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It is no accident that in French-dubbed versions of Hollywood films, African-American characters usually speak with the accent heard in the Paris banlieues.
Nobody should be surprised that efforts by the government to find "community leaders" have had little success. There are no leaders in these areas for a very simple reason: there is no community in the neighborhoods.
Traditional parental control has disappeared and many Muslim families are headed by a single parent. Elders, imams and social workers have lost control.
Paradoxically, the youths themselves are often the providers of local social rules, based on aggressive manhood, control of the streets, defense of a territory. Americans and critics of America in Europe may see in these riots echoes of the black separatism that fueled the violence in Harlem and Watts in the 's.
But the French youths are not fighting to be recognized as a minority group, either ethnic or religious; they want to be accepted as full citizens.
They have believed in the French model individual integration through citizenship but feel cheated because of their social and economic exclusion. Hence they destroy what they see as the tools of failed social promotion: schools, social welfare offices, gymnasiums. Disappointment leads to nihilism. For many, fighting the police is some sort of a game, and a rite of passage.
Contrary to the calls of many liberals, increased emphasis on multiculturalism and respect for other cultures in France is not the answer: this angry young population is highly deculturalized and individualized. There is no reference to Palestine or Iraq in these riots. Although these suburbs have been a recruiting field for jihadists, the fundamentalists are conspicuously absent from the violence.
Muslim extremists don't share the youth agenda from drug dealing to nightclub partying , and the youngsters reject any kind of leadership.
So what is to be done? The politicians have offered the predictable: curfews, platitudes about respect, vague promises of economic aid. It's a little cancer.
She'll show up with six family members who are just all, you know, this cancer has got to be treated, when the woman has got a life expectancy probably less than two years. He was frustrated and baffled that he had been asked by the emergency room physician to treat the patient's acute bleeding.
However, when faced with an acute choice between surgery and palliative care where the best surgical outcome is described as prolonged hospitalization and long-term nursing home care, seniors viewed this either as a choice between life and death or a decision about how to die.
Others believed that surgery would only prolong the dying process and expressed a desire to control how they die emphasizing comfort and time with family. Although surgeons agreed that very frail patients should not have surgery they held conflicting views about how to present treatment options; some surgeons would not offer surgery, others would heavily favor palliative care and some would state the options and let the patient or family decide.
Surgeons noted several factors beyond their control that contribute to a clinical momentum promoting surgical intervention despite professional concerns that surgery is not valuable. These findings are important because they suggest that misunderstandings and faulty expectations determine the outcome of high-stakes surgical decision making. Observation of these challenges to surgical decision making presents an opportunity to assist frail elderly patients and their families in the setting of acute surgical illness and has important implications for surgeons, patients and policy makers.
For surgeons, it is critical to appreciate and dispel false assumptions about treatment outcomes for frail elderly patients. As intra operative death is a rare occurrence, surgeons need to illustrate the cascade of postoperative complications and interventions that typically precede postoperative death rather than simply stating the statistical probability of death. Surgeons will also need to describe the range of surgical outcomes for the individual patient within the context of the patient's overall prognosis with careful attention to the patient's health trajectory before surgical illness.
Given patient skepticism and popular notions about the capacity of modern medicine 18 this may require support from surgical colleagues or the patient's primary care physician.
Furthermore, such efforts may prevent surgeon frustration, dismay and emotional accountability stemming from downstream withdrawal of postoperative life supporting treatments. Because physicians in general discuss treatments and fail to offer information about long-term prognosis 22 - 24 patients and their families are woefully unprepared for an acute event and struggle to place a decision about surgery within the larger context of their overall health.
Instead they use heuristics to choose surgery 25 and may not incorporate their previously stated preferences and values about quality of life.
These overly simplified decisions may lead to unwanted invasive treatments at the end of life. We are hopeful that some seniors were able to do the harder work of imagining their reaction to future health states and could see that the best outcome of surgery was a state where quality of life was not acceptable.
Future efforts to improve decision making will need to focus on helping patients move from intuitive-emotional decision making and embrace effortful and more analytic decision making. Hospital processes that increase efficiency may benefit patients through provision of earlier treatment, reduced length of stay and decreased hospital costs.
However, these same efficiencies inhibit opportunity for deliberation between doctors and patients about whether intervention is even appropriate.