Tuesday, August 24, 2010

NDY Concerns Included in US Human Rights Network Stakeholder Reports to UN Human Rights Council

Today - August 24, 2010 - The US Human Rights Network (USHRN) published a compilation of 26 stakeholder reports in response to the report on domestic human rights submitted by the US State Department to the United Nations Human Rights Council.

From the press release of the USHRN announcing the stakeholder reports:

The report on domestic human rights issues submitted to the United Nations Human Rights Council today by the State Department is a positive step, says the US Human Rights Network, but more work needs to be done in order to rectify well-documented human rights problems in the United States and ensure compliance with international human rights standards. In contrast to the federal report, a compilation of 26 stakeholder reports published by the US Human Rights Network reveals the full breadth and depth of human rights issues that U.S. citizens continue to confront on a daily basis.

The government report, prepared as part of the ongoing U.N. Universal Periodic Review (UPR) process, addresses some of the deficiencies in human rights policies and practices identified in consultations with civil society groups around the country earlier this year. However, it falls short of acknowledging the persistent infringements of human rights in the U.S., and the corrective measures touted in the report do not go far enough to guarantee a timely and thorough fix. “We welcome the Obama administration’s active participation in the UPR process,” says US Human Rights Network Executive Director Ajamu Baraka. “At the same time, we remain concerned that the report will be seen as an end point rather than a springboard to action.”

The Network’s comprehensive report on human rights in the U.S. highlights significant shortcomings in domestic compliance with international human rights standards, as well as U.S. obligations under multiple human rights treaties and agreements. That report, a compilation of 26 independent submissions covering a sweeping range of human rights topics, took almost a year to research and was endorsed by more than 200 organizations and hundreds of advocates across the country.
“Comparing the State Department report with the Network’s, it is clear that gaps remain in our
respective understanding of the issues and the solutions needed to resolve them” says University of Pennsylvania Law School Practice Associate Professor Sarah Paoletti, Senior Coordinator for the Network’s UPR Project. “We look forward to working with the Administration to narrow that gap in future months.”
Not Dead Yet was one of the stakeholder organizations involved in the Report on Human Rights of Persons with Disabilities.  Here is are the groups that participated in creating the document, followed by organizations that endorsed it:
Human Rights of Persons with Disabilities

Submitted by:

ADAPT
Center for the Human Rights of Users and Survivors of Psychiatry
Nationwide Organizing Call to Action: Stop Forced "Mental Health" Treatment
Not Dead Yet
Self Advocates Becoming Empowered
The Opal Project
The U.S. Network of Users and Survivors of Psychiatry

Endorsed by:

All About You Home Care; CAFETY; Center for Disability Rights; Dreamweavers Peer Support Inc.; Disability Rights Education and Defense Fund; Human Rights Caucus, Northeastern University School of Law; International Disability Alliance; Ithaca Mental Patients Advocacy Coalition (IMPAC); Justice Now; Leonard Peltier Defense Offense Committee; Mental Health Empowerment Project Inc.; Mind Freedom International; National Council on Independent Living (NCIL); New York Association on Independent Living; New York State ADAPT; New York State Independent Living Council; People's Health Movement; Regional Center for Independent Living; South Bay Communities Alliance; The Icarus Project; Three Treaties Task Force of the Social Justice Center of Marin; Voices of the Heart, Inc.; We The People; World Network of Users and Survivors of Psychiatry
I would recommend that people take the time to read the entire report, which reflects the experience and concerns of many segments of the disability community in the US.  Below is an excerpt that is of direct relevance to readers who are concerned about the issues NDY gets involved in:
2) Non-voluntary and Involuntary Euthanasia
4. Third party decisions to withhold life-sustaining treatment, without the consent of the person concerned, are an increasing human rights concern. These decisions may be made by a surrogate appointed by a court or by operation of law, or a health care provider in opposition to an individual or surrogate decision in favor of treatment. In either case, current U.S. law does not adequately protect the individual‟s right to not be deprived of life.

5. First, with respect to decisions made by surrogates, other than those appointed by the individual through a document such as a durable power of attorney, constitutional standards must be met before life-sustaining treatment can be withdrawn. As discussed by the U.S. Supreme Court in Cruzan (1990)ii, it cannot be assumed that surrogates are able to represent patient wishes. Use of surrogate decision-makers instead of requiring a best attempt to discern the wishes of the person concerned is contrary to the recognition of the legal capacity of PWDs on an equal basis with others, as required by CRPD Article 12 (to which the U.S. is a signatory) and constitutes discrimination based on disability under UDHR Articles 2 and 6, and ICCPR Article 26.

6. Decisions by physicians and other health care providers to withhold life-sustaining treatment in opposition to the decision of the individual or their surrogate present an even clearer violation of constitutional and human rights. Nevertheless, approximately 40 states authorize such decisions in some form under health care laws adopted over the last decade. Often labeled “futility” provisions, they do not require an objective determination that a particular health care treatment is futile, but rather confer civil and criminal immunity from liability based on vague and undefined professional judgments that treatment is inappropriate,iii and increasing cognitive disability is a factor in such considerations.iv Such measures violate the right to life of people with serious medical conditions, who are a subset of PWDs, under UDHR Article 3 and ICCPR Article 6, as well as CRPD Article 10.

3) Physician-Assisted Suicide
7. Laws permitting physician-assisted suicide in the states of Oregon and Washington do not adequately protect people from deprivation of their life without consent because they empower the physician over the patient. A double standard exists, in which these laws facilitate suicide by PWDs whose quality of life is seen by physicians to be poor, particularly individuals with significant physical disabilities, while in other situations “suicidality” is attributed to mental illness and physicians are empowered to detain the person and administer compulsory mental health treatment. Both aspects of this double standard constitute disability-based discrimination.

8. Terminology such as „death with dignity‟ used to justify assisted suicide masks discrimination. While there are two existing laws that apply only to people predicted to die within six months due to terminal conditions, laws have been proposed in other states (e.g. New Hampshire) that include people with non-terminal disabilities.v People with terminal conditions constitute a subset of PWDs and, moreover, physician predictions are not always accurate.vi Furthermore, „indignities‟ are often described in terms that include people with non-terminal conditions as well, such as the need for assistance in daily activities like bathing and toileting. Like derogatory racist and sexist language, the equation of disability and “indignity” is an insult to the disability community.

9. The rhetoric of personal choice diverts attention from the fact that assisted suicide laws actually make physicians the gatekeepers of assisted suicide, granting them the power to determine who is eligible for assisted suicide and conferring blanket immunity for exercising that power based on a mere claim of “good faith.” In addition, the nominal safeguards in the law end at the point in which the lethal prescription is granted, with no requirements at the time the lethal dose is administered, raising concerns about involuntary administration by others in a society with a high prevalence of elder abuse by family members.vii
You can read the entire disability joint report here.

For more information, you can:

Read the entire compilation of 26 stakeholder reports here.

Just about every group stakeholder report discusses concerns that weren't mentioned in the US Government's submission - which can be found here.  --Stephen Drake

Friday, August 20, 2010

Introducing "Life Support" - a blog by Laura Hershey (and a tribute to Barb Knowlen)

Last month, friend and colleague Laura Hershey started a new blog hosted on the website of the Christopher & Dana Reeve Foundation titled "Life Support."  Laura is a (quoting from her website) "writer, poet, activist, consultant."  She is also a board member of Not Dead Yet and a friend.  She will be posting bimonthly.

Her latest entry is related to a recent one here.  Laura has posted a blog entry titled "Remembering Two More Heroes."  She opens with the news of the death of Paul Longmore, and provides links to tributes and information about his life.

The bulk of her blog is given over to a tribute to Barb Knowlen, a long-time activist and advocate who died in late July.  As Laura notes, very little attention has been paid to her passing.

As I mentioned in my earlier post on Barb Knowlen, I knew her work, but had never met Barb at all.  Laura has intimate knowledge of Barb Knowlen's work and the impact it had on people.

If you really want to know about the impact Barb Knowlen had on people's lives - working to that end until shortly before her death - then you should really go read Laura Hershey's latest blog entry.  You might want to bookmark the blog itself while you're at it.  Blogs that are hosted on websites don't always show up google news feeds reliably - just go check it yourself once a week or sign up to subscribe to the rss feed.  --Stephen Drake

Wednesday, August 18, 2010

NDY Attorney Anne Studholme discusses Betancourt Ruling on WHYY

I just received this in my news feed.  Taunya English at WHYY aired a piece on the Appellate Court Ruling on Betancourt v. Trinitas.  The case involved the effort of Trinitas Regional Medical Center in New Jersey to remove treatment from a patient over the objections of the family.  Having lost in a trial court, Trinitas - with support from other medical organizations - sought to have the trial court's ruling overturned.  Since the court ruled the case moot due to the death of the patient, the trial court ruling stands.

Anne's comments are at the end of the piece.  Comments from family attorney Todd Drayton are included, as well as remarks from Thaddeus Pope.

Anne Studholme's comments:

Attorney Anne Studholme represents a coalition of disability rights organizations led by Not Dead Yet. In the appeal case, she argued on behalf of the group as a friend of the court.

Studholme: People with disabilities are quite sensitive to the sort of thinking which says, 'Well, I wouldn't want to live that way, therefore, he must not want to live that way.' A lot of people say: Just try living that way for a while. You might find you prefer to live.
 Read the entire story here.

Just in: According to Thaddeus Pope, there is one article that reports the hospital hasn't ruled out an appeal.

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Tuesday, August 17, 2010

Another loss: Barbara Knowlen 1941-2010

I never had direct contact with Barb Knowlen, but I've appreciated her work as I've come across it in in film and in the disability press.  I also appreciated the posters from her "Barrier Breakers" that I encountered on the doors and walls of friends in the disability community.  Many more knew her through her work in helping disabled people live above the poverty level without losing their Medicaid coverage and other benefits.

On her facebook page, which is now a memorial page, she described her work this way under "employment":

Self Employed - assist people with disabilities in Social Security issues; write Plans for Achieving Self Support, most people I never meet, work over internet
You can get a better feel for what that assistance consisted of by visiting the archived copy of the "Barrier Breakers" website at the Internet Archive.  Make sure to check out the posters that they used to offer.

For more about and/or by Barb Knowlen, check out:

When Billy Broke His Head - and other tales of wonder: Award-winning documentary by Billy Golfus, which Golfus says "ain't exactly your inspirational cripple story."

Maximizing Your Benefits was published in 2001 in New Mobility.

Finally, Mouth Magazine has a story by Barb Knowlen online that touches on concerns related to Not Dead Yet.  The story talks about the fears that many disabled people have about doctors - who don't value them, who won't listen to them, and are too ignorant and arrogant to realize they could kill some of us through this combination of factors.  In her case, it resulted in a very scary brush with a potentially lethal set of avoidable complications in the hospital:
PHYSICIANS ARE APPROXIMATELY 9.000 TIMES MORE DANGEROUS THAN GUN OWNERS.

Statistical proof: There are 80 million gun owners in the U.S., and 1,500 accidental gun deaths per year. There are 700,000 physicians in the U.S. who cause 120,000 accidental deaths each year.

It looks to this mathematician like doctors are approximately 9,000 times more dangerous than gun owners!

And who are they most dangerous to? Us, of course. People with disabilities, people who depend on medications, treatments, supplies, and attendant services just to survive — all of which have to be prescribed through a doctor.

Factor this in, too: people with disabilities get sick more often, and get a lot sicker than, people who are not disabled. And have less money to buy the best specialists, the most reputable doctors.

Too many of us don’t take the threat of dangerous doctors seriously. I didn’t.

I am a disability rights activist, with two decades in the independent living movement. I believed, preached, and lived the conviction that our lives cannot be defined by medical issues, that we cannot be controlled by doctors. I still do. But now I know how easily doctors can kill us.
Read the rest of Dr. Danger here.

The one consolation of losing vital people in our community is that they all leave us so much to remember them by.  --Stephen Drake

My thanks to Laura Hershey for informing friends on Facebook of Barb Knowlen's death and to Maria 'Ria' Strong for looking up the "Barrier Breakers" site on the Internet Archive.

Monday, August 16, 2010

Two More Tributes to Paul Longmore

The Los Angeles Times published a long obituary in the Sunday (August 15) edition of the paper.  Here are the first three paragraphs of the obit:

Unable to use his hands because of a childhood bout with polio, Paul K. Longmore wrote his first book by punching a keyboard with a pen he held in his mouth. It took him 10 years, and when he was done, he burned a copy in front of the Federal Building downtown.

By taking a match to "The Invention of George Washington" in 1988, the scholar brought national attention to a campaign to reform Social Security policies that discourage disabled professionals from working.

Some of the most restrictive penalties were soon lifted — including one preventing him from earning royalties on books — in a policy change that became known as the Longmore Amendment.
And - appropriately - there is another long obituary in AHA Today - a publication of the American Historical Association.

I'm still working on putting together at least a few of Paul Longmore's NDY-related writings for the blog.  It might take a bit since some things that were once online seem to have disappeared.  All that means is it will take me a little longer than I'd hoped.  --Stephen Drake

An additional - and more accessible - copy of the Betancourt ruling

Leagle.com is a site that describes itself as "dedicated to making legal content and the knowledge contained therein more accessible and discoverable than ever before – anytime, anywhere, for anyone, through innovative, relevant web-based and mobile-media solutions."

They seem to be serious about that.  I know there are quite a number of people who have trouble - or are unable - to access pdf documents.

Leagle.com has posted the Appellate Court ruling in Betancourt v. Trinitas  in standard html format.  It won't print out looking the same as the published ruling, but the content is all there - easy to access and read.

Sunday, August 15, 2010

New Jersey: More Coverage/Commentary on Betancourt Ruling

A later story by Sue Epstein has been published in the New Jersey Star-Ledger.  This article is a little more detailed than the first and includes a brief comment by Anne Studholme, who represented NDY and our co-amici.

The Wall Street Journal also published an article about the decision, written by Suzanne Sataline.


New Jersey Today published an editorial that concludes that the court's "sidestepping" of the issues in the case means that health care providers are free to overrule families in life-and-death decisions.  Thaddeus Pope has responded on his blog.  He points out that the court's dismissal leaves the original ruling in place - and decisionmaking in the hands of families and/or the individual.  --Stephen Drake

Friday, August 13, 2010

New Jersey: Appellate Court Issues Ruling in Betancourt v. Trinitas

The Appellate Division of the New Jersey Superior Court issued its ruling today in Betancourt v. Trinitas Hospital.  The hospital had asked the Court to rule that it had the right to discontinue dialysis treatments for Ruben Betancourt, a patient with a hypoxic brain injury, based on doctors' claims that prolonging his life was "futile" and "inhumane" because his life lacked "dignity," in part due to his brain injury and in part due to his overall poor state of health, and his age -- 73.

Not Dead Yet filed an amicus brief along with ADAPT, Center For Self-Determination, National Council On Independent Living, National Spinal Cord Injury Association, American Association of People With Disabilities and Disability Rights of New Jersey.

Here is what our lawyer, Anne Studholme, said upon reading the decision:

Not Dead Yet led a consortium of disability rights organizations in filing a friend-of-the-court brief and participating in oral argument when the case was heard on April 27, 2010.  We reminded the Court of the significance of New Jersey's historic prior jurisprudence on issues of personal medical autonomy, and described how the concept of "futility" devalues the lives of people with disabilities.

The case had been brought to the Appellate Division by Trinitas Hospital, which had lost at trial.  The trial court found in favor of Mr. Betancourt's autonomy, finding that his daughter had offered evidence as to her father's wishes and would be a faithful guardian in carrying out his desires under New Jersey's concept of surrogate decisionmaking.

The day before the hospital's appellate brief was due to be filed, on May 29, 2009, Mr. Betancourt died.  His family asked the Court to dismiss the case as moot.  We joined in that motion, in part because of our concern that it might be too easy for a court to overlook the individuality of the person at the heart of the case if he was already dead.  It would also be too easy to dismiss him as 'dying.'  We also feel that the Court acknowledged our concern that this case risked conflating mentally incapacitated people with people whose doctors describe them as 'dying.'  People in both situations are vulnerable to having their lives declared futile.

The court agreed that Mr. Betancourt's death rendered the case moot, and that for other reasons to do with idiosyncrasies of the facts and the record, it would not be reviewed under the narrow exceptions which permit review of moot cases.  The Court quoted our brief: that Betancourt's "death 'casts an aura of hindsight wisdom over the doctors' declarations that he was "dying[]" ' and makes this a poor case in which to adjudicate the rights of mentally incapacitated individuals."

This distinguished appellate panel gave the matter appropriate attention, handing down a 26-page opinion.  Had the merits been reached, five New Jersey Supreme Court opinions would have given strong guidance to this intermediate court, and even at the higher level were the case to proceed there. 

"Unlike Conroy and Farrell [two of the five prior NJ Supreme Court decisions protecting medical autonomy], the uncertainties as to Ruben's condition and prognosis do not lend themselves to the resolution of the important issue involved here. A decision here may be applicable not only to a patient on the threshold of death but also to a mentally incapacitated, yet stable, patient. Such a decision would neither serve the interests of the parties here nor the public at large. Vague decisions based on unique facts do not lend themselves to the type of resolution required here."

The Court acknowledged the high public importance of the issues raised, and invited legislative consideration and administrative policy-making.  As we said at oral argument, legislative fact-finding can help illuminate the issues, but it is also important that the courts stand as the bulwark to protect the rights of politically vulnerable people.
So - basically, this ruling makes it a pretty good Friday the 13th for us.

For more info, commentary and coverage:

Thaddeus Pope, who also filed an amicus brief in the case, has shared his initial analysis of the decision on his Medical Futility Blog.


The New Jersey Star-Ledger has coverage of the ruling.

NJ Today also has a story about the ruling.


The ruling itself can be read here in pdf format.


For any member of the media wanting comment on the case:

Contact info for Anne Studholme:
Tel: (609) 945-3955
Cell:  (609) 651-6211
Fax: (609) 935-0567

(space inserted in email as a spam precaution)
anne @manewitzstudholme.com
anne @alumni.princeton.edu

Thursday, August 12, 2010

More Bloggers Remembering Paul Longmore

As promised, this is a list of additional blogs marking the death of Paul Longmore:

That's pretty much everything I have found so far.  I still intend to put together a post of NDY-related references and material by Paul, but it will have to wait for next week.  We got word earlier today that there will be an important development tomorrow - we don't know yet if it's a good development or a bad one.

Looks like I have to hit the ground running in the morning - metaphorically, as it pertains to reading, processing and synthesizing.  --Stephen Drake

Diane Coleman Remembers Paul Longmore

From Diane Coleman, president and founder of Not Dead Yet:

Paul was one of a few disability rights activists and thinkers who changed my life in the 1980's. He lived in Los Angeles then, and I was brand new to the movement, just finishing law school and joining my first CIL board.

He often wrote for the Disability Rag, which I started reading cover-to-cover every month. Paul merged disability scholarship and political activism in a powerful way that helped frame and advance our movement.

I was privileged to participate in his famous book burning protest against oppressive Social Security and Medicaid policies. We were both judges in media access awards, part of small groups watching and commenting on media portrayals of disability.
Paul's unmatched historical knowledge of disability in the media poured out in enlightening and often sarcastic quips. But his work as a spokesperson of our community pertaining to the early assisted suicide/euthanasia cases involving Elizabeth Bouvia and Larry McAfee had the biggest impact on me. His media interviews and writings on those cases helped shape my understanding of society's profound oppression of people with disabilities and how that oppression translates in medical settings. His contributions toward the founding of Not Dead Yet are a major part of Paul's legacy that can never be forgotten.
Part of Diane's tribute to Paul is included in the obituary that is posted on New Mobility.

Wednesday, August 11, 2010

Bloggers Remember Paul Longmore

Since I wrote yesterday, there have been many moving tributes to Paul Longmore from friends, colleagues - and many who have been affected by his academic work and political advocacy.

His facebook page is filled with messages of appreciation and remembrance.  I don't know if his page is viewable to non-facebook users or even to nonfriends on facebook, but you could check it out to find out.

Here is a list - I can't pretend it's complete - of blog entries mourning the loss of Paul Longmore and reflecting on his life and work:

Also, Joe Shapiro has posted a long obituary on the NPR health blog (yes - we know what Paul might say about ending up on the health blog).

I apologize to any blogger - especially any disability blogger - I haven't linked to.  I'm sure this list isn't comprehensive - and I am also sure that there are new blogs that have been posted since I started writing this post.  I'll do a new search tomorrow and share ones I either overlooked or that have been published since the completion of this post.

I'll also try to put together a set of links on articles and/or interviews with Paul Longmore that are NDY-related.  I'll include one that was a collaborative effort - between myself, Diane Coleman, and Paul.

Still waiting for any San Francisco mainstream media to notice that a great man has died.  --Stephen Drake

Tuesday, August 10, 2010

A Tremendous Loss - Paul Longmore Has Died

(Pictured above: Profile picture of Professor Paul Longmore, copied from his facebook page.)

I just received the news via various sources that Paul Longmore - professor, hisorian, disability rights scholar and disability rights activist - died unexpectedly last night.  The following note from a friend and colleague of his appeared on Paul's facebook page last night:

It is with a heavy heart that I write to inform you of the passing of Paul Longmore. He was found non-responsive in his apartment earlier this evening (8/9/10). I received a phone call from close mutual friends--not long there after--telling me of the news.

SF State has lost a brilliant scholar and the world... I know not the words to say... I consider myself blessed to have known Paul in one capacity, or another, for the past twenty years--first as an undergraduate, a mentee, a young professional, a colleague, and, most importantly, a friend. My Mom and I will miss making and delivering him his apple pie this Thanksgiving.I'll write more as I learn it and can...

Disabled and Proud,

Gene

As a graduate student at Syracuse University, I had read some of Paul's work in the course of my studies.  However, it wasn't until the start of the disability community's opposition to assisted suicide that I came into direct contact with him.  Paul was one of the most prominent and articulate voices in the disability community regarding the opposition to legalization of assisted suicide before, during and after the formation of Not Dead Yet.  He has continued to be a prominent spokesperson for the disability rights movement in California, where a broad coalition of organizations has - so far - been successful in keeping assisted suicide advocates at bay.

Here is an essay from 1997 in which Paul Longmore explains why he got involved with opposition to the assisted suicide movement.

Here is a link to Paul Longmore's biography, taken from the San Francisco State University's Institute on Disability.

When searching for links for those who might want to know more about Paul, I was pleasantly surprised to find a youtube video of a speech he gave at the San Francisco Celebration of the 20th anniversary of the ADA.  I apologize in advance - the video isn't captioned.  I try to stay away from that, but I thought a lot of people might want to watch and listen to the very recent speech by Paul Longmore - July 26, 2010.  Barely two weeks ago - from the time this blog entry is written:




I suspect there will be some obituaries and tributes appearing in the next few days.  I will share them here.  Paul had a strong influence on my own writing and advocacy.  A lot of his writing combined impeccable sourcing and fact-checking with an obvious anger - even contempt - for those who used cultural stereotypes to promote a "better dead than disabled" set of public policies.  In much of what I write, it's that combination I aim for, knowing that no one could ever top the real master.  And now he's gone.  I miss him already.  --Stephen Drake

Wednesday, August 4, 2010

Blog - "Euthanasia: Dog vs. Man" - A Succinct Analysis from a Nurse

Regular readers have read several posts here dealing with the use of pet euthanasia by pro-euthanasia advocates to promote their agenda. You can read posts on the subject here, here, and here.

Well, today there's a short blog post on the pretty much the same topic at the blog "Nursing: You Wanna Know What I Think?," authored by Pat Veitenthal, who has been in the nursing profession for 42 years, according to the blog.

It pains me a little to say this, but she may have made the point about the inappropriateness of using animal euthanasia in the debate about human euthanasia more effectively than anything I've written.  It's certainly a gentler message than I tend to write - but very clear nonetheless.

Here's what she has to say in "Euthanasia: Dog vs. Man":

When I was a young nurse, euthanasia was a word only whispered, if spoken at all. Now it is a regular topic of discussion among us. We cover it from all points of view: ethical, religious, political, moral...even animal.

I am one of those sickening pet owners. I kiss on my bichon frise, love her dearly, talk to her, carry her, worry about her, take her bye-byes in the car, give her clothes, toys and treats, and I do it all devotedly and unapologetically.

The argument among nurse pet owners like myself is that if euthanasia is the humane thing for the pets we love as much as members of our family, why don't the humans we love deserves the same humane end if they so choose?

I've actually been pondering this reasoning very carefully, and I happened upon the thought of looking at it another way.

Regardless of how much I do cherish my beloved dog Hollywood, the love for her is actually not the same. I would take a bullet for my son, but I would not take a bullet for my dog. So let's leave our pets out of this very important debate.

It needed to be said...
 Yes, it did need to be said - and just the way that Pat Veitenthal said it.  If you think that way too, please go visit her blog and leave a note of appreciation.  I did.  --Stephen Drake