Top U.S. Commander in Afghanistan Is Linked to Petraeus Scandal

PERTH, Australia — Gen. John R. Allen, the top American and NATO commander in Afghanistan, has become ensnared in the scandal over an extramarital affair acknowledged by David H. Petraeus, a former general. General Allen is being investigated for what a senior defense official said early Tuesday was “inappropriate communication” with Jill Kelley, a woman in Tampa, Fla., who was seen by Mr. Petraeus’s lover as a rival for his attentions.

Chuck Burton/Associated Press

F.B.I. agents carried boxes and a computer from the home of Paula Broadwell on Tuesday.

In a statement released to reporters on his plane en route to Australia early Tuesday, Defense Secretary Leon E. Panetta said that the F.B.I. on Sunday had referred “a matter involving” General Allen to the Pentagon.

Mr. Panetta turned the matter over to the Pentagon’s inspector general to conduct an investigation into what a defense official said were 20,000 to 30,000 pages of documents, many of them e-mails between General Allen and Ms. Kelley, who is married and has children.

A senior law enforcement official in Washington said on Tuesday that F.B.I. investigators, looking into Ms. Kelley’s complaint about anonymous e-mails she had received,  examined all of her e-mails as a routine step.

“When you get involved in a cybercase like this, you have to look at everything,” the official said, suggesting that Ms. Kelley may not have considered that possibility when she filed the complaint. “The real question is why someone decided to open this can of worms.”

The official would not describe the content of the e-mails between General Allen and Ms. Kelley or say specifically why F.B.I. officials decided to pass them on to the Defense Department. “Generally, the nature of the e-mails warranted providing them to D.O.D.,” he said.

Under military law, adultery can be a crime.

The defense official on Mr. Panetta’s plane said that General Allen, who is also married, told Pentagon officials he had done nothing wrong. Neither he nor Ms. Kelley could be reached for comment early Tuesday. Mr. Panetta’s statement praised General Allen for his leadership in Afghanistan and said that “he is entitled to due process in this matter.”

A senior Defense Department official said General Allen has denied having an extramarital affair with Ms. Kelley. But the official said the content of some of the e-mails “was of a flirtatious nature; some were of an affectionate nature.”

“That is what makes the e-mails potentially inappropriate,” the official said, adding that it was unclear whether the tone of flirtation was from General Allen to Ms. Kelley or from Ms. Kelley to General Allen, or both. 

The official said he had not read the e-mails but had been briefed on the content, and he said that they did not contain anything inappropriate regarding operations or security. Pentagon officials cautioned against making too much of the number of documents, since some might be from e-mail chains, or brief messages printed out on a whole page, or simply copies of messages sent to other people.

The Pentagon inspector general’s investigation opens up what could be a widening scandal into two of the most prominent generals of their generation: Mr. Petraeus, who was the top commander in Iraq and Afghanistan before he retired from the military and became director of the C.I.A., only to resign on Friday because of the affair, and General Allen, who also served in Iraq and now commands 68,000 American troops in Afghanistan.

Although General Allen will remain the commander in Afghanistan, Mr. Panetta said that he had asked President Obama to delay the general’s nomination to be the commander of American forces in Europe and the supreme allied commander of NATO, two positions he was to move into after what was expected to be easy confirmation by the Senate. Mr. Panetta said in his statement that Mr. Obama agreed with his request.

Gen. Joseph A. Dunford, the assistant commandant of the Marine Corps who was nominated last month by Mr. Obama to succeed General Allen in Afghanistan, will proceed as planned with his confirmation hearing. In his statement, Mr. Panetta urged the Senate to act promptly on his nomination.

The National Security Council spokesman, Tommy Vietor, said in a statement on Tuesday that Mr. Obama also believes that the Senate should swiftly confirm General Dunford.

Scott Shane and Thom Shanker contributed reporting from Washington.

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Digital Domain: Online Merchants Again Pursue Same-Day Delivery Service

IN the exhilarating, anything-is-possible days of 1998 to 2001, Kozmo.com offered an online store with a quick delivery service in a number of American cities. “Free delivery in under an hour” was its motto.

Kozmo would perish, but some online merchants and their delivery partners are inching back toward that shining vision. Though they aren’t promising free delivery within an hour, they are trying out same-day service for a fee. And in doing so, they are addressing the asymmetry that has bedeviled online purchases of physical goods since Kozmo’s demise: it takes mere seconds to find and buy goods on the Web, but often several days for them to arrive at the doorstep.

Could the wait again be shortened to just an hour? That remains to be seen.

The United States Postal Service will experiment with same-day delivery of online orders in San Francisco. It sees the new option, called Metro Post, as a way to put its delivery infrastructure to fuller use while developing a new source of revenue — a matter of pressing importance as the service’s finances go from bad to worse.

The Postal Service proposes once-a-day pickup of goods ordered online from participating retailers in the city before 2 p.m. and delivery to homes between 4 and 8 p.m.

John G. Friess, a Postal Service spokesman, says the packages won’t go through the normal processing centers, but will instead be passed directly between the Postal Service workers who pick them up and deliver them.

“This will be a new experience,” Mr. Friess says, “having a uniformed Postal Service employee knocking on your front door at this hour, delivering the package that you had ordered earlier in the day.”

A flat rate will be charged for all packages up to 25 pounds, he says, but the price has not been announced and may be adjusted as the trial proceeds.

With its fleets of trucks, United Parcel Service also has the delivery infrastructure for same-city, same-day service. But for now, the company is not set up to do both pickup and delivery in the same day, in the same city, at a modest price.

I used the online U.P.S. pricing guide to find the cost of having a one-pound book picked up at a San Francisco bookstore at 2 p.m. and delivered to a home address a mile and a half away by 8 p.m. the same day. This required U.P.S.’s “Express Critical” service, and the company estimated the cost at $226.46.

If U.P.S. decided it wanted to enter the intracity delivery business in a serious way, it could no doubt offer much more attractive pricing. In fact, it would seem positioned to offer a lower price than the Postal Service, whose market tests of experimental products are regulated by the Postal Regulatory Commission. The Postal Service’s filing with the commission to try out Metro Post is timorous in tone and lists self-applied hobbles. For example, the service says it will enlist 10 or fewer companies for the trial and limit the volume to 200 packages a day, at least until it can “further test its operational capabilities.”

The big online retailers are running their own experiments with same-day delivery in some markets.

 

Last month, Wal-Mart announced that it had begun same-day delivery of online orders in a handful of cities. A check last week of the price of two-hour delivery windows in San Francisco showed flat fees of $6 to $7. (The minimum order is $45.) Amazon also offers a same-day delivery option in 10 markets. In addition to a delivery charge of $8.99 for all orders other than gift cards, it adds a charge of 99 cents for each item in the order.

Very fast delivery of online purchases can be found in Lower Manhattan, the area served by UrbanFetch, which offers 10,000 products online that will be delivered within an hour. The speed is the same as Kozmo’s — in fact, the company was founded in 2005 by Chris Siragusa, who was chief technology officer at Kozmo — but the selection of goods is far larger.

Customers must live within an eight-square-mile service area, and all deliveries are carried by bicycle. There is no delivery fee for orders of more than $100; a $4.95 fee is charged for smaller orders.

When Mr. Siragusa set out to build an online store with home delivery — originally called MaxDelivery — he did not plan to match Kozmo’s one-hour promise. With friends and family, he first tried a service in which the ordering was done earlier in the day and the deliveries in the evening. But he concluded that late-in-the-day delivery was not compelling to customers. “It was still more convenient to walk to the store yourself,” he said.

UrbanFetch’s fast delivery is possible because its goods are physically close to its customers in a densely packed city.  In other places, online customers must be a bit more patient, as Son of Kozmo is not in sight.

Randall Stross is an author based in Silicon Valley and a professor of business at San Jose State University. E-mail: stross@nytimes.com.

This article has been revised to reflect the following correction:

Correction: November 13, 2012

An earlier version of this column referred imprecisely to the Postal Regulatory Commission’s oversight of the Postal Service. While the commission regulates the Postal Service’s market tests of  experimental products, regulatory approval is not required for all its operational decisions.

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Q & A: Weighing the Evidence

Q. My husband weighs twice as much as I do, yet we take the same dose of over-the-counter medications, as recommended on the packaging. Shouldn’t weight be a factor?

A. There is little information about using weight as a factor in adjusting doses of either prescription or over-the-counter medications, said Dr. Steven A. Kaplan, director of the Iris Cantor Men’s Health Center at NewYork-Presbyterian/Weill Cornell hospital.

“We are beginning to study different responses by weight,” he said, but he and other researchers have reached no conclusions on recommendations for therapy.

“In my own field, urology,” he added, “my opinion is that it is more likely for the recommended dose to be ineffective in a larger person rather than to be toxic in a thinner adult.”

Some prescription drugs, like chemotherapy agents, already have their dosages adjusted for weight because of their highly toxic nature. As for over-the-counter drugs, recommended doses generally tend to be weighted in favor of safety rather than efficacy, Dr. Kaplan said.

He and other doctors emphasized the importance of following package directions. For example, acetaminophen (like Tylenol) can present a life-threatening risk if the liver cannot process a high dose. If you find that the recommended dose does not work for you, Dr. Kaplan said, speak to your doctor.

C. CLAIBORNE RAY

Readers may submit questions by mail to Question, Science Times, The New York Times, 620 Eighth Avenue, New York, N.Y. 10018, or by e-mail to question@nytimes.com.

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Q & A: Weighing the Evidence

Q. My husband weighs twice as much as I do, yet we take the same dose of over-the-counter medications, as recommended on the packaging. Shouldn’t weight be a factor?

A. There is little information about using weight as a factor in adjusting doses of either prescription or over-the-counter medications, said Dr. Steven A. Kaplan, director of the Iris Cantor Men’s Health Center at NewYork-Presbyterian/Weill Cornell hospital.

“We are beginning to study different responses by weight,” he said, but he and other researchers have reached no conclusions on recommendations for therapy.

“In my own field, urology,” he added, “my opinion is that it is more likely for the recommended dose to be ineffective in a larger person rather than to be toxic in a thinner adult.”

Some prescription drugs, like chemotherapy agents, already have their dosages adjusted for weight because of their highly toxic nature. As for over-the-counter drugs, recommended doses generally tend to be weighted in favor of safety rather than efficacy, Dr. Kaplan said.

He and other doctors emphasized the importance of following package directions. For example, acetaminophen (like Tylenol) can present a life-threatening risk if the liver cannot process a high dose. If you find that the recommended dose does not work for you, Dr. Kaplan said, speak to your doctor.

C. CLAIBORNE RAY

Readers may submit questions by mail to Question, Science Times, The New York Times, 620 Eighth Avenue, New York, N.Y. 10018, or by e-mail to question@nytimes.com.

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Wall Street Moves Higher

Wall Street stocks fell at the start of trading Tuesday, but later managed small gains, after international lenders clashed over help for Greece and investor concern grew over how a lack of agreement in Congress could hurt the nation’s economy.

Equities have been pressured in recent sessions by worries over a series of stringent budget cuts and tax increases that are scheduled to take effect in the new year. Market participants are concerned that if no deal is reached to modify the changes, the economy could fall back into recession.

In afternoon trading, the Standard & Poor’s 500-stock index added 0.2 percent to about 1,383 points, the Dow Jones industrial average rose 0.2 percent to about 12,842, and the Nasdaq composite index was 0.2 percent lower.

Concerns over the fiscal discussions contributed to the S.&P. 500’s losses last week, the worst week for the index since June. On Monday, the index ended up only by 0.1 percent, off its highs of the session.

“Stocks will be stuck where they are until we get some kind of resolution on this, and if we don’t get something done, people will be even more disenchanted with equities than they are now,” said Art Hogan, managing director of Lazard Capital Markets in New York.

American lawmakers return to the Capitol Tuesday with a seven-week deadline to reach agreement over the budget and taxes, and while most analysts expect some kind of deal will be forged, concerns remained. Barclays on Tuesday cut its year-end target for the S.&P. 500 to 1,325 points from 1,395, saying there was “little basis to believe a grand compromise is in the offing.”

Home Depot, the home improvement retailer, rose 4 percent after it reported earnings that beat expectations and raised its outlook.

“Home Depot has two things going for it — an improvement in the housing sector and the rebuilding efforts after Hurricane Sandy,” Mr. Hogan said. “That’s a backdrop where the company is very well positioned.”

The euro started weaker after euro zone finance ministers said Greece should be given until 2022 to meet a goal for reducing its debt mountain to a more manageable level, but Christine Lagarde, chief of the International Monetary Fund, insisted the existing target of 2020 should stay.

Behind the differences was a debate over whether euro zone governments should write off some of their Greek debt holdings to help Athens, an idea that Germany opposes.

European stocks closed higher. The DAX in Germany added less than a point, and the CAC 40 in France gained 0.6 percent. The FTSE 100 in Britain added 0.3 percent.

The S.&P. 500 was still up about 10 percent for 2012, despite losses in recent weeks. The Nasdaq has fallen for five straight weeks.

Stocks closed little changed Monday, with investors limiting bets ahead of the negotiations in Washington. Volume was light, with the bond market and government offices closed for Veterans Day.

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Syrian Jet Strikes Close to Border With Turkey

Murad Sezer/Reuters

Syrians fled from Ras al-Ain after an airstrike by Syrian forces on Monday.

GAZIANTEP, Turkey — A Syrian MIG-25 jet bombed the rebel-held town of Ras al-Ain a few yards from the Turkish border on Monday, Syrian witnesses said.

Veli Gurgah/Anadolu Agency, via European Pressphoto Agency

Smoke rose from Ras al-Ain as it was bombed.

Murad Sezer/Reuters

Syrians crossed into Turkey after the airstrike.

Murad Sezer/Reuters

A boy was wounded in the attack.

The attack demolished at least 15 buildings and killed many civilians, Nezir Alan, a doctor who witnessed the bombing, said. Local officials, quoted by The Associated Press, said at least six people were killed, but Dr. Alan said the toll was higher.

“We pulled bodies of 12 people from the rubble and are now trying to reach bodies of 8 others,” he said in a telephone interview. “There are around 70 injured, 50 of whom were in critical condition, and they are being transferred to Turkish hospitals across the border.”

Turkish fighter jets were seen in Turkish airspace shortly after the explosion, and a Syrian helicopter hovered above Ras al-Ain, which is only few yards from Ceylanpinar, a Turkish border town, Syrian witnesses said. “The plane appeared in seconds, dropped a bomb and killed children. Here is total chaos,” Dr. Alan said.

Ambulances were rushed to Ceylanpinar, Haber Turk, a private news television station, reported.

Windows of shops and houses in Ceylanpinar were shattered, and people on both sides of the border were seen running in panic, while military vehicles raced down streets as a huge cloud of smoke hung over the area, Haber Turk footage showed minutes after the explosion.

There were no immediate reports of any deaths or injuries on the Turkish side of the border.

Clashes in Ras al-Ain have intensified in recent days, prompting thousands of Syrians to seek refuge in Turkey.

Civilians in Ceylanpinar and other nearby towns were advised not to travel in areas close to the border.

Five Turkish civilians were killed in October when a Syrian shell landed in Akcakale, another border town about 75 miles west of Ceylanpinar, an act that prompted the Turkish Parliament to revise engagement rules and allow the military to retaliate in case of a direct threat from the border region.

The Turkish Army has increased its deployment along the 550-mile border with Syria since June, after Syria shot down a Turkish military jet, straining already tense relations between Ankara and Damascus.

The Turkish government is also considering asking NATO to station Patriot missiles in its border region to counter potential attacks from Syria.

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As Apple and HTC End Lawsuits, Smartphone Patent Battles Continue

Apple has shut down one front in what Steven P. Jobs, the company’s late chief executive, once described as a thermonuclear legal war against Android, Google’s mobile operating system. But a wider truce in the patent battles engulfing the mobile industry is most likely still a long way off.

Late Saturday, Apple and HTC, the Taiwanese smartphone maker, announced they had agreed to dismiss a series of lawsuits filed against each other in a feud that started more than two years ago when Apple accused HTC of improperly copying the iPhone. The companies said their settlement includes a 10-year license agreement that grants rights to current and future patents held by both parties.

The companies declined to disclose the financial terms of the deal, though it is widely believed that HTC is paying Apple as part of the agreement. HTC doesn’t expect the deal to have “an adverse material impact on the financials of the company,” Sally Julien, a spokeswoman for HTC, said in a statement.

The deal was the first settlement between Apple and a maker of devices that use Android, an operating system that has rapidly swallowed most of the smartphone market and threatened Apple’s position in the mobile business in the process. Other patent lawsuits continue around the globe, including far more significant ones between Apple and Samsung, by far the biggest maker of Android smartphones.

Apple’s settlement of an Android-related lawsuit could be interpreted as a sign that Mr. Jobs’s successor at Apple, Timothy D. Cook, is eager to end the distraction and risks of patent fights. In the past, Apple executives had been hostile in their remarks about companies they believed were copying their innovations.

“It’s the first major sign of a stand-down we’ve seen in the smartphone wars,” said Christopher V. Carani, a patent lawyer with McAndrews Held & Malloy in Chicago.

Mr. Carani, though, cautioned against reading the HTC settlement too deeply as a sign that Apple would settle its legal fight with Samsung, a dispute that he believes involves more important patents. A jury in August awarded Apple more than $1 billion in damages in a federal lawsuit against Samsung, though Samsung is challenging the ruling.

The stakes in Apple’s dispute with Samsung are far higher than they were in its battle with HTC. Samsung ranked No. 1 in smartphone market share during the third quarter of this year, shipping 56.3 million of the devices, while Apple was second with 26.9 million smartphones, according to estimates by IDC. HTC, in contrast, was fifth, shipping 7.3 million phones.

The HTC suit, however, was the first one Apple filed against an Android phone maker and a harbinger of future Apple legal challenges aimed at the software. Apple filed patent infringement suits against HTC in March 2010 in federal court in Delaware and before the International Trade Commission.

The suit was the start of what is widely viewed as a proxy war between Apple and Google, the creator of the Android operating system. In a few years, Android has become ubiquitous on mobile phones, accounting for three-quarters of all new smartphone shipments in the third quarter, to Apple’s 14.9 percent, according to IDC.

The week Apple filed the suit against HTC, Mr. Jobs, who died late last year, erupted in fury over Android, in a scene depicted in Walter Isaacson’s biography of him. “I’m going to destroy Android, because it’s a stolen product,” Mr. Jobs said, according to the book.

Lawyers say Apple has chosen not to sue Google itself because it is easier to calculate financial damages in suits against companies that are selling Android handsets. Google gives the Android software to phone makers and generates revenue from advertising and other services on the phones.

Apple sued Samsung in 2011. Another Android maker, Motorola Mobility, sued Apple in late 2010, and Apple subsequently countersued. Google now owns Motorola.

While Mr. Jobs appeared to be uncompromising in his views of Android, Mr. Cook is viewed as more pragmatic about such matters. While he, too, has stressed his disapproval of rivals’ copying of Apple products, Mr. Cook has said publicly that he is not an enthusiastic combatant in the patent wars.

“We are glad to have reached a settlement with HTC,” Mr. Cook said in a statement about the deal. “We will continue to stay laser-focused on product innovation.”

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The New Old Age Blog: What Chemo Can't Do

Let’s start with a simple medical fact: Chemotherapy doesn’t cure people who have very advanced Stage 4 lung or colon cancer.

Chemo can be quite effective at earlier stages. Even in late-stage disease, it may relieve symptoms for a while; it might help someone with tumors in his lungs breathe more easily, for example. Chemo can extend life for weeks or months.

It can also make the recipient feel nauseated, wiped out and generally lousy, and require him to spend more time in clinics and hospitals than a dying person might choose to. But it can’t banish cancer. Many aspects of medical prognosis and treatment are uncertain. Not this one.

Such patients’ doctors have almost certainly told them their cancer is incurable. Those who opted for chemotherapy anyway had to sign consent forms spelling out the potential side effects. Yet Dr. Jane Weeks, a research oncologist at Dana-Farber Cancer Institute in Boston, knew from previous studies that cancer patients can develop unrealistic ideas about their odds of survival.

So as she and her co-authors began analyzing results from the first representative national study of patients with advanced cancer, all undergoing chemotherapy, to see what they thought about its effects, Dr. Weeks expected many — perhaps a third of them — to get it wrong.

She was staggered to see how mistaken she was.

Nearly 1,200 patients or their surrogates were interviewed within months of a diagnosis of Stage 4 colon or lung cancer. They answered a number of questions during these telephone interviews, but the key one was: “After talking with your doctors, how likely did you think it was that chemotherapy would cure your cancer?” The only correct answer: “Not at all likely.”

But a great majority chose one of the other responses indicating some likelihood of cure or else said they didn’t know. The study, just published in The New England Journal of Medicine, found that 69 percent of lung cancer patients and 81 percent of those with colon cancer misunderstood the purpose of the very treatment they’d been undergoing.

The misperception was significantly higher among African-Americans, Asians and Hispanics than among whites — but not because of education levels, the usual variable in studies of health knowledge. “It suggests that this reflects cultural differences,” Dr. Weeks said.

Strangely, the patients who responded inaccurately also were more likely to highly rate their communications with doctors. Those who grasped that chemo wasn’t curative were, in effect, penalizing the doctors who helped them reach that understanding.

In a way, Dr. Weeks said, this makes sense. It reflects what researchers call optimism bias — or what Dr. Douglas White, a University of Pittsburgh bioethicist, has called “the powerful desire not to be dead.”

These were not very elderly people.  The bulk were ages 55 to 69. Only about a quarter of colon cancer patients and about a third of those with lung cancer were over age 70.

“It’s completely understandable that patients want to believe the chemo will cure them,” Dr. Weeks said. “And it’s understandable that physicians hesitate to take away that false hope.”

But this confusion can have unhappy consequences. For patients to make truly informed decisions, “they need to understand the outcomes,” Dr. Weeks said. “If they’re missing this critical fact, that can’t happen.”

People often hit rough times during weeks of chemotherapy. Common side effects include nausea and vomiting, diarrhea and fatigue; there are many trips to hospitals for IV drugs, X-rays and blood tests. “They’ll soldier on if they think it will cure them,” Dr. Weeks said. “Any of us would.”

But if these patients might respond differently if they understand that chemo is meant to make them feel better but may have the opposite effect, or that it may buy them another 10 to 12 weeks (a reasonable average for lung cancer) or maybe a year (for colon cancer) but won’t prevent their deaths.

Moreover, “if patients think chemo has a chance of curing them, they’ll be less likely to have end-of-life discussions early on,” Dr. Weeks said. “And they pay a price for that later” — if they enter hospice care much too late or die in hospitals instead of at home, as many prefer.

Possibly, at the time of the initial discussions, these patients recognized that chemo didn’t equal cure, she hypothesized. Then, they and their doctors began to focus on doing something, and they stopped seeing their cancer as incurable.

But realism — as palliative care doctors know — doesn’t have to mean despair. “A really good physician can communicate effectively and still maintain patient trust and confidence,” Dr. Weeks said.

“We have the tools to help patients make these difficult decisions,” two Johns Hopkins physicians, Dr. Thomas J. Smith and Dr. Dan Longo, wrote in an editorial published with the study. “We just need the gumption and incentives to use them.”

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Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

Read More..

The New Old Age Blog: What Chemo Can't Do

Let’s start with a simple medical fact: Chemotherapy doesn’t cure people who have very advanced Stage 4 lung or colon cancer.

Chemo can be quite effective at earlier stages. Even in late-stage disease, it may relieve symptoms for a while; it might help someone with tumors in his lungs breathe more easily, for example. Chemo can extend life for weeks or months.

It can also make the recipient feel nauseated, wiped out and generally lousy, and require him to spend more time in clinics and hospitals than a dying person might choose to. But it can’t banish cancer. Many aspects of medical prognosis and treatment are uncertain. Not this one.

Such patients’ doctors have almost certainly told them their cancer is incurable. Those who opted for chemotherapy anyway had to sign consent forms spelling out the potential side effects. Yet Dr. Jane Weeks, a research oncologist at Dana-Farber Cancer Institute in Boston, knew from previous studies that cancer patients can develop unrealistic ideas about their odds of survival.

So as she and her co-authors began analyzing results from the first representative national study of patients with advanced cancer, all undergoing chemotherapy, to see what they thought about its effects, Dr. Weeks expected many — perhaps a third of them — to get it wrong.

She was staggered to see how mistaken she was.

Nearly 1,200 patients or their surrogates were interviewed within months of a diagnosis of Stage 4 colon or lung cancer. They answered a number of questions during these telephone interviews, but the key one was: “After talking with your doctors, how likely did you think it was that chemotherapy would cure your cancer?” The only correct answer: “Not at all likely.”

But a great majority chose one of the other responses indicating some likelihood of cure or else said they didn’t know. The study, just published in The New England Journal of Medicine, found that 69 percent of lung cancer patients and 81 percent of those with colon cancer misunderstood the purpose of the very treatment they’d been undergoing.

The misperception was significantly higher among African-Americans, Asians and Hispanics than among whites — but not because of education levels, the usual variable in studies of health knowledge. “It suggests that this reflects cultural differences,” Dr. Weeks said.

Strangely, the patients who responded inaccurately also were more likely to highly rate their communications with doctors. Those who grasped that chemo wasn’t curative were, in effect, penalizing the doctors who helped them reach that understanding.

In a way, Dr. Weeks said, this makes sense. It reflects what researchers call optimism bias — or what Dr. Douglas White, a University of Pittsburgh bioethicist, has called “the powerful desire not to be dead.”

These were not very elderly people.  The bulk were ages 55 to 69. Only about a quarter of colon cancer patients and about a third of those with lung cancer were over age 70.

“It’s completely understandable that patients want to believe the chemo will cure them,” Dr. Weeks said. “And it’s understandable that physicians hesitate to take away that false hope.”

But this confusion can have unhappy consequences. For patients to make truly informed decisions, “they need to understand the outcomes,” Dr. Weeks said. “If they’re missing this critical fact, that can’t happen.”

People often hit rough times during weeks of chemotherapy. Common side effects include nausea and vomiting, diarrhea and fatigue; there are many trips to hospitals for IV drugs, X-rays and blood tests. “They’ll soldier on if they think it will cure them,” Dr. Weeks said. “Any of us would.”

But if these patients might respond differently if they understand that chemo is meant to make them feel better but may have the opposite effect, or that it may buy them another 10 to 12 weeks (a reasonable average for lung cancer) or maybe a year (for colon cancer) but won’t prevent their deaths.

Moreover, “if patients think chemo has a chance of curing them, they’ll be less likely to have end-of-life discussions early on,” Dr. Weeks said. “And they pay a price for that later” — if they enter hospice care much too late or die in hospitals instead of at home, as many prefer.

Possibly, at the time of the initial discussions, these patients recognized that chemo didn’t equal cure, she hypothesized. Then, they and their doctors began to focus on doing something, and they stopped seeing their cancer as incurable.

But realism — as palliative care doctors know — doesn’t have to mean despair. “A really good physician can communicate effectively and still maintain patient trust and confidence,” Dr. Weeks said.

“We have the tools to help patients make these difficult decisions,” two Johns Hopkins physicians, Dr. Thomas J. Smith and Dr. Dan Longo, wrote in an editorial published with the study. “We just need the gumption and incentives to use them.”

---

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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You're the Boss Blog: Will Higher Taxes Affect Small Businesses? You Tell Us

The Agenda

How small-business issues are shaping politics and policy.

President Obama may have won a decisive reelection victory, but it is John Boehner, the Republican speaker of the House, who is making the rounds and claiming a mandate. And everywhere he goes, he’s talking about what would happen to small businesses if the Bush-era tax cuts on the wealthiest Americans are allowed to expire. To ABC News’s Diane Sawyer, Mr. Boehner said, “Raising taxes on small-business people is the wrong prescription given where our economy is.” He told USA Today, “Raising taxes on small businesses will kill jobs in America. It is as simple as that.”

In a statement to reporters the day after the election, Mr. Boehner made what some observers described as a concession: House Republicans would consider new revenue as part of a deal to avert the “fiscal cliff.” But he then explained that the new revenue could not come from higher tax rates. “In the New Testament, a parable is told of two men. One built his house on sand; the other built his house on rock,” he said. “The foundation of our country’s economy — the rock of our economy — has always been small businesses in the private sector. I ran one of those small businesses, and I can tell you: raising small businesses’ taxes means they don’t grow.”

To support the claim, Mr. Boehner turned to the same controversial Ernst & Young study on which Mitt Romney relied in the first presidential debate in Denver.

Of course, this view is no less controversial now than it was at the time of that debate. Since the debate, we’ve learned about a September report (pdf) from the nonpartisan, and respected, Congressional Research Service, which surveyed the historical record and found that “the reduction in the top tax rates have had little association with saving, investment, or productivity growth” — but “appear to be associated with the increasing concentration of income at the top of the income distribution.” The Congressional Research Service withdrew the report after Republican senators complained.

Then, last week, a report from the Congressional Budget Office seemed to suggest that raising the tax rates on the wealthiest Americans would have little effect on economic output in the fourth quarter of 2013.* Extending the top tax rates would cost the economy 200,000 jobs, according to the C.B.O., an estimate well below the 700,000 jobs that Ernst & Young predicted would be lost. In fact, the C.B.O. figures show that while raising taxes (on everybody) amounts to about two-thirds of the total deficit reduction in 2013, it has a much smaller effect on gross domestic product, the measurement for output. (The C.B.O. report relies in part on economic modeling, much like the Ernst & Young study, meaning that the C.B.O.’s assumptions about the relationship between taxes and economic output informed the results.)

And Agenda readers who own small businesses have weighed in as well. Jed Horovitz in New Jersey wrote, “Each year, I decide how much money to re-invest in my company and how much to take out. Because I pay taxes on my profit, I always look for productive ways to invest in my company first. Spending pretax money makes sense. If my taxes were lower, I would take more money out and just put it in the bank.”

Carol Gillen, who described herself as “the wife and bookkeeper of a small-business owner” in New York, said, “Demand drives hiring, not the personal income tax of the owner.”

But The Agenda would like to hear from more business owners. We want to take a close look at how you and your companies would be affected by increasing the top tax rates, including how it might affect hiring and investment plans. It would be an intensive profile — we would want to talk through specifics on revenue, income, taxes and investments. (We have made the same request to the National Federation of Independent Business and the S Corporation Association of America, both of which strongly oppose any income tax increase.)

It’s a lot to ask, we know, but it’s an important issue. If you own such a company and have employees — making you a job-creator — and you’re game, please drop us a line to let us know you’re interested.

*More precisely, the C.B.O. report said that extending all of the Bush tax cuts and fixing the Alternative Minimum Tax so that it does not reach deeper into the middle class would add about 1.4 percent to the nation’s gross domestic product in the fourth quarter of 2013. Meanwhile, fixing the Alternative Minimum Tax and extending all of the Bush tax cuts except for wealthier Americans would add about 1.3 percent to G.D.P., so the additional G.D.P. attributed to extending the tax cuts for the top two tax brackets amounts to one-tenth of 1 percent.

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