Digital Naivete

I suppose it was inevitable; I suppose I should have guessed… When you are charged with consulting on a generation that seeks its information online, there are issues that are only apparent in that venue. And treatment algorithms which don’t take that into consideration are woefully naïve. Doomed to fail.

There are smartphone apps for everything I guess, but in an Ob/Gyne practice like mine, there are only two that my patients seem willing to share with me: obstetrical dating apps that disclose the expected date of baby’s arrival, and period tracking apps. In an age of constant immersion in information sharing and with an understandable need for inclusion in any decision making, I think that both of these programs -especially the menstrual tracker- would be considered especially useful to any women at risk of pregnancy, particularly so if they also suffered from irregular periods. A natural extension of that, then, might be to extend its use. To adapt it for another purpose for which it was not originally intended -a technological exaptation.

But an article a while ago in the BBC news (also an app, by the way) looked at some of the pros and cons of menstrual tracking apps: http://www.bbc.com/news/health-37013217 that raise some serious concerns.

The idea of being able to follow one’s periods without the need to carry a marked calendar around is appealing, to say the least. It might also allow the recognition of a pattern in an otherwise seemingly random sequence. And even with a predictable cycle, other discernibly helpful patterns may become obvious. As one English singer put it: “When you are starting your period or you’re pre-menstrual, the hormones that rush around your body affect your larynx in ways that are detrimental to your singing voice. I use the app to avoid auditions, premieres or really important performances on those days if I can.” And, ‘The app also helps her identify connections with changes in her emotions, eating habits and headaches’.

So far, so good. As that English singer put it: “Being able to chart what happens to you and how you uniquely respond to your cycle is a great way of taking ownership of something that really sucks – but is completely necessary.” Perhaps the more you know about how unique you are (or aren’t) the more likely you are to feel in control –not simply a table of random numbers, a caster of dice… But there is a danger in relying too heavily on a reading and analysis of an app that merely calendarizes a menstrual cycle –especially an irregular one.

Yes, it is generally true that one usually ovulates about two weeks (or so) before the period starts, but each cycle has been exposed to a different set of conditions –stress, exercise, illness, and so on- so the rule is not reliable. Especially for contraception. The time period before ovulation (the follicular phase) while the egg is being readied in the follicle can be quite variable. If not using serial blood tests, or the like, one needs at least temperature charting and/or mucous testing to discover more reliably when ovulation has occurred… and then, of course, it’s probably too late to take precautions to avoid pregnancy.

The phase after ovulation (secretory phase) is also variable –although often less so- for a variety of reasons, so it won’t reliably predict the exact timing of an oncoming and expected period either.

The whole tracker app thing can be thought of as a digital rhythm method. And if you subscribe to that philosophy, a period tracker app may help you to remember when your last period started, so you can practice periodic abstinence. The Mayo Clinic suggests that with dedicated and consistent observance of this method, one might expect a failure rate of perhaps 13%. Although we all must decide what risk is acceptable given our circumstances, it does seem high in comparison with most other forms of contraception. And, ‘[…] the Royal College of Obstetricians and Gynaecologists has warned they [period tracking apps] should not be used as a form of contraception.’

Another thing that worries me about many of these apps –especially the downloadable free ones- is security of the information that you need to submit. As a privacy campaigner for medConfidential –a British privacy advocacy group- points out: ‘[…] if an app is free, consider whether you are paying for it in effect by giving away your data – and investigate where it might be going.’

With the blooming crop of digital savants, I suppose the posting of a cautionary list is merely an annoying Jeremiad from an older, and more naïve generation. And yet, there is more than a tittle of necessity to the reminders. Sometimes even the young need to step back and critically examine what they have come to believe is commonly accepted and practiced amongst their peers. The wisdom of the crowd differs markedly from the wisdom of the individual and although we may wish something to be so, as Plato observed: ‘Real knowledge is to know the extent of one’s ignorance.’

Or, put another way, with all due deference to the digital generation, Shakespeare’s immortal line in Julius Caesar: ‘Your wisdom is consumed in confidence’. Don’t let it be so…

 

 

 

 

 

 

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Why do we Know something?

Knowledge is interesting. But what is it, exactly? What does it mean to say you know something? Plato defined it as being justified true belief, but is it? Take Bertrand Russel’s famous thought experiment: the ‘stopped clock case’, for example. Alice looks at a clock and says it is two o’clock. Well, because the clock does indeed confirm that it is two o’clock, it seems justified; and because it is, in reality, two o’clock, it also seems a true belief. She could therefore be said to know that it is two o’clock… But, unknown to Alice, the clock had actually stopped working exactly 12 hours previously, so did she know that it was two o’clock? Or was it a fortuitous guess and not knowledge?

All this is a little out of my comfort zone to say the least, so I’m not even going to attempt straying into such philosophical realms as the ‘Gettier Problem’ (whether something that happens to be true but is believed, as with Alice, for incorrect or flawed reasons should be counted as knowledge). It is truly thought-provoking, though, isn’t it?

But Knowledge is not just a list of facts that happen to be true –whatever truth is- nor a compilation of disparate evidentiary items. It is not only an encyclopedia, it is a diary as well: the story of why it exists. There is often a purpose to it –or at least in its acquisition there may have been a reason, even if you stumbled upon it by accident.

In other words, there is another way of approaching the concept of knowledge other than how we know something to be true –the Scientific Method, for example- and that is why we know it. And I don’t mean to stir the lid of Pandora’s box with the ‘why question’, nor to intimate some sort of heterodox Creationist linkage, but merely to introduce something that I learned from a patient a few years back -a professor of philosophy at one of the local universities.

Nancy was a thin, forty-seven year old woman who had been sent to me for a recent episode of irregular menstrual bleeding. She was otherwise healthy and somewhat embarrassed at having to see me for something her mother and aunt had managed to work through without having to seek medical advice. Her family doctor had ordered an ultrasound of the pelvis and it had not revealed anything suspicious. In fact it had stated that no abnormalities had been seen to explain the bleeding.

I suggested it would be a good idea to sample the uterine cells with an office endometrial biopsy as a final reassurance that nothing had been missed. But I could see that she was uncomfortable with the idea.

“What are you hoping an endometrial biopsy will find, doctor?” she said suspiciously.

“Actually, I’m hoping to find nothing,” I said in my best, confident voice. “The ultrasound didn’t see anything to worry about…”

An eyebrow slowly crawled up one side of her forehead. “I realize that; my GP showed me the result.” The other eyebrow shot up to join its sister. “So… Why would you want to do a biopsy?”

I get asked this a lot. “Well, the ultrasound is not a microscope. It can’t tell anything about the type of cells that are in there.” She still looked unconvinced, I have to say, so I pulled out another of my usual analogies. “I suppose it’s something like trying to make a diagnosis from a shadow. You can guess a person’s height and perhaps her weight from her shadow, but even if you could tell she had long hair, you would have no idea of its colour. Nor would you know anything about her heart.”

Nancy was quiet for a moment, obviously thinking it through. I could tell from her face that she thought it was a rather clumsy explanation -not well conceived, and not terribly illustrative of her problem. “So,” she finally said, looking up at the ceiling for help, “The ultrasound is normal, the blood tests my GP did suggest I’m in the menopausal transition now, the abnormal bleeding only occurred in one menstrual cycle a few months ago, and I’ve been doing well since then…” She dropped her eyes onto my face and left them hovering there for a moment as she shook her head. “Tell me again why you think a biopsy would be a good idea.”

I have to admit that when she put it like that I had second thoughts, but nevertheless I pushed on, regardless. Was I just trying to save face, or was there truly a principle at stake? “Well… clearly there are different ways of approaching your bleeding… But if we do the biopsy, and it is normal, then at the very least we will have a baseline that reassures us that if it happens again in the near future, we can probably assume the cells are still normal…”

Nancy was good; she could read the hesitation in my voice. She smiled gracefully, but it was a polite smile. “Wouldn’t it make equally good sense to wait and see if it starts to happen more frequently and then do the biopsy?”

She had me. “Yes, I suppose that is an equally acceptable option.”

She sat back in her chair, crossed her legs, folded her arms across her chest and stared at me –not unkindly, not aggressively, but curiously, like a mother might watch a mischievous child. “I won’t ask you how you came to that conclusion, or how you know that a biopsy might be justified. Those are all fairly standard medical teachings, as I understand…” Her face wrinkled in concern. “But I’d be curious as to why you know that.”

I returned her stare. Why I knew that? Why does anybody know something? Because they read it, or were taught it, or figured it out… Why indeed?

“We all have options in our learning,” she continued. “There are many opinions to which we are exposed, rival paradigms, competing theories. And they all promise success; they all answer the questions differently. Like a hundred people crossing a single bridge, it’s not the same bridge for any of them. It’s a hundred bridges…”

Her face softened, like a teacher that realizes she has confused her pupil. “From all that reality has to offer, we have to decide what to privilege. There are just too many routes to the truth to take them all. We have to choose…

“But why do we choose one view, one approach instead of another? That’s what I’m asking.” She sighed, as if even the question, let alone the answer to it, was hopeless. “Why do you know one thing and not something else?”

Her question still troubles me. I had no answer for her then; nor do I now. I still wallow in the permutations and combinations of perpectives I confront daily and wonder how I manage to choose my direction without getting lost. Maybe it’s a confirmation bias: I have come to believe in the correctness of a particular viewpoint over the years and so only consider the evidence that confirms it. The diagnosis that points that way. And if the results don’t justify the approach? Well, there’s always rationalization to light the path I’ve chosen.

But do I really know why I know what I do, believe what I believe, think what I think? No, not so far… and yet the fact that I’m even aware of the discrepancy, and see the signs to other roads, is a good start isn’t it? As Marcel Proust wrote: The real voyage of discovery consists not in seeking new lands but seeing with new eyes.

Can Anyone Laugh?

Frailty, thy name is woman, Hamlet said, upset about his mother’s behaviour. Perhaps Turkey’s Deputy Prime Minister Bulent Arinc had bad memories of the play. In a recent speech on moral corruption in Turkey, he is quoted as saying that : “Chastity is so important. It is not only a name. It is an ornament for both women and men. [She] will have chasteness…. [The woman] will know what is haram and not haram. She will not laugh in public. She will not be inviting in her attitudes and will protect her chasteness.

http://www.syracuse.com/news/index.ssf/2014/07/deputy_prime_

minister_of_turkey_says_women_shouldnt_laugh_in_public.html   

She will not laugh in public? This part, at least, is so patently stupid that I wondered whether it hid a voracious appetite for literature and philosophy -some reference or other to something pedantic or arcane. He is reputedly well educated and intelligent; perhaps he was naively mindful of Nietzsche and his assertion that laughter is an escape from the prison of reason and logic, while also having the potential of expressing social conflict. Maybe Arinc is afraid that women may have reason to stir up social tension.

Too academic? Okay then, suppose he has read Henri Bergson who felt that laughter may eliminate eccentric behaviour because it derides those who deviate from social norms… On the other hand, maybe he hasn’t: I suspect this is a bit more of a Mobius strip than Arinc would like.

Well, there’s always Plato, who didn’t feel that laughter had much value for human experience and in fact may be malicious. He argues that laughter is a malicious reaction to the domination over a more unfortunate member of society, and those occasionally engaged in laughter are exposed to something base which should be avoided. (Many of these quotes are from Sewanee Senior Philosophy Essays:

http://www.sewanee.edu/philosophy/Capstone/2002/Greenfield.html)

But of course Arinc would then be cognizant of the various classical theories of laughter – the three most mentioned ones being: Superiority Theory which is the one advanced by Plato and which suggests that “all laughter is a response to the comical ignorance in others.” And then there is the Relief Theory engendered by stress or anxiety. Another would be the Theory of Incongruity which is a reaction to something unexpectedly inappropriate…

But these don’t seem to capture the thrust of his argument. Maybe he understood the impenetrable words of Thomas Hobbes: “The passion of laughter is nothing else but sudden glory arising from sudden conception of some eminency in ourselves, by comparison with the infirmity of others, or with our own formerly.” –although isn’t that just the Superiority Theory disguised by words..?

My own theory is that he was unduly influenced by the Wikipedia take on Herodotus:

For Herodotus, laughers can be distinguished into three types:[32]

  • Those who are innocent of wrongdoing, but ignorant of their own vulnerability
  • Those who are mad
  • Those who are overconfident

Why not Wikipedia? It’s easily found, easily assimilable and, in a pinch, easily editable. And it would be simplistic enough to appeal to people who are only half listening to his speech. Who only half remember his words. Too bad he didn’t plagiarize the page –then he could have been exposed for more than just propounding a silly statement. But no, he decided to try on the philosophical garb of religious authority.

And yet, when I actually stop and think about what he said, I have an uneasy feeling that his comments were not steeped in philosophy –Western philosophy, at any rate. They seem to emanate from an assumption that women are beginning to assume a too prominent –too equal–  role in Turkish society. You note that he uses the term ‘haram’ to contain a woman’s actions. As I understand the term, it is an Arabic one of Islamic jurisprudence employed to designate any action forbidden by Allah, and referred to in the Quran as such.

Clearly I am not an Islamic scholar and may be way off the mark, but I cannot seem to find any prohibition on laughter –male or female- in my research. It doesn’t appear to be haram… So what is Arinc talking about? Occuring as it does in a speech for an Eid el-Fitr meeting July 28, it is not likely to be a simple off-the-cuff remark.

http://www.hurriyetdailynews.com/women-should-not-laugh-in-public-turkish-deputy-pm-says-.aspx?pageID=238&nID=69732&NewsCatID=338

No, I suspect this was an ill-conceived, and terribly naïve attempt to curb the rising power of women in Turkey. It no doubt disturbs the sleep of those in power –those with vested interests in maintaining the archaic status quo. But by using the religious card, it is all the more abhorrent. That any religion –any culture, for that matter- would proscribe laughter for its adherents is itself ridiculous. Unbelievable. Risible…

At the risk of parsing the stereotype, let me return one final time to Shakespeare –this time to Valentine in The Two Gentlemen of Verona:

“That man that hath a tongue, I say is no man,                                                                                   If with his tongue he cannot win a woman.”  

Listen up Arinc; the world is waiting…and laughing.