In praise of an empty brain

How do I love thee, Age? Let me count the ways… Well, actually I’m not actually going to, because of late, I’ve fallen out with it. Perhaps it’s just my memory that’s falling, though: I was about to parody Shakespeare -it’s what I knew I knew, and yet I didn’t (it was Elizabeth Barrett Browning. I checked). A simple mistake, perhaps, and yet, once again, the hubris of my years led me along the wrong neurons. I feel embarrassed about it now, but suppose I had offered it to someone as a valid Shakespearean quotation and, out of respect for my age, I had not been contradicted? For that matter, what if I’d felt there was no need even to look it up?

Although I am now retired after a long career in medicine, people still ask for my opinion. I answer them, of course, but I do wonder if what I say is still up to date and correct. And often as not, I will look up the answer when I get home. Whether it be age or temperament, the assumption of knowledge I do not possess sits poorly with me. Nowadays, I am far more likely to shrug and admit that I do not know the answer to the question asked -or at least admit that I am uncertain.

However for an expert, I suppose it’s a matter of pride to speak with certainty, even if that confidence is apt to block, or even deride other viewpoints. It seems to me that knowledge is never a locked door -we can always learn by opening it from time to time.

Of course I have never been able to keep track of my keys, so I suppose I am particularly vulnerable. The other day while I was meandering through my apps, for example, I stumbled upon an intriguing essay in Psyche: https://psyche.co/guides/how-to-cultivate-shoshin-or-a-beginners-mind

The author, Christian Jarrett, a cognitive neuroscientist, writes that ‘The Japanese Zen term shoshin translates as ‘beginner’s mind’ and refers to a paradox: the more you know about a subject, the more likely you are to close your mind to further learning.’ He cites several historical examples of the inability to accept new findings, including one that promises my increasing years the hope of new clothes: ‘belief in the legendary Spanish neuroscientist Santiago Ramón y Cajal’s ‘harsh decree’ that adult humans are unable to grow new neurons persisted for decades in the face of mounting contradictory evidence.’

But, of course this is hardly confined to academia. Expertise in any field breeds hubris. ‘Merely having a university degree in a subject can lead people to grossly overestimate their knowledge… participants frequently overestimated their level of understanding, apparently mistaking the ‘peak knowledge’ they had at the time they studied at university for their considerably more modest current knowledge.’ In fact, ‘there is research evidence that even feeling like an expert also breeds closed-mindedness.’

Jarrett then suggests something obvious: ‘Approaching issues with a beginner’s mind or a healthy dose of intellectual humility can help to counter the disadvantages of intellectual hubris… being intellectually humble is associated with open-mindedness and a greater willingness to be receptive to other people’s perspectives.’

Good idea for sure, but how can a dyed-in-the-wool expert stoop to conquer their own hard-earned arrogance? One way that I thought was clever was ‘to make the effort to explain a relevant issue or topic to yourself or someone else in detail, either out loud or in writing. This exercise makes the gaps in our knowledge more apparent and bursts the illusion of expertise.’ It also makes me think of that famous quote from St. Augustine: What then is time? If no one asks me, I know what it is. If I wish to explain it to him who asks, I do not know.

But, I have to say there is another method that Jarrett suggests, almost as an addendum, that has to be my favourite: ‘deliberately invoking in oneself the emotion of awe. Several studies have shown that awe quietens the ego and prompts epistemological openness’. In other words, ‘Gaze at the night sky, take a walk in nature, or listen to a stirring symphony. Any activities that invoke in you the emotion of awe (wonder at the enormity and beauty of the world) will increase your feelings of humility, and inspire a more open-minded perspective.’

The essay reminded me of something that happened to me many years ago while I was in the thrall of my freshly earned medical degree. Nancy, my date and I had been invited to her uncle Arvid’s house for dinner, and I suppose I felt a little intimidated sitting across the table from a recently retired professor of history. I don’t know why I was uncomfortable. He was an absolutely delightful man who was so energetic when he spoke that his arms seemed to explode upward as if they were spring-loaded. He wore his snow-white hair long and each time his hands unfurled to make a point, a curly lock would roll onto his forehead and his eyes would twinkle in response as if he found the whole thing hilarious. Sophie, his wife, was all smiles, as well, although she wore her hair short and could only resort to smoothing it out each time she laughed.

It was clear from the start that they wanted to put me at ease, and Arvid was careful that he didn’t seed his usually witty remarks with historical references; he didn’t even mention the university position he had held. But I wanted to let Arvid know that I, too, was interested in history and knew something about his area of specialization: the French Enlightenment. Well, actually I only started reading about it when Nancy told me about the dinner.

During a lull in the conversation when we were helping ourselves to dessert, I decided to make my move. “Is it true that the Little Ice Age may have played a part in the French Revolution, Arvid?” I asked, as casually as I could manage.

Arvid smiled at me as he scooped some strawberries from a bowl onto his plate. “Climate was probably a factor, G,” he replied pleasantly. “But all of Europe was affected by that as well.”

“I suppose I was drawing a bit of a parallel with current climate change issues -although certainly not an Ice Age…”

“You mean the effects that major climate shifts may have on political stability?” He seemed genuinely interested.

I nodded and took my turn with the strawberries. “I suspect that our crop yields may suffer as they did in France with the climatic upheavals of the time…” I left the sentence open so he would know I was only offering it as a possible result.

Arvid seemed to think about it as he scooped some ice cream on top of his plate of strawberries. “That’s an interesting comparison, G.” He took a tentative sample of the dessert and studied the spoon for a moment. “I must say we historians sometimes content ourselves with the proximate causes of events: endemic corruption, increased taxes, and the unaffordable price of bread in the case of the French Revolution…”. He tasted the heaping spoonful and then attacked the dessert more seriously. “I think you have a point, G. I must look into that a bit more…” he added between bites, then glanced at his wife who had been largely silent so far.

Their eyes touched briefly and she smiled indulgently as she no doubt always did when hosting dinners for his many students over the years.

Look the other way, please.

There really are inconvenient truths, aren’t there? There are some things that seem to slip quietly under the radar -things that go unremarked until they  are brought our our attention. And even then, they are perhaps dismissed as unimportant -or worse, accepted and rationalized in an attempt to justify them as tools that enable the greater good of humanity. We, after all, are what it’s all about; our welfare is paramount, not to mention our survival. And when you frame it in those terms, there is little room for noblesse oblige. Survival of the fittest, quickly becomes survival of the ruthless -of the remorseless.

Perhaps I should explain. I live on a little hobby farm in the country, and when I was actively breeding sheep, chickens, and llamas, I was well acquainted with interested visitors, both two and four-legged. Everybody, it seemed, had or wanted, a stake in the game. Friends wanted eggs for their breakfasts, colleagues wanted lamb for their dinners, and I wanted an escape from the city. But, to share with some, was to share with all.

That’s how Life works, I suppose: word gets around, and soon there are all manner of uninvited guests -not all of whom knock, or ask permission. Some just appear -like carpenter ants- but some try not to advertise their arrival, and in fact seem to want to stay out of sight, if not out of mind. They’re the ones I used to worry about -if they’re in the barn, where else might they hide?

Of course I’m talking about rats -not so much the mice which kept my three cats busy in the night. No, the rats who hid in the engine of my pickup truck and ate the plastic off the wires to my distributor, or the battery wires in my car; the rats who patrolled the barn and left their distinctive trail through the uneaten bits of grain I fed the sheep; the rats who also holed up in the woodpile in my garage, and wherever else they could gather relatively undisturbed.

And yes, I declared war on them with spring traps baited with peanut butter, and put warfarin-like pellets in short, narrow little PVC pipes so the cats couldn’t get into them, but alas, the rats outlasted my efforts. Only when I retired and the chickens died in a well-fed old age, and only when I sold the sheep and llamas did the supply of grain eventually disappear -only then did the rats disappear. And I’ve never seen a rat, or droppings since. It reminded me of  the last stanza of Longfellow’s poem The Day is Done:

                                 And the night shall be filled with music,

                                      And the cares, that infest the day,

                                Shall fold their tents, like the Arabs,

                                     And as silently steal away.

I know, I know -they’re only rats, but their leaving seemed so sudden; I came to think of them as having made a collective decision to move their troupe away to greener fields -sort of like the Travellers in Britain with their little trailers, able to leave when conditions are no longer hospitable for them. I suppose I Disneyfied them in my over-active imagination, and yet there was something about their migration that softened their attributes. I’ve never been fond of rats -especially their tails- but on the other hand I’ve always found it hard to believe all of the sinister lore attached to their sneaky habits. After all, they’ve lived with mankind and our middens from the beginning, I would imagine… and we’re both still here in spades. You have to assume a certain degree of intelligence to coexist with us for so long, despite our best efforts to exterminate them.

As these things happen, I tripped over a tantalizing essay co-written by Kristin Andrews, a professor of philosophy at York University in Toronto, and Susana Monsó, a post-doctoral fellow at the Messerli Research Institute in Vienna. https://aeon.co/essays/why-dont-rats-get-the-same-ethical-protections-as-primates

The first three sentences of the article hooked me: ‘In the late 1990s, Jaak Panksepp, the father of affective neuroscience, discovered that rats laugh. This fact had remained hidden because rats laugh in ultrasonic chirps that we can’t hear. It was only when Brian Knutson, a member of Panksepp’s lab, started to monitor their vocalisations during social play that he realised there was something that appeared unexpectedly similar to human laughter.’ And then, okay, they tickled them. ‘They found that the rats’ vocalisations more than doubled during tickling, and that rats bonded with the ticklers, approaching them more frequently for social play. The rats were enjoying themselves.’

Of course, there were some other features, that if further substantiated, we likely don’t want to hear: ‘We now know that rats don’t live merely in the present, but are capable of reliving memories of past experiences and mentally planning ahead the navigation route they will later follow. They reciprocally trade different kinds of goods with each other – and understand not only when they owe a favour to another rat, but also that the favour can be paid back in a different currency. When they make a wrong choice, they display something that appears very close to regret.’ I’ve left the links intact, for reference, in case the reader’s credulity level sinks to the Fake News level.

But, for me at least, ‘The most unexpected discovery, however, was that rats are capable of empathy…  It all began with a study in which the rats refused to press a lever to obtain food when that lever also delivered a shock to a fellow rat in an adjacent cage. The rats would rather starve than witness a rat suffering. Follow-up studies found that rats would press a lever to lower a rat who was suspended from a harness; that they would refuse to walk down a path in a maze if it resulted in a shock delivered to another rat; and that rats who had been shocked themselves were less likely to allow other rats to be shocked, having been through the discomfort themselves.’

The reason the essay intrigued me, I’m sure, is because it has long been a practice to utilize rats (and mice, of course) as mindless fodder for our experimental quandaries. And, there’s little question that it is better to experiment on an animal than on a human, and especially a time-honoured nuisance and villain like a rat rather than a chimpanzee, or whatever. I don’t think I would be prepared to argue their utility for this, nor that until we have devised non-living alternatives -cell cultures, or AI modelling, perhaps- some things will require validation in functioning organisms to advance our knowledge for the benefit of the rulers (us).

My hope, however, is to point out that our hubris may tend to blind us to the increasing likelihood that rats, are not mindless protoplasms living forever in the ‘now’ of their experiences. Are they sentient beings…? I suppose their sentience , like ours, is on a spectrum, isn’t it?

But if we are to continue to utilize them as unwitting research subjects, it seems to me that we should treat them with kindness and a degree of respect. Remember the words of Gloucester after he has been blinded by Cornwall, in Shakespeare’s King Lear: ‘As flies to wanton boys are we to the gods. They kill us for their sport.’ Let us not stoop to that…

Biding the Pelting of this Pitiless Storm

Hubris –the extreme arrogance that was so offensive to the old Greek gods that they reacted with punishment and an exile from grace- is that what this is? I’m not sure anymore… It’s not, perhaps, so obvious as the vaulting ambitions of a Macbeth or the arrogance of a Caesar, nor even the overweening pride of an Oedipus in the Sophoclean plays, and yet… And yet, viewed from a distance, it’s hard not to notice the similarities that inhere in the attitude that End justifies Means, that intentions trump consequences, that methodology is the servant of results –however narrowly beneficent we define them. And it’s important that we not be so blinded by those touted benefits that we ignore other, perhaps less harmful routes, to achieve them.

And what, you may reasonably ask, prompted this jeremiad? It was a study reported in the New England Journal of Medicine (NEJM) on the addition of a second and possibly more powerful prophylactic antibiotic during non-elective Caesarian Sections to reduce post-operative infection rates: http://www.nejm.org/doi/full/10.1056/NEJMe1610010?query=gynecology-obstetrics -certainly a worthy aim, to be sure. Who could possibly take issue with that? Well, in this era of increasing antibiotic resistance, and the unfortunate dearth of replacement antibiotics in the wings, I think not only the study, but also the idea demands more than a cursory analysis. This is not to criticize the intent, so much as to explore alternative roads to the same destination.

Few would argue that antibiotics, when they are deemed necessary, should be used according to the infecting bacterial sensitivities if they are available –or considered expectations as to sensitivities if they are not. It’s why we can no longer use penicillin for everything –not all infections would respond. Surgical prophylaxis (where there is not yet an infection) is one of the few exceptions, and even there, the antibiotics are chosen in anticipation of the type of bacteria that might reasonably be expected in the surgical field (although there are some who believe that their effect is merely that of decreasing the total bacterial load in the area whether or not the expected ones have been targeted). But, nevertheless, we toy with resistance at our peril.

I’ve chosen to link the editorial rather than the study itself because of the insights it offers. The full-length study to which it refers can be accessed via a link in that editorial, however.

As I mentioned, the study by Tita and colleagues, in a randomized trial, attempted to reduce post-operative infections by adding another broad-spectrum antibiotic (Azithromycin) to the usual antibiotic (cefazolin) in non-elective Caesarian sections (i.e. there was some condition in mother or baby that required urgent delivery) where the current infection rate was 12% -and it worked! Compared to the usual group that just received the cefazolin alone, they dropped the infection rate to 6.1% -not zero, but at least an improvement. And, ‘Neonatal outcomes, which were tracked up to 3 months, were similar in the two trial groups.’

But on closer analysis, 73% of the population in the study was obese -and that, plus the fact that the Caesarians were unplanned, certainly added to their risk of infections. So far, so good.

But, as the editorialist wonders, could the fact that these women were obese have meant that the usual dose of cefazolin was inadequate: ‘[…] should the potential pharmacologic benefit of higher doses of cefazolin alone be evaluated further before the addition of a second agent?’

Another consideration leading to the study of adding azithromycin to the regimen, was that it may be useful for eliminating a potentially  infective organism in the vagina –ureaplasma– that cefazolin doesn’t touch. Unfortunately, there are no prospectively adequate data for the contention that the organism was even present in the studied women.

And finally, the azithromycin was more beneficial in those women whose incisions were closed with staples, and there seems to be evidence that staples, themselves, may increase the post-operative infection rate.

So why, you may ask, have I chosen to comment on this rather obscure study –especially since it seems to have demonstrated the benefits it expected? First of all, I think we have to be careful that we don’t lose sight of the forest as we wend our way through the undergrowth. There do seem to be other options that could be explored before the addition of yet another antibiotic –and indeed should be anyway, given the non-zero infection rate even with the addition of azithromycin. Such things as more ‘stringent adherence to infection-control protocols’, avoiding the use of staples in this high-risk population, or even re-calculating the dose of the standard prophylaxis (cefazolin) to account for differing patient weights before deciding to add the new antibiotic.

I don’t mean to be the new Cassandra, issuing thundering prophesies of doom that will not be heeded anyway, or aspersing well-intentioned attempts to improve our lot… And yet we must not forget that consequences follow actions, not precede them. To be fair, we do try our best to anticipate and thereby avoid, or at least minimize them, but history is riddled with examples of unintended outcomes. The road to disaster is paved with should’ves –only seen with clarity, after arrival.

It seems to me that, wherever possible, we should be exploring options that reduce the likelihood of incurring bacterial resistance. And the answer may not lie in the reliance on new antibiotics -new guns for our on-going war with the microscopic world. It’s a battle in which we cannot hope for more than a temporary truce while we search for peace. Without that, as the map makers of old were said to write on unexplored regions, Here be dragons.