Prohibiting your faculty from using industry representatives to ghostwrite their articles! Now I’ve seen everything! The gall.

Yes, word’s getting around. This is from the University of Iowa.

They’ve been hammering away at the research misconduct at some of the president’s neuroscience labs, and he has been as high-handed and obnoxious with the little buggers as you’d imagine. But the school journalists were right on the money. They persisted, and they brought the dude down. The school’s investigation found “repeated instances of manipulation of research data and/or subpar scientific practices from different people and in labs run by Dr. Tessier-Lavigne at different institutions.”

[Stanford’s] investigation [of Marc Tessier-Lavigne] took eight months, with one member stepping off after The Daily revealed that he maintained an $18 million investment in a biotech company Tessier-Lavigne cofounded. Reporting by The Daily this week shows that some witnesses to an alleged incident of fraud during Tessier-Lavigne’s time at the biotechnology company Genentech refused to cooperate because investigators would not guarantee them anonymity, even though they were bound by nondisclosure agreements.

Of course some sleuthing would turn up a financial conflict of interest on the committee: that’s SOOOO Stanford. And as to the skeeziness on protecting the identity of sources — why wouldn’t the committee guarantee anonymity, given the Genentech people’s legal vulnerability?

Much of the writing and reporting for the Daily has come from the genetically overdetermined Theo Baker.

This page has links to Baker’s reporting on Tessier-Lavigne.

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A comment in response to an article in the NYT:

In three successive labs headed by this man, data was manipulated (ie, fraudulent). The connecting link is Lavigne, who apparently rewarded post-docs who produced findings that advanced his career, and penalized those who couldn’t do so. The obvious conclusion is that he consistently cut corners and closed his eyes to what his behavior led underlings to do. And when the misconduct began to surface, he simply refused to issue the necessary corrections. He is not a victim or some innocent party here. His research was shabby and he has now got what he deserves: loss of his primary job and his reputation.

… and since he’s a feisty fellow, ever ready to defend his position, UD sees a promising future for him.

He’s entirely unfazed that the editors of America’s three major medical journals found a recent study he published (it argues that the FDA’s product reviews stifle the medical device industry) scientifically shoddy and rife with conflict of interest. A congressional committee report summarizes:

“After reviewing the paper, the editors of the three premier peer-reviewed medical journals concluded that the study would not be fit for publication in a peer-reviewed journal.” Dr. [Gregory] Curfman concluded that “it is not really a study at all.” Dr. [Rita] Redberg found “several serious methodological issues with the Makower report that render its findings scientifically invalid.” Dr. [Howard] Bauchner determined that “[g]iven the extent of these limitations, the inferences and conclusions that can reliably drawn from this report are limited.” Finally, all three editors identified significant conflict of interest concerns with the report.

The objections to the study were similar to reactions by Dr. Jeffrey Shuren, director of the Center for Devices & Radiological Health, who lambasted the study when it was released in December. Shuren told MassDevice that the study was “horrible.”

“That’s well below the quality level of a good study,” Shuren told us at the time. He pointed out that lower response rates would magnify the opinions of people unhappy with the process. He added that a sufficient response rate would have been 35 to 40 percent. “We want to have good data.”

The Minnesota Star Tribune provides more conflict of interest details:

Dr. Curfman writes that he was surprised Makower did not disclose his financial ties to the device industry since they “clearly constitute a significant conflict of interest.” Further, he states, “this isn’t a study as all. This is an opinion piece that is dressed up to look like a research study.” The authors had a specific agenda from the outset, he continues, and “they conducted their work in a biased manner.” The CHI report “advocates a potentially dangerous position — that regulation stifles innovation, he says, and “do a serious disservice to medicine and the health of the public.”

Now on to Dr. Redberg, who says there are “serious methodological issues” with Makower’s report, claiming a selection bias among the companies that responded to his inquiry. She goes on to claim the authors, funders and survey respondents may have a conflict of interest because their “livelihood depends on fast approval of medical devices.”

She also quibbles with the report’s conclusion that FDA regs are driving med-tech companies abroad. This argument is flawed, Redberg writes, because approving unsafe devices “actually hurts the economy by allowing limited health care dollars to be spent on expensive devices that do not help patients” [which leads] to higher health care costs that may result in economic difficulties and possible bankruptcies of small businesses.

Stanford is a hotbed of professor-entrepreneurs for whom fast approval is of course the name of the game. Note to Congress: Shut up and get out of the way. Note to Stanford: Terrific research program you’ve got going there.

It’s hard to keep a good shill down. Ignoring explicit conflict of interest policies, at least twelve hucksters who teach at Stanford University’s medical school are still at it, trading their institution’s prestige for tens of thousands of dollars from drug companies each semester.

A public interest group pointed this rule-breaking out to do-nothing Stanford, which is apparently – in response to growing press interest in the scandal – slowly beginning to discipline these people.

As long as universities consider it not quite the done thing to call its pitchmen and pitchwomen out on their sales careers, COI policies will remain a joke.

… of non-compliance.

… [M]ore than a dozen of the school’s doctors were paid speakers in apparent violation of [Stanford’s conflict of interest] policy.

… Dr. Alan Yeung, vice chairman of Stanford’s department of medicine and chief of cardiovascular medicine, who was paid $53,000 from Eli Lilly & Co. since 2009. In an e-mail, Yeung said he quit speaking for the company this fall.

“I take full responsibility for this error,” he said. “Even though I felt that these activities are worthwhile educational endeavors, the perceived monetary conflict may be too great.”

Child psychiatrist Hans Steiner was paid $109,000 by Lilly to deliver talks about a drug for attention deficit hyperactivity disorder. In an e-mail, Steiner said he spoke in “very rural and other impoverished settings which only have limited access to experts like me.”…

Those poor schlubs! You would deny them experts like me!

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The Stanford University Motto:

Adipiscitor pecuniam medicam cum ex digitis mortuis nostris revulseris.

(You’ll get our drug money when you pry it from our cold dead fingers.)

It’s right there in their headline:

18-Year-Old’s Science Reporting Leads Stanford President to Quit

It takes a child to point out to the world that the emperor has no standards.

Everyone else – especially at places like Stanford, which make scientific entrepreneurs like Stanford’s president billionaires – plays the games, the insider trading, irreproducible results, conflict of interest, ghost writing, pharmawhore games.

And everyone’s making so much money playing the games that no one’s going to make a peep.

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So making noise about it takes some snot-nosed self-righteous little person at the student newspaper who thinks exposing corruption is more important than being able to stash billions away in your tax haven.

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Certain universities – Louisville, USC, Yeshiva, the University of Miami – have the smell of more or less criminal enterprises. They’re always generating high-level, multifaceted, scandal; some of their trustees are crooked or even criminal financiers. Yeshiva had Bernard Madoff as treasurer; Ezra Merkin also sat on their board. Also, I believe, Ira Rennert. The school continues to have as a trustee Zygmunt Wilf. These are not pretty people.

Now, Harvard and MIT were indeed buddies with Jeffrey Epstein; Harvard even celebrates as an emeritus professor Alan Dershowitz, at least an Epstein intimate, and at most (according to one of Epstein’s slaves) a secret sharer in the sex. Its erstwhile president, who helped run a hedge fund while president, hung out with Epstein too. (He also hung out with Andrei Shleifer…) But these schools are not the rackety dives those other schools are. They’re not just in it for the money. Nor are they just in it for the sports: The heavy campus hand of plutocrat college sports fans (the recently departed T. Boone Pickens at Oklahoma State; Phil Knight at Oregon) generates scandals, too – but these are the tired, expected scandals of the jock school.

No, MIT and Harvard are great schools, serious schools, productive schools – they are among the world’s greatest intellectual institutions. They fuck with plutocrats because of their professors’ smokin’ ambition to understand, to invent, to cure. They want money, money, and more money to fund their projects. To be sure, some of this generative creative activity makes some of their professors personally wealthy — the ex-head of MIT’s Media Lab took money from Epstein for his own investments, which adds to the embarrassment of it all… More commonly, professors monetize their medical and technical breakthroughs, producing all kinds of conflict of interest trouble at cutting edge places like Stanford…

We little people, looking in at all of this from the outside, are assured that COIs can be “managed” – the word is always managed – and we shouldn’t worry our pretty little heads. Yessir!

**************

Now look. Most people are pretty greedy; many putrid plutocrats realize that a university affiliation can clean them up real good. It’s a marriage made in heaven. But here’s what UD finds remarkable: MIT’s endowment is close to 17 billion; Harvard’s is close to forty billion. In ten years or so, Harvard’s wealth will be, say, a hundred billion. Harvard is a superplutocrat.

These schools are currently in trouble for promiscuous plutocrat fraternization; but given how INSANELY – not to say unconscionably – rich they are, why is this sort of thing happening at all? Just make an appointment with the “super-secret and dictatorial Harvard Corporation” and explain to them that you’d rather dip into the school’s billions and billions and billions than have to take research money from a guy in jail for sexually enslaving fifteen year olds. The worst they can say is no!

And while we’re at it – Why do superbillionaires like Harvard feel compelled to appoint rich turds like Epstein visiting fellows? We know that legacy parents can pay their kids’ way into Harvard; we know that rich parents can bribe coaches to get their kids into schools like Harvard and Yale. I’m not sure we knew that profit-oriented Harvard faculty can gift generous rich guys official appointments. Not a good look. Not a good look at all. But when Larry Summers spends his presidency running a hedge fund, losing $1.8 billion of Harvard’s endowment on market gambles, and defending a faculty crony who misused, for personal gain, government funds to Harvard, whadaya expect? That crony cost Harvard tens of millions in federal penalties, and it made not one bit of difference in terms of his high-profile position in Harvard’s economics department. That’s the way plutocracies work, kiddies. Plutocracies are even smart enough to know when their workings have become too public, which is why right after Larry Summers, Harvard appointed preachy anti-materialist Drew Faust (‘And while you’re at it, find me a woman, for crap sake!”) to maintain the non-profit theatrics.

Skeptical of the clean-up crew function of women when plutocrat sausage parties get out of hand? Read and learn. As FIFA went, so went Harvard – when things get truly desperate and you can’t hide what you’ve been doing any longer, Find A Woman, Pronto. You can always go right back to men when it all blows over.

***********

As ever, sing it.

[Before and after his conviction in 2008, Epstein was a regular on the masturbatory tech gadfly circuit — an attendee and sponsor of “billionaire dinners” and related sausage-factory soirees at which ultrawealthy men (among them the founders of Amazon and Google), elite scientists and various other male luminaries discussed the future they were collectively trying to build (or, depending on your perspective, squander.)]

***********

The party’s over

It’s time to find us a dame

Until we start up again

I’m going to miss our game

It’s time to wind up

The masquerade

There’s no more Epstein

To keep us paid…

Stanford’s got a bit of a problem on its hands. It’s the sort of problem you get when you’re an exceedingly entrepreneurial university and you’ve got your hands and your professors’ hands in a lot of businesses.

Remember the problem they had with Alan Schatzberg’s investments and Alan Schatzberg’s research? It just doesn’t look good for empirical analysis when you stand to make gazillions on its outcome… So Stanford spends half its time tweaking its conflict of interest rules…

And another thing. Take NU Skin, an outfit that, among other things, sells face-whitening cream to women in the Philippines who want to look white, and an outfit with which Stanford’s had a long relationship (meaning NU Skin gives Stanford big money to do anti-aging research). NU Skin’s in serious trouble with the FDA for this and that — the usual stuff, questionable marketing tactics, questionable claims… And Stanford’s name’s being dragged into it… NU Skin’s scientific claims for its products rest on its association with Stanford researchers, and NU Skin talks up that association in its advertising.

So, seeing the shit about to hit the fan, Stanford has done a cease and desist letter

asking the company to stop using a university researcher’s name in its advertising, adding new scrutiny to the skin product maker’s business claims and practices.

According to a copy of the letter emailed to Reuters, Stanford geneticist Stuart Kim is listed as a “Nu Skin Partner” in developing its ageLOC anti-aging products, though he has nothing to do with the company. Nu Skin touts its skin creams and pills as using innovative technology to “reset” genes that promote a more youthful look and feel for its clients, according to its website.

“Neither Dr. Kim nor Stanford is a ‘Nu Skin Partner’ and neither has anything to do with the company,” states the letter, signed by Steven Rosen from Stanford’s Office of the General Counsel.

Which isn’t true, I’m afraid. Kim did do research with NU Skin money (he doesn’t anymore), and while that doesn’t make him what you’d call a “partner,” I guess, it certainly doesn’t rise to nothing to do with the company. To make matters even less factual, Stanford indeed continues its long association with NU Skin via the work of other faculty researchers.

As this guy, an outraged NU Skin investor (its stock value has withered like a ninety year old kneecap) points out, Stanford had to issue another letter directly contradicting this one and admitting that the school has plenty of NU Skin in the game:

Not only does the university cite their longstanding relationship with the company, they essentially apologize for creating any misunderstanding that a relationship did not exist.

It is rather bad form to take millions and millions of dollars from someone, and then when that person has a run-in with the law to disown him. But these are the dilemmas inherent in the entrepreneurial university business model.

Stanford University’s Eugene Carragee gets it said with beautiful concision.

And with authority: He’s the editor of The Spine Journal, and, as Paul Thacker notes, Carragee has devoted an entire issue of his journal to the appalling ongoing story of Infuse. (This New York Times article, which appeared minutes ago, provides background.)

Paul wonders if this particular revelation of the ghostwriting, conflicts of interest and undisclosed payments behind the promotion and use of a destructive medical device might be “a critical turning point, when we see physicians finally break free from [the] corrupt influence of industry and begin to put patients first and money second.”

UD‘s primary interest is in the ways universities collude – through passivity or cynicism or ineptitude – in the activities of conflicted professors on their faculties.

And it’s not merely collusion. Often these people – easily identified by the 800 or so articles they claim on their cvs to have written (many of these publications are ghost- or guest-written) – are among the highest-profile, most celebrated faculty on campus.

Among the highest-paid, too. Keep that in mind when you read this, from the NYT article:

The median amount of Medtronic money received over time by researchers involved in some studies ranged from $12 million to $16 million, with most of that going to a few individuals…

“A consistent number of people involved with these studies got extraordinary sums,” [Carragee] said.

The surgical operation at play here is known as cash infusion.

Dan Berrett, at Inside Higher Ed, updates us on the corruption of the field of economics, and the profession’s glacial pace toward ethics and conflict of interest policies.

… [T]he Academy Award-winning documentary “Inside Job” has cast a harsh light on the chumminess of regulators, bond raters and bankers — and on the academic economists who were supposed to have rendered disinterested advice and analysis.

… [If] an ethics code and conflict of interest policy were to be adopted, …economists would state relevant sources of financial support, or ownership stakes in firms that might benefit as a result of policies they are advocating when writing op-eds or testifying in front of Congress.

[E]conomists at top programs, such as Harvard, Princeton and Stanford, share a somewhat common perspective and ideology about financial markets and regulation — and … professors from these departments also tend to get consulting work at private firms or at government agencies, thus circulating a fairly consistent ideology throughout the most influential agencies and universities.

There’s seems to be a kind of weird double-tracking going on in academic economics at the moment. Economists are either mooning over their own math (“[T]he central cause of the profession’s failure [to predict the economic collapse] was the desire for an all-encompassing, intellectually elegant approach that also gave economists a chance to show off their mathematical prowess,” writes Paul Krugman.) or lusting after corporate liaisons. Either way, you’ve got a lot of academics distracted from respectable intellectual work.

In a recent interview, Christopher Hitchens explains that he almost never watches television, because the spectacle it presents, hour after hour, show after show, is so repellent:

“It’s… the Barry Manilow effect, when you see Barry Manilow and you think, ‘There are people who want to hear this, and they want more of it.’ Clearly there’s something I’ve missed.”

UD has struggled with a variant of the Barry Manilow Effect through all the years of her coverage, on this blog, of academic psychiatry at some of America’s most esteemed (Stanford, Harvard, Minnesota, Brown) universities. Although she recognizes the importance of the subject of campus medical research for any blog calling itself University Diaries, UD is always tempted to avert her eyes from the steaming piles of Conflict of Interest, irresponsibly recruited subjects, non-operating oversight boards, and ineptly designed studies that litter this activity.

And not only are there people who want to sponsor this work – people at the National Institutes of Health – but NIH is taxpayer funded; so, whether or not we like the tune these researchers are singing, we’re compelled by the government to hear more of it.

Which really makes us dupes, doesn’t it? We pay for bad studies that might put dangerous drugs on the market, and then we’re damaged by said drugs… said very expensive drugs…

Hard to think of a more thorough fucking-over than that.

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UD‘s thinking about this because of yet another sordid revelation from the academy…

Slowly, slowly, slowly, American and Canadian universities begin to react to the scandal of drug companies corrupting their institutions.

Stanford’s industry-compromised professors are today’s big news; but smaller, just as important stories – like this one from the University of Toronto – give UD just the tiniest bit of hope that in the struggle between pharma and ethical people, ethical people can win the occasional tussle.

A Toronto med student in a pain management course featuring a pharma-paid guest lecturer – who gave free copies of a pharma-written book to the students – reported this circumstance to two UT med school professors. The son of one of these professors died not long ago of an accidental OxyContin overdose, and the professor wasn’t happy to see that OxyContin’s manufacturer was essentially the author of the book.

In the book, notes another UT professor:

“[O]xycodone … is listed as a moderate-potency opioid, when I think everybody agrees it’s a very strong opioid, up to twice as strong as morphine.”

While it’s appropriate to prescribe oxycodone for severe acute pain or cancer pain …the book suggests that physicians can prescribe the drug for chronic non-cancer pain with relative safety for the patient.

… “When you prescribe to people with chronic non-cancer pain, it’s very difficult to do that safely,” he said, noting that the book pays little attention to issues of addiction and deaths from overdose.

“The book in several places makes reference to a claim that the rates of addiction if opioids are used for chronic non-cancer pain are very low. And they’re not nearly as low as is claimed in the book.”

In fact, a study by [this professor] and colleagues published last year showed prescription rates for opioids — including OxyContin, a long-acting form of oxycodone — soared in Ontario over the last two decades, as did the number of deaths linked to the narcotic.

What’s of greatest concern, of course, is how such information imparted to medical students as part of their curriculum will affect prescribing practices once they become doctors…

UT has announced that the course will be revamped, but who knows? An obvious huckster and his wares happened to get noticed by one student ; that student was enterprising enough to contact the right professors about it, etc. See how unusual it is for anyone to do anything about this? How risky? (Why isn’t the medical student named?) How much in denial the university remains? (The guy in charge of the pain program says there wasn’t any real conflict of interest.)

One of the UT professors who complained to the administration puts it very bluntly.

“It is in the interests of the drug company to have physicians prescribing as many opioid medications to as many patients as possible.”

… at the American Economic Association. Also on lack of disclosure, conflict of interest – the stuff Stanford University’s You CAN Have It All! medical staff is dealing with at the moment.

The New York Times recently noted the AEA’s amoral ways.

You can argue that things like ethics codes don’t make no nevermind one way or the other; but somehow their absence, when every other professional organization has something along these lines, feels like a statement in itself.

Asked about this, UD‘s acquaintance James Galbraith (economist; brother of Peter) says:

You can’t have an ethical code unless ethical people design it. No sign of that sensibility at the AEA. I think what should happen is the formation of small societies with codes joined by subscription. Then people could distinguish between economists who avoid or disclose conflicts, and those who do not.

… on the faculty of the University of Chicago when Les UDs were students there, has died.

… “His big contribution was to bring philosophy from the abstractions of reason and logic — Plato’s world — to the reasonableness of making inquiries into human situations in which questions of morals, ethics and logic come to life,” said Roy Pea, the director of the Stanford Center for Innovations in Learning at Stanford University.

… Mr. Toulmin’s provocative ideas often encountered resistance at first, especially in Britain, and his work on argument was no exception. He proposed, instead of formal logic’s three-part syllogism, a model of persuasive argument consisting of six components. Some, he maintained, apply universally but others do not. Arguments, in other words, do not unfold in a Platonic ether, but in particular contexts…

From his 1997 Jefferson Lecture:

Print taught readers to recognize the complexity and diversity of our human experience: instead of abstract theories of Sin and Grace, it gave them rich narratives about concrete human circumstances. Aquinas had been all very well, but figures like Don Quixote or Gargantua were irresistible. You did not have to approve of, or condemn such figures: rather, they were mirrors in which to reflect your own life. Like today’s film makers, 16th century writers in the Humanities from Erasmus and Thomas More to Montaigne and Shakespeare present readers with the kaleidoscope of life. We get from them a feeling for the individuality of characters: no one can mistake Hamlet for Sancho Panza, or Pantagruel for Othello. What count are the differences among people, not the generalities they share. As Eudora Welty said in appreciation of V.S. Pritchett, who died just recently at the age of 96: ‘The characters that fill [his stories] — erratic, unsure, unsafe, devious, stubborn, restless and desirous, absurd and passionate, all peculiar unto themselves — hold a claim on us that cannot be denied. They demand and get our rapt attention, for in the revelation of their lives, the secrets of our own lives come into view. How much the eccentric has to tell us of what is central!’

… Writing early in World War II, near the end of his Notes toward a Supreme Fiction, [Wallace Stevens] refers [to] the contrast I have emphasized here, between reasonableness and rationality. For him, too, Reasonableness is more important than Rationality; and its importance is itself more than an intellectual one. It is the expression – as he puts it – of a “more than rational distortion – the fiction that results from feeling.” I recall one of my Chicago colleagues lecturing on the theme, “Is it rational to act reasonably?” Unless reasonable actions could be proved to fit his abstract moral theory with geometrical precision, respect for human frailty was for him intellectually suspect. Yet, rather than ask, “Is it rational to be reasonable?”, we might equally well ask, “Is it reasonable to argue in rational terms alone? In what situations can we reasonably rely on formal theories?”

… To sum up: like the uniqueness of names, the individuality or particularity of cases and characters divides the world of practice, in its actuality, from the world of theory, with its abstractions. Behind the contrast of the reasonable and the rational, behind the rival attractions of Nation State and Global Future, underlying the survival in a time of general toleration of the things Jefferson called bigotry and priestcraft, lie abstractions that may still tempt us back into the dogmatism, chauvinism and sectarianism our needs have outgrown… Nor is this conflict likely to be resolved permanently. It is another of those conflicts that demand eternal vigilance. So listen again to Wallace Stevens, writing in 1942… :

We shall return at twilight from the lecture,
Pleased that the irrational is rational . . . .
Soldier, there is a war between the mind
And sky, between thought and day and night. It is
For that the poet is always in the sun,
Patches the moon together in his room
To his Virgilian cadences, up down,
Up down. It is a war that never ends.

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More on Toulmin. An interviewer summarizes:

[L]ike Stanley Fish, Richard Rorty, and many others, Toulmin sees “no legitimate role for theory” and advises that we “be prepared to kiss rationalism goodbye and walk off in the opposite direction with joy in our hearts.” These views are entirely understandable given the fact that Toulmin’s mentor at Cambridge and his principal intellectual influence was Wittgenstein, from whom he inherited “a kind of classical skepticism.” As a committed pragmatist, then, Toulmin’s life’s work has concerned “the recovery of the tradition of practical philosophy that was submerged after the intellectual triumph of theory in the seventeenth century.”

… Toulmin would rather be known as a “neo-premodernist” than as a postmodernist; he believes “the thing to do after rejecting Cartesianism is not to go on through the wreckage of the temple but to go back into the town where this heretical temple was built and rediscover the life that was lived by people for many centuries before the rationalist dream seized hold of people’s minds.”

From his remarks during the interview:

[Jürgen] Habermas comes here to Northwestern most years, and we have a jolly two or three days when he’s here. He gives a couple of lectures, usually on Kant’s ethics as being the ultimate font of universalization and impartiality and the rest. He and I have a kind of joking relationship: he gets up and denounces the neo-Aristotelians, by whom he means some people in Germany who call themselves neo-Aristotelians; then I get up like St. Sebastian, take the arrows full in my chest, and say, “I’m happy to be a neo-Aristotelian.” So we chew that one a bit. Sometimes I ask my colleague Tom McCarthy, “What’s really biting Jürgen; why does he have so much investment in his pragmatics being universal?” Tom explains how different it was growing up in Germany after the Second World War from growing up in England just before and during the Second World War. We really do come out of situations in which what reasonably mattered to us was very different.

… There was a very intelligent conservative politician called Edward Boyle who died ridiculously young. I remember having an amusing conversation with him in which he was explaining how there were certain nineteenth-century novelists–the one he chose to talk about was Thomas Hardy–who could only have written after the invention of the railway and before the invention of the automobile. Chekhov is similar: everybody in Chekhov is always dreaming of going to Moscow in the same way that everybody in Hardy is dreaming of going to London. This comes out in Anna as well. One of the central things in Anna is that Anna finds herself in a series of situations that become progressively intolerable to her; she can’t cope. Because the moral demands made on her are for one reason or another too intense, too unbearable, what happens again and again is that she goes down to the railway station and gets on a train to go somewhere. Where the train is going is the last matter of importance. Right at the end, of course, she is doing it again, only this time a train journey is not enough. This is why, in some ways, the invention of the private car made it much harder to distinguish between the people with whom we are actively engaged in a moral way from day to day, and other people.