Thursday, March 31, 2011

The Social Responsibility of Business is to Increase its Profits

When I hear businessmen speak eloquently about the "social responsibilities of business in a free-enterprise system," I am reminded of the wonderful line about the Frenchman who discovered at the age of 70 that he had been speaking prose all his life. The businessmen believe that they are defending free enterprise when they declaim that business is not concerned "merely" with profit but also with promoting desirable "social" ends; that business has a "social conscience" and takes seriously its responsibilities for providing employment, eliminating discrimination, avoiding pollution and whatever else may be the catchwords of the contemporary crop of reformers. In fact they are–or would be if they or anyone else took them seriously–preaching pure and unadulterated socialism. Businessmen who talk this way are unwitting puppets of the intellectual forces that have been undermining the basis of a free society these past decades.
The discussions of the "social responsibilities of business" are notable for their analytical looseness and lack of rigor. What does it mean to say that "business" has responsibilities? Only people can have responsibilities. A corporation is an artificial person and in this sense may have artificial responsibilities, but "business" as a whole cannot be said to have responsibilities, even in this vague sense. The first step toward clarity in examining the doctrine of the social responsibility of business is to ask precisely what it implies for whom.
Presumably, the individuals who are to be responsible are businessmen, which means individual proprietors or corporate executives. Most of the discussion of social responsibility is directed at corporations, so in what follows I shall mostly neglect the individual proprietors and speak of corporate executives.
In a free-enterprise, private-property system, a corporate executive is an employee of the owners of the business. He has direct responsibility to his employers. That responsibility is to conduct the business in accordance with their desires, which generally will be to make as much money as possible while conforming to the basic rules of the society, both those embodied in law and those embodied in ethical custom. Of course, in some cases his employers may have a different objective. A group of persons might establish a corporation for an eleemosynary purpose–for example, a hospital or a school. The manager of such a corporation will not have money profit as his objective but the rendering of certain services.
In either case, the key point is that, in his capacity as a corporate executive, the manager is the agent of the individuals who own the corporation or establish the eleemosynary institution, and his primary responsibility is to them.
Needless to say, this does not mean that it is easy to judge how well he is performing his task. But at least the criterion of performance is straightforward, and the persons among whom a voluntary contractual arrangement exists are clearly defined.
Of course, the corporate executive is also a person in his own right. As a person, he may have many other responsibilities that he recognizes or assumes voluntarily–to his family, his conscience, his feelings of charity, his church, his clubs, his city, his country. He ma}. feel impelled by these responsibilities to devote part of his income to causes he regards as worthy, to refuse to work for particular corporations, even to leave his job, for example, to join his country's armed forces. Ifwe wish, we may refer to some of these responsibilities as "social responsibilities." But in these respects he is acting as a principal, not an agent; he is spending his own money or time or energy, not the money of his employers or the time or energy he has contracted to devote to their purposes. If these are "social responsibilities," they are the social responsibilities of individuals, not of business.
What does it mean to say that the corporate executive has a "social responsibility" in his capacity as businessman? If this statement is not pure rhetoric, it must mean that he is to act in some way that is not in the interest of his employers. For example, that he is to refrain from increasing the price of the product in order to contribute to the social objective of preventing inflation, even though a price in crease would be in the best interests of the corporation. Or that he is to make expenditures on reducing pollution beyond the amount that is in the best interests of the corporation or that is required by law in order to contribute to the social objective of improving the environment. Or that, at the expense of corporate profits, he is to hire "hardcore" unemployed instead of better qualified available workmen to contribute to the social objective of reducing poverty.
In each of these cases, the corporate executive would be spending someone else's money for a general social interest. Insofar as his actions in accord with his "social responsibility" reduce returns to stockholders, he is spending their money. Insofar as his actions raise the price to customers, he is spending the customers' money. Insofar as his actions lower the wages of some employees, he is spending their money.
The stockholders or the customers or the employees could separately spend their own money on the particular action if they wished to do so. The executive is exercising a distinct "social responsibility," rather than serving as an agent of the stockholders or the customers or the employees, only if he spends the money in a different way than they would have spent it.
But if he does this, he is in effect imposing taxes, on the one hand, and deciding how the tax proceeds shall be spent, on the other.
This process raises political questions on two levels: principle and consequences. On the level of political principle, the imposition of taxes and the expenditure of tax proceeds are governmental functions. We have established elaborate constitutional, parliamentary and judicial provisions to control these functions, to assure that taxes are imposed so far as possible in accordance with the preferences and desires of the public–after all, "taxation without representation" was one of the battle cries of the American Revolution. We have a system of checks and balances to separate the legislative function of imposing taxes and enacting expenditures from the executive function of collecting taxes and administering expenditure programs and from the judicial function of mediating disputes and interpreting the law.
Here the businessman–self-selected or appointed directly or indirectly by stockholders–is to be simultaneously legislator, executive and, jurist. He is to decide whom to tax by how much and for what purpose, and he is to spend the proceeds–all this guided only by general exhortations from on high to restrain inflation, improve the environment, fight poverty and so on and on.
The whole justification for permitting the corporate executive to be selected by the stockholders is that the executive is an agent serving the interests of his principal. This justification disappears when the corporate executive imposes taxes and spends the proceeds for "social" purposes. He becomes in effect a public employee, a civil servant, even though he remains in name an employee of a private enterprise. On grounds of political principle, it is intolerable that such civil servants–insofar as their actions in the name of social responsibility are real and not just window-dressing–should be selected as they are now. If they are to be civil servants, then they must be elected through a political process. If they are to impose taxes and make expenditures to foster "social" objectives, then political machinery must be set up to make the assessment of taxes and to determine through a political process the objectives to be served.
This is the basic reason why the doctrine of "social responsibility" involves the acceptance of the socialist view that political mechanisms, not market mechanisms, are the appropriate way to determine the allocation of scarce resources to alternative uses.
On the grounds of consequences, can the corporate executive in fact discharge his alleged "social responsibilities?" On the other hand, suppose he could get away with spending the stockholders' or customers' or employees' money. How is he to know how to spend it? He is told that he must contribute to fighting inflation. How is he to know what action of his will contribute to that end? He is presumably an expert in running his company–in producing a product or selling it or financing it. But nothing about his selection makes him an expert on inflation. Will his hold ing down the price of his product reduce inflationary pressure? Or, by leaving more spending power in the hands of his customers, simply divert it elsewhere? Or, by forcing him to produce less because of the lower price, will it simply contribute to shortages? Even if he could answer these questions, how much cost is he justified in imposing on his stockholders, customers and employees for this social purpose? What is his appropriate share and what is the appropriate share of others?
And, whether he wants to or not, can he get away with spending his stockholders', customers' or employees' money? Will not the stockholders fire him? (Either the present ones or those who take over when his actions in the name of social responsibility have reduced the corporation's profits and the price of its stock.) His customers and his employees can desert him for other producers and employers less scrupulous in exercising their social responsibilities.
This facet of "social responsibility" doc trine is brought into sharp relief when the doctrine is used to justify wage restraint by trade unions. The conflict of interest is naked and clear when union officials are asked to subordinate the interest of their members to some more general purpose. If the union officials try to enforce wage restraint, the consequence is likely to be wildcat strikes, rank-and-file revolts and the emergence of strong competitors for their jobs. We thus have the ironic phenomenon that union leaders–at least in the U.S.–have objected to Government interference with the market far more consistently and courageously than have business leaders.
The difficulty of exercising "social responsibility" illustrates, of course, the great virtue of private competitive enterprise–it forces people to be responsible for their own actions and makes it difficult for them to "exploit" other people for either selfish or unselfish purposes. They can do good–but only at their own expense.
Many a reader who has followed the argument this far may be tempted to remonstrate that it is all well and good to speak of Government's having the responsibility to impose taxes and determine expenditures for such "social" purposes as controlling pollution or training the hard-core unemployed, but that the problems are too urgent to wait on the slow course of political processes, that the exercise of social responsibility by businessmen is a quicker and surer way to solve pressing current problems.
Aside from the question of fact–I share Adam Smith's skepticism about the benefits that can be expected from "those who affected to trade for the public good"–this argument must be rejected on grounds of principle. What it amounts to is an assertion that those who favor the taxes and expenditures in question have failed to persuade a majority of their fellow citizens to be of like mind and that they are seeking to attain by undemocratic procedures what they cannot attain by democratic procedures. In a free society, it is hard for "evil" people to do "evil," especially since one man's good is another's evil.
I have, for simplicity, concentrated on the special case of the corporate executive, except only for the brief digression on trade unions. But precisely the same argument applies to the newer phenomenon of calling upon stockholders to require corporations to exercise social responsibility (the recent G.M crusade for example). In most of these cases, what is in effect involved is some stockholders trying to get other stockholders (or customers or employees) to contribute against their will to "social" causes favored by the activists. Insofar as they succeed, they are again imposing taxes and spending the proceeds.
The situation of the individual proprietor is somewhat different. If he acts to reduce the returns of his enterprise in order to exercise his "social responsibility," he is spending his own money, not someone else's. If he wishes to spend his money on such purposes, that is his right, and I cannot see that there is any objection to his doing so. In the process, he, too, may impose costs on employees and customers. However, because he is far less likely than a large corporation or union to have monopolistic power, any such side effects will tend to be minor.
Of course, in practice the doctrine of social responsibility is frequently a cloak for actions that are justified on other grounds rather than a reason for those actions.
To illustrate, it may well be in the long run interest of a corporation that is a major employer in a small community to devote resources to providing amenities to that community or to improving its government. That may make it easier to attract desirable employees, it may reduce the wage bill or lessen losses from pilferage and sabotage or have other worthwhile effects. Or it may be that, given the laws about the deductibility of corporate charitable contributions, the stockholders can contribute more to charities they favor by having the corporation make the gift than by doing it themselves, since they can in that way contribute an amount that would otherwise have been paid as corporate taxes.
In each of these–and many similar–cases, there is a strong temptation to rationalize these actions as an exercise of "social responsibility." In the present climate of opinion, with its wide spread aversion to "capitalism," "profits," the "soulless corporation" and so on, this is one way for a corporation to generate goodwill as a by-product of expenditures that are entirely justified in its own self-interest.
It would be inconsistent of me to call on corporate executives to refrain from this hypocritical window-dressing because it harms the foundations of a free society. That would be to call on them to exercise a "social responsibility"! If our institutions, and the attitudes of the public make it in their self-interest to cloak their actions in this way, I cannot summon much indignation to denounce them. At the same time, I can express admiration for those individual proprietors or owners of closely held corporations or stockholders of more broadly held corporations who disdain such tactics as approaching fraud.
Whether blameworthy or not, the use of the cloak of social responsibility, and the nonsense spoken in its name by influential and prestigious businessmen, does clearly harm the foundations of a free society. I have been impressed time and again by the schizophrenic character of many businessmen. They are capable of being extremely farsighted and clearheaded in matters that are internal to their businesses. They are incredibly shortsighted and muddleheaded in matters that are outside their businesses but affect the possible survival of business in general. This shortsightedness is strikingly exemplified in the calls from many businessmen for wage and price guidelines or controls or income policies. There is nothing that could do more in a brief period to destroy a market system and replace it by a centrally controlled system than effective governmental control of prices and wages.
The shortsightedness is also exemplified in speeches by businessmen on social responsibility. This may gain them kudos in the short run. But it helps to strengthen the already too prevalent view that the pursuit of profits is wicked and immoral and must be curbed and controlled by external forces. Once this view is adopted, the external forces that curb the market will not be the social consciences, however highly developed, of the pontificating executives; it will be the iron fist of Government bureaucrats. Here, as with price and wage controls, businessmen seem to me to reveal a suicidal impulse.
The political principle that underlies the market mechanism is unanimity. In an ideal free market resting on private property, no individual can coerce any other, all cooperation is voluntary, all parties to such cooperation benefit or they need not participate. There are no values, no "social" responsibilities in any sense other than the shared values and responsibilities of individuals. Society is a collection of individuals and of the various groups they voluntarily form.
The political principle that underlies the political mechanism is conformity. The individual must serve a more general social interest–whether that be determined by a church or a dictator or a majority. The individual may have a vote and say in what is to be done, but if he is overruled, he must conform. It is appropriate for some to require others to contribute to a general social purpose whether they wish to or not.
Unfortunately, unanimity is not always feasible. There are some respects in which conformity appears unavoidable, so I do not see how one can avoid the use of the political mechanism altogether.
But the doctrine of "social responsibility" taken seriously would extend the scope of the political mechanism to every human activity. It does not differ in philosophy from the most explicitly collectivist doctrine. It differs only by professing to believe that collectivist ends can be attained without collectivist means. That is why, in my book Capitalism and Freedom, I have called it a "fundamentally subversive doctrine" in a free society, and have said that in such a society, "there is one and only one social responsibility of business–to use it resources and engage in activities designed to increase its profits so long as it stays within the rules of the game, which is to say, engages in open and free competition without deception or fraud."

STAKE HOLDERS

stakeholder

Definition

A person, group, or organization that has direct or indirect stake in an organization because it can affect or be affected by the organization's actions, objectives, and policies. Key stakeholders in a business organization include creditors, customers, directors, employees, government (and its agencies), owners (shareholders), suppliers, unions, and the community from which the business draws its resources.

Although stakeholding is usually self-legitimizing (those who judge themselves to be stakeholders are stakeholder ), all stakeholders are not equal and different stakeholders are entitled to different considerations. For example, a company’s customers are entitled to fair trading practices but they are not entitled to the same consideration as the company's employees. See also corporate governance.

THE CORPORATION AND SOCIETY

http://ocw.mit.edu/courses/sloan-school-of-management/15-668-people-and-organizations-fall-2005/lecture-notes/lecture_9.pdf

Tuesday, March 29, 2011

Local Complications of Fractures

Local Complications of Fractures:

Fractures around the trunk are often complicated by visceral injury.

E.g. Rib fractures are associated with life threatening pneumothorax or with spleen, liver injuries.
E.g. Pelvic injuries are associated with bladder or urethral rupture and cause sever hematoma in the retroperitoneum .
Surgery of visceral injuries should take precedence over the treatment of fracture.

VASCULAR INJURIES
Most associated with injuries around knee, elbow, humerus and femoral shaft.
Commonly associated with high-energy open fractures.
They are rare but well-recognized.
Cause : From initial trauma or from bone fragment

Mechanism of injuries:
** The artery may be cut or torn.
** Compressed by the fragment of bone.
** normal appearance with intimal detachment that lead to thrombus formation.
** segment of artery may be in spasm.

—
Classical presentation of ischemia 5 Ps:
Pain , Pallor, Pulseless , Paralysis , and Paraesthesia

X-ray: suggest high-risk fracture.
Angiogram should be performed to confirm diagnosis.

— Management
this is an emergency because the effect of ischemia especially on the muscle is irrevesible after 6 hours.

1. Temporary vascular shunt to perfuse distal limb.
2. Skeletal stabilization – temporary external fixation often used.
3. Definitive vascular repair.
4. Staged definitive skeletal internal fixation if required.

— - It’s more common than arterial injuries.
- The most commonly injured nerve is the radial nerve
in its groove or in the lower third of the upper arm especially in oblique fracture of the humerus.
- Common with humerus, elbow and knee fractures
- Most nerve injuries are due to tension neuropraxia.

—The nerve is rarely severely affected (just neuropraxia or axontmesis) and spontaneous recovery is usually the role.

—If not; the nerve should be explored because it sometimes trapped between the fragment and occasionally it is found to be divided and more likely to be completely injured.

—And should be explored during wound debridement or in 2nd operation.

•A complete lesion(neurotmesis) is more likely, the nerve is explored during wound depridement and repaired, either then or 3weeks later by nerve suturing and grafting.

—
**Most commonly in forearm and calfs.
**Muscles are arranged in different compartments and surrounded by one fascia , this arrangement called osteofascial compartment.
**Compartment syndrome occurs when muscle swells within osteofacial compartment and occluds its blood supply >> infarction and late ischemic contracture.

**Trauma is the most common cause.

reasons that lead to increase the pressure inside:
1. Bleeding
2. Edema
3. Infection

— Fracture of the arm and leg can give rise to severe ischemia even if there is no damage to major vessel. Bleeding or edema will increase the pressure within one of the osteofascial compartments, this lead to decrease in capillary blood flow which in turn leads to muscle ischemia, further edema, still greater pressure, and yet more profound ischemia….vicious circle.

— After 12 hours or less, this vicious circle ends in necrosis of nerves and muscles within the compartment.
Nerve are capable of regeneration, but the muscle once infarcted can never recover and are replaced by fibrous tissue. This condition is called volkmann s ischemic contracture.

— Distal pulses and neurological functions are normal until very late.
Muscle will be dead after 4-6 hrs of total ischemia so there is no time to lose!

                  —           When do we have to suspect compartment syndrome?
1..High-risk injuries : -fracture of the elbow
                                   - fracture of the forearm
                                   - fracture of the proximal third of the tibia
2.Predisposing factor: operation ( internal fixation) ,infection.
3.Classical feature of ischemia ( 5ps)
4. very painful, swollen, tense limb.

                                                                                                                                                                                                                                                                                                                       —      Cont..

5. the muscle should be tested by stretching; if the pain increase then this goes with compartment syndrome.

6. In doubtful cases, the diagnosis is confirmed by measuring the compartment pressure by using a catheter which is introduced into the compartment close to the level of fracture.

   àA differential pressure (the difference between diastolic and compartment pressure) of less than 30mmHg is an indication for immediate decompression

— Treatment :
1. Decompression ….by Immediate open fasciotomy
(open all compartment through medial and lateral incisions) and left open for 2 days

2. If there is muscle necrosis , debridement can be done

3.if tissue is healthy the wound can be sutured, or skin-grafted. or the wound is left to heal by secondary intention

4. Limb should be examined every 15 min for 2 hours if there is no improvement , or if the pressure falls below 30 …

— *Bleeding into a joint spaces.
*Occurs if a joint is involved in the fracture.

Presentation:
swollen tense joint; the patient resists any attempt to moving it.

treatment:
blood aspiration before dealing with the fracture; to prevent the development of synovial adhesions.

—
*usually seen in open fractures; rarely with closed fractures unless opened by operation (ex; internal fixation).

*Open fracture in 6 hrs the risk of infection increases up to 10x.

*All open fracture should be treated by prophylactic antibiotics ,
*appropriate early management; wound excision and debridement, skeletal stabilization and wound closure.
*Post-traumatic bone infection is the most common cause of chronic osteomyelitis
*Infection may be early within days after surgery or late occurring months after surgery

General complications of fractures

                                                                                                                                                                                                                                                                                                                                                                    §

General complications of fractures

                  presented by:
                              R.R.M.F.A

§ General complications

** Deep vein thrombosis and pulmonary embolism.

**Tetanus.

**Gas gangrene.

** Fat embolism syndrome.

** hypovolemic Shock.

crush syndrom.**

§ Deep vein thrombosis and pulmonary embolism.

** DVT is very common complication after fracture and major orthopedic operation.

** Site: leg, thigh and pelvic vein.

**Risk factors:

à Knee and hip replacement

à Elderly

à Immobility

à Malignancy and CV disease

à Trauma ( fracture of spine , pelvis , femur and tibia)

à hypercoagulable status

§ Symptoms and signs

1. Pain and tenderness in calf or thigh usually unilateral

2. swelling

3.hotness

4. positive homan’s sign.

5. pulmonary embolism as primary presentation ( dyspnea, hemoptysis , tachypnea and fever).

§ Diagnosis:
Duplex ultrasonography , V-Q scan,
spiral CT and angiography.

Prevention:
1.Elastic stockings.

2.Elevation the foot.

3.Early mobilization.

4.Low molecular weigh heparin 40mg\day .

§ Tetanus

** Is wound infection caused by C.tetani .

** Tetanus toxin passes to anterior horn cells

where it fixed and can’t be neutralized so

produces hyper excitability and reflex muscle spasm.

Symptoms:

**Tonic and clonic contractions of esp. jaw, face, around the wound itself ,neck ,trunk, finally spasm of the diaphragm and intercostal muscles leads to asphyxia and death.

:Prophylaxis
:…DTP for general population
(pediatrics)

…>10 years à booster dose of toxoid after all trivial skin wound

…Not immunized and wounded?

 wound toilet and antibiotic ( consider antitoxin if contaminated wound and give the toxoid immunization)

§ Gas gangrene

Cause:

It caused by clostridium (perfringens) and this organism survive and multiply only in tissue with low oxygen tension. Characterized by rapid and extensive necrosis of muscle accompanied by gas formation and systemic toxicity .

Its associated with traumatic wounds that are deep, necrotic and without communication to the surface.

§ Clinical features:

1. sudden onset of pain localized to the infected area.

2. swelling , edema

3.no pyrexia (cool)

4.profuse serous discharge with sweetish and mousy odor .

5. Gas production

§ Treatment:

1. early diagnosis .

2. surgical intervention and debridement are the mainstay of treatment.

3. IV antibiotics

4.fluid replacement.

5. hyperbaric Oxygen

§ Fat embolism

Usually occurs in young adult after closed fractures of long bone .

Characterized by occlusion of the small blood vessels by fat globules.

Risk factors

Closed fractures-

Multiple fractures -

- Pulmonary contusion

- Long bone/pelvis/rib fractures

§ Clinical feature:

- Sudden onset dyspnoea

- Hypoxia

- tachypnea and tachycardia

- Confusion, coma, convulsions

- -Transient red-brown petechial rash affecting upper body, especially axilla

*no defenitive test, but hypoxia <60mmHg after major trauma is suspicious

§
Treatment :

- Supportive treatment
- O2 administrated.
-Blood, fluid replacement
- Iv steroid + heparin ( may reduce pulmonary edema and IV clotting )
-Surgical stabilization of fracture

§ shock

**A generalized state of decreased tissue perfusion.

**If prolonged it may lead to irreversible damage of the life supporting organs.

causes:

Cardiogenic:direct injury to heart, the pump is not working properly ( massive MI).

§ Clinical features

Thirst, rapid shallow breathing, the lips and skin are pale and the extremities feel cold,if the compansation fails….. impaired renal function test and decreased urinary output.

§treatment

1.IV morphine and oxygen: to arrest bleeding and replace blood loss.

2.Early reduction and splinting of fracture.

3.Restoration of blood volume by rapid infusion of crystalloid solution.

4.Keep monitoring of vital signs.

§ If no quick respond, blood transfusion is mandatory ( we can use O blood group Rh (-) until cross matching is available

§ CRUSH syndrome

§ Serious medical condition characterized by major shock & renal failure following a crushing injury to skeletal muscles or tourniquet left too long…

§ It’s a re-perfusion injury seen after the release of crushing pressure, there will be release of muscular breakdown products(myoglobin,k+,p) which have nephrotoxic effect on the kidney…

Clinically:

§ Shock

§ Pulsless limb à redness  swelling

§ Loss of muscle sensation and power

§ Decrease renal secretion

§ Uremia, acidosis

§ CRUSH syndrome: prognosis

§ If renal secretion return within 1 week the patient survive

§ But most of them die within 14 days

§ CRUSH syndrome : treatment

§ Avoid the disaster by amputation above the site of compression and before compression release

§ If compression is already released à cool the limb and treat for shock and renal failure (dialysis)

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