28.3: Oral Antidiabetic Drugs
By the end of this section, you should be able to:
- 28.3.1 Identify the characteristics of oral diabetes drugs.
- 28.3.2 Explain the indications, actions, adverse reactions, contraindications, and interactions of oral diabetes drugs.
- 28.3.3 Describe nursing implications of oral diabetes drugs.
- 28.3.4 Explain the client education related to oral diabetes drugs.
Oral diabetes drugs are used to treat type 2 diabetes. They are ineffective with type 1 diabetes because type 1 diabetic β cells are not functioning. These drugs lower blood glucose levels in various ways, such as stimulating insulin production from β cells, decreasing insulin resistance, slowing glucose absorption from the gastrointestinal tract, and altering the release of glucose by the liver (American Diabetes Association, n.d.-a).
Sulfonylureas
Sulfonylureas are a group of diabetes drugs that bind to potassium channels on β cells and stimulate them to produce more insulin. They are effective in clients with diabetes who have functioning β cells. They are not effective in all clients with type 2 diabetes. Sulfonylureas may lose their effectiveness over time, requiring an increase in dosage (Costello et al., 2022).
Safety Alert
Sulfonylureas
Sulfonylureas should be used cautiously with beta blockers. Beta blockers can mask the early symptoms of hypoglycemia, such as tachycardia and tremors. Also, when taken with a sulfonylurea, a nonselective beta blocker can prevent the body from compensating for hypoglycemia, resulting in critically low levels especially when the client is sleeping (Costello et al., 2022; Dimakos et al., 2023).
First-Generation Short-Acting Sulfonylureas
First-generation short-acting sulfonylureas lower blood glucose levels by causing the pancreas to produce insulin. These drugs were previously used along with diet, exercise, and, at times, other diabetes drugs to control type 2 diabetes; however, they have been discontinued for use in the United States with the development of second-generation sulfonylureas (Costello et al., 2022).
Second-Generation Sulfonylureas
Second-generation sulfonylureas increase insulin secretion through the pancreatic β cells. They are used along with diet, exercise, and sometimes other diabetes drugs to control glucose levels. Second-generation sulfonylureas typically have lower dosing, a longer duration of action, and fewer side effects than first-generation sulfonylureas. These drugs are metabolized in the liver and excreted in the urine. They should be used cautiously in clients with hepatic and renal impairment. Dosage usually begins with a low dose and is increased based on the client’s glucose control needs (Costello et al., 2022).
Glipizide
Glipizide is a second-generation sulfonylurea that stimulates the pancreas to produce insulin, thereby lowering blood glucose levels. Glipizide is used along with diet and exercise to improve glucose homeostasis in adults with type 2 diabetes. Glipizide comes in tablet form and should be taken 30 minutes before the first meal of the day. It also comes in an extended-release form. The extended-release form should not be chewed, crushed, or broken and should be swallowed whole. The extended-release form should be taken with the first meal of the day.
Adverse effects of glipizide include headache, irritability, sweating, tachycardia, dizziness, nausea, blurred vision, feeling shaky, hypoglycemia, drowsiness, tremor, insomnia, myalgia, weight gain, and paresthesia. Serious adverse effects include agranulocytosis, aplastic anemia, thrombocytopenia, hepatic failure, and syndrome of inappropriate antidiuretic hormone (SIADH). Liver enzymes should be monitored closely when using this drug (National Library of Medicine, 2022b).
Glyburide
Glyburide is a second-generation sulfonylurea that stimulates the pancreas to produce insulin. Glyburide is used along with diet and exercise to control glucose levels. It comes in tablet form and is taken once or twice daily. Adverse effects include indigestion, flatulence, arthralgia (joint pain), blurred vision, dizziness, hypoglycemia, and irritability. This medication should be used cautiously with beta blockers because severe hypoglycemia may occur when they are taken together (National Library of Medicine, 2022c).
Glimepiride
Glimepiride , like glyburide and glipizide, is a second-generation sulfonylurea used along with diet and exercise to control blood glucose levels in the body. It is often used along with insulin to treat type 2 diabetes. Glimepiride comes in tablet form and is taken once daily with the first meal of the day. Adverse effects include dizziness, nausea, jaundice, upper abdominal pain, diarrhea, hypoglycemia, blurred vision, weight gain, and elevated serum alanine aminotransferase (ALT) levels (National Library of Medicine, 2022a; DailyMed, Glimepiride , 2021).
Non-Sulfonylurea Biguanides
Non-sulfonylurea biguanides are a group of oral diabetes drugs that prevent the production of glucose in the liver. They improve the body’s sensitivity to insulin and reduce the amount of glucose absorbed by the intestines. Non-sulfonylurea biguanides are used to treat type 2 diabetes (Corcoran & Jacobs, 2022).
Metformin is a non-sulfonylurea biguanide. It is used to treat type 2 diabetes along with diet, exercise, and sometimes other diabetes drugs or insulin. Metformin comes as an immediate release tablet, an extended-release tablet, and an oral solution. Adverse effects include dizziness, headache, weakness, hypoglycemia, palpitations, flushing, nausea, vomiting, diarrhea, and flatulence. Metformin should be used cautiously in older clients and in clients with renal and hepatic impairments. Clients should not drink alcohol while taking metformin (Corcoran & Jacobs, 2022).
Safety Alert
Metformin and Contrast Dye
Contrast dye can increase the risk of lactic acidosis (when lactic acid production exceeds lactic acid clearance in the body) in clients who are taking metformin and have decreased renal function. Metformin should be withheld 24 hours prior to and for 48 hours after contrast dye administration if the estimated glomerular filtration rate (eGFR) is less than 30 mL/min (Yale School of Medicine, 2022).
FDA Black Box Warning
Metformin
Lactic acidosis is a rare but potentially severe consequence of therapy with the non-sulfonylurea biguanide metformin.
Alpha-Glucosidase Inhibitors
Alpha-glucosidase inhibitors lower blood glucose levels by inhibiting enzymes such as amylase, maltase, and sucrose in the GI tract, thus delaying the digestion and intestinal absorption of carbohydrates (Akmal & Wadhwa, 2022).
Acarbose
Acarbose was the prototype alpha-glucosidase inhibitor. It delays digestion and absorption of carbohydrates to diminish the increase in blood glucose levels after meals. Acarbose is rapid acting and peaks in 1 hour. It is metabolized by the GI tract and excreted in the urine and feces. Adverse effects include nausea, vomiting, diarrhea, malabsorption, leukopenia, thrombocytopenia, and anemia. It is contraindicated for use in clients with severe renal and hepatic impairments (Feingold, 2022).
Miglitol
Miglitol slows the digestion of carbohydrates. It is used in combination with diet, exercise, and sometimes other drugs to control blood glucose levels. It is rapidly absorbed and excreted in the urine. Adverse effects include bloating, flatulence, diarrhea, and abdominal pain or cramping (Feingold, 2022).
Thiazolidinediones
Thiazolidinediones lower blood glucose levels by decreasing insulin resistance. They are referred to as “ glitazones ” or “ insulin sensitizers ” (Feingold, 2022; Eggleton & Jialal, 2023).
Pioglitazone hydrochloride is a thiazolidinedione that is used along with diet and exercise to decrease blood glucose levels. It works to enhance the body’s response to insulin, thereby decreasing glucose in the blood. Adverse effects include muscle pain, weight gain, sore throat, blurred vision, and tooth problems. Pioglitazone hydrochloride is contraindicated in those with liver impairment (Feingold, 2022).
Meglitinides
Meglitinides lower blood glucose levels by stimulating the pancreas to secrete insulin. This class of drug has the potential to produce rapid, short-lived insulin output in those with type 2 diabetes. Because of the rapid onset and short duration of action with these drugs, they should be administered 1–30 minutes prior to meals (Feingold, 2022).
Repaglinide is a meglitinide that works in clients with type 2 diabetes by closing potassium channels in the pancreatic beta cells, thereby increasing insulin secretion, which lowers glucose levels in the blood. It is absorbed through the GI tract and peaks in 1–1.5 hours. Metabolism occurs in the liver, and it is excreted in the urine and feces. Adverse effects include GI upset, upper respiratory infections, and hypoglycemia. It is contraindicated for use in those with type 1 diabetes and those with diabetic ketoacidosis (Feingold, 2022).
Dipeptidyl Peptidase 4 (DDP 4) Inhibitors
Dipeptidyl peptidase 4 inhibitors block the action of dipeptidyl peptidase 4, an enzyme that destroys incretin. Incretin helps the body produce insulin only when it is needed to reduce the excess amount of glucose being produced by the liver. DDP 4 inhibitors are used to treat type 2 diabetes (Kasina & Baradhi, 2022).
Sitagliptin
Sitagliptin is a DDP 4 inhibitor used to treat type 2 diabetes. It is rapidly absorbed, peaks in 1–4 hours, and has a 12-hour half-life. It is mainly excreted through the urine. Adverse effects include runny nose, sore throat, headache, and upper respiratory infections. Hypoglycemia may occur when used in combination with other drugs. Sitagliptin is contraindicated in those with congestive heart failure (Zhou et al., 2019).
Linagliptin
Linagliptin, like sitagliptin, is a DDP 4 inhibitor used to treat type 2 diabetes. It is rapidly absorbed and long acting. It peaks in 1.5 hours and has a 12-hour half-life. Adverse effects include bloating, skin rash, stomach pain, back pain, and joint pain. It should be used cautiously in those with hypersensitivity, exfoliative dermatitis, or bronchial hypersensitivity (Gharabaghi et al., 2022).
Selective Sodium Glucose Transporter 2 (SGLT2)
Selective sodium glucose transporter 2 drugs are used to treat clients with type 2 diabetes. SGLT2 drugs lower blood glucose levels by blocking the reabsorption of glucose in the kidneys and promoting the excretion of glucose in the urine (Padda et al., 2022).
Dapagliflozin
Dapagliflozin is an SGLT2 drug that reduces reabsorption of filtered glucose and thereby promotes urinary glucose excretion. It is rapidly absorbed and peaks in 2 hours. It is metabolized in the liver and excreted mainly in the urine. Adverse effects include increased urination, skin rash, dehydration, hypotension, back pain, and genital infections including UTIs. It is contraindicated in those with renal impairment (Dhillon, 2019).
Empagliflozin
Empagliflozin is an SGLT2 drug that is rapidly absorbed. It peaks in 1.5 hours. Empagliflozin is metabolized by the liver and excreted mainly in the urine. Adverse effects include increased urination, bladder pain, painful urination, vaginal irritation or discharge, and pain during intercourse. It is contraindicated in those with renal impairment (Sizar et al., 2022).
Fixed Combination Oral Diabetes Drugs
Fixed combination oral diabetes drug therapy may be required in the control of type 2 diabetes. Combination oral diabetes drug therapy is used when monotherapy, diet, and exercise alone cannot control blood glucose levels. Although in the past these drugs were taken as separate tablets, several fixed-dose single-tablet combinations have been manufactured (Kalra et al., 2020).
Link to Learning
In this video, Lisa Kroon, a Doctor of Pharmacy, describes general treatments for glycemic control (hyperglycemia) in people with type 2 diabetes.
Glyburide-Metformin
Glyburide-metformin is a combination of a second-generation sulfonylurea and a non-sulfonylurea biguanide. It is used in conjunction with diet and exercise for clients with type 2 diabetes that was not controlled with a monotherapy diabetes drug. Dosing is a combined tablet of 1.25 mg glyburide and 250 mg metformin one to two times daily. The maximum dose is 20 mg glyburide and 2000 mg metformin daily. It is not recommended for use in children. Adverse effects include blurred vision, drowsiness, excessive hunger, headache, nausea, nervousness, sore throat, and unusual tiredness. Glyburide-metformin is contraindicated in those with severe renal and liver impairment. Those with congestive heart failure should use it cautiously because this drug may increase the risk of myocardial infarction (Shuster et al., 2020).
Sitagliptin-Metformin
Sitagliptin-metformin is a fixed-dose combination diabetes drug that combines a dipeptidyl peptidase 4 inhibitor and a non-sulfonylurea biguanide. Sitagliptin-metformin is used to treat type 2 diabetes when the diet, exercise, and monotherapy diabetes drugs were ineffective. The recommended starting dose in clients not currently treated with metformin is 50 mg sitagliptin and 500 mg metformin HCl twice daily, with gradual dose escalation recommended to reduce gastrointestinal side effects associated with metformin. The starting dose in clients already treated with metformin should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and the dose of metformin already being taken. For clients taking metformin HCl 850 mg twice daily, the recommended starting dose of sitagliptin-metformin is 50 mg sitagliptin and 1000 mg metformin HCl twice daily. The maximum recommended daily dose is 100 mg of sitagliptin and 2000 mg of metformin hydrochloride (HCl). Adverse effects include diarrhea, upper respiratory tract infection, headache, nausea, vomiting, abdominal pain, hypoglycemia, EKG changes, pancreatitis, acute renal failure, myalgia, and pain in extremity (DailyMed, Sitagliptin , 2023; He et al., 2021).
Liraglutide-Insulin Degludec
Liraglutide-insulin degludec is a fixed-dose combination of liraglutide and insulin degludec. It is used to treat type 2 diabetes when diet, exercise, and drug monotherapy were ineffective. It comes in a subcutaneous pen similar to an insulin pen. The pen is a combined dose of insulin degludec 50 units and liraglutide 1.8 mg. Adult and pediatric dosing is based on the client’s blood glucose level and must be determined by the health care provider. Adverse effects include bloating, blurred vision, chills, confusion, constipation, dry mouth, headache, hives, increased hunger, lightheadedness, muscle aches, nausea, sweating, tachycardia, and trouble swallowing. It is contraindicated in those with hypoglycemia, pancreatitis, and hypersensitivity (DailyMed Victoza, Liraglutide injection , 2023).
Unfolding Case Study
Part B
Read the following clinical scenario to answer the questions that follow. This case study is a follow-up to Case Study Part A.
Alaina Sanders was diagnosed with type 2 diabetes, and the health care provider prescribed extended-release glipizide 5 mg orally and lifestyle modifications. The client returns to her health care provider’s office today for a 6-month follow-up appointment after starting drug treatment and lifestyle modifications.
Laboratory Results
Glycosylated hemoglobin
6 Months Ago
7.8%
Today
6.9%
| Vital Signs | Physical Examination | |
| Temperature: | 97.4°F |
|
| Blood pressure: | 108/72 mm Hg | |
| Heart rate: | 84 beats/min | |
| Respiratory rate: | 18 breaths/min | |
| Oxygen saturation: | 97% on room air | |
| Height: | 5'5" | |
| Weight: | 173 lb |
Which statement by the client indicates to the nurse that Alina understands her treatment plan?
- Answer
-
“I take extended-release glipizide with my breakfast.”
Based on the client’s glycosylated hemoglobin results, which treatment plan does the nurse anticipate the health care provider will prescribe?
- Answer
-
No changes to the treatment plan
Hypoglycemia Drugs
Hypoglycemia drugs raise blood glucose levels. These drugs are used to treat severe hypoglycemia and hypoglycemic reactions that are often associated with diabetes. They are used after conservative measures to treat severe hypoglycemia are ineffective (Mathew & Thoppil, 2022).
Glucagon
Glucagon is a hormone secreted by alpha (α) cells of the islets of Langerhans in the pancreas. Glucagon increases blood glucose levels by stimulating glycogen breakdown in the liver. Peak time is 15 minutes after dosing. Glucagon comes as an injectable and as a nasal spray. Adult and pediatric dosing is based on the client’s age and weight. Glucagon is used when the client is semiconscious, unconscious, or unable to ingest sugar-containing food. Blood glucose levels should be reassessed 15 minutes after administering this drug. Adverse effects include nausea, vomiting, and temporary tachycardia. Glucagon is contraindicated in clients with hypersensitivity and with known pheochromocytoma (Morris & Baker, 2022).
Diazoxide
Diazoxide is a non-diuretic benzothiadiazine and works by inhibiting insulin release from the pancreas by opening potassium channels in the beta cell membrane. It is used to treat hypoglycemia in clients with hyperinsulinemia. This drug is also a vasodilator and used to treat hypertensive emergencies. It is rapidly absorbed and highly protein bound. Diazoxide is metabolized by the liver and mainly excreted by the kidneys. The usual adult daily oral dosage is 3–8 mg/kg, divided into two or three equal doses every 8 or 12 hours. Its onset is 1 hour, and its duration is 8 hours. Adverse effects include anorexia, nausea, vomiting, abdominal pain, tachycardia, palpitations, and increased uric acid levels. Diazoxide is contraindicated in clients with a hypersensitivity to sulfonamide and thiazide diuretics (Chen et al., 2021).
Table 28.7 lists common oral diabetes drugs and typical routes and dosing for adult clients (with pediatric exception note for metformin ).
| Drug | Routes and Dosage Ranges |
|---|---|
|
Acarbose
( Precose ) |
25 mg orally 3 times daily with meals.
Maximum dose: 300 mg daily. |
|
Dapagliflozin
( Farxiga ) |
Dosage is adjusted based on estimated glomerular filtration rate (eGFR):
|
|
Empagliflozin
( Jardiance ) |
10 mg orally once daily.
Maximum dose: 25 mg daily. Data are insufficient to provide a dosage recommendation in clients who have type 2 diabetes mellitus and established cardiovascular disease with an eGFR <30 mL/min/1.73 m 2 or heart failure with an eGFR <20 mL/min/1.73 m 2 . |
|
Glipizide
( Glucotrol , Glucotrol XL ) |
5 mg orally daily 30 minutes before breakfast.
Maximum dose: 40 mg daily. Extended release: Once daily with breakfast. |
|
Glyburide/metformin
( Glucovance ) |
1.25 mg glyburide/250 mg metformin orally daily. Titrate 2 weeks after initial dosing up to 1.25 mg glyburide/250 mg metformin orally every 12 hours. Maximum dose: 20 mg glyburide/2000 mg metformin orally daily. |
|
Liraglutide/insulin degludec
( Xultrophy ) |
10 units insulin degludec/3.6 mg of liraglutide subcutaneously once daily.
Maximum dose: 50 units insulin degludec/1.8 mg liraglutide subcutaneously daily. |
|
Metformin
( Glucophage , Glucophage XR ) |
Immediate release:
Adults: 500–1000 mg orally twice daily. Maximum dose: 2000 mg daily. Children (the only oral diabetes drug that is safe for use in children 10–17 years of age): 500 mg orally twice daily. Maximum dose: 2000 mg daily in divided doses. Extended release: Adults: 250–500 mg once daily with evening meal; increase dose by 500 mg/week on the basis of glycemic control and tolerability. Maximum dose: 2000 mg/day. Children: Health care provider should determine dose based on body surface area and glucose target range. Oral solution: Adults and children: 500 mg/5 mL daily up to a maximum dose of 2000 mg/day. |
|
Miglitol
( Glyset ) |
25 mg orally 3 times daily at the start of each meal.
Maximum dose: 200 mg 3 times daily. |
|
Pioglitazone
( Actos ) |
15–30 mg orally once daily.
Maximum dose: 45 mg daily. |
|
Repaglinide
( Prandin ) |
0.5–4 mg orally 3–4 times daily, 15–30 minutes before meals.
Maximum dose: 16 mg daily. |
|
Sitagliptin
( Januvia ) |
100 mg orally daily.
For clients with an eGFR ≥45 mL/min/1.73 m 2 to <90 mL/min/1.73 m 2 : No dosage adjustment required. For clients with moderate renal impairment (eGFR ≥30 mL/min/1.73 m 2 to <45 mL/min/1.73 m 2 ): 50 mg once daily. For clients with severe renal impairment (eGFR <30 mL/min/1.73 m 2 ) or with end-stage renal disease (ESRD) requiring hemodialysis or peritoneal dialysis: 25 mg once daily. May be administered without regard to the timing of dialysis. |
|
Sitagliptin/metformin
( Janumet ) |
Clients not currently treated with metformin:
Initial dose: 50 mg sitagliptin/500 mg metformin orally twice daily with gradual escalation.
Clients already treated with metformin: Initial dose: 50 mg sitagliptin twice daily and the dose of metformin already being taken. Maximum dose: 100 mg sitagliptin/2000 mg metformin orally daily. |
Adverse Effects and Contraindications
Common adverse effects of oral diabetes drugs include gastrointestinal symptoms (nausea, vomiting, diarrhea, abdominal discomfort), hypoglycemia (symptoms include dizziness, shakiness, sweating/chills, clammy skin, feeling faint, agitation, confusion, blurred or impaired vision), fluid retention, weight gain, and headache.
Contraindications include hypersensitivity to the drug or any of its components, severe kidney disorders (as most of these drugs are excreted in the urine and can further impair renal function), hepatic insufficiency (as most of these drugs are metabolized by the liver and can result in further impaired hepatic function), and disorders with fluid retention (such as heart failure and renal failure, as these drugs can cause additional fluid retention and volume overload).
Table 28.8 is a drug prototype table for oral diabetes drugs featuring metformin. It lists drug class, mechanism of action, adult and pediatric dosage , indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Non-sulfonylurea biguanide Mechanism of Action Decreases intestinal absorption of glucose and improves insulin sensitivity by increasing glucose uptake |
Drug Dosage
Immediate release: Adults: 500–1000 mg orally twice daily. Maximum dose: 2000 mg daily. Children (the only oral diabetes drug that is safe for use in children 10–17 years of age): 500 mg orally twice daily. Maximum dose: 2,000 mg daily in divided doses. Extended release: Adults: 250–500 mg once daily with evening meal; increase dose by 500 mg/week on the basis of glycemic control and tolerability. Maximum dose: 2000 mg/day. Children: Health care provider should determine dose based on body surface area and glucose target range. Oral solution: Adults and children: 500 mg/5 mL daily up to a maximum dose of 2000 mg/day. |
|
Indications
To control hyperglycemia in those with type 2 diabetes Therapeutic Effects Decreases glucose production in the liver by reducing gluconeogenesis Reduces glucose absorption from the intestines |
Drug Interactions
Alcohol Dolutegravir Ginseng Psyllium Contrast dye Food Interactions Fiber-rich foods Grapefruit juice Guar gum |
|
Adverse Effects
Dizziness/weakness Headache Hypoglycemia Palpitations Flushing Nausea/vomiting/diarrhea/flatulence Abdominal pain Weight loss Vitamin B 12 deficiency |
Contraindications
Renal and hepatic impairment Metabolic acidosis Megaloblastic anemia History of myocardial infarction Caution: Monitor closely for signs of hypoglycemic reaction; use cautiously in older clients with renal and hepatic impairments |
Nursing Implications
The nurse should do the following for clients who are taking oral diabetes drugs:
- Assess the client’s knowledge about diabetes, signs and symptoms, and treatment and clarify any gaps in knowledge.
- Monitor blood glucose levels as ordered and as needed when symptoms of hypoglycemia/hyperglycemia are present.
- Provide client teaching regarding how the drug is administered and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an oral diabetes drug should:
- Report symptoms of hypoglycemia such as headache, nervousness, sweating, clammy skin, tremor, and tachycardia.
- Report symptoms of hyperglycemia such as increased thirst, increased urine output, hot/dry skin, sweet, fruity breath odor, and ketones in urine.
- Keep 15 grams of carbohydrates on hand in case of a hypoglycemic reaction. Orange juice, graham crackers, and hard candy are appropriate carbohydrate choices during hypoglycemia.
- Show family members and their support system how to administer glucagon during a hypoglycemic reaction if the client cannot eat or drink or is unconscious.
- Keep a blood glucose journal for tracking blood glucose levels.
- Make lifestyle modifications as directed by their health care provider, such as diet, exercise, and weight loss, to help control blood glucose levels.
The client taking an oral diabetes drug should not:
- Drink alcohol with oral diabetes agents because it may impair hepatic function.


19.14: Employees vs Contractors
- Evaluate the use of resources: employee vs. independent contractor
To employ or not to employ? That is the question of the small business owner much of the time. The answer lies in the answer to a couple of other questions—mainly how much responsibility does the owner want to have for that employee, and how much control does the owner want to have over the final product or service?
Independent contractor growth is outpacing small business hiring, which means that more small businesses are opting to contract over bringing on a new employee. [1] And even though an independent contractor works from her own office, bringing her own equipment to the job and paying her own benefits, she’s not always the best choice for a small business.
Let’s start by understanding the difference between an employee and an independent contractor.
Employees
An employee is someone whose quality and manner of work the employer has a right to control. They are, legally speaking, in a master/servant relationship, and often referred to as W-2 employees, a reference to the federal income tax form they are served at year end with their total wages for the year.
As an employer, the small business owner controls the behavior of the employee, including a method for doing the work, a schedule on which that work will be done, and so on. The small business owner, as employer, handles the pay rate and pay schedule of this individual, as well as associated payroll taxes and benefits costs. Often, this employee will develop relationships with other co-workers at the owner’s place of business.
The cost of an employee goes beyond a normal salary or hourly rate. A payroll function goes along with that first employee, one that takes time and costs money. Checks must be written on a regular basis. Taxes, social security, and Medicare must be withheld, and payroll taxes paid. Other costs incurred with an employee would include the cost of a place to work, and the supplies with which to do that work, which can include a computer, office supplies, and more. Creating a positive, motivating work culture for that employee is also important, and that comes at a cost.
Independent Contractors
An independent contractor, on the other hand, is someone the small business owner engages to perform a certain task, but whose manner of work the owner does not have a right to control. This person is sometimes legally referred to as a 1099 employee, in reference to the tax form he or she receives at year-end outlining how much the business has paid to the contractor that year.
The contractor works either short term, or on a project-by-project basis. He or she pays all taxes on earnings, including any federal, state, local taxes, or social security. Sometimes, the quality of the contractor’s work is governed by professional standards or codes, like that of an electrician or plumber. These are standards and codes the small business owner doesn’t have to know or understand, and for that reason contractors can be attractive.
Another reason why contractors can be attractive to small business owners is because they get the work done without all the extra paperwork that comes along with having one’s own employees. But there is danger in treating a contractor like an employee. While the IRS doesn’t have any hard and fast definition of contractor vs. employee, they do provide a 20-item checklist that helps small businesses understand if they’re crossing the line. There are some hefty penalties in store for those business owners that don’t stay within those guidelines.
So what’s the cost of a contractor? Basically, costs with a contractor are negotiated up front, before the work begins, and the final fee is paid when the work is complete. Because contractors are responsible for all their own taxes, social security and Medicaid payments, their fees are usually higher to cover such costs. An employer’s only obligation to the contractor is to pay their invoices in a timely manner and issue a 1099 at the end of the year for their tax purposes.
The downside is that a contractor isn’t as loyal to the small business as an employee would be, and he or she is legally limited to only 1,040 hours of work (which is six months at 40 hours a week). And, because that contractor is self-employed, his or her timing might not match that of the owner, and the owner doesn’t really have any control over the quality of work or the time it takes to complete. While you can create contracts that stipulate acceptance criteria, there’s additional cost of time or money to get work redone. These are all hidden costs to a small business owner.
Employee or Contractor?
As an HR professional, it can be difficult to determine which way to go with this position that needs to be filled. Will the contractor be less expensive and more efficient, or is it time to bring a new employee on board?
A contractor is the best choice when
- The work requires a level of expertise no employee in the business has, and it would cost too much time and money to train someone to do it (e.g., IT specialty, an electrician, a physician)
- The work is seasonal, and extra hands are needed to fulfill orders
- The work is administrative, like bookkeeping or other tasks that can be done remotely and typically don’t require a full-time employee
An employee works best when
- The work requires close supervision in order to be completed
- The work requires regular local knowledge and an employee can bring specialized local knowledge to the table
- The work requires extensive knowledge of what’s going on within the walls of the small business
HR professionals can help small business owners determine the cost and relationship benefits of a contractor versus an employee and can assist in avoiding any misclassification of either.
Sources
Fleischer, Charles H. HR for Small Business: An Essential Guide for Managers, Human Resources Professionals, and Small Business Owners . Naperville, IL: Sphinx Pub., 2009.
-
Paychex, Inc. “
New Paychex Data Shows Independent Contractor Growth Outpaces Employee Hiring in Small Businesses
.” PR Newswire, January 9, 2019. ↵
Contributors and Attributions
- Employees vs Contractors. Authored by : Freedom Learning Group. Provided by : Lumen Learning. License : CC BY: Attribution
- Authored by : mohamed_hassan. Provided by : Pixabay. Located at : pixabay.com/illustrations/multi-tasking-efficiency-manager-2840792/. License : CC0: No Rights Reserved . License Terms : Pixabay License
- Authored by : picjumbo_com. Provided by : Pixabay. Located at : pixabay.com/photos/female-diary-journal-write-865110/. License : Public Domain: No Known Copyright . License Terms : Pixabay License


1.25: Sweetening the deal- improving health outcomes for patients with diabetes mellitus
At the end of this case, students will be able to:
- Identify the broad factors and social determinants of health that impact health outcomes for patients with diabetes mellitus
- Create optimized medication therapy plans for patients with diabetes mellitus based on individual patient resources
- Deliver culturally appropriate lifestyle counseling for patients with diabetes mellitus
- Identify ways that pharmacists can positively impact care through development of team-based care approaches, utilizing referrals, and connections to community resources
Introduction
Diabetes mellitus (DM) is a chronic metabolic condition that impacts blood glucose levels in the body. According to the Centers for Disease Control and Prevention (CDC), type 2 DM encompasses approximately 90-95% of individuals who are diagnosed, while the remaining 5-10% of persons have type 1 DM. Type 2 DM is the result of a defect in insulin action, also known as insulin sensitivity, while Type 1 DM is an autoimmune reaction which stops the body from producing sufficient insulin. Other forms of DM include gestational diabetes, which develops during pregnancy, and prediabetes, which is an abnormal blood sugar level that has not yet reached the point of a full DM diagnosis. 1-2
In the United States, approximately 34.2 million adults have DM, which is the seventh leading cause of death in the US and the leading cause of kidney failure, lower-limb amputations, and adult blindness. It is also a significant contributor to the development of atherosclerotic cardiovascular disease. Populations at highest risk for developing DM includes those who are overweight, over 45 years of age, have a family history of DM, and/or are in one of the following populations: African American, Hispanic/Latino, American Indian, Alaskan Native, Pacific Islander or Asian American. Collectively, racial/ethnic minorities account for approximately 23% of the US population at risk for prediabetes and type 2 DM. 1 Organizations such as the CDC and American Diabetes Association (ADA) have developed numerous strategies to treat and prevent DM, which encompasses lifestyle modifications, dietary changes, and pharmacological interventions. 1-3 As pharmacists, it is important to consider a holistic view of the patient, considering not only medications, but lifestyle factors and other social determinants of health that may affect disease management.
The ADA recommends incorporation of care management teams, including various providers, such as pharmacists, nurses, and dieticians, as a strategy to improve the outcomes related to DM. 3 Due to extensive medication and disease knowledge, pharmacists are well positioned to participate in management of DM. Involvement of pharmacists across settings, including community pharmacies, primary care clinics, and hospitals has shown positive outcomes related to HgbA1c, blood pressure, low-density lipoprotein (LDL), triglycerides, and body mass index (BMI). 4 Racial/ethnic minorities appear to also benefit from pharmacist management of DM, with evidence of improved outcomes and patient perceived support regarding medication education and management, non-medication related education, social support, and care coordination. 5-6 Collaborative practice agreements, through which a licensed provider refers a patient to a pharmacist under a protocol allowing the pharmacist to perform specific patient care functions, are one way in which pharmacists can become directly involved in DM management to help improve the health of individual patients and larger communities.
Case (part 1)
You are a pharmacist in a community pharmacy setting.
CC: “I need to refill my prescriptions.”
Patient: PN is a 48-year-old Vietnamese male (66 in, 75.5 kg).
HPI: Through the assistance of an interpreter service, PN speaks with your pharmacy technician regarding his refills. However, he does not bring the prescription bottles and does not know which medications he needs to have refilled. The technician asks you to review the patient’s medication profile.
PMH: T2DM (x 8 years)
FH: Unknown
SH: Unknown
Medications:
- Metformin 1000 mg one tablet twice daily (#60 last refill one month ago)
-
Glipizide 10 mg twice daily (#60, last refill four months ago)
- Patient reports that he stopped taking it a few months ago because it made him feel “low” while he was at work, and he was afraid of being fired from his job
- Sitagliptin 100 mg once daily (#90, last refill 45 days ago)
- Rosuvastatin 10 mg daily (#90, last refill one month ago)
Allergies: NKDA
SDH: The patient moved with his family to the US from Vietnam approximately nine years ago. He does not drive and relies on public transportation to get to the pharmacy. He has Medicaid insurance with $0 copays for covered medications on a limited drug formulary.
Case Questions (part 1)
- What questions can the pharmacist ask PN to identify the factors contributing to their nonadherence?
- What causes might be contributing to PN’s reported/unconfirmed hypoglycemia?
- What types of resources can community pharmacists provide or connect patients to improve health outcomes associated with DM?
Case (part 2)
You are now a pharmacist in a family medicine clinic.
CC: “I know I should be taking better care of myself to improve my blood sugar control, but I am so busy and constantly worried about my family and their wellbeing that I don’t have time for myself.”
Patient: PN presents to your family medicine clinic for an initial comprehensive medication management visit after medication non-adherence was identified by the community pharmacist. His wife accompanies him today and helps to translate.
FH:
- Mother: alive; T2DM
- Father: alive; HTN
- Maternal grandfather: deceased; T2DM
- Four children; two live in Vietnam, two live with him
SH:
- Tobacco smoker x 30 years
- Drinks alcohol socially
ROS: (+) polyuria, polydipsia, numbness in fingers
Surgical history: None
Vitals :
- BP 130/78 mmHg
- HR 90 bpm
Labs:
| Lab | 1 month ago | 3 months ago | 9 months ago | Normal range |
|---|---|---|---|---|
| HgbA1c | 12.1% | 10.6% | 13.0% | 4.2-6.5% |
| TSH | 2.16 IU/mL | 0.34-5.60 IU/mL | ||
| Na | 138 mEq/L | 130 mEq/L | 136-145 mEq/L | |
| K | 4.4 mEq/L | 4.1 mEq/L | 3.4-5.0 mEq/L | |
| SCr | 1.2 mg/dL | 0.8 mg/dL | 0.6-1.3 mg/dL | |
| Glu (random) | 259 mg/dL | 314 mg/dL | 70-99 mg/dL | |
| Total chol | 153 mg/dL | 100-199 mg/dL | ||
| TG | 361 mg/dL | 0-149 mg/dL | ||
| HDL | 29 mg/dL | 50 mg/dL | ||
| LDL | 52 mg/dL | 0-99 mg/dL | ||
| Alb:Cr | >300 mg/g | 30-300 mg/g | 0-30 mg/g |
SDH: The patient speaks only Vietnamese. PN lives in a multigenerational household with his wife, children and two grandchildren. He works two jobs to support everyone, including a day job at a Vietnamese restaurant and an evening job as a janitor at elementary school. He relies on public transportation and takes multiple buses across the city to get to the clinic.
His annual income is at 75% of the federal poverty level, which, based on the size of his household, qualifies him for Medicaid with a limited drug formulary that includes prior authorization requirements for sodium-glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 (GLP-1) agonists. In the past, the patient has expressed concern about utilizing injectable medications as he and his family associate this with loss of limb and even death, plus he states that he is fearful of being perceived by his boss as injecting “drugs.” Additionally, he does not want his family members to think that he is no longer capable of providing for their needs. He has a relatively good understanding of his medical diagnosis and the importance of managing it.
PN states that he eats a traditional Vietnamese diet. His breakfast consists of Vietnamese coffee, with white rice with eggs. His lunch is usually rice with some sort of meat (chicken/pork/beef) and various vegetables. His dinner consists of either a noodle or rice dish (like lunch). He drinks a variety of beverages (tea, water, fruit juices, coffee) and eats snacks such as rice cakes and fruits. He says he does not engage in regular physical exercise.
Case Questions (part 2)
- What social determinants of health may be impacting PN and how might these negatively affect his type 2 DM control?
- What type of referrals can the ambulatory care pharmacist make that would be beneficial for improving health outcomes for this patient?
- Considering patient-specific factors, how would you approach lifestyle counseling with PN?
- Create a medication therapy plan to improve PN’s DM outcomes, including monitoring and follow-up. How would you address the patient’s concerns about injectable therapy?
Author Commentary
The prevalence of DM in Asian adults living in the US is 19.1%. 7 Asian Americans develop type 2 DM at younger ages and at lower body weights compared to the general population in the US, leading to one in two Asian Americans who have DM not being aware of their diagnosis. 8 This is important to consider when screening this population for type 2 DM, and once a diagnosis is established, culturally appropriate treatment and counseling is necessary to ensure respectful and effective treatment. Factors that may impact patients’ goals, treatment and blood glucose management include lifestyle, race/ethnicity, and cultural perceptions. 9 Minoritized racial and ethnic groups, including Asian Americans, should be treated in a way that addresses specific barriers and cultural beliefs and misconceptions. 10 Moreover, prevailing social determinants of health and systemic inequality in access to healthcare services continue to have significant negative consequences on health outcomes for people living with DM. 11
DM is a major public health concern, especially among certain racial and ethnic communities, in the US and across the world. 12 As the third-largest group of healthcare professionals in the US, pharmacists must play a role in preventing and improving health outcomes related to DM. 13 Due to a growing shortage of primary care providers and an increasing number of medication classes approved for use in DM, the accessibility and knowledge of pharmacists is becoming increasingly important to help curb this public health concern. 14-15
Patient Approaches and Opportunities
Pharmacists have a unique opportunity to contribute to the management of DM due to their drug therapy expertise, ability to optimize medications while considering cost effectiveness, and availability for counseling and educating patients on adherence and lifestyle considerations. 16 Addressing patient-specific goals and barriers such as diet, exercise, familial obligations, and treatment options promotes shared-decision making with patients. While pharmacists can make significant contributions to improving DM-related health outcomes, it is important to recognize limitations within this role and be able to effectively utilize available resources to enhance patient care. Furthermore, collaboration among pharmacists working in different settings (e.g., community, ambulatory care, hospital inpatient, long-term care) and between pharmacists and other healthcare professionals will help to address barriers and ensure adequate, equitable treatment for patients in our communities.
Related chapters of interest:
- Saying what you mean doesn’t always mean what you say: cross-cultural communication
- More than just diet and exercise: social determinants of health and well-being
- Let your pharmacist be your guide: navigating barriers to pharmaceutical access
- Uncrossed wires: working with non-English speaking patient populations
- Only a mirage: searching for healthy options in a food desert
- The great undoing: a multigenerational journey from systemic racism to social determinants of health
- Experiences of a Caribbean immigrant: going beyond clinical care
- You say medication, I say meditation: effectively caring for diverse populations
- Digging deeper: improving health communication with patients
External resources:
-
Websites:
- ADA Standards of Medical Care in Diabetes. https://professional.diabetes.org/content-page/practice-guidelines-resources
- Centers for Disease Control and Prevention. Diabetes. https://www.cdc.gov/diabetes/index.html
- National Diabetes Prevention Program. https://www.cdc.gov/diabetes/prevention/index.html
- US Diabetes Surveillance System. https://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html
- US Department of Health and Human Services Office of Minority Health. https://minorityhealth.hhs.gov/
- CultureVision. https://www.crculturevision.com
- USDA Ethnic & Cultural Resources. https://www.nal.usda.gov/fnic/ethnic-and-cultural-resources-0
- EthnoMED. https://ethnomed.org
-
Journal articles:
- De Souza LR, Chan KT, Kobayashi K, Karasiuk A, Fuller-Thomson E. The prevalence and management of diabetes among Vietnamese Americans: a population-based survey of an understudied ethnic group. Chronic Illn 2020;<PHONE_NUMBER>959422.
- Nguyen TH, Nguyen TN, Fischer T, Ha W, Tran TV. Type 2 diabetes among Asian Americans: prevalence and prevention. World J Diabetes 2015;6(4):543-7.
References
- Centers for Disease Control and Prevention. Diabetes and prediabetes. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/diabetes-prediabetes.htm . Accessed February 16, 2021.
- American Diabetes Association. Classification and diagnosis of diabetes: standards of medical care in diabetes–2021. Diabetes Care 2021;44(Suppl 1):S15-33.
- American Diabetes Association. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes–2021. Diabetes Care 2021;44(Suppl 1):S111-24.
- Pousinho S, Morgado M, Falcão A, Alves G. Pharmacist interventions in the management of type 2 diabetes mellitus: a systematic review of randomized controlled trials. J Manag Care Spec Pharm 2016;22(5):493‐515.
- Naseman KW, Faiella AS, and Lambert GM. Pharmacist-provided diabetes education and management in a diverse, medically underserved population. Diabetes Spectrum 2020;33(2):210-4.
- Nabulsi NA, Yan CH, Tilton JJ, Gerber BS, and Sharp LK. Clinical pharmacists in diabetes management: What do minority patients with uncontrolled diabetes have to say? J Am Pharm Assoc (2003) 2020;60(5):708-15.
- Cheng YJ, Kanaya AM, Araneta MRG, et al. Prevalence of diabetes by race and ethnicity in the United States, 2011-2016. JAMA 2019;322(24):2389-98.
- Centers for Disease Control and Prevention. Diabetes and Asian Americans. https://www.cdc.gov/diabetes/library/spotlights/diabetes-asian-americans.html . Accessed February 16, 2021.
- Hill J, Nielsen M, Fox MH. Understanding the social factors that contribute to diabetes: a means to informing health care and social policies for the chronically ill. Perm J 2013;17(2):67-72.
- Li-Geng T, Kilham J, McLeod KM. Cultural influences on dietary self-management of type 2 diabetes in East Asian Americans: a mixed-methods systematic review. Health Equity 2020;4(1):31-42.
- Hill-Briggs F, Adler NE, Berkowitz SA, Chin MH, Gary-Webb TL, Navas-Acien A, et al. Social determinants of health and diabetes: a scientific review. Diabetes Care 2020;44(1):258-79.
- Centers for Disease Control and Prevention. Addressing health disparities in diabetes. https://www.cdc.gov/diabetes/disparities.html . Accessed February 26, 2021.
- US Bureau of Labor Statistics. Occupational employment and wages, May 2019: 29-1051 pharmacists. https://www.bls.gov/oes/current/oes291051.htm . Accessed March 26, 2021.
- Zhang X, Lin D, Pforsich H, and Lin VW. Physician workforce in the United States of America: forecasting nationwide shortages. Hum Resour Health 2020;18(1):8.
- Manolakis PG, Skelton JB. Pharmacists’ contributions to primary care in the United States collaborating to address unmet patient care needs: the emerging role for pharmacists to address the shortage of primary care providers. Am J Pharm Educ 2010;74(10):S7.
- Smith M. Pharmacists’ role in improving diabetes medication management. J Diabetes Sci Technol 2009;3(1):175-9.


4.4: Punching Up and Down in the Comic Thunderdome
During the 2016 Golden Globes, British comic Ricky Gervais told a joke so appalling that the world collectively gasped:
I’ve changed. Not as much as Bruce Jenner. Now Caitlin Jenner, of course, and what a year she’s had. Became a role model for trans people everywhere, bravely breaking down barriers and destroying stereotypes. She didn’t do a lot for women drivers. But you can’t have everything, can ya? Not at the same time. 34
Referencing a fatal automobile accident involving Olympian Caitlin Jenner prior to her gender transition surgery, Gervais’s joke pokes fun at the tragic death of another, “deadnames” a transgendered person, while perpetuating trite and misogynistic stereotypes. Ricky Gervais is known for his abrasive comedy, but the widespread backlash from all sides of the cultural and political divide indicated that this joke had crossed a line. For most, Gervais’ joke was a classic example of “punching down”—i.e., when humor functions by “making fun of” a socially marginalized or vulnerable party. In recent years, the punch up/punch down framework has dominated popular discourse regarding what constitutes ethical comedy, and perhaps in no small part for its ability to make simple comedy’s complex terrain. According to this framework, humor that punches up is not only ethical, but an act of social justice; humor that punches down, based on cheap and easy laughs of an already marginalized group, is considered bullying. Yet, is this framework too simple? This chapter examines the ethics of punching up (and down) and its suitability for assessing the ethics of humor in popular discourse.
Fighting with Humor
Comedy’s pugilistic character is embedded in the violent language we use to talk about humor. A comedian “kills,” “murders,” “slaughters” and “slays” on stage … if not, they “die”! Humor is biting, searing, and burning. Comics rip, roast, and tear into their targets in the punchline—a word with its origins in Mr. Punch’s “playful” pummeling of wife Judy in the Punch and Judy puppet plays of the 19th century. The ferocious and aggressive nature of comedy’s violent comic spirit manifests most explicitly in 20th century slapstick, a very physical comedic performance entailing a litany of violent comedic pratfalls—face slapping, eye-poking, nose turning, nose pulling, board thwacking, bowling-ball-head-hitting—to the uproarious amusement of its audience. Hence, on the surface it does not seem altogether misguided that we should discuss comedy with regard to throwing and receiving punches. Further, everyone has experience in comedic violence. Everyone has thrown a comic punch; everyone has been the butt of a joke. Yet, most fail to cultivate their comic sensibility so that they may harness its unruly spirit and reap the full potential for personal and social flourishing. Like the philosopher Spiderman once said, “with great power comes great responsibility,” and like all powers, it must be used with great concern and care.
Punching up at Goliath: Comedy as a Defensive Strategy
In the realm of comic sparring, punching up is typically presumptive of a defensive (rather than offensive) attack. Presumably derivative of the expression “punching above one’s weight” in boxing where one scraps against a far more powerful adversary, punching up indicates a David and Goliath battle where one of its combatants is an underdog. In most instances of punching up the target is perceived as physically stronger, but morally inferior. Such a comic jab is reactive and retaliatory—a form of self-defense against a bully or aggressor.  You can do anything.” 35 As both a woman and person of color, Brown’s target punches up, from a marginalized position, at an individual who is perceived as a bully by multiple parties—not just to minorities and women, but to all victims of sexual harassment and assault.
The Power of the Comic Punch as Self-Defense
In the hands of a skilled wit, humor packs a powerful punch. Ancient Roman orator and rhetorician Cicero argued that humor is more effective than rational dispute in “break[ing] the force of offensive remarks (II.LVIII),” stating that “all admire wit . . . because it overthrows the adversary, or hampers him, or makes light of him, or discourages, or refutes him (II.LVIII).” As a means of self-defense, the searing retort of a skilled wit not only shields her from the cruel words a verbal assault, but temporarily strips one’s aggressor of their privileged status through laughter’s debasing ridicule. No one is fully protected from humor’s eviscerating force—not even the Gods! When ancient Greek drama introduced comic elements into depiction of Gods and religious themes in their performances, German philosopher G.W. F. Hegel argued that the Gods become indistinguishable from humans because “the religious consciousness no longer distinguishes between the divine and itself.” (Hegel, 450, 452-3) While many comic “Davids” have long praised humor as a great political equalizer, many political Goliaths, seeking to preserve their power and control, have loathed its debasing and destabilizing force. As John Lennon succinctly stated from his week-long “Bed In for Peace” in 1969, “The only thing they [the establishment] don’t know how to handle is non-violence and humor.” 36
Comedy as A Preemptive Power
An essential presumption of the punch up/punch down framework is the idea that a joke or comedic piece’s normative (ethical) value is located in the power structure between the humorist and its target, and not its content. On the surface, this framework seems far superior than attempts to view humor from the vague “offensiveness standard,” which suggests a joke is wrong if one has taken offense. Because offensiveness is an elusive quality varying from person to person and culture to culture, the mere feeling of being offended offers little ethical guidance in thinking about the ethics of humor. Such a consequentialist ethical framework, which reduces the normative value of comedy to matters of personal and cultural attitudinal tolerance, not only muddies the waters of ethical comedy but offers no consistent framework to think about one’s target prior to potentially degrading them. In addition, in instances where offense is taken, the joker can always shirk responsibility for the insult on the basis that one was “only joking” or unaware of one’s threshold for offense, which is of little comfort to the scorned victim of a painful insult. However, the punching up/punching down distinction does offer a consistent framework for thinking about humor before one tells the joke. Prior to hurling a potentially incendiary remark, one can ask, “does this joke harm someone or a class of people who are vulnerable? If so, I should probably hold this one back.” With these preliminary remarks in mind, let us examine the primary arguments in favor of punching up in comedy.
Arguments for Punching Up
(1) Punching up Levels Social Inequities
The primary justification for punch-up humor is the argument that punching up levels inequities, while punching down exacerbates them. In the 1883 satirical print cartoon “The Protectors of our Industries,” robber barons Vanderbilt, Gould, Field, and Sage lethargically rest on bags of gold while patting their bloated bellies with dollar signs bursting through their opulent suits. 37 As the reader’s gaze drifts from the gluttony depicted at the top of the picture to the bottom of the cartoon’s panel, the true source of their wealth is revealed to be the exploited 19 th century industrial workers whose backs strenuously toil to support the greedy oligarchs for slave wages. Contrary to the self made “titans of industry” (or in more current language “job creators”) to be most esteemed for their bootstrap-pulling grit and determination, the cartoon depicts the robber barons as greedy, lazy, lecherous scoundrels who keep their bellies and coffers fat off the backs of exploitative wage labor. The cartoon not only directly attacks specific people, but the idea of capitalism as a whole. The cartoon “levels” the power structures by stripping the “titans” of their perceived greatness while empowering those who are the true wealth generators of the world—the nation of factory workers and laborers who toil daily for meager pay. On the other hand, political humor debasing a marginalized group with a history of oppression—as was the case in Charlie Hebdo’s racist depiction of Muslims as violent terrorists—further divide existing power structures in ways that only perpetuate present inequities with no vision for resolution.
(2) Punching up has an Ethical Foundation
Further, because the idea of punching-up is an idea with its foundation in an ethical purpose—namely righting some larger social injustice—it encourages people to approach humor in relation to right and wrong, good and bad, just and unjust, while simultaneously placing serious demands on wielders of weaponized comedy to take deep responsibility for the consequences of their words in the free play of comedic jousting. Long before the phrase “punch up comedy” came into vogue, satire from its earliest days has always punched up. From Aristophanes to Swift, the greatest satirists aim to instigate social change for the common good. In the previous example, the political cartoon’s attack is not, as some would argue, a spiteful reaction to the success of the affluent, but an earnest hope for a more equitable world. While not all punching up functions to bring about social reform, the fact that punching up has baked into it a social aim offers a far more fruitful framework for navigating comedy’s complex ethical terrain than critics allow.
(3) Punching Up is Non-Violent Political Participation
Finally, the force of laughter’s power is as close you can get to violence, without actually committing real physical violence. To quote a T-Shirt I once saw at an amusement park: “I love sarcasm … It's like punching people in the face, but with words.” Comic burns sting and fester in one’s psyche, sometimes for years after the 148 punch was thrown. However, while it is not impossible die from laughter, 38 no one has been physically murdered by a joke. In addition, like other forms of non-violent protest and political engagement, late night satirical news programs have become an integral component of contemporary political discourse in recent decades and continues to drive public discussion on important social issues of the day. Of course, there will always be those who abuse the free space of humor without concern for ethics, and sometimes such reckless use of the comic results in real physical violence, as was the case on January 7, 2015 when two hooded gunmen forced their way into the Paris offices of Charlie Hebdo and committed France’s deadliest terrorist attack—killing 12 of the Hebdo staff. However, such examples only demonstrate the need for a preemptive ethical framework. If one were to consider the power dynamics of any social conflict prior to attacking it and any potential consequences that might arise when anger, offense, and resentment foment into real violence—rather than recklessly abusing the free frivolity of humor by lobbing comic haymakers from protected walls of power and privilege—such tragedies would likely never happen.
Consequently, there is good reason to consider the punching up framework as a general tool for thinking about comedy. Where punching up is based in an earnest concern for justice and comes to the issue through lenses of social reform, punching down recklessly abuses the free space of the comic in order to further assert power over already vulnerable and oppressed groups in ways that only further exacerbate inequities their oppressors enable. Yet, the idea of punching up is not without its critics. Let us now examine some of its major challenges.
Arguments Against Punching Up
Criticism 1: Comedy Trivializes Important Social Matters and Problems
From satire’s early origins, adherents of punching up have faced a recurrent attack from critics on both sides of the political divide. If the purpose of punch-up comedy is to right a wrong or achieve major social, political or economic reform, humor seems a poor rhetorical device to reach such a goal. Not only does the ambiguity of comedy afford a real danger for misinterpretation, 39 but, even when understood, a piece of satire always risks diluting and (even worse) devaluing its message in the playful levity of humor’s frivolity. Satirical attempts at addressing institutional misogyny or racism, even in good faith, have been attacked for trivializing important social issues that, critics argue, should be treated with sober and earnest concern. More recent attacks correlate political apathy to the “memeification” of culture that transforms every important social, cultural, and political event into a viral meme. For these critics, because everything becomes a joke, so does civic and political engagement. While some argue that these memes give light to important social issues, many question the ability of memes to have any lasting impact on the short-term memory of a social consciousness so easily distracted by the shared social seduction of meme culture’s latest obsession. 40
Some critics see a far sinister consequence of using comedy to address social issues—nihilism. Thinkers from Plato to Baudrillard have bemoaned the apathy that results from devaluing and debasing important ideals, values and social problems. Lamenting the post-irony of contemporary culture long before it would become memeified, American author David Foster Wallace (1962 - 2008) attacked his generation’s apathetic insincerity. 41 For such critics, when all is suitable in comic jesting nothing is taken seriously and everything becomes a joke. It is for this reason that thinkers like Plato place strict regulations on the use of humor against the state and its institutions. For Plato, joking about important ideas runs the risk of devaluing essential religious, ethical, and political structures that society is based upon. Since Plato, many critics have expressed similar concern regarding the use of humor as a means for achieving social reform. Instead of social change, these critics argue that jesting about important social issues is more likely to result in skepticism and nihilism—a far sinister threat to society.
Criticism 2: Only the Marginalized Can Joke
Other critics argue that punching up places burdensome and unnecessary limits on the free play of comedy, absurdly restricting humor to the marginalized and oppressed. From this interpretation, a person in power who unjustly falls victim to mob rule (as happens when one is called out or “cancelled” online) seems to prohibit retaliation given their placement in the social hierarchy. Nearly all agree that jesting is an acceptable means of self-defense, and it seems contradictory to allow for humor in the name of equality while placing restrictions on who can joke about what and why. These attacks typically result in arguments over the importance of free speech and the need for ideas and jokes to play out in the cultural (rather than political) marketplace. In short, even in the name of social justice, most democratic societies would find implausible the idea that humor should be regulated by one’s social hierarchical position.
Criticism 3: Which Way is Up?
Finally, and most importantly, who or what party determines the direction of a joke’s punch? In examining Gervais’ Golden Globes’ joke about Caitlyn Jenner, the majority of his critics perceived it as a clear instance of “punching down.” Yet, from Gervais’ perspective, he was punching up. In his comedy special “Humanity” (2018) 151 released two years after the Golden Globes’ backlash, the British comic had this to say of his joke:
I'm playing with the notion of stereotypes. I start off saying she's a real woman... and I go, 'Oh, well, she's a real woman, I hit them with the old fashioned reactionary stereotype: She must be a bad driver then. The target of the joke is a celebrity killing someone in their car … Let's not forget that, shall we? A celebrity killing someone in their car, running home and popping on a dress — that's the target of the joke, just so we're clear. 42
In Gervais’ mind, the joke intended to draw attention to the fact that a powerful celebrity got away with murder. 43 For him, the joke’s target is not the transgender community, but rich and powerful celebrities who use their position of power to cheat the system. Even though Caitlyn Jenner is a member of the most marginalized group in the LGBTQ community, 44 Gervais insists his target was not the transgender community. Regardless, it cannot be denied that Caitlyn Jenner, as a member of one of the most visible and powerful families (the Kardashians), is seated in a far higher position of social power with far greater global presence and power than Gervais.
Gervais’ joke reveals a major problem in the punch-up model that defenders must address. As the previous example illustrates, the simplicity of punching up or down posits a Manichean moral perspective where one party is evil, the other good—when in reality all relationships are based in a very complicated web of power structures with its own unique set of ethical challenges. In most conflicts, rarely is a singular oppressor outed as a Machiavellian Goliath universally recognizable to all. In short, identifying and objectifying power structures in the complicated power dynamics of society, culture, government, politics and religion is an incredibly difficult task, especially when each party perceives its adversary as the oppressor (as is certainly the case in many longstanding political, religious, and cultural conflicts). Regardless of who is in power, all parties see themselves as the oppressed, and some argue that examining comedy through the lenses of social hierarchy only further obfuscates already complex social conflicts.
Responses to Criticisms
If true, the above challenges reveal some major flaws in the punch up framework. Yet, I think these attacks assume a weak version of the position uncharitable to the spirit of the model, whose flexible framework seems to facilitate (not obstruct) the free flow of public discourse between power structures in conflict with one another. Let us address these attacks so that we can come to see why such a framework is more productive than critics suggest.
Response to Criticism 1: “Comedy Trivializes Important Social Matters and Problems”
The claim that punch-up comedy trivializes and ultimately devalues the issues it aims to remedy is a concern for all who wield comic power on the battlefield of social reform. Yet, while it is true that the playful levity of comic sphere affords a freer means of discourse for addressing important social issues, to suggest that satire universally and consistently devalues the social problems it aims to remedy overlooks the presence and importance of art (and comedy in particular) throughout the major cultural and political shifts since antiquity. Political and social change is inseparable from the art and comedy that emerges within its unrest. Satire has long been utilized as a weapon against political oppressors to not only degrade their adversary, but to also inform and illuminate social conscious as a whole on important political, ethical, religious and social problems apart from the establishment’s account. In short, comedic aesthetics will always be a voice of the oppressed in their fight for social reform. While it is true that research suggests that satire has little impact on changing people’s mind (only emboldening pre-existing attitudes), 45 any piece of political art provides an opportunity for discussion, reflection and sometimes action. While memes, as with any comic rhetorical device, always run the risk of relegating important matters to a punchline or ironic hashtag, the playful realm of humor offers a less belligerent space to illuminate and discuss complicated social issues in ways that can foster meaningful discussion in hopes of working towards a peaceful resolution.
In short, to blame the crass nihilism of modernity on grumpy cat memes—and not the structural problems that enable oppression—seems to misunderstand the realities of class conflict and how democratic political systems operate. While comedy can debase and devalue targets, such debasing can be good if it draws attention to important social issues that some may be otherwise oblivious to. While there will always be causalities that lay in the battlefield of comedy’s vicious assaults, the potential that comedy holds for furthering public and social discourse on important political issues seems to far outweigh any potential harms it might cause on the way to social reform.
Response to Criticism 2: “Only the Marginalized Can Joke”
The challenge from critics that punch-up comedy denies non-marginalized parties from using humor in public discourse seems to straw man the position into a framework few would defend. A more charitable interpretation would never deny or limit specific voices from engaging in public discourse within the comic thunderdome— especially if speech is the only legal means of retaliation in a democratic society. In all, those in favor of punching up for social reform would surely want to advocate for the free use of humor. However, this charitable framework would oblige people to consider the direction of their verbal attacks and thereby assume responsibility for harms beyond its initial sting, including the values and voices that are raised up and devalued in the process. Consequently, the retweeting of a degrading meme targeting an AfricanAmerican football player for his refusal to stand for the national anthem by the President of the United States to his hundreds of millions of followers worldwide is not only outright bullying, but immoral.
Response to Criticism 3: “Which Way is Up?”
The most compelling critique of punch up comedy is that it lacks a clear indicator for identifying unjust power structures. If true, weaponized comedy on the battlefield would offer little guidance when each combatant views its adversary as the morally inferior party. Without a God’s-eye battlefield perspective to designate who is the oppressed and oppressor in each conflict, it is unclear how such a framework could be used for facilitating social progress. In response to this criticism, this problem would be less of an issue if all parties adopted the punch up framework, including the comic Goliaths of the world who abuse their power to silence others. The punch up framework is a preemptive battle strategy that forces people to consider the context of the situation, the historical relationship leading up to the conflict, and the weight and meaning of words as they relate to these historical and material forces. Although this framework would not expect to eliminate bias from the conflict, it does seem to offer a space for each party to think through the various power dynamics that may otherwise be concealed by power and privilege.
This interpretation seems to also address attacks that the punching up/punching down dichotomy oversimplifies the complex nuances of contemporary humor. To the contrary, viewing comedy from the perspective of power seems to allow for far greater nuance than its critics allow. Those who come to the comic battlefield with an eye to complex web of power structures and cultural forces in play with have a better strategy for navigating and battling through the complicated debate that confronts them and the issues and values at stake for all involved.
For those who remain unconvinced of the viability of an ethics of humor that is based on righting unjust power structures, it must be reiterated that the entire system is based in an ethical foundation of justice that obliges all to take responsibility for their comic assaults—especially for the marginalized who are calling out and publically berating their presumed oppressors. Those who challenge authority with weaponized humor must see it as their obligation—as it is with all who challenge authority and status quo—to establish the burden of proof that the standards, values, and ideals in question 155 are indeed in need of reform. Such comic warriors will have to carry out their fight with unrelenting political vigilance both in and out of the comic thunderdome.
Conclusion
To summarize, the punching up framework deserves continued consideration as a means for navigating the complex and chaotic battlefield of weaponized humor. While some critics challenge that the ambiguity and frivolity of humor muddles and ultimately counteracts the problems satirists address, such a position overlooks the value of using the free space of the comic to play with and think through complex ideas in a way that facilitates, and often furthers, public discourse on important social matters. Until a better model is offered by its critics, and given the increasing role of humor in political discourse, it seems we must learn to punch up.
Footnotes
34 https://www.hollywoodreporter.com/ne...-golden-854126
35 https://www.nytimes.com/2016/10/08/u...ranscript.html
36 “When it gets down to having to use violence, then you are playing the system’s game.  Because once they’ve got you violent, then they know how to handle you. The only thing they don’t know how to handle is non-violence and humor.” During the Bed-In for Peace in Montreal, Canada (1 June 1969)
37 https://www.loc.gov/pictures/item/94507245/
38 Though incredibly rare, with nearly all instances of death laughter sourced from classical and medieval commentators, there have been but two recorded instances of death laughter in the 20th century, with none since March 24, 1975 when Alex Mitchell was said to have laughed himself into cardiac arrest while watching an episode of The Goodies entitled "Kung Fu Kapers" starring a Scottish "Eckythump" ninja who is “armed with a black pudding.” His widow is said to written the show to thank them for making her husband’s final breaths so happy. https://www.telegraph.co.uk/news/hea...Tsyndrome.html
39 In a 1974 research case study on public perceptions of Norman Lear’s satirical program “All in the Family,” it was revealed that many had simply misunderstood Lear’s satirical aim, instead viewing the bigoted patriarch in a likeable and comical way. (see Vidmar and Rokeach 1974)
40 While the viral Kony meme remains a mainstay in meme culture, the “invisible children” were forgotten when the internet became obsessed with the death of a 17-year-old Gorilla at the Cincinnati zoo, which was shot by a zoo worker to protect a 3-year-old who climbed into the gorilla’s habitat. Today few would recall what either viral meme was about, but both Kony and Harambi remain comedic pillars of meme culture.
41 In Wallace’s "E Unibus Pluram: Television and U.S. Fiction" (1993), he calls for a new genre of literature that is based in a sincerity, not apathetic post ironic posturing. This theory would be developed in his 1996 novel, “Infinite Jest.”
42 https://www.standard.co.uk/stayingin...-a3789111.html
43 While prosecutors did not charge her criminally, three civil suits were filed against Jenner which reached out of court settlements of an undisclosed amount.
44 The transgender community has the highest rates of mental illness, homelessness and drug abuse. See Kattari and Begun (2017).
45 See Knobloch-Westerwick & Lavis (2017) and Boukes, Marjolein Moorman, & de Vreese (2015).
Bibliography
Boukes, Marjolein Moorman, & de Vreese. "At Odds: Laughing and Thinking? The Appreciation, Processing, and Persuasiveness of Political Satire." Journal of Communication (65) 2015: 721-744.
Silvia Knobloch-Westerwick & Simon M. Lavis. “Selecting Serious or Satirical, Supporting or Stirring News? Selective Exposure to Partisan versus Mockery News Online Videos.” Journal of Communication (67) 2017: 54–81
Cicero, Marcus Tullius. Cicero on Oratory and Orators: With His Letters to Quintus and Brutus. (ed) J. S. Watson. London: Henry G. Bohn, 1855.
Hegel, G. W. F. Phenomenology of Spirit, Translated by A. V. Miller. Oxford: Oxford University Press, 1977.
Kattari, S. K., & Begun, S. “On the Margins of Marginalized: Transgender Homelessness and Survival Sex.” Affilia, 32 (1) 2017: 92–103.
Vidmar and Rokeach. “Archie Bunker's Bigotry: A Study in Selective Perception and Exposure.” Journal of Communication. (24:1) 1976: 36-47.


<IP_ADDRESS>: Productive innovation
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Productive innovation
Social democracy
Many of the decisions and practices of the high-tech innovators and oligarchs have gained support from prevailing assumptions about the market, the consumer, a minimal role for government and so on. Yet despite its broad influence the durability of neoliberalism as a guiding ideology should not be overstated. An in-depth review of neoliberalism by Metcalf refers to a 2016 paper published by the International Monetary Fund (IMF) that explicitly connects the former with some of its most significant consequences. These include ‘pushing deregulation on economies around the world … forcing open national markets to trade and capital, and for demanding that governments shrink themselves via austerity or privatisation’ (Metcalf, 2017 ). While such insights may appear unremarkable in themselves they represent a startling admission by the IMF whose policies have long supported such practices. The author also suggests that the ideology should not be seen merely a ‘standard right wing wish list’ but rather ‘a way of reordering social reality, and of re-thinking our status as individuals’ (Metcalf, 2017). Viewed in this light the main premise – that ‘competition is the only legitimate organising principle for human activity’ – seems unlikely to remain viable over the longer term since it rules out and overwhelms vital human capacities. These include care, compassion, philanthropy and the like which all healthy societies need in order to function at all. The decline of neoliberal values and assumptions would also mean that previously unthinkable options would emerge, as would new strategies to reform the system. A ‘new normal’ would have its chance to become established.
In the UK a then resurgent Labour Party raised the possibility that just such a development could occur through the rise of social democracy. Rundle (2017) summarised what he considered to be some of the wider implications. In this distinctively optimistic view local, national and global societies could be run as a tripartite process of state, market and community institutions, with a “democratically enabling” state enforcing limits to the private sector, mandating social-economic spaces into which community / open / free / collective activities could expand, with democratic socialised ownership, whole or part, of key economic sectors. Such a shift would have major implications for all sectors of the economy – including IT systems and the Internet. As other essential social resources (including water, energy, finance) transitioned to shared ownership and control, Google, and other large companies could be regarded as having self-socialised (Rundle, 2017). As such there’s no good reason why they could not be subjected to the very same institutional arrangements.
Such raw suggestions have a long way to go before they can be rendered into widespread practice. Yet they make a good deal of sense in the current context. Google / Alphabet, for example, may thus far have avoided the rigours of US anti-trust regulations but this may turn out to be a temporary ‘victory’ as other governments step in to take actions based on alternative assumptions and views (see below). Rundle’s (2017) piece also demonstrates yet again why so many observers and critics of the IT revolution argue that the central issues are not primarily technical but social and political. Society as a whole needs to take part in multi-faceted conversations of this kind.
New infrastructure
There’s no shortage of ideas and proposals regarding ‘what needs to be done’ to re-design and re-direct the Internet and, by extension, high-tech innovation in general. Helen Magretts of the Oxford Internet Institute is no exception. In order to deal with aspects of Internet aggression she suggests that:
Any successful attempt to prevent extremist, abusive and hateful behaviour online must be multifaceted, thoughtful and collaborative. It will involve ethical and legal frameworks to guide as well as mandate good behaviour; working with tech companies rather than making enemies of them; smarter policing of activities that are already illegal; and crowdsourcing safety, so that people and social enterprises play a role (Magretts, 2017).
Cathy O’Neil (2016) puts a strong case for the establishment of a new infrastructure to deal with the uses and misuses of algorithms. She seeks to create reliable records of how these tools are used and by whom. She also knows that to do so will not be easy as powerful organisations normally resist being called to account. As noted before Cathy O’Neil calls for the establishment of a new infrastructure to deal with the uses and misuses of algorithms. She seeks to create reliable records of how these tools are used and by whom. She also knows that to do so will not be easy as powerful organisations normally resist being called to account. Taplin (2017), however, goes even further in proposing what he calls a ‘digital renaissance.’ This has various features that include:
- a shorter working week and the establishment of a universal basic income (UBI);
- measures to get the technical and creative communities working together;
- revisions of the ‘safe harbour’ provisions in the DMCA act;
- the Library of Congress issuing new guidelines as to the ‘fair use’ of creative and copyrighted material;
- revisions to, and wider application of, anti-trust regulations (to break up monoplies); and,
- a proliferation of co-operatives, non-profit companies, and what he calls ‘zero-marginal-cost distribution systems.
In this respect Taplin (2017) echoes suggestions by Rushkoff (2016). Rushkoff is interested in exploring a range of social and economic inventions in the context of re-thinking what money is and is for (Rushkoff, 2016). Finally Morozov (2017), whose work has contributed substantially to this enquiry, suggests that a single data utility would be best placed to make the best use of material from divergent sources. In the light of current experience with commercial entities it would need to be non-commercial and publically owned, much as Rundle (2017) has suggested. Given that progressive governments could set up such utilities quite easily the next step would be to ensure that ‘whoever wants to build new services on top of that data would need to do so in a competitive, heavily regulated environment while paying a corresponding share of their profits for using it,’ (Morozov, 2017a). Morozov (2017a) adds that ‘such a prospect would scare big technology firms much more than the prospect of a fine’.
Effective regulation
When the European Union (EU) handed Facebook a $120 million fine in May 2017 and Google a heavy $2.4 billion in June, both for market abuses, many wondered what the next step would be. By mid-2017 the answer came in the form of another acronym – the GDPR (or general data protection regulation). Long-time observer of the IT scene, John Naughton, emphasised that GDPR was not a directive but a regulation so it would become law in all EU countries at the same time. Some of the implications follow:
- The purpose of the new regulation is to strengthen and rationalise data protection for all individuals within the EU. It also covers the export of personal data to outside the bloc. Its aims are to give control back to EU residents over their personal data and to simplify the regulatory environment for international business by unifying regulation.
- The GDPR extends EU data-protection law to all foreign companies that process the data of EU residents. So even if a company has no premises or presence within the EU, if it processes EU data it will be bound by the regulation. And the penalties for non-compliance or infringement are eye watering, even by Internet standards: fines up to €20m and/or 4% of global turnover.
- More significantly, the GDPR extends the concept of “personal data” to bring it into line with the online world… The regulation gives important new rights to citizens over the use of their personal information… Valid consent has to be explicitly obtained for any data collected and for the uses to which it will be put.
- Citizens will now have the right to request the deletion of personal information related to them (Naughton, 2017a).
This was obviously what pundits call a ‘game changer’ as it fundamentally changed the rules for how these organisations collect, use and manage private data. Naughton (2017a) called it an ‘existential threat’ to those currently operating beyond the reach of existing data regulation laws. It certainly helped to resolve a situation in which people’s private lives everywhere are regarded as ‘fair game’ to entities whose sole interests lie in sales, profit and power. And it went a long way toward resolving some, but by no means all, of the concerns expressed so clearly by Zuboff (2015) and others. At the same time public service sectors such as education and health need to adjust their own procedures which will involve considerable costs.
The technical is political – the return of anti-trust
As the oligarchs have steadily penetrated ever more areas of human and economic life they’ve become so powerful that they abjure regulation by elected bodies and are frequently said to be way ‘ahead’ in terms of their products and services. But this is a mistake. If we accept that the technical is political it is harder to confuse technical mastery with other forms of expertise. As ever, Morozov (2017b) nails the core of this confusion by reference to underlying social interests. He poses the following question:
How could one possibly expect a bunch of rent-extracting enterprises with business models that are reminiscent of feudalism to resuscitate global capitalism and to establish a new New Deal that would constrain the greed of capitalists, many of whom also happen to be the investors behind these firms? (Morozov, 2017b.)
During mid-to-late 2017 it was clear that, while the Internet giants were not about to collapse, social and political forces on both sides of the Atlantic were beginning to line up in broadly the same direction. Signs were emerging that might be called their ‘golden age’ could be coming to a close. In September, for example, the Guardian editorialised that ‘Amazon’s dominance of the eBook market may not have raised prices, but it left the sector anaemic and competition floundering’. Another commentator was quoted as saying of the oligarchs that he did not think ‘any credible economist who isn’t an Ayn Rand lunatic would accept that these are not monopolies’. More people than ever are becoming aware of the fact that something is very wrong with this picture.
During the same month Ben Smith, a well-regarded Buzzfeed writer, was among the first of many to confirm what he called a ‘palpable, perhaps permanent, turn against the tech industry,’ (Smith, 2017). He added that ‘the new corporate leviathans that used to be seen as bright new avatars of American innovation are increasingly portrayed as sinister new centres of unaccountable power,’ (Smith, 2017). In his view this constituted ‘a transformation likely to have major consequences for the industry and for American politics’ (Smith, 2017). He also reported on how politicians of widely differing views were urging ‘big tech’ to be considered less as private companies than as ‘public utilities,’ (Smith, 2017). After years of denying the value or relevance of treating the high-tech giants in the same way that Bell Telephone and Microsoft had been treated in earlier years (i.e. broken up into small units) anti-trust legislation was finally back on the agenda. Similarly Washington senators Elizabeth Warren and Claire McCaskill both became involved in making anti-trust regulations part of the Democratic agenda over the next four years. Overall, the gap between ideas and effective action was perceptibly closing.


8.1: Rotating Frames of Reference
Learning Objectives
- Explain rotation and rotating coordinate system
No clock synchronization
Panels 1 and 2 of figure \(\PageIndex{1}\) recapitulate the result of Example 1.4.6. The set of three clocks fixed to the earth in \(\PageIndex{1}\) (1) have been synchronized by Einstein synchronization (Example 1.1.4), i.e., by exchanging ﬂashes of light. The three clocks aboard the moving train, \(\PageIndex{1}\) (2), have been synchronized in the same way, and the events that were simultaneous according to frame 1 are not simultaneous in frame 2. There is a systematic shift in the times, which is represented by the term \(t' = ... - vγx\) in the Lorentz transformation (Equation 1.4.1).
Now suppose we take the diagram of the train and wrap it around, \(\PageIndex{1}\) (3). If we go on and close the loop, making the chain into a circle like a chain necklace, we have a problem. The trend in the clock times can continue until it wraps back around to the beginning, but then there will be a discrepancy.
We conclude that clocks can’t be synchronized in a rotating frame of reference. Such a frame does not admit a universal time coordinate because Einstein synchronization isn’t transitive: synchronizing clock A with clock B, and B with C, does not imply that A is synchronized with C. This nontransitivity is one way of defining what we mean by rotation. That is, if the operational definition of an inertial frame given in section 5.1, shows that our frame is noninertial, and we want to know more about why it’s noninertial, testing for this nontransitivity is a way of finding out whether it’s because of rotation.
Rotation is locally detectable
The people aboard the circular train know that their attempts at synchronization fail, so they can tell, without reference to anything external, that they’re going in a circle.
Although this is a book on special, not general, relativity, it’s interesting to note the following possibility. Suppose that we verify, by local experiments, that we have a good, nonrotating, inertial frame of reference. It is then imaginable that if we view distant galaxies from this frame, we will see them rotate at some angular frequency \(Ω\) about some axis on the celestial sphere. If this is observed, then we must infer that it is the universe as a whole — not our laboratory! — that is rotating. Such an effect has been searched for, and, for example, an upper limit \(\Omega \lesssim 10^{-7}\) radian/year was inferred by Clemence. 1 General-relativistic models of such rotating cosmologies have a preferred vector constituting the direction of the axis about which matter rotates, but there is no global center of rotation. Current upper limits on \(Ω\) are good enough to rule out any significant effect on cosmological expansion due to centrifugal forces.
The Sagnac effect
Although the train scenario is obviously unrealistic, the time shift is far from hypothetical. This type of effect, called the Sagnac effect, was first observed by M. Georges Sagnac in 1913, and it relates to the principle of the ring laser gyroscope (Example 1.1.4), used in passenger jets. (The name is French, and is pronounced \sah-NYAHK.") To find the Sagnac effect quantitatively, we note that in the circular train example (ignoring signs) the relevant term in the Lorentz transformation, \(v\gamma x\), would accumulate, after one complete circuit of Einstein synchronization, a discrepancy \(\delta\) equal to the circumference of the circle multiplied by \(v\gamma\). If the circle's radius is \(r\) and the angular velocity \(\omega\), we have \(\Delta t = 2\pi \gamma r^2\omega\). This can be rewritten in terms of the circle's area \(A\) as \(\Delta t = 2A\omega\), or, reinserting factors of \(c\) to accomodate SI units, \(\Delta t = \frac{2A\omega }{c^2}\). The proportionality to the enclosed area is not an accident; the product \(vx\) has the form of the integrand \(F\cdot ds\) occurring in Stokes' theorem.
Example \(\PageIndex{1}\): Sagnac effect in the Hafele-Keating experiment
A clock at the equator of the earth rotates at a frequency \(ω\) of \(2π\) radians per sidereal day, suffering a Sagnac effect of \(210\: ns\) per day. The traveling atomic clocks in the Hafele-Keating experiment went around the world in both directions, and were compared with a third set of clocks that stayed in Washington,DC. Since the time required to ﬂy around the earth was also on the order of one day, the differences in the values of \(ω\) for the three sets of clocks were on the same order of magnitude as the \(ω\) of the earth, and we therefore expect cumulative differential Sagnac effects that are also on the order of a hundred nano seconds. These effects exist only in the rotating frame of the earth, but the things being measured are proper times, and proper time is a scalar, so the experimental results are independent of what frame of reference is used for calculating them. Since the airline pilots provided Hafele and Keating with navigational data referred to the rotating earth, they analyzed their results in the rotating frame, in which there was a Sagnac effect. They could equally well have transformed their data into the frame of the stars, in which case the same result would have been predicted, but it would have been described as arising from kinematic time dilation.
Example \(\PageIndex{2}\): Ring laser gyroscope
The ring laser gyroscope in the photo in Example 1.1.4 looks like it has an area on the order of \(10^2\: cm^2\) and uses red light. For use in navigation, one wants to be able to detect a change in course of, say, one degree in our hour, or \(ω ∼5×10^{-6}\: radian/s\). The result is a time shift \(∆t ∼ 10^{-24}\: s\), which for red light is a phase shift of only \(∆φ = 4πAω/cλ ∼3×10^{-9}\) radian. In the original nineteenth-century experiments, this phase shift would have had to be measured by producing interference between the two beams and measuring the change in intensity resulting from this change in phase. Our estimate of \(φ\) shows that this is impractical for a portable instrument. In a modern ring laser gyroscope, an active laser medium is inserted in the loop, and the result is that the loop resonates at a frequency that is shifted from the laser’s natural frequency by \(∆f ∼ ∆φc/L\), where \(L\) is the circumference. The result is a frequency shift of a few Hz, which is easily measurable. An alternative technique, used in the fiber optic gyroscope, is to wrap \(N\) turns of optical fiber around the circumference, effectively changing \(A\) to \(NA\).
A rotating coordinate system
The GPS system is a practical example of a case where we naturally want to employ a rotating coordinate system. Hikers and sailors, after all, want to know where they are relative to the earth’s rotating surface. Since locations need to be determined to within meters, the timing of signals needs to be done to a precision of something like \((1 m)/c\), which is a few nanoseconds. This is why the GPS satellites have atomic clocks aboard, and timing to this precision clearly requires that relativistic effects be taken into account. We therefore need not a rotating Newtonian coordinate system but a rotating relativistic one. Let’s start with the nonrotating frame, and define coordinates \((t,r,θ,z)\), with the spatial part \((r,θ,z)\) being ordinary cylindrical coordinates. For simplicity, we’ll neglect the \(z\) coordinate in what follows. Extending the result of problem Q1 in chapter 7 from \(2 + 0\) dimensions to \(2 + 1\), we have the metric
\[ds^2 = dt^2 - dr^2 - r^2 d\theta ^2\]
The results above show that we do not expect to be able to define a completely satisfactory time coordinate in the rotating frame, so let’s start with the minimal change \((t,r,θ) → (t,r,θ')\), where \(θ' = θ - ωt\). This is at least enough to make world-lines of constant \(θ'\) be ones that revolve around the origin at the appropriate frequency. Substituting \(dθ = dθ' + ω dt\), we find
\[ds^2 = (1 - \omega ^2r^2)dt^2 - dr^2 - r^2 d\theta '^2 - 2\omega r^2 d\theta 'dt\]
Recognizing \(ωr\) as the velocity of one frame relative to another, and \((1 - ω^2r^2) {-1/2}\) as \(γ\), we see that we do have a relativistic time dilation effect in the \(dt^2\) term. But the \(dr^2\) and \(dθ'^2\) terms look the same as in Equation \(\PageIndex{1}\). Why don’t we see any Lorentz contraction of the length scale in the azimuthal direction?
The answer is that coordinates in relativity are arbitrary, and just because we can write down a certain set of coordinates, that doesn’t mean they have any special physical interpretation. The coordinates \((t,r,θ')\) do not correspond physically to the quantities that a rotating observer \(R\) would measure with clocks and meter-sticks. If \(R\) uses a ruler to measure a short arc along the circumference of the circle \(r = r'\), the distance is a distance being measured between events in spacetime that are simultaneous in the rest frame of the ruler, and these do not occur at the time value of the time coordinate \(t\). In the Lorentz transformation, for linear motion, it is the \(-vγx\) term applied to the times that fixes this problems and makes t0 properly represent simultaneity in the new frame. In our rotational version, we could try to do something similar by defining a time coordinate \(t' = t + fθ'\), where \(f\) is a function of \(r\) that is engineered so that the \(dθ'dt\) cross term in the metric would go away. This can be done (the function \(f\) that works turns out to be \(ωr^2/(1 - ω^2r^2)\)), but the problem is that the \(t'\) coordinate is not single-valued, in the sense that \((t,r,θ)\) and \((t,r,θ + 2π)\) would not produce the same \(t'\). This is inevitable, as we’ve seen in in the beginning of this section, so we can’t improve on the coordinates \((t,r,θ')\) and the metric (Equation \(\PageIndex{2}\)).
The coordinates \((t,r,θ')\), with the metric (Equation \(\PageIndex{2}\)) are the ones used in the GPS system, and in that context are called Earth-Centered Inertial (ECI) coordinates. (Another name is Born coordinates.) Their time coordinate is not the time measured by a clock in the rotating frame but is simply the time coordinate of the nonrotating frame of reference tied to the earth’s center. Conceptually, we can imagine this time coordinate as one that is established by sending out an electromagnetic “tick-tock” signal from the earth’s center, with each satellite correcting the phase of the signal based on the propagation time inferred from its own \(r\). In reality, this is accomplished by communication with a master control station in Colorado Springs, which communicates with the satellites via relays at Kwajalein, Ascension Island, Diego Garcia, and Cape Canaveral.