We are now at...

Alert Orange

Virus becoming increasingly better adapted to humans but may not yet be fully transmissible , requiring close contact with an index case.

Larger clusters appear in one or two places outside Singapore but a pandemic has not yet been declared. A cluster of cases may also occur in Singapore but human-to-human spread remains localized.

Public health measures such as isolation and quarantine will be effective to break the chain of transmission.

Strategy is to contain spread arising from any local cases and break the chain of transmission, while preserving essential services and resources.

All the measures taken in Alert Yellow will continue where operationally feasible.

Action:

Implement “No visitor” rule at all hospitals.

Restrict all inter-hospital movement of patients or healthcare workers.

Set up Flu Clinics at the 18 Polyclinics for assessment and anti-viral treatment of flu-like patients.

Commence antiviral prophylaxis for identified essential services.

Encourage temperature taking at schools and all non-healthcare workplaces, markets, places of mass gatherings etc.

Carry out temperature screening for in-bound and outbound passengers at all air, sea and land border checkpoints.

Consider closing of schools and suspension of public gathering and events.

(Don't worry about angry doc - there'll be a medal and a bonus at the end of it for him... if he survives.)

Waiting for the Barbarians

-What are we waiting for, assembled in the forum?

The barbarians are due here today.

-Why isn't anything going on in the senate?
Why are the senators sitting there without legislating?

Because the barbarians are coming today.
What's the point of senators making laws now?
Once the barbarians are here, they'll do the legislating.

-Why did our emperor get up so early,
and why is he sitting enthroned at the city's main gate,
in state, wearing the crown?

Because the barbarians are coming today
and the emperor's waiting to receive their leader.
He's even got a scroll to give him,
loaded with titles, with imposing names.

-Why have our two consuls and praetors come out today
wearing their embroidered, their scarlet togas?
Why have they put on bracelets with so many amethysts,
rings sparkling with magnificent emeralds?
Why are they carrying elegant canes
beautifully worked in silver and gold?

Because the barbarians are coming today
and things like that dazzle the barbarians.

-Why don't our distinguished orators turn up as usual
to make their speeches, say what they have to say?

Because the barbarians are coming today
and they're bored by rhetoric and public speaking.

-Why this sudden bewilderment, this confusion?
(How serious people's faces have become.)
Why are the streets and squares emptying so rapidly,
everyone going home lost in thought?

Because night has fallen and the barbarians haven't come.
And some of our men who have just returned from the border say
there are no barbarians any longer.

Now what's going to happen to us without barbarians?
Those people were a kind of solution.

Constantine P. Cavafy

Change in AWARE EGM venue 2

angry doc would like to inform his readers that the venue for AWARE's EGM has been changed again.

Details can be found here.

Turn up and fight the good fight if you can. angry doc has another war to fight...

We are still at...

S'poreans should be on the alert for swine flu, but not unduly alarmed

SINGAPORE: Singaporeans should be on the alert for the emergence of swine flu in the country, said ministers at a news conference on Wednesday.

Some hospitals here are already on orange alert even though the government has placed the threat level at yellow. Orange alert means that the no-visitor rule is in place and healthcare workers must be in full protective gear.

Since the SARS epidemic in 2003, Singapore has put in place a comprehensive response plan in the event of an outbreak of infectious diseases. However, the government said this does not mean the public should let its guard down.

Deputy Prime Minister and Home Affairs Minister Wong Kan Seng said: "We are a very open society – many people come to Singapore, many Singaporeans travel overseas and they come back home. With the transmission being so efficient, it is possible that we can get hit by the Mexican swine flu. All of us should be alert, but don't be unduly alarmed by what is happening."

Health Minister Khaw Boon Wan said: "We cannot be complacent for the simple reason that this Mexican swine flu is not the same as the SARS virus that we dealt with. I think we did well last time, but that was an old war. This is a new war and we have to adapt our approach to deal with this new enemy. In many ways, this new enemy is much more difficult than SARS."

Mr Khaw pointed out why it is more challenging to contain the swine flu. Firstly, it is more contagious – spreading faster than SARS did; unlike SARS, infected patients can be infectious even before symptoms appear, making it difficult to identify those with the virus through thermal scanners at checkpoints.

As with all pandemics in the past, the swine flu infection is expected to be a long-drawn affair.

"The bottomline is that this is a very dynamic situation. But it does not mean that a global pandemic with a very high death rate, as what happened 90 years ago, is inevitable. It may happen, then again it may not.

"A lot depends on how the world responds to it and (if) the people within the country work hard together and do what is right, we may be able to reduce the casualties and fatalities," said Mr Khaw.

Doing what is right includes practising personal hygiene like frequent handwashing and being socially responsible by seeing a doctor and staying home when one falls ill.

A diagnostic kit for the swine flu is already being developed in the labs here, but authorities are still waiting for samples of the virus from the World Health Organisation which will help to determine if a virus detected here is indeed the swine flu.

- CNA/so

Readers who want more technical details can find them in the ministry's briefing slides.

angry doc notes that "[a] 23-month-old child has died of swine flu in Texas".

We are now at...

Alert Yellow:

Inefficient human-to-human transmissions of flu caused by a novel virus, requiring close and sustained contact to an index case. Further spread can be prevented through public health measures to isolate cases and quarantine contacts.

Risk of import into Singapore elevated. Isolated imported cases may occur but there is no sustained transmission.

Strategy is to prevent further import of cases, and to ring fence and isolate cases to prevent spread. The focus will be to provide treatment of all cases, and antiviral prophylaxis to contacts including exposed healthcare workers.

Action:

Alert Green action apart, institute home quarantine for close contacts of cases.

Institute temperature screening and impose restriction on hospital and clinic visitors.

Restrict inter-hospital movement, except in emergencies.

Healthcare workers to take temperature twice a day.

Institute temperature screening for passengers arriving from affected countries at border control checkpoints.

Travellers from affected countries given Health Alert Notices (HANs) and advised to monitor their temperature daily for 1 incubation period.

Keep safe, my friends.

Change in AWARE EGM venue

angry doc would like to inform his readers that the venue for AWARE's EGM has been changed.

Details can be found here.

Play nice. And don't let the swine-flu bug bite.

(Curse these Y-chromosomes!)

Swine flu is God's punishment for lesbians...

Makes sense, doesn't it?

Swine flu hits Singapore, people stay indoors, no one attends the AWARE EOGM, and the New Exco stay in power...

(Laugh while you can; when it really hits you won't be able to.)

Almost time to panic...

Or is it?


Alarm grows as flu toll mounts and spreads to Europe

MEXICO CITY - The rising death toll from the Mexican swine flu epidemic sent a wave of alarm around the world Monday with the United States declaring a public health emergency and Europe's first confirmed case reported in Spain.

Mexican Health Minister Jose Angel Cordova said the number of confirmed and suspected swine flu deaths in Mexico had hit 103, while the number of suspected cases has reached 1,614, up from 1,324.

President Felipe Calderon called for calm but news that a man in Spain had brought the flu back from Mexico heightened the international alert and stock markets blamed the disease for a new share battering.

China, Thailand and Indonesia joined Russia in banning meat imports from Mexico and the five US states where 20 swine flu cases have been confirmed.

The European Union called an emergency meeting of health ministers, and governments put strict security around flights from Mexico, taking any suspected cases into quarantine.

The World Health Organisation has warned that the swine flu strain -- apparently born out of a mix of human and avian flu viruses that infected pigs -- could become a pandemic and called for all nations to "intensify surveillance".

The virus particles can be spread through coughs and sneezes. Victims report fevers, coughs and headaches.

Mexico City's streets were deserted after its 20 million residents were ordered to avoid crowds, and a football game Sunday at the 105,000-seat Aztec stadium was played behind closed doors.

Residents donned blue face masks and stocked up on food and water in anticipation of a long lockdown as Calderon urged Mexicans to "move fast, but to maintain calm and cooperate with the authorities."

The only confirmed cases outside Mexico are the 20 in the United States, six in Canada and now one in Spain.

The United States will screen visitors arriving from infected areas, Homeland Security Secretary Janet Napolitano said, announcing a public health emergency order.

Richard Besser, acting head of the US Centers for Disease Control and Prevention, said there were eight confirmed cases in New York City, seven in California, two in Texas, two in Kansas and one in Ohio.

US President Barack Obama has ordered a "very active, aggressive, and coordinated response," said White House homeland security advisor John Brennan.

Napolitano said the government would release a quarter of the national stockpile of 50 million doses of the Tamiflu and Relenza anti-viral drugs.

The Defence Department, she added, has procured seven million treatment courses of Tamiflu.

After China, Thailand, Indonesia and Russia banned US pork imports, US officials insisted it was virtually impossible to catch swine flu from eating meat as long as it is properly cooked.

Authorities across the Asia-Pacific region, which has in recent years been at the forefront of the SARS and bird flu epidemics, stepped up checks at airports and urged the public to be on guard for symptoms.

Nine students and a teacher from New Zealand who recently travelled to Mexico are "likely" to have contracted swine fever, Health Minister Tony Ryall said.

Two Australians admitted to hospital after returning from Mexico finally tested negative. But Australian National University epidemiology specialist professor Paul Kelly said swine flu is more worrying than bird flu because it is spread much more readily between humans.

Thai and Indonesian authorities installed thermal scanners at airports to monitor passengers. Russia said it was monitoring all flights from North and South America. Malaysia said that travellers from the United States were being watched.

Spain screened all passengers on flights from Mexico. The confirmed Spanish case in the city of Almensa was among 10 under observation. Two patients in Scotland were also being watched.

Nine people in Colombia and one in Brazil were under observation with flu symptoms. In the Middle East, a 26-year-old Israeli was hospitalized in Netanya. All those under observation had recently been in Mexico.

Swiss pharmaceutical group Roche said it was ready to send out more stocks of Tamiflu, which it manufactures, but stock markets around the world took fright over the outbreak.

Airline stocks in particular plunged on worries that governments could impose travel restrictions.

"Swine flu is ripping through the markets creating uncertainty in its wake," said Manoj Ladwa, senior trader at ETX Capital in London.

- AFP/ir

Things ain't gonna be pretty for angry doc for the next few weeks, that's for sure.

Keep yourselves safe, gentle readers.

Support Love 5

(acoustic version here)

Letter to the Editor, SMA News

Dear Editor,

I write in response to the article "Traditional Chinese Medicine - Friend or Foe?" by Dr Jeremy Lim in the March 2009 issue of SMA News.

While I understand that Dr Lim was writing in his personal capacity, and that his views do not represent those of the editorial board or SMA, I am nevertheless disappointed by his uncritical support for Traditional Chinese Medicine (TCM).

Dr Lim began his defence of TCM with the 'science was wrong before' argument. While he is correct in pointing out that Jenner and Semmelweis' views were rejected by their colleagues in their days, they were eventually vindicated via the scientific method - their findings were accepted to be true because they explained observed phenomena, and not because the medical community decided to adopt a different standard of assessing a scientific claim. Dr Lim could well have included Dr Barry Marshall as a recent example of a 'misunderstood innovator', but we should remember that in trying to gain acceptance for his theory he did not appeal for a different 'metric' to be applied to it, but sought to provide evidence by drinking H. pylori. Why should TCM be held to a different standard?

Dr Lim then went on to state that "Western medicine has no monopoly on knowledge and we must actively and aggressively seek ways to compare Western methods and TCM, finding metrics that can be applied equally to both." I would like to contend that this is a misrepresentation of Western medicine today. Western medicine"does not claim to have a monopoly on knowledge; what it does claim to have is a valid tool for assessing claims in the form of the scientific method. The scientific method make us test each claim by demanding observable evidence, and to abandon a claim or a theory if it did not fit observed phenomena - it contains within itself the mechanism to correct previous assumptions, and is in fact the method that vindicated Jenner, Semmelweis, and Marshall. In contrast, TCM is based on a pre-scientific theory of unobservable qi and meridiens. Neither of these entities have been demonstrated objectively, while at the same time efficacy from modalities of treatment used in TCM have been shown to be due to processes that can adequately be explained by modern science (pharmacological properties of active compounds in herbs, endorphins-production in acupuncture), yet both continue to be taught and used as if they were true - it is not Western medicine that is claiming monopoly in knowledge here. The "metric" that should and must be applied equally to TCM and Western medicine, and for that matter all forms of alternative medicine, is the scientific method - it has been an objective and reliable method for evaluating claims, and proponents of different "metrics" have yet to come up with anything as effective as it.

Dr Lim then quotes Dr Lee Tat-Leang on the difficulty in performing randomised controlled trials for TCM treatment modalities because they involve "individualized and prolonged treatment", and mentioned in particular the difficulty of finding an appropriate placebo for acupuncture. This argument is a poor defence for the lack of quality evidence for TCM since a randomised controlled trial is not the only acceptable form of evidence, nor does the design of a randomised controlled trial necessarily forbid "individualized and prolonged treatment". With regards to placebo for acupuncture, I would like to point out that that sham acupuncture in the form of blunt or retractable needles which do not penetrate the skin or needling at points which are not identified to be acupoints have been widely used and accepted as forms of placebo in acupuncture studies. A recent meta-analysis of 13 studies on analgesic effect of acupuncture and placebo acupuncture [1] showed no significant difference between the two, which supports the view that the theory of qi and meridiens upon which acupuncture is based is not an adequate explanation of observed phenomena.

While I agree with Dr Lim's next point that it is possible to study the use of TCM in clinical trials that look at objective parameters, I believe that the important distinction between the treatment modalities used traditionally in TCM and the theories behind it must be made. We must not commit the logical error of accepting the that the theories behind TCM are true simply because a certain modality (be it herbal remedy, acupuncture, or traditional massage) has shown efficacy, but continue to test each claim. More importantly, we must not be lulled into thinking that "patient satisfaction" is more important than scientific rigor, and that the "philosophy" behind the treatment is not important as long as our patients are satisfied. Such an attitude promotes complacency, and will allow other forms of unproven therapy or pseudoscientific "alternative" medicine to claim legitimacy.

Dr Lim ends his article with a commentary on how "Singapore's Unique Position" means we are well-placed to "critically appraise the different elements of TCM viz-a-viz Western medicine" because of our "greater understanding and respect" for TCM. I would argue that any presumption of "understanding" and any unwarranted "respect" for TCM may in fact be detrimental to scientific study as it would prejudice the investigators' minds. As for Dr Lim's question of whether we will "seize the opportunity" in "blending" TCM and Western medicine, I would like to point out that Germany and the USA have already been studying TCM for many years, with the US National Institute of Health having set up a National Center for Complementary and Alternative Medicine (NCCAM) to conduct research on TCM and other forms of alternative medicine. The German social insurance had a few years ago withdrawn reimbursement for acupuncture for treatment of certain conditions based on studies that showed no difference between acupuncture and standard treatment for these conditions (while inexplicably continuing to pay for those conditions where no difference was found between treatment with acupuncture and sham acupuncture), while NCCAM had spent more than US$800 million on research since 1991 but have not managed to demonstrate the efficacy of any alternative medicine - the "opportunity" had already been seized by other people, and I am not sure that was a loss to us.

Sincerely,
angry doc

1. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ 2009 Jan 27;338:a3115.

Support Love 4

angry doc is not sure how much support AWARE used to give the the gay community, or whether the planned withdrawal of this support by the new exco will make any significant difference at all to them.

But he does know that sometimes we need to be reminded that there are still people who care for and support us.

Hug a lesbian today.

(angry doc would like to take this opportunity to thank his friends for their support.)

First do no harm?

An interesting topic for angry doc and all you newly-minted doctors out there about to be handed the power to harm patients to think about:


Correcting aberration of nature? No dilemma: Goh

BEING born fused to a twin is an “aberration of nature”, and the resulting extreme deformities deserve help, argued Dr Keith Goh in response to Health Minister Khaw Boon Wan’s suggestion to reconsider operating on Indian twins Veena and Vani, 5. They were born fused at the skull.

“Nature never intended for one human being to be stuck in such a manner to another,” the neurosurgeon told Today. “To allow nature to simply take its course is not something I personally believe in. Where is the dilemma there?”

Their situation was different from “procedures that healthy people undertake to beautify themselves and bring large profits to their doctors”.

Mr Khaw had said on Friday that while life may appear “intolerable” for conjoined twins, they could progress to adulthood and “to change the course of nature may do more harm than good”.

Dr Goh agreed with Mr Khaw that ethical issues in conjoined twins cases are “huge and immensely complex ... (But) this is not likely to be the case with Veena and Vani”.

Mr Khaw had said international studies based on 40 pairs of twins joined at the head show that half the patients die while hospitalised, during or after a separation surgery. The outcome of Singapore’s two such surgeries — where three of the four twins have died — “reaffirmed these awful statistics”, he had said.

But Dr Goh, who performed both operations, pointed out that one twin, Ganga, had died only seven years later, and from a chest infection. To his knowledge, nine out of 12 patients worldwide have survived twin separation surgeries since 2000.

In any case, his decision to operate on Veena and Vani will not be based on numbers — but on “their medical condition, anatomy and physiology, and whether we can minimise the risks and complications,” said Dr Goh, who is waiting for the Indian government to work out the logistics and funding for tests, before deciding if he will do the surgery.

ALICIA WONG


The first questions on whether or not to attempt separation of a pair conjoined twins are not of ethics, but of medical science: given the anatomy of the conjoined twins and what we know about physiology and the success (and complication) rates of various surgical techniques we can employ, and with the given resources at hand in terms of manpower, infrastructure, social support etc., what are the risks of mortality and morbidity, and what kind of outcome we can reasonably expect given those circumstances?

Once those things are known, it becomes possible to assess the risks, and to discuss the issue intelligently.

The question of whether or not one is justified in offering or taking those risks for the expected benefits is an ethical one (as is that of whether the state has any right to intervene in the decision of a pair of twins to undergo that risk or for their parents to choose to let them undergo that risk), but to venture an opinion without taking into account those facts in a given pair of conjoined twins is, in angry doc's opinion, irresponsible.

The fact is practically everything we do to a patient as a doctor has the potential to do harm. The only way to do no harm (actively) is to do nothing at all. And what will tell you how much potential harm and how much potential good a given intervention can have is not ethics, but knowledge. If we wanted to allow nature to simply takes its course then we might as well just huddle around a fire in a cave and hope that the sabretooth cats won't attack tonight.

So, my youthful colleagues, as you take your first tentative steps into the wards without a lab-coat, ask yourselves: should the maxim be "First do no harm", or "Kill as few patients as possible"?

(The correct answer is: Neither - call your MO.)

"What's your answer?"

An article on the interview for admission to medical school on Today today posed "some questions asked during admissions interviews" to the readers.

What are your answers?

The perennial question

Why do you want to become a doctor?

Current affairs

Should General Practitioners practise aesthetic medicine?

Ethical dilemmas

With one organ and two patients who need it equally, who would you decide to give it to?

Two patients are admitted to the Accident and Emergency department — one a father, the other an old lady. Both are in equally serious condition but there’s only one bed available. Who would you give it to?

Support Love 3

Fellow Clearthought-blogger continues to track the news on the new AWARE exco...

(Of course they were - they were fruits, for crying out loud...)

Support Love 2

Fellow Clearthought-blogger Leng Hiong, who has 'no horse run' in this race, has nevertheless compiled updates on the topic so angry doc won't have to.

Thanks, pal.

Support Love

Thanks to fellow Clearthought-blogger Leng Hiong, angry doc now has a way to take over the Singapore Medical Association.

But seriously, folks...

This episode seems to have made people who keep an eye on the issue of LGBTQ rights worried (see here and here and other pages linked to).

angry doc doesn't know if their fears will become true, but he will be watching. It will be interesting to see how AWARE will dress a homophobic agenda as something that promotes "Gender Equality for All".

When angry doc started this blog, he made a conscious decision to not 'show his politics' here, but that came to an end when he decided to rebut a letter to the ST Forum that he believed was misrepresenting medical science - he did not have a horse in the race himself when it came to the issue of LBGTQ rights, but the tactics employed by the anti-gay lobby bugged him at an intellectual level.

But things have happened in angry doc's life since then that makes him now consider the issue of LBGTQ rights as something that concerns him personally, and he is now willing to use the meagre influence of his blog to raise awareness on it and to champion it, even when the context of the topic at hand is not something strictly related to science or medicine.

Even if it will cost him eventually. Even if it will hurt him.

Support love.

Because if it's not going to be about love in the end, then what's the whole point?

Where morality lives

angry doc hasn't been posting anything of substance for the past few weeks. He has been struggling: with work, with travel, with politics, with the mechanics of living, with real life, and with ideas, one of which is something featured in this news article:


Scientists locate brain's moral centre
Certain parts of brain activated when faced with moral dilemmas

LONDON: - Scientists have made significant headway into a realm generally left to philosophers and theologians.

In a report to be published in the American Medical Association's journal Archives of General Psychiatry, researchers say they have identified the parts of the brain that help humans when they are faced with difficult moral dilemmas, Britain's The Sunday Times reported.

Using sophisticated brain scanning techniques, researchers found that humans respond to moral quandaries by activating areas of the brain associated with abstract thought and such basic emotions as sex, fear and anger.

'Our research suggests there may be a basis in neurobiology for wisdom's most universal traits,' said Dr Dilip Jeste, a professor of psychiatry and neuroscience at the University of San Diego.

Dr Jeste and his colleague Thomas Meeks found that when faced with a simple situation calling for altruism, humans call upon the medial prefrontal cortex, an area linked to intelligence and learning.

But when forced to make a difficult moral judgment, other areas in the brain were activated, including those connected both with rational thought and basic emotions.

'Several brain regions appear to be involved in different components of wisdom. It seems to involve a balance between more primitive brain regions, like the limbic system, and the newest ones, such as the prefrontal cortex,' Dr Meeks said.

Increasingly sophisticated brain scanning techniques such as functional magnetic resonance imaging (fMRI), which allows researchers to see which parts of the brain become active when people undertake mental tasks, have made such research possible.

Other recent studies have tried to understand aspects of the human condition such as empathy, compassion and emotional stability, which are widely regarded as part of the intangible concept of wisdom.

A recent paper published in Britain's Nature journal addressed the neurological basis of free will. In it, Professor Patrick Haggard of the Institute of Cognitive Neuroscience, University College London, wrote: 'Modern neuroscience is shifting towards a view of voluntary action being based on specific brain processes, rather than being a transcendental feature of human nature.'

Such research has also been used to study disorders such as obesity and gambling, suggesting the brains of people suffering from such afflictions are wired in a way that makes self-control difficult.

'Brain scans of some people suffering from morbid obesity show they have an abnormal response to food. Their brains respond so powerfully that they are driven to eat too much,' said Dr James Rowe, a consultant neurologist and researcher at Cambridge University.


angry doc isn't surprised by the findings - we have long known that thought processes and emotions are related to or 'located' in certain parts of the brain - if a certain part of our brain is damaged, our function, cognition, and indeed personality can change in a way that is largely predictable based on our knowledge of neuroanatomy.

You may argue that morality does exist as an independent entity apart from neurophysiological processes, and that it is morality that activates certain areas of the brain up and not vice versa, but then that would be like arguing that it is the reflection of a tree in the water that causes the tree to exist, and not the other way round. Except for anecdotal accounts of 'reincarnation' (some of which are remarkably convincing), there is no good evidence to show that emotions and thoughts, and by extension consciousness, can exist without a functioning brain, whereas all instances of emotions, thoughts, and abstract concepts we know of and deal with every day exist only in relation to a functioning brain. Near-death experiences, being 'near' death and not actual death, are actually accounts from a functioning brain after the event, and so are not evidence for consciousness outside of a brain. In other words, the concept of morality, as with thoughts and emotions, is an epiphenomenon.

So no, angry doc is not at all surprised by the fact that abstract concepts such as morality and altruism are related to certain parts and are thus functions of the brain. In fact, the opposite will surprise him more.

What does it all mean though?

As the article suggested, the implication is that 'free will' as we currently conceive of it may not be as 'free' as we think it is. Consequently, those of us who are less successful in life - the 'slackers', the 'stupid', the 'lazy' and the 'weak' - and those who are deemed to be morally-deficient somehow - addicts, sociopaths, sexual deviants, repeat criminals, and even that jerk in your office who pisses everyone off regularly - may not be as free to not be what we are than society think.

The flip side also is that those of us who are successful in life, who are kind, patient, wise or compassionate, or otherwise a paragon of a certain virtue, may have less reason to be proud of being who we are than we may now be.

The fact is our current system of ethics and morality is evolved and built upon the assumption of free will, that each man should be held accountable for his wilful actions, and that our current system of meritocracy, of rewarding people, is also based on the assumption that it is just to give higher rewards to those who contribute more and to give those who perform less well lower rewards.

Yet if everything is ultimately contingent on how our brains are wired, are those systems of morality and reward-and-punishment still valid? Are they still just?

angry doc believes that it doesn't matter. At the end of the day, we are still unwilling to let people who steal our possessions get away with it, or to accept that someone who obviously performs less well than us should be rewarded as much as we are - the validity of the concept aside, we will still think it is 'unjust'.

Moral imperative, at the end of the day, is just electrical impulses in our brain.

Nerd Test

Nerd Test.
angry doc scores 6.