Bullying by Medical “Professionals”

At my yearly check-up my family doctor found that I had a high PSA (prostate specific antigen) reading: 133. Anything over 5 is a serious warning of prostate cancer. So she sent me to a urologist to check for cancer, though it took 2.5 months to get an appointment. I wasn’t worried because I have no symptoms. Still, I thought about what I would do if there is cancer. If it’s metastasized, no treatment, certainly not chemotherapy since I’ve seen friends suffer and die from that before the cancer got them. I figured my best treatment plan would be spontaneous remission. I really wasn’t worried, though I did make some plans for what to do with a last year of life: I went out and bought lottery tickets and a bottle of good scotch.

So I go to the urology clinic. They take my vitals and have me fill out some questionnaires. I tell them I have no symptoms at all. Then the physician’s assistant says that she is scheduling a biopsy for me. She’s marking that down on the chart. Then I ask: what’s a biopsy? They go through your lower bowel, puncturing it and taking samples from your prostate. And what are the risks? She tells me, and they are substantial, possibly life-altering. So I say, no biopsy thanks. And she says “Knowledge is power!” And I think “Ignorance is bliss.” I ask her for more information, and it’s clear she is reciting from a memorized script, ready to move on to the next patient. I object and want to talk to the physician. That will take 6 weeks I’m told. I object more and finally I talk to the clinic supervisor, who is a nurse with lots of clinical experience in urology. She goes over options, and I agree to have scans done that will tell us if there is cancer, though not if it’s slow-growing or fast-growing. Only a biopsy will do that. So I get two scans at the hospital the next week. And I also ask my family doctor to do another PSA test.

When the results are in, I see my family doctor. She is wonderful, so clear and helpful, working with me about what to do. The results: no sign of cancer at all. If there is any cancer it must be miniscule, and with no symptoms don’t worry about it for another year. The PSA test came back at 133 again, and that is really strange, but apparently it can happen.

So I call the supervisor of the clinic and tell her that the results show no cancer. And she says we should do a biopsy. I said no, just cancel my follow-up appointment.

Can you say “Overtreatment”? The cure and testing are worse than the (possible) disease.

So why am I telling you folks about this? It’s not (just) because I am a garrulous old man who wants to tell everyone about his health. I really don’t want to share my medical history. But it is such a perfect example of how people get bullied by medical “professionals”. If I’d just gone along, I wouldn’t have made a bad decision. I wouldn’t have made any decision at all. The physician’s assistant and the supervisor would have made the decisions for me. No talk even of risk versus benefit. And that’s why I’ve written the new book *How to Reason*. It’s a small book, based on the old *Pocket Guide to Critical Thinking*, but better (I used my experience teaching in the local jail). It’s meant to lead to the final section “Making Decisions”, which has a chapter on evaluating risk that includes a part on medical decisions.

We, all of us, need to know how to stop and reason, how to think in order to make decisions. And crucial to that is learning how to evaluate risk. Your life is your own. Don’t give it away to a medical “professional”.

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TIME and FREE WILL

“The Tapestry of Time” from the 2018 draft of *Time and Space in Formal Logic*

Let us suppose:

Some of what we do we choose freely to do.

Consider, then, the following picture. At every moment at which a free choice is made, the world branches. So there is a split at the moment at which I chose to sit down to type: in one branch I sit down to type, in another I do not. But that branching is not just a single splitting. Rather, there is a different path according to any of the choices I might have made: go for a walk, play with my dogs, go inspect the sheep corral, stick my head under a faucet to ease my allergies, . . . .

Similarly, the world branches depending on whether this electron moves to this or that energy level in this atom, if such movements are random. Particular random happenings and particular free choices in any combination lead each to a different branch.

At each “moment” there is a multiplicity of branchings, beyond our ability to comprehend except one branch in comparison to another specific branch.  These branchings continue on. What we call “a branch” is just a particular path through all such moments at which a free choice and /or random happening occurs. We do not have any reason to believe that any branch ever stops; nor do we have any reason to think that any branch does not stop. Nor do we have any reason to believe that each point on each branch has a unique path to it: there might have been many ways to arrive at the same point. If we count memory as part of our path, though, then a conscious free choice creates a branching that cannot be reached by any other branch. But a random act of an electron could lead to a point that could be reached by other random physical happenings. This is a way in which the internal world could differ from the external world.

Laws of nature, if there be any, give the substratum of all these branchings. When I choose to sit down and type, I do not have any choice in how the chemical reactions in my blood continue. Given this particular disintegration of the radon atom, the Geiger counter will make a sound.
Each branch is real, as real as any other. These are not “alternate worlds”, “alternate possibilities” compared to the world I am in. They are all real, equally real. At a branching, the “I” up to that point continues in a multiplicity of branches, and in each one it is reasonable to say it is the same “I”, for they all come from the same branching. Thus, the “I” of this branch is the same “I” as the one in which I chose to go for a walk instead of typing because they can be traced back to that moment at which the “I”s branched apart due to a free choice. If we had the ability to see all these branches, we could say, “That is one way I might have been had I done that instead of this.”

The world, then, is a tapestry of branchings so multitudinous as to be beyond comprehension in their details: only the general form is conceivable to us. The tapestry is not flowing; there is no movement in the tapestry, only threads that make up the whole. What we call “time” is a branch: the tapestry is oriented, and that orientation is what we call the arrow from the past to the future. What we call “now” is the consciousness we have of being right here on this branch. Every point on every branch is as real as any other: the unreality of the past and of the future, for me, is that they are not at the point that I call “now” on this branch where I am.

We, each of us, choose which branch we follow, though equally, another person, exactly the same “I” up to a particular branching point, chooses a different branch, and then a different branch, and a different branch again forever. There are some branchings in which the “I” of when I was nineteen chose to be mean to her, and one branch, followed through all its multiple branchings, in which “I” from nineteen on lived a blameless life, good to the point of being saintly.

In this conception, free will is fully compatible with the assumption that there is an omniscient God who knows the future as well as the past. God would be the only intelligence that could comprehend all branches at once. He can see the point on the branch of Jesus’ life at which Judas betrayed him and see a branching where Judas did not betray Jesus: in all the branchings that followed the one choice, Judas is damned; in all the branchings that followed the other choice, Judas is saved. Or perhaps not: in some of those branchings he may have repented and been saved; in some of those branchings he could have betrayed Jesus also. Only God knows.

Now all we need is some empirical evidence to support this view.

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A Question in Metaphysics and a Question in Ethics

Someone was visiting me, we were the only ones at Dogshine. The radio was playing music when we went for a walk. When we got back the radio was playing music. I asked my friend, “Do you think the radio was playing music all the time we were away.” She said, “Yes.” So I responded, “In that case, where did the music go?”

If a dog barks his head off in the forest for a long time, and there’s no human around, is he still a bad dog?

Arf (aka Richard L. Epstein)

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It’s So Easy to Count

Even small children do it. So what does it mean to say that some collection is countable? Here is what I recently published in Think.

Recently I had a short conversation that helped bring into focus different views of the nature of mathematics. My student Esperanza Buitrago-Díaz and I went to the airport to pick up Henrique Antunes Almeida for his first visit to my research institute, the Advanced Reasoning Forum. On the way home I mentioned that we have sheep there.

Henrique: How many sheep do you have?

Me: I don’t know. Every time I try to count them I fall
asleep. . . . They’re uncountable.

Esperanza: That’s ridiculous. That’s not uncountable.
I can count them.

I was taking “countable” to mean: can be counted by me. That’s a completely subjective, personal standard. So my sheep are uncountable.

Perhaps, though, countable should mean: can be counted by almost anyone. That’s an intersubjective standard. It would seem that by that standard my sheep are countable. But I’m not sure, since my friend’s six-year old can’t count them. We’d have to give some clearer description of what we mean by “almost anyone” for this to be a useful definition. And then we’d have to add that they (almost always) get the same number.

Such an intersubjective standard would make the number of stars visible in the night sky at my ranch January 6, 2014, uncountable. Yet we feel that those are countable. But by what standard? You might say that it’s because there aren’t an infinite number of them, to which I’d respond: How do you know? If you can’t count them, then there might be an infinite number of them: there’s no functional difference. Perhaps you could invoke some analysis in physics to show that there couldn’t be an infinite number of them. Would that make it clear that they are countable?

It seems that a different standard is being invoked: can in theory be counted. That “in theory” is the refuge of someone who wants to keep the notion of countability close to what we can do, but without our poor human limitations. It must mean something like: a person who had unlimited time and attention and memory could count them. That’s a
considerable abstraction from our own capacities, yet still grounded in abstracting from those. This is the kind of definition Turing proposed and we now accept for the notion of computability.

Or we could say that our capacities are of no concern in defining what “countable” means—not what we mean but what it does mean, the reality of it. And that is simply: there is a one-to-one, onto function from either an initial segment of the natural numbers or from the entire set of natural numbers to that collection. This gives a definition that is clear. It assumes, however, some kind of abstract, impersonal notion of natural number and counting.

Sometimes that fully abstract definition is made a little closer to human abilities: there is a constructive one-to one, onto function from either an initial segment of the natural numbers or from the entire set of natural numbers. That however, requires a supplementation to the notion of computability to cover functions to or from collections other than numbers.

Only two definitions of “countable” are clear, entirely precise, and require no supplementation: the fully subjective and the fully abstract. The former is clear but does not lead to a shareable standard. The latter is clear but removes the notion from our lives, except to the extent that we can actually construct an enumerating function.
These different standards reflect different conceptions about how we do or should do mathematics, conceptions which have been adopted by both mathematicians and philosophers, though I shall not try to enumerate those here.

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The PROBLEM of EVIL and the MEANING of LIFE

A short review

How can there be a benevolent God when the wicked prosper and the just suffer?
What is the meaning of life?


Here are short summaries of how some have answered these questions.

ECCLESIASTES
I’m going to die!
You’re going to die!
We’re all going to die!
Whine, whine, whine.
So I better fear God.

BHAGAVAD GITA
This guy is ready to battle his cousins and teachers to gert a crown or to die.
He doesn’t want to kill them–he realizes it would be wrong.
The god Krishna says it’s O.K. to kill them because it’s part of his bigger plan, and don’t worry, they’ll all be reborn anyway.
So the guy says O.K. and kills them.

The RUBAIYAT
We’re all going to die!
So let’s get drunk.

JOB
Job: It isn’t fair, the wicked prosper and the just suffer.
God: Who are you to complain?
CRASH! Fear me.
Job: OMG! O.K.

DOCTOR FAUSTUS
Power! Riches! Lust!
Enjoy it for a long time.
Then you’ll go to hell.

SERMON on the MOUNT
Be kind.
Be generous.
Do no violence.
Love God.
And if you do, your suffering will be redeemed in heaven.
And if you don’t, you’ll go to hell.

An Analysis:
If you are wicked, then you will suffer.
You are suffering now. Therefore you are wicked.
Bad reasoning (affirming the consequent).
Need: Only the wicked suffer.
Only the good prosper.
[The mediocre just get by?]
This goes against our experience.
So 1. The wicked really do suffer–they just don’t realize it.
or 2. You’re looking at it too short term. The wicked will suffer in the afterlife, and the good will be happy in the afterlife.
So against our experience, either we should be satisfied because “suffering” doesn’t really mean what you thought, it includes unconscious suffering, and/or believe in an afterlife that redeems justice.

The BARK of DOG
Be kind.
Be generous.
Count not the giving and taking but give unconditionally.
Harm no human.
Harm no dog.
Put from thee all thought of power save the power of a loving heart.
All sentient beings have the chance to learn to love.
But there is no deep love without suffering.
There is no heaven above the earth: heaven is here, giving and sharing.
There is no hell beneath the earth: hell is here, knowing you could have helped but didn’t.

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Addiction

Perhaps you know that I’ve been trying to help folks with addiction. You can read about how I taught critical thinking and non-violence to the inmates in the local jail (there’s a link to “Teaching Addicts” on the homepage of the Advanced Reasoning Forum, http://www.AdvancedReasoningForum.org). Alex Raffi and I have written a draft of a comic book about addiction, “Addiction in the Body—Too Good Is Just Awful” (also on the ARF homepage).

There is much we can do to help. We can teach critical thinking. We can lead people to see a better life through our understanding not of theoretical ethics but of a way of non-violence. You can find how I teach a way of non-violence in my translation of “The BARK of DOG” (the Introduction of that is on the website TheBARKofDOG.org).

Though many people have approved of the essay “Teaching Addicts” and have told me that the approach is excellent and I should continue, I found that I couldn’t take the program into prisons and rehabilitation centers because they accept only “evidence-based” programs. Catch 22: you can’t teach it because there’s no evidence it works, but you can’t get evidence because you can’t teach it. Yet, the more I considered it, that wasn’t the problem. The problem is what is meant by “evidence-based program”.

So I set out to find what was meant, reading some papers and books. Then I set those aside and asked what we could do in evaluating treatment programs for addicts. First, there is the large problem of deciding what is meant by saying that a treatment program is “effective”. This involves values and goals, an analysis to make clear the assumptions behind various prescriptive claims. Some programs are deemed in need of evidence, others not, and the criteria for whether a program requires evidence are not made explicit. For example, it seems that administrators do not ask for evidence that teaching reading helps addicts. Nor do they ask for evidence that Bible classes help addicts.

Second, administrators want objective data as evidence. Yet that is rarely linked to the unstated subjective conclusions that are hidden in the objective conclusions. Ending addiction is not ending just certain behaviors, because all definitions of addiction use subjective criteria.

Third, any evaluation is an attempt to establish causal relations: this program helped this person, or this program–via a cause-in-population study–is likely to help these people. Just going from basic observations about what is meant to be studied, I found that there is very little, perhaps almost nothing that can be established in the way of causal claims about the effectiveness of any addiction treatment
program. I’ve written up a draft of that analysis, which you can get from me if you like. But it needs a lot more research to show how the analysis plays out in specific evaluations that have been done, and for that I would need funding.

Then I read the book Heavy Drinking: The Myth of Alcoholism as a Disease  by Herbert Fingarette, written in 1988. It is a superb analysis of just the issues I was worried about, though only for alcohol addiction. Fingarette uses the best of the skills of critical thinking and philosophy to piece out what we do or should consider in treating
alcohol addiction. He shows that the programs for treating “heavy drinking” have not been shown to be “effective”. The work is a masterpiece we can all learn from.

There is much that we can do to help. We can teach addicts. We can encourage addicts to find a better way. We can learn and then teach others about the nature of addiction and what can be done to lessen the problems of addiction.

To do this, we use our skills in reasoning and in philosophy, and theology and ethics. I have based my work on the analysis of cause and effect in my critical thinking books, which I have set out in scholarly form in my book of essays Cause and Effect, Conditionals, Explanation”.  I have drawn on the analysis of how to reason with\ subjective claims that Fred Kroon, Bill Robinson, and I have given in
the essay “Subjective Claims” in my book of essays The Fundamentals of Argument Analysis. And essential also is knowing how to reason with prescriptive claims, which I describe in my book Prescriptive Reasoning.  But don’t wait to read all those before you start.  Begin now, so that you can integrate your experience with what you study.

There is little that works in helping addicts quit. But some does. We need to help those who are addicted, those who are hurt by the addiction of their family or friends, and help those who must decide how to spend money on addiction programs to understand and make good decisions.

Critical thinking is not a theoretical skill but a practical guide to reasoning that should, indeed must, have an ethical basis and good goals. And for that, we need virtue.

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Why Cost-Benefit Analysis Cannot Be the Basis of Ethics

An article about morality and ethical choices has just appeared in Think, number 50, pp. 85-89, “Organ Donor or Gratuitous Moral Failure” by Luke Semrau. It provides an excellent example of what can go wrong in ethical analyses if you don’t know how to reason with prescriptive claims.

Semrau first introduces an example from Peter Singer. “Imagine walking past a pond in which a small child is drowning. You can safely save the child’s life but only at some expense to yourself: your shoes will be ruined. There is widespread agreement that in this situation you ought to save the child. . . . The cost to you is simply so low, and the benefit secured is so high, that on any plausible view you should perform the rescue.” Semrau makes a similar case for why one should be an organ donor: the benefits far outweigh any likely costs to the person who checks a box on his or her driver’s license to donate organs in the event of death.

In “Reasoning with Prescriptive Claims” in my book of essays Prescriptive Reasoning I present two distinct ways to evaluate prescriptive claims. In the first, one accepts a prescriptive claim, like “You should not torture dogs”, on the basis of some standard. Perhaps in this case it might be standards from the Bible or the tenets of Buddhism. Or one might take the claim to be itself a standard, not depending on another. Debates about whether to accept a prescriptive claim then focus on our basic standards, which typically can be compared for their consequences but cannot be directly judged as better or worse any more than metaphysical claims can, beyond the issue of coherence. How we derive a prescriptive claim from other claims requires an analysis of what counts as a good inference that involves prescriptive claims, for simple validity is not sufficient nor perhaps necessary, as
I show in my paper.

In this approach, we ask why a cost-benefit analysis should be adopted, for that is the standard from which Semrau (and Singer apparently) derive “You should save the child”. But reliance on cost-benefit analyses does not seem to be an irreducible standard, a basic belief that we can (or should) all agree on. That’s because we must ask what counts as cost and what counts as benefit?

For someone who has never had shoes in her whole life, who has just got her first pair of shoes, whose whole life is summarized in her pride or satisfaction in having shoes, the cost of saving the child’s life seems very high (compare Gogol’s “The Overcoat”). To dismiss the cost of losing one’s shoes reflects a culture in which everyone can have a pair of shoes, either purchased cheaply or given from some charitable organization. For someone who believes that the only hope for humanity is to reduce the number of people on the earth, saving a child’s life seems a gratuitous insult to all of us. We can dismiss or minimize the significance of such views, but not with another cost-benefit analysis–only on the basis of more substantial prescriptive standards.

The cost-benefit analysis works even worse with organ donor choices. Semrau does not consider that for some religions it is a prescriptive standard that a person must be buried with all his or her body parts. No benefit to oneself or others can possibly outweigh that.

The other approach to reasoning with prescriptive claims is to justify them as best leading to satisfaction of certain aims. Thus, “Dick should close the window” is justified because it is the best way (in context) for Dick to stop shivering from the cold breeze. There can be subjective, intersubjective, and objective aims. I do not see what aim could justify us in adopting cost-benefit analyses as the basis of making moral choices. It is not just the problems of what counts as cost and what counts as benefit. On what intersubjective or objective basis can we say that always doing what comes out positive in a cost-benefit analysis should be done? That is not so far from the whole approach to adopting aims as the basis for evaluating prescriptive claims, but each step of such an evaluation must be justified in a way that Semrau does not. Absent a clear conception of cost and benefit, we are left to ask why the person should save the child, what aim does it satisfy? And for that I can conjecture: saving lives, being an example of good, . . . or one of many other possible aims that we might agree on.

It seems to me that to employ a cost-benefit analysis we must rely on other more fundamental ethical standards, comparing them through
prescriptive reasoning. Or else we must rely on adopting some ultimate aims that are intersubjective or objective. In my paper, I show that
there is no (obvious) translation between evaluating claims according to standards and evaluating claims according to aims.

I take it as a basic standard that we should reason well in making ethical choices; or as an ultimate aim, to reason well in making ethical choices. The cost of learning to reason well with prescriptive claims is small in compared to the benefit of making better ethical choices.

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Dogs and Guns

There’s a small village of about 1,000 people on the mountain near where I live.  Lots of people there have dogs—they consider it their right to have a dog.  But many say there’s a dog problem in the village.  Dogs run loose, leaving their droppings everywhere.  Some people feel threatened by them, and rarely one will bite a bicyclist.  The solution to the problem is for dog owners to keep their dogs under control, most say.

What would you think if someone suggested that the solution is for everyone to get a dog?  And not just any dog, but one trained to be an attack dog.  If you go walking or bicycling, you’d have your guard dog with you.  The village could have a law that everyone will have a guard dog.  And if your guard dog when it’s with you attacks someone, that’s OK as long as you feel you were threatened by that person.

Certainly the companies that breed and train attack dogs will be behind this.  They’ll put up lots of money for the proposal, saying it’s a person’s right to have a dog and to be guarded by a dog.  They’ll help form committees throughout the country to promote ownership of attack dogs, through an organization they’ll call the National Rescue Attack Dogs, the NRA-D.  They’ll promote making a law that everyone should be allowed to take their attack dog with them everywhere, into a school, into a bar, into a court.

Of course with time people will see that the attack dogs are dangerous to everyone, that people can’t control them, and sometimes an attack dog will bite or maul a family member.  But, the NRAD says, that’s the price we have to pay to be safe.  We’ll just make a law that people who can’t control a dog can’t have an attack dog, though still anyone can buy an attack dog from a private person.

How is this different from saying that we can solve the gun problem in this country by arming everyone, by having guards at every school, every church, every synagogue, every mosque, every public building?

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Analogy

When my dog has a wound, an open cut, he licks it and it gets better, really fast compared to when I get a bad cut. So if I get a cut, which should I do?

• Let my dog lick my wound.

• Lick the wound myself.

In peace, Arf (aka Richard L. Epstein)

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