Fairness Which Strikes the Eye

Sometimes it seems we cannot help ourselves –the pull of the tide is just too strong to resist. And sometimes an argument, when considered too quickly, too uncritically, captures us with its ostensibly intuitive wisdom. We have no need to question it. No need to probe the basis of its logic.

The rhetoricians of old were well versed in this form of argument –the art of persuasion and how to best achieve it. Aristotle, for example, suggested three essential features of a convincing argument: ethos –the credibility of the contention; pathos –understanding the needs and emotions of the audience; and logos –the patterns of reasoning and the words chosen. His wisdom, although modified and woven into the contemporary tapestry, has not been lost in modern times.

What could provoke a greater sense of outrage in a population than the 1% contention? That is to say, in at least one of the iterations fostered by the Occupy Movement, that in the United States, 1% of the population controls 40% of the wealth. And to many, that unequal distribution of wealth, is symptomatic of what is wrong with Capitalism. It certainly resonates with those of us in the 99% who hear it. It begs for remonstrance; it demands rectification.

And yet there are usually many sides to a story –or at least this one, at any rate. There are times  when we need to move back a step or two in order to appreciate the different perspectives. Even so, I have to admit that an article in the BBC Future series came as an intriguing surprise: http://www.bbc.com/future/story/20170706-theres-a-problem-with-the-way-we-define-inequality It allowed me to entertain an alternative that I had not even considered.

As they tease at the beginning, ‘Some researchers argue that income disparity itself may not be the main problem. The issue, they say, is not the existence of a gap between rich and poor, but the existence of unfairness. Some people are treated preferentially and others unjustly – and acknowledging that both poverty and unfairness are related may be the challenge that matters more […] While many people may already view inequality as unfairness, making the distinction much clearer is important.’

They go on to say that ‘In a paper published in April in the journal Nature Human Behaviour called ‘Why people prefer unequal societies’, a team of researchers from Yale University argue that humans – even as young children and babies – actually prefer living in a world in which inequality exists. […] Because if people find themselves in a situation where everyone is equal, studies suggest that many become angry or bitter if people who work hard aren’t rewarded, or if slackers are over-rewarded.

‘“We argue that the public perception of wealth inequality itself being aversive to most people is incorrect, and that instead, what people are truly concerned about is unfairness,” says Christina Starmans, a psychology post-doc at Yale who worked on the paper.

“In the present-day US, and much of the world, these two issues are confounded, because there is so much inequality that the assumption is that it must be unfair. But this has led to an incorrect focus on wealth inequality itself as the problem that needs addressing, rather than the more central issue of fairness.” And as Mark Sheskin, one of the co-authors remarks, ‘“People typically prefer fair inequality to unfair equality”’.

In a way, a lot of the argument hinges on definitions. There are, after all, several ways to look at inequality: equality of opportunity, equality of distribution of benefits, and of course, equality of outcome. Must all of them be addressed, or is there a priority? Is the existence of a super-rich 1% the problem, or would it be more helpful ‘ to concentrate more on helping those less fortunate, who via a lack of fairness, are unable to improve their situation’?

‘Harry G Frankfurt is a professor emeritus of philosophy at Princeton University. In his book On Inequality, he argues that the moral obligation should be on eliminating poverty, not achieving equality, and striving to make sure everyone has the means to lead a good life.’ Poverty, in other words, is the problem; it is unfair…

I suppose, when considered practically, it would be unrealistic and unduly Utopian, to think that we could ever dispense with at least some degree of income disparity. People ‘don’t typically work, create or strive without the motivation to do so’. It seems to me that the unfairness does not lie in the money fairly accumulated for work done, so much as in the fact that ‘not everyone is afforded the same opportunities to succeed, even if they put in that hard work.’

But, on the other hand, it’s not all simply a matter of the equality of opportunity, nor even of equality, per se. Fairness is something different. The issue of fairness is in a different Magisterium altogether. I’m Canadian, and I believe that no one should have to live in poverty. Not everyone has the skills, or indeed, the capacity to hold a job, even if an opportunity presents itself. Some are disadvantaged by appearance, or gender; some are discriminated against by virtue of their origins, or life-style; some, even, have succumbed to past failures and have given up trying… It is unfair to give up on them –any of them- simply because of the lotteries of birth or circumstance.

Fairness, it seems to me, is universally available and accessible health care. It is a living wage that allows even the poorest to feed their family. It is safe and obtainable shelter. It is the respect afforded even to those we do not understand. It is toleration of difference, even when the rest of us may not understand, or agree with it.

It seems to me that inequality, by itself, is not what drives revolutions. Inequality is not what causes societies to weaken and their moral fabric to unweave. Inequality is just the chipped and discoloured veneer most easily visible on the surface. What festers directly underneath, sometimes only detectable when the surface weakens or is pulled asunder, is inequity. Injustice. Unfairness… Poverty, unlike wealth, offers little protection. And that is the iniquitous thing.

For some reason, I’m reminded of Shakespeare’s King Lear: Through tattered clothes great vices do appear; Robes and furred gowns hide all. Plate sin with gold and the strong lance of justice hurtless breaks. Arm it in rags, a pigmy’s straw does pierce it.

Prove me wrong…



The Doors of Persuasion

The Doors of Perception, by Aldous Huxley -I loved that book; I read it when I was a teenager and was intrigued by the idea that there could be doors to abstractions as well as to rooms -doors to other areas, other places. Invisible portals that existed alongside more tangible things, and yet magical, somehow -like the door to Communication.

Communication is such an obvious and basic requirement to enable us to function that it is often invisible until pointed out. Almost everything we do is a form of communication; writing, creating, building -perhaps even imagining- are all done for someone else to notice –despite our ego-dominant protestations to the contrary. We, none of us, live in a vacuum –nor would we be able to, even if we mistakenly thought we might like to try it for a while.

No, the need to communicate is a given; we are social creatures. And there are many reasons for it: to reach out and feel the presence of another is a major one -to share the solitude we all inhabit and reassure ourselves that we are not alone.

And yet the other main purpose of communication –the imparting of information- can be more difficult. Is more difficult. We are all unique, and we guard the differences behind a variety of walls: culture, education, gender… There are so many ways. So many reasons. So many locks on so many doors. The art of communication has always involved the art of persuasion; to open a door, you must first want to open it -and trust that what is on the other side is neither harmful, nor antithetical to what you have become accustomed to, or are able to accept. Willing to accept.

In medicine, to open doors, we have often relied on the magic of arcane knowledge. But although communication through authority can force, it cannot persuade. Cannot convince people that what we advise is necessarily in their best interest, especially if the advice flies in the face of what they have always believed, what those around them have always lived, or what their culture or milieu has always prohibited. There is always other advice, other authorities they can consult that harmonize more readily with what they have been taught, so why should Western Medicine, as we have come to classify ourselves, be specially privileged?

I’m not convinced that in all cases, and in all circumstances it should be. There is usually not one answer that suffices, not just one approach to a problem. But if someone has come to a doctor for advice, or more unfortunately, has been swept into his purview through circumstances not of her choosing, it would be helpful to approach the issue with all the respect it demands. The trust one engenders as the doctor is assigned; it has not yet been earned on that first encounter. Authority of the sort we as doctors possess breaks down rapidly when it attempts to enforce an opinion. Contradicts a belief.

If I, for example, say that something is my belief, I may be closing a door unless the person to whom it is addressed already shares that opinion. Especially if uttered in a fashion or in a circumstance that negates the other person’s opinion -makes them lose face, or does not allow for a compromise that permits their own beliefs, and makes allowances for their own cultural practices. I am not talking life-and-death situations where emergency surgery is required to remove a ruptured appendix, say, or an antibiotic is needed to rescue the body from an overwhelming sepsis… More the situation where there may well be other options –some, perhaps not as appropriate or effective, but where the choice could still be construed as a matter of opinion –mine.

Each of us is the agent of our own lives and we should be free to decide for ourselves what path to walk. Some choices may be unwise and later we may wish we had chosen something else, but wherever possible, the choice should not be forced upon us. And indeed, one of the major premises of medical ethics forbids just that: the principle of autonomy –we should be free to choose whatever option we wish, even if the doctors disagree.

So, if we feel persuaded about the validity of our own beliefs, our own view of the world, it behooves us to unlock the doors of persuasion, not coercion. We are not always right –and that is surely not the point- but we have the best interests of our patients at heart and believe we can help. We do that by earning their trust, their respect, and their confidence. The object, after all, is not to prove that they are wrong and we are correct, but rather to help them to see that, in the face of the legion choices they could make, the one we suggest is most likely to produce the results we both desire.

I sometimes find that is the hardest part. It is difficult for me to listen sensitively to a monologue on ‘cleansing’, say, when I do not accept the thesis that disease is caused by toxins in the gut that need to be removed. It smacks too much of bloodletting, or leeches, of purgatives and enemas, of spells cast on the unwary… Attestations that the poor heart would fain deny, yet dare not. Even placebos help for a while, after all -it is the kingdom of Hope.

But it is not enough to merely try to keep an open mind -as the King says in Hamlet: My words fly up, my thoughts remain below: Words without thoughts never to heaven go. The object, where ever possible, is to stop for a moment to listen -no matter what is said. There is often fear in the other voice. And it’s a dare of sorts that the patient issues: ‘Prove me wrong; convince me if you can -I need something- but first, listen, then explain your point of view. Let me believe I have been heard…’

I want to believe that hope springs eternal in both our breasts.