Breathing health into a stone?

Are my emotions mine? That is, do they live inside me, or are they things that are shared -exist between me and others, in other words? Are they more the combination of genetic predisposition and situational features which are dependent on societal norms that we were taught from our early years at home and in the community?

It seems to me that it is an important point: where should we direct our efforts if we feel  emotions are getting out of hand? Is simply treating me sufficient, or am I the fabled canary in the coal mine? I’ve been retired from specialist medical practice for some years now, and I can feel my loyalties shifting. It’s not that I have joined the dark side, or anything -more that I can see both sides better from the border.

If we are to confront medical skepticism, it is a good idea to examine it from a historical perspective. I found a helpful essay by Bernice L. Hausman, professor and chair of the Department of Humanities at the Penn State College of Medicine in Hershey, Pennsylvania: https://aeon.co/essays/what-explains-the-enduring-grip-of-medical-skepticism

Early in her explanation, she writes that ‘while medical therapeutics have advanced considerably, many current treatments are also aggressive… Consider the expansion of disease categories to include personality quirks and body types, side-effects that demand further medications, drug interactions that are deadly, and medical supervision of things left well enough alone. If 18th-century medicine lacked a scientific basis, our problem might be too many therapies for our own good. The expansion of treatment has led to a critical response – ‘medicalisation’, which describes a skeptical approach to mainstream medicine’s social role in defining health.’

Indeed, what is ‘health’? Is it merely a state of being free of injury or illness, or is there something else involved as well? Something that medicine often fails to address: who has the social authority to decide what constitutes health -not so much for society as a whole, but for the individual? And how it should best be treated, for that matter?

Take an old example: TB. The proximate cause, of course, is the tuberculum bacillus, Mycobacterium tuberculosis, but in some sense the bacterium is merely opportunistic. The ultimate, or distal cause may well be something like impaired immunity from malnutrition or poverty. So, which cause should be addressed -the proximate one, of course, but should we leave it at that? Is it enough to rub our hands and say ‘done’? For that matter, to whom should we look for a remedy?

But, the problem is still with us -for example, the current pandemic of Covid 19 with its massive social and economic upheavals. From time to time, there has been promulgated the exculpatory mantra that the virus knows no boundaries; the virus does not discriminate, unlike our political borders. But of course it does. The communities of colour -African American and Latino, in America at least- seem to be disproportionately affected. Why? Well, there are a few obvious factors at play. ‘African-Americans have higher rates of underlying conditions, including diabetes, heart disease, and lung disease, that are linked to more severe cases of COVID-19′. And, ‘They also often have less access to quality health care, and are disproportionately represented in essential frontline jobs that can’t be done from home, increasing their exposure to the virus,’ according to a report (May30/2020) from NPR.

And, from the same report, ‘Latinos are [also] over-represented in essential jobs that increase their exposure to the virus… Regardless of their occupation, high rates of poverty and low wages mean that many Latinos feel compelled to leave home to seek work. Dense, multi-generational housing conditions make it easier for the virus to spread.’ Of course, by now that is old hat… isn’t it?

I suspect I saw it differently when I was in practice, but perspective is often beguiling -the old aphorism about the hammer and the nail, perhaps? ‘In Medical Nemesis (1975), Illich [the intellectual iconoclast, Ivan Illich, a Croatian-Austrian Catholic priest] made a starkly prescient argument against medicine as a dangerous example of what some call ‘the managed life’, where every aspect of normal living requires input from an institutionalised medical system. It was Illich who introduced the term ‘iatrogenesis’, from the Greek, meaning doctor-caused illness. There were three levels of physician-caused illness, as far as he was concerned: clinical, social and cultural. Clinical iatrogenesis comprises treatment side-effects that sicken people. Social iatrogenesis describes patients as individual consumers of treatment who are self-interested agents rather than actively political individuals who could work for broader social transformations to improve the health of all.

But, cultural iatrogenesis is the one that interests me the most, I must admit: that ‘people’s innate capacities to confront and experience suffering, illness, disappointment, pain, vulnerability and death are [being] displaced by medicine.’

Illich thinks that ‘medicine takes a technical approach to ordinary life events, hollowing out the rich interpersonal relations of caring that defined being human for millennia.’ But to be fair, Illich still felt that ‘Sanitation, vector control, inoculation, and general access to dental and primary medical care were hallmarks of a truly modern culture that fostered self-care and autonomy.’ He was more concerned with the impersonal bureaucracy that surrounded medicine. An interesting criticism, and one that I also share -albeit one that seems to stem from the medical system as he saw it from south of our Canadian border.

And yet I think the thrust of Hausman’s essay was more a reaction to the disillusionment that followed the initial promise of modern medicine. Things like delegating the definition of health to professionals who have a vested interest in defining it in a way that seems to mandate the continued need for them. I think this view is unfair, but, given Illich’s iatrogenesis concerns, I can see how that attitude might seem plausible.

Have we doctors been -are we still- sometimes too aggressive in our treatments, too arrogant in our knowledge, too certain of our advice, and too resistant to alternative approaches? I’m not suggesting that we cave to pseudoscience, or acquiesce to theories just because they are currently fashionable; Science is never perfect, and is open to change. But still, primum non nocere is a good aphorism to guide us: First of all, do no harm. I seem to remember promising something like that in my medical oath…

Gedankenexperimentophobia

It’s fun to play with thoughts, to riffle through ideas, don’t you agree? Take ‘thought experiments’ for example -think up a problem, set some parameters to confine it and see what your brain, unconstrained by external reality, comes up with. It’s almost akin to the Scientific Method some would argue: ask a question; form a hypothesis about it; make a prediction based on the theory; test the prediction; and finally, come to some conclusion. But is it? Can a mind sitting quietly by itself in an armchair, circumvent the need for external reality?

Ever since I first heard it, I have felt uncomfortable with ‘the Trolley Problem’. There have been several iterations of it over the years, but by and large it consists of a runaway coach on a track that is approaching a switch. Down one track is a single person, whereas down another are several people. The coach cannot be stopped, the person (or people) cannot get out of the way, but the switch can be thrown to direct which track is used. The question, of course, is which track to use -either track will result in death.

What does the choice of one track or the other say about the person who has to decide? About their morality? About ethics? About anything, really? It seems far too monochromal for my liking. And, unlike its real-life cousin, by definition a thought experiment cannot really be subjected to any rigorous objective analysis. It’s more like an experiment done in a lab where all parameters are carefully controlled, unlike what would happen in the real world.

But for years I’ve wondered whether my discomfort was misplaced. After all, Einstein used thought experiments. My concerns, like an unused city lot, lay fallow until I wandered into an essay by James Wilson, a professor of philosophy at University College London: https://aeon.co/essays/what-is-the-problem-with-ethical-trolley-problems

As he writes, thought experiments are ‘short hypothetical scenarios designed to probe or persuade on a point of ethical principle. Such scenarios are nearly always presented context-free, and are often wildly different from the everyday contexts in which ethical sensibilities are formed and exercised… Even when scenarios are highly unrealistic, judgments about them are thought to have wide-ranging implications for what should be done in the real world. The assumption is that, if you can show that a point of ethical principle holds in one artfully designed case, however bizarre, then this tells us something significant.’

Sometimes, however, when considered as things that might happen in the real world, we can envisage other conditions that would invalidate, or at least complicate, any conclusions drawn in the thought experiment. We know too much, as it were. ‘Thought-experiment designers often attempt to finesse the problem through an omniscient authorial voice that… is able to say clearly and concisely what each of the thought experiment’s actors is able to do, their psychological states and intentions. The authorial voice will often stipulate that choices must be made from a short predefined menu, with no ability to alter the terms of the problem. For example, the reader might be presented with only two choices, as in the classic trolley problem: pull a lever, or don’t pull it.’ Exactly.

So constraining the choices limits the possibility of novel approaches to the stated problem. ‘Imaginative ethical thinkers look beyond the small menu of obvious options to uncover novel approaches that better allow competing values to be reconciled. The more contextual knowledge and experience a thinker has, the more they have to draw on in coming to a wise decision.’

But there are at least two other difficult challenges with thought experiments: internal and external validity. ‘Internal validity relates to the extent to which an experiment succeeds in providing an unbiased test of the variable or hypothesis in question. External validity relates to the extent to which the results in the controlled environment translate to other contexts…[but] the very features that make an environment controlled and suitable to obtain internal validity often make it problematically different from the uncontrolled environments in which interventions need to be applied.’ In other words, the world just doesn’t work like that.

I remember trying out the Trolley Problem on the guys who meet for coffee some mornings in the food court. I wondered if they felt the same unease with it as I did.

“So, which track are you going to switch the trolley onto?” I asked, after giving them a brief summary of the thought experiment.

Burt put his doughnut back on the paper plate, and wiped some sugar off his cheek. “It’s so obvious, G -I’d ring the bell. All trollies have bells, eh?”

“But what if the workers on the track don’t hear it…?”

Burt rolled his eyes, as he brushed a lock of his paper-white hair off his forehead. “I’d keep ringing it. The workers would hear it when it got closer…”

“But suppose the workers are tied to the track.”

Burt glared at me for a moment. “You didn’t say that. And anyway, why would they be tied to the track? That’s a bit Little Orphan Annieish, don’t you think?”

I decided to relent a little to make it more -what?- real worldy. “Okay, let’s say they’re just deaf…”

Burt was clearly unmoved by my compromise. “Still…”

Jason, who had been quietly munching on a bagel put his hand up.

Burt sneered at the hand. “You’re not in school, Jas…”

Jason blinked and lowered his hand, and then glared at Burt. “Whatever. Anyway G, you said they were working on the track. They’d be able to feel the vibrations on the rails from a moving trolley, so that would warn them to get out of the way.”

I had to sigh; the guys were not really getting into the spirit of the ethical problem I’d offered. “I don’t know how much warning that would give, but let’s say they weren’t actually standing on the rails…” I had to think quickly here. “Let’s say they were on the ties between the rails then.”

Arthur, who had been teacher before he retired, sighed loudly and shook his head. “You folks are missing the point.”

Burt took a big bite from his doughnut. “The point being…?” It was hard to distinguish word from doughnut, but Arthur ignored the sounds.

“It seems to me the problem is bimodal.”

I smiled and nodded my head at him -finally somebody understood the ethics at stake. “Correct,” I interrupted, “There are two choices: the left track or the right track -several deaths, or one death. Which one would you choose, Art?”

He glanced at me quizzically. “I didn’t say there were two choices; I said bimodal: values occurring most frequently in the data set we were given…”

Jason, Burt and I stared at him, but it was Burt that summed it up. “You had too many cookies, Art…?”

It was Arthur’s turn to roll his eyes. “What I mean is that we have to consider two data streams that affect the choice of track…”

“Too much sugar in his coffee,” Jason whispered to Burt.

Arthur ignored them. “First of all, there’s the trolley driver. He would be ringing the bell, of course, but presumably to be allowed to drive the trolley, he’d have been expected to know about things like the switch signs that indicated which track was open.” He stared at me. “Would that not be the case?”

I shrugged, but I had to agree with him.

Then a wry smile appeared to hover tentatively along his lips. “And then there is the person whose responsibility it is to work the switches.” His smile softened briefly. “A very important job, as you can imagine.”

None of us disagreed. I was more interested in where this was leading, though.

“So,” he continued, “We can assume that the switch person knows that the driver has to have some expertise in reading the switch signs…” He looked at each of us for a second to see if we were following him. Nobody moved. “Therefore, the switchman flags the approaching trolley to let the driver know he understands the trolley is out of control, and then sets the switch only at the halfway position. The driver would see this as an uncompleted switch and realizes it will derail the trolley, so he jumps clear.”

Arthur sat back in his chair this time with a big sloppy grin on his face. “So, nobody dies. Problem solved…”

I suddenly remembered that scene in Shakespeare’s Hamlet: There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy.

I wonder if Hamlet could have resolved the Trolley Problem as quickly as Arthur, though.

Preposterosity

What is it to be absurd? Can we even wrap our heads around the concept when to do so threatens to unravel the fabric we each wear from day to day, risks unweaving the very rainbow we have come to worship?

But, just because something doesn’t make sense, doesn’t necessarily make it absurd, of course. Many things don’t make sense until we invest some time and effort into interrogating them further. And even if the effort comes up fruitless, we often throw a pattern over it to make it accessible -or should I say acceptable? Without a framework to compare it to, there is a tendency to reject it -or worse, to regard it as nonsense. Pointless. Unsettling.

Still, is there a universal threshold for absurdity -something everybody would agree makes no sense? Or is that a silly question, and one that is dependent on culture, expectations, or previous exposure to inexplicable incongruity?

In that regard, art springs to mind, I suppose -abstract art in particular, perhaps. Depending on the type and the artist -Kandinsky, for example- it is sometimes just a jumble of different colours with a title attached to it. Sometimes resolvable, yet equally often not, it is difficult to know how to process it. Eventually, however, it is usually possible to step back and appreciate it as, well, interesting, if not beautiful. But is it still absurd, in that case? Or is it just the expectation that was created by its title that was confusing?

Maybe the ultimate example of artistic absurdity would be Malevich’s Black Square -a black square of paint. I’m certainly not an art critic, and although I know a little bit of its history and subsequent versions, as well as his intention of having it symbolize a sort of beginning: “It is from zero, in zero, that the true movement of being begins” a black square is difficult to process meaningfully; we have to judge it differently. Of course, perhaps that is the point… In which case, it is no longer absurd.

Clearly, I have to admit that I find the very concept of absurdity a little absurd, and this confusion no doubt contributed to my interest in an essay by the science writer, David Robson: https://psyche.co/ideas/a-touch-of-absurdity-can-help-to-wrap-your-mind-around-reality

‘Many works of art deliberately challenge our understanding of the world in this way, including other films by Lynch [of Mulholland Drive fame], the writing of Franz Kafka and the humour of Monty Python, to name but a few. All feature illogical and incongruous elements and the uncanny juxtaposed with the familiar… According to research on the ‘meaning maintenance model’ of human reasoning, surreal and absurd art can be so unsettling that the brain reacts as if it is feeling physical pain, yet it ultimately leads us to reaffirm who we are, and sharpens the mind as we look for new ways to make sense of the world. The findings also suggest new ways to improve education, and even help to explain our responses to some of the more absurd political events of recent years.’

‘Heine [psychologist Steven Heine] and his team proposed that our mental representation of the world is like a delicate web of interconnected beliefs, documenting the relations between ourselves and the people, places and objects around us. When we are confronted with an apparently inexplicable event that appears to break that framework, we feel profound uncertainty – the ‘feeling of the absurd’.’

Heine describes three ways in which we might process the absurd: building a new mental representation to incorporate the inexplicable event, reinterpreting the event so that it fits our existing mental model, or strengthening other beliefs and values -even those relating to a completely unconnected domain- and then retreating to a safe place where the world makes sense again: so-called ‘fluid compensation’.

I can see how using absurdity might have an interesting affect on education –‘teachers could deliberately create feelings of uncertainty to prompt students to look harder for meaning in the material they’re studying.’ On the other hand, I suspect this would only make sense in situations where the students are prepared for this beforehand; I don’t think it would work for everybody, either -me, for example.

I think back to when my daughter was small and, of course, bringing back artwork from her kindergarten and Grade 1 classes. One of them I remember well. It was a largish sheet of white art-paper with random sine-wave type squiggles on it in green crayon, and then a straight red line through it diagonally across the page.

I smiled when I saw it, and by now I was used to her drawings so I started to put it on the fridge door with her other creations.

“No, no Daddy,” she almost shouted at me, “That was just an extra that I didn’t hand in.” She was quite adamant about it and went into her usual arms-across-her-chest scowl. She did that whenever she thought I didn’t understand something.

I took the magnet off and put the drawing on the kitchen table. “Why didn’t you hand it in, sweetie?” I asked.

She climbed on a chair and looked at the paper. “ ‘Cause I made a mistake, daddy…” She studied my face for a reaction.

“Oh,” I said, as nonchalantly as I could and examined the drawing more closely. “It’s nice, though…” I stopped, because I hadn’t the slightest idea what she’d been drawing. “What were you drawing?”

She screwed her little face up and stared at me as if I really should have known. “It’s attack art, of course…” She sighed and rolled her eyes. “It’s not s’pposed to be anything…!”

I had to think about the word for a moment. Was she telling me it was meant to offend the viewer…? She sometimes got new words mixed up, though, so it could have been anything. I just nodded my head as if I suddenly understood why she hadn’t handed it in. I didn’t, of course.

“So, what did the drawing you handed in look like?” I thought maybe I could figure it out from that.

A little smile surfaced on her lips and her eyes twinkled at me. “Same thing, but I did the wavy lines in blue…” She thought about it some more, and then added “Except for the straight line, of course.” She fixed me with a knowing stare. “You only put the straight lines in when you’ve made a mistake and want everybody to know.”

I thought about her drawing that night after she went to bed. ‘Attack art’? And it’s not supposed to be about anything…? Then, suddenly it dawned on me: she meant Abstract Art. I went into the kitchen and revisited the drawing. I thought it was pretty good for abstract art, you know -although I agreed with her, the squiggles would  probably look better in blue.

The things they were starting to teach kids about in school impressed me. In my day, if I’d handed in something like that to the teacher, my mother would have got a phone call from the school counsellor that evening… or did they even have counsellors then?