledges “an epochal change which challenges all sorts of traditions. It challenges Talmudic law [based on a morality from “out there.” Is this what Nietzsche had in mind?

Not so English philosopher Thomas Hobbs who had another understanding of moral law. Hobbes’s pointed out that if one gets to prefer one’s own internal judgments to the judgments of authorized external bodies the result will be the substitution of personal whim for general decorum.”

The Supreme Court appears to agree with Hobbs. In a series of cases stretching from Reynolds v. United States (1878) to Employment Division v. Smith (1990), the Supreme Court has ruled that when the personal imperatives of one’s own… morality” lead to actions in violation of generally applicable laws the violations will not be allowed. For, says the court in Reynolds, “To permit this would be to make the professed doctrines of [personal] religious belief superior….and in effect to permit every citizen to become a law unto himself.”

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