Exploring Level Confusion Through Vices

Exploring Level Confusion with Vices

Level confusion is an incredible challenge, and one that I grapple with all the time. I am never quite sure when to pin something on personal responsibility and when to pin something on structural factors. It is not just vices and negative aspects of an individual I often struggle to attribute to either personal or structural factors. I often cannot tell whether I should praise someone for the good that they do, or praise the structures and systems which allow the individual to do such good. My challenges with thinking about personal level versus societal level responsibility are an example of level confusion and why it can be an important factor to be aware of when we think about the world. According to Quassim Cassam in his book Vices of the Mind, I am not alone in this dilemma.
“Vices themselves,” writes Cassam, “have a deeper explanation in the social circumstances of their possessors. … It could still be true … that some doctors are overconfident but to explain what is actually a systemic or structural phenomenon – medical error – in such personal terms is to be guilty of what might be called a level confusion.”
Vices are in many ways personal. We are often to blame for vices and often have control over whether we acquire a vice or whether we improve our behavior and eliminate vices. But how often we can pin a particular harm or bad outcome on our individual vice is hard to say. Certainly any of us who are called out for our vices could come up with numerous structural factors which enabled our vice or compelled us toward such a vice. Cassam’s quote shows that this can be done within medicine. How much can an individual medical error be pinned on a doctor? Arrogant doctors can probably be expected to make more errors than humble doctors, but how often can an individual error be pinned on a doctor’s arrogance rather than another factor that allowed the error to take place?
Cassam continues, “this discussion brings out just how difficult it can be to decide whether a particular outcome is best explained in personal or structural terms. Having said that, it is also true that the personal and the structural are often intertwined, and that one and the same phenomenon can sometimes be explained at both levels.”
Level confusion is going to always be unavoidable given how complex and intertwined our world is. Ultimately, what I think is important is that we step back from our preferred view, either the personal or the structural, and think more deeply about the alternative role in the outcomes we see. If we typically blame people for their outcomes, then we must step back and recognize the structural and systemic forces that make some decisions and outcomes easier for some and harder for others. If we typically adopt a structural view, then we must step back and recognize the importance of personal responsibility and the necessity of personal responsibility in decision-making. With such level confusion we may never be able to agree on how much personal or structural factors matter, but we can accept the complexity and at least begin to address those factors which allow people to take more personal responsibility, initiating the changes we want to see within the larger structures.
Standard Stories Continued

Standard Stories Continued

“Is there anything wrong with standard stories?” asks Quassim Cassam in Vices of the Mind. “That depends,” he continues, “on one’s view of their two most striking theoretical commitments, individualism and their psychologism: they focus on a small number of individuals (‘designated actors’) and attribute the outcomes they want to explain to the psychology of these individuals.”
In almost any movie we see (I am particularly thinking about Disney movies here) there is a pretty small cast of characters. There are a handful of main characters who interact and drive the story forward, and then a few surrounding characters like co-workers, cousins, or fellow train passengers who are just in the background and don’t really contribute to the story. Standard stories flatten the world, and relying on them too much to understand our own worlds isn’t realistic because we have so many more people who play prominent roles in our lives, or who play important roles at different times, but are not consistently a main character in the story.
Cassam continues, “standard stories are, in this sense, personal and they have plots like those of a novel or a play. According to structuralism that is the fundamental problem. Because of their focus on individuals and their idiosyncratic psychologies standard stories forget that individuals only exist within complex social structures.” The narratives we create in our own minds and the stories we create for movies and television ignore the complex social structures (or at least fail to directly consider them) that drive a lot of our behavior and psychology. We attribute a great amount of influence and power to individual level decision-making. Specific character traits are elevated, describing and defining everything we need to know about an individual, and the correct set of thoughts and traits is all a character in a standard story needs in order to succeed and reach happily-ever-after. Again, this flattens our reality. The real world has complex social structures, institutions, and systems that are not always transparent, hard to navigate, and can limit many of the decisions in our lives.
Finally, Cassam writes, “what that means is that in many cases it isn’t individuals’ psychologies that explain their actions but the constraints imposed by the structures within which they operate.” Standard stories work well in our Western Educated, Industrialized, Rich, and Democratic  (WEIRD) culture in the United States. It highlights the power and possibility of the individual, elevating our decision-making, our hard-working ethos, and our beliefs that our thoughts and actions are what determine our success or failure in all that we do. Unfortunately, the world is more complex than what we see in standard stories. We become over-reliant on explanations for the world based on individuals and their psychologies, and don’t spend enough time thinking deeply about the structures and systems within which we live. Success in a standard story is incredibly rewarding, after all, it is all about you. However failure in such a story is crushing, because it doesn’t acknowledge the factors that limited your ability and decision-making. Standard stories place any failure entirely within the individual. they are simplified ways to understand the world, but are also inaccurate and leave us with a flattened understanding of what our existence is truly like.
Revision Responsibility

Revision Responsibility

My last post was about acquisition responsibility, the idea of whether we are responsible for having acquired vices that we may have. The idea is tackled in Quassim Cassam’s book Vices of the Mind where Cassam looks closely at epistemic vices – vices which obstruct knowledge. Cassam writes that we can’t always be acquisition responsible for our vices. We cannot necessarily be blamed for acquiring prejudices if we were indoctrinated into a culture that emphasizes those prejudices. Nor can we be responsible for acquiring epistemic vices like closed-mindedness or gullibility. These are traits and ways of thinking that just happen and that take effort and practice to escape.
While we may not be acquisition responsible for epistemic vices then, we may still be revision responsible for our vices. Cassam writes the following:
“If a person has the ability to modify their character traits, attitudes, or ways of thinking then they still have control over them, and because of that, can be responsible for them. This form of responsibility is revision responsibility since the focus is on what the subject can and can’t change or revise. In principle, one can be revision responsible for a vice which one is not acquisition responsible.”
We can still think of someone as being blameworthy for epistemic vices even if we can’t blame them for originally acquiring the vice according to Cassam’s argument. The question comes down to whether a vice is within the control of an individual. So someone who is gullible, prone to wishful thinking, or arrogant can be revision responsible for their vices. They can always make a change to be less gullible, to think more accurately about good and bad outcomes, and to be more humble. Making these changes would improve rather than hinder knowledge, eliminating their epistemic vices.
The idea of revision responsibility can still be a challenging question. An individual indoctrinated by the Taliban is the example Cassam uses to identify someone with epistemic vices for which they are not acquisition responsible, but it is hard to say that individual is revision responsible for their vices as well. Escaping those vices may put their life at risk. It is hard to know what exactly is within ones control to change, especially if we think that we are not a single coherent individual and that we are the product of the multitude of experiences our brain absorbs over time. Nevertheless, as a society and culture we can identify vices and virtues and find ways to encourage and discourage them appropriately. This can be the pressure to push people to make changes, and viewing people as having control over their vices can encourage people to actually make changes. We don’t have to assign blame based on acquisition responsibility, but we can still do so based on revision responsibility, and we can still use ideas of control to encourage more virtuous behavior.

Acquisition Responsibility

We are not always responsible for the acquisition of our virtues and vices. For some of us, being good natured and virtuous toward other people comes naturally, and for others of us, being arrogant or closed-minded comes naturally or was pushed onto us from forces we could not control. I think it is reasonable to say that virtues likely require more training, habituation, imitation, and intentionality for acquisition than vices, so in that sense we are more responsible for virtue acquisition than vice acquisition. It is useful to think about becoming versus being when we think about virtues and vices because it helps us better consider individual responsibility. Making this distinction helps us think about blameworthiness and deservingness, and it can shape the narratives that influence how we behave toward others.
In Vices of the Mind Quassim Cassam writes, “a person who is not responsible for becoming dogmatic might still be responsible for being that way. Acquisition responsibility is backward-looking: it is concerned with the actual or imagined origin of one’s vices.”
In the book, in which Cassam focuses on epistemic vices, or vices that obstruct knowledge. Cassam uses an example from Heather Battaly of a young man who is unfortunate enough to grow up in a part of the world controlled by the Taliban. The young man will undoubtedly be closed-minded (at the very least) as a result of being indoctrinated by the Taliban. There is little the man could do to be more open minded, to avoid adopting a specific viewpoint informed by the biases, prejudices, and agendas of the Taliban. It is not reasonable to say that the man has acquisition responsibility for his closed-mindedness. Many of our epistemic vices are like this, they are the results of forces beyond our control or invisible to us, they are in some ways natural cognitive errors that come from misperceptions of the world.
When we think about vices in this way, I would argue that it should change how we think about people who hold such vices. It seems to me that it would be unreasonable to scorn everyone who holds a vice for which they have no control over the acquisition. Being backward-looking doesn’t help us think about how to move forward. It is important to recognize that people hate being held responsible for things they had no control over, even if that thing lead to serious harms for other people. An example might be people who have benefitted from structural racism, and might like to see systems and institutions change to be less structurally racist, but don’t want to be blamed for a system they didn’t recognize or know they contributed to. Being stuck with a backward-looking view frustrates people, makes them feel ashamed and powerless, and prevents progress. People would rather argue that it wasn’t their fault and that they don’t deserve blame than think about ways to move forward. Keeping this in mind when thinking about how we address and eliminate vices for which people are not acquisition responsible is important for us if we want to continue to grow as individuals and societies and if we want to successfully overcome epistemic vices.
Can We Improve Time Usage by focusing on the U-Index? Joe Abittan

Can We Improve Time Usage?

I believe that we can come together as a society and make decisions that will help improve the world we live in. I believe we can cooperate, we can improve systems and structures, and we can change norms, customs, and procedures to help make the world a better place to live in. I believe we can reduce the U-index in each of our lives.

 

Daniel Kahneman describes the U-index, a term his research team coined, in his book Thinking Fast and Slow by writing, “We called the percentage of time that an individual spends in an unpleasant state the U-index. For example, an individual who spent 4 hours of a 16-hour waking day in an unpleasant state would have a U-index of 25%.”

 

To a certain extent, the U-index is a measure of how well people use their time. Some of us are great at maximizing our waking hours and filling our time with meaningful and enjoyable activities. Some of us are not great at it, and some of us have serious limitations that prevent us from being able to use our time in a way that would maximize our individual U-index. “The use of time is one of the areas of life over which people have some control,” Kahneman writes, but still, there are larger structural factors that shape how we can use our time. Long commutes, limited child care, poor service quality in the public and private sectors, and limited spaces for socialization and exercise can all contribute to the amount of time people spend in unpleasant states, and are largely beyond the control of a single individual. Investments in these spaces will help improve the U-index for the people who get trapped by them. They are also areas where we can make public investments, come together as communities to improve the use of public space, and pool resources to develop new technologies that can reduce travel time, create more responsive and quicker services, and reduce the effort spent dealing with unpleasant people and spaces.

 

For things we can control, Kahneman has a recommendation, “The feelings associated with different activities suggest that another way to improve experience is to switch time from passive leisure, such as TV watching, to more active forms of leisure, including socializing and exercise.”

 

Watching TV, listening to podcasts, or reading a book can be great leisure, but we are social animals, and we need some degree of interaction with others. Unfortunately, we have become more dependent on TV and other fairly antisocial and isolating forms of entertainment. As each of us retreats into our homes (during non COVID times of course) for entertainment and leisure rather than spending time in our community with others, we reduce the opportunities for and the value of social activities. The more we get out and connect, the better our lives will be collectively.

 

And that is why I believe it is important that we believe that we can make the world a better place. There is an element of personal responsibility in making better use of our time and improving our U-index through our own choices and actions. Simultaneously, there is a social and public need for investment and collective action to help us make those choices which are more active and engaging. We won’t want to get out and take part in social activities if we have a long and difficult commute. If we can’t live in the city or in an interesting place with opportunities to interact with others because we can’t afford to live close by, then we won’t make the effort to get involved. If we don’t have safe, clean, and inviting parks and public spaces where we can engage with others, if businesses and public agencies can’t provide spaces with adequate and friendly services, then we won’t want to connect with the world. Kahneman suggest that even small reductions of say 1% to our societal U-index would be hugely impactful. Anything we can do to help reduce the time people spend in unpleasant states will mean fewer suicides, less depression and anger, and fewer negative interactions between people. Making investments to speed up travel, free people from menial tasks and chores, and make public spaces more inviting will help us connect and be happier as an entire society. At that point, it becomes easier to chose active rather than passive leisure and to be more involved rather than to retreat into our homes and Netflix accounts.
Downward Spirals of Drug Addiction

The Downward Spirals of Drug Prohibition

In his book Chasing the Scream, Johann Hari describes the ways in which drug prohibition leads to downward spirals for those dealing with drug addiction. From what he has seen first hand, the drug war doesn’t stop people from using drugs and doesn’t help the planet get closer to a point where no one uses or abuses drugs, but instead creates more drug users. It forces drug addicts to the lowest possible rung on our social ladder and ensures they can never improve their lives.

 

Hari writes, “Prohibition—this policy I have traced across continents and across a century—consists of endlessly spreading downward spirals. People get addicted so we humiliate and shame them until they become more addicted. They then have to feed their habit by persuading more people to buy the drugs from them and become addicted in turn. Then those people need to be humiliated and shamed. And so it goes, on and on.”

 

People who abuse drugs and develop drug addictions are pushed out of our homes, out of public spaces, and out of the work force. We force them into dangerous situations where they can be taken advantage of, abused, and harmed by tainted drugs and needles. When people become so isolated and have no connections to help improve their lives, the only thing they can turn to is more drugs. To finance their habit they begin dealing drugs, often mixing the drug with other substances to have more to sell. They pressure the few people they have connections with to become drug users, so they can have some income to then further their habit.

 

The drug war doesn’t help rehabilitate these people, doesn’t show them that we care about them and want them to get better. It tells them they are worthless, and discourages and degrades them. The entire system creates negative downward spirals in peoples lives, in communities, and in our economy. It propels itself, creating the evil that it lives to fight against.
Shifting Away From The Drug War

Shifting Away from the Drug War

In the context of supporting the war on drugs, Johann Hari, in his book Chasing the Scream, describes most people as, “admirable people who have a series of understandable worries about the alternative. They support the drug war out of compassion for all the people they fear might become victims if we relaxed the laws. They are good people. They are acting out of decency.”

 

However, Hari believes that support for the drug war is actually more costly in the long run, and damages the lives of those who use drugs to an unreasonable extent. In the book, Hari looks at recreational drug users who don’t develop addictions and don’t generally cause a lot of harms through drug use. He compares these individuals to those who do develop addictions, and who contribute to crime and public health problems as a result of their drug dependencies. A key difference between the groups is that many of the people who develop addictions also have severe trauma in their lives. They are often isolated, have had adverse childhood experiences, and are suffering from physical or psychological pain without a supportive community to aid them. Not all harmless recreational drug users are free from pain and trauma, and not all addicts have a traumatic past, but the frequency of past trauma and ongoing psychological pain is a substantial difference between the two groups. Punishment and making life harder for drug addicts who have experienced pain hurts them and makes it more likely they will feel stuck and isolated, with no alternatives to alleviate their suffering besides the temporary relief of continued drug use.

 

The idea of punishment for drug use makes sense when we think about recreational drug users who we want to prevent from causing problems as a result of drug use. But those individuals, aside from contributing to an illicit economy, are not  contributing to the major drug use problems that we see. We can see this in our alcohol policy. Responsible recreational drinkers are not problems, but people who either have trouble consuming alcohol responsibly or simply chose not to consumer responsibly (perhaps college binge drinkers fit in both categories) do create problems for the rest of us. Helping an alcoholic is often understood as helping them develop a safe social setting where they can avoid alcohol or use it responsibly with people who understand their addiction and/or other alcohol challenges.

 

At another point, Hari writes, “We all want to protect children from drugs. We all want to keep people from dying as a result of drug use. We all want to reduce addiction. And now the evidence strongly suggests that when we move beyond the drug war, we will be able to achieve those shared goals with much greater success.” Moving beyond the drug war means that we will develop real, meaningful treatments and supports for drug addicts. It means we can have safe, legal drugs that people can use in supervised settings. It means that people with a history of drug use won’t be barred from ever finding even the most menial of jobs, and will be able to reintegrate back into society, rather than being forced out into situations where continued drug use is almost inevitable. Our approach to drug policy via the drug war has had disastrous consequences, and Hari encourages us to reconsider the path we are on.
Fiduciary Healthcare Responsibility

Fiduciary Healthcare Responsibility

For many Americans, their job provides them with some type of retirement savings account. Historic legal action, laws, and regulations require that companies who offer retirement savings vehicles responsibly manage the money they invest on behalf of their employees. The investment options that employers chose must perform at a reasonable level. A company can’t push all of its employees to invest back in the company (as Enron did in the 1990’s) and a company can’t just take employees retirement savings accounts and put them in a low return savings account at a bank – the return to the employee in interest would be so small that it would be meaningless. Employers fiduciary duty requires that they offer legitimate retirement savings options that are in the best interests of their employees and will likely achieve a reasonable level of return on the investment. We understand this fiduciary responsibility for employers when it comes to our retirement savings, and now, some leaders are starting to look closely at the fiduciary healthcare responsibility of employers in the same way.

 

In his book The Opioid Crisis Wake-Up Call, Dave Chase explains his concerns regarding wage stagnation in the United States. He shows that real hourly wages in the United States, across all education groups, has fallen since 2007 (the book was published in 2019 making the time period of falling wages 12 years). At the same time that wages have fallen or stagnated, healthcare costs and expenditures have soared. With out of pocket spending rising, employer contributions to health plans going up, and patient premiums also getting more costly, Chase argues that the lost wage increases for American’s have been channeled into an under-performing healthcare system.

 

This is where the fiduciary healthcare responsibility of our employers becomes an important issue. Our employers are offering us (for about 50-65% of Americans) health insurance at the expense of higher wages. The money used for purchasing the plans offered to us and helping us access care, can be thought of like a retirement savings account. It is our money, and the company has a responsibility to ensure it is used in our best interest and that the products and services purchased with our money are safe, effective, and likely to provide us with a reasonable return on our investment. The healthcare dollars spent by our employers for health insurance today does not measure up.

 

Chase predicts a series of lawsuits targeting the fiduciary healthcare responsibility of employers in the near future. Lawsuits could target ever rising expenditures for diminishing or stagnant healthcare quality. They could address limits in services that hinder health outcomes for individuals. Companies could be on the hook for failing to do background checks on brokers or failing to shop for the best insurance plan for their employers. All of these issues are addressed by Chase in his book, and he believes that if employers took their fiduciary healthcare responsibility seriously, they could be a major asset in changing the future direction and costs of healthcare in the United States.

Markets & Civil Society Organization

I tend to be a bit hard on the idea of free markets. I grew up learning about the invisible hand and in a family that started a business and did well. I (mostly because of my family’s business) appreciated the idea that setting up a market and running a business was a good thing from the standpoint of finding an efficient point at which to price a product or service. Today however, perhaps as a result of my healthcare interests, I see numerous examples of markets falling short of the goal we establish in our minds based on the idea of the invisible hand.

 

Rather than seeing markets find an efficient point where competition drives efficiency and provides everyone with better products at better prices, I see too many externalities from free markets and unfettered competition. We are producing a lot of greenhouse gasses that harm life on the planet. CEOs are getting better (maybe deservedly so) at capturing greater salaries from their companies, driving economic inequality, and straining social stability. Private health insurance markets seem to drive overall healthcare costs up at every turn, and no one seems to be able to understand how health insurance actually works. The free market, and open competition, does not appear to function as clearly and organize as succinctly as my simple understanding from high school would have suggested.

 

What is missing is something that ties markets and capitalism back into civil society. Bruce Katz and Jeremy Nowak, in their book The New Localism, suggest that shifting political power and decision making back to local contexts within cities and metropolitan regions can help correct these problems. They write, “New Localism is a mechanism for converting the self-organizing power of markets and civil society into structured fiscal and financial resources, and ultimately, political power.”

 

National and multinational sized corporations often have a responsibility to maximize profits for shareholders or top executives. Their huge scale means that any local or regional place is less important for them, since there are always markets in other countries and other states. However, when local governments exert more control over such companies, the local contexts begin to matter more. When CEOs and executives from these companies are invited in to help shape policy beginning at the local level, and are held accountable to the local individuals in the places where their markets are strong or where their employees actually live, the business motives that encourage negative externalities are shifted. The dynamic becomes one where civil responsibility is elevated, and ultimately political power is shifted in a way to help organize business in a more responsible manner in relation to the local context.

 

The lesson that Katz and Nowak share is that businesses on their own are encouraged to organize themselves in a way that maximizes profit at the expense of the local communities in which they operate. By giving localities more power and better networked governance structures, big businesses can instead be a cooperative part of the political and social structure, re-organizing themselves within society in a way that helps make Adam Smith’s invisible hand dream a little more plausible. The Invisible hand in this model is not so invisible, but more of a structured handshake creating a commitment to more than just profits.

Personal Medical Decisions?

A couple weeks back my grandma sent me a message on Facebook that was a picture of two very obese individuals eating a giant pizza and drinking soda. A caption on the photo read, “This is why I don’t want to pay for your healthcare.” As a person who is interested in and taken classes about public health and health policy, I actually think about these things all the time. I recognize the importance of making smart health choices, but I also understand that health outcomes can be a result of a complex web of social determinants of health. There are factors that are beyond our control in regard to living healthy, and there are some factors that seem like easy decisions to some people, that are monumental challenges to others. Despite the amount of time I spend thinking about these things, I don’t have a clear answer in my head for when people need a tough love kick in the pants versus compassion, and when a given outcome is generally more the result of poor individual decisions and habits or more the result of uncontrollable social determinants of health. There likely is no clear answer to this question, and I think it is reasonable to say, “I have thought about this a lot and I don’t know.”

 

This leads me to another factor that compounds the complexity of healthcare decisions: What choices, decisions, and behaviors are personal, and which ones should be considered public? If I chose to smoke, is that a personal decision even though there may be public consequences if I die early, have poor health overall, and require more emergency medical care which ultimately drives everyone’s healthcare premiums up? Do I have to exercise every day to stay healthy as a public good and not just as a private good? If I go get an x-ray on the ankle I sprained to make sure it isn’t broken, is that going to take time away from medical professionals who could help someone that really needs it when all I likely need to do is ice it a little bit?

 

In the book The Elephant in the Brain, Kevin Simler and Robin Hanson write about Steve Jobs and his decision to forgo cancer treatment as recommended by the American Medical Association’s best practices. Jobs is an interesting case because the fortunes of a company that many people love rested on his medical decisions. Beyond just his own health and the considerations of his family, people felt that they had their own money on the line if they owned apple stocks. If Jobs lived and survived his illness, it would be good for Apple, but if he denied standard treatment and died, what did that mean for the public?

 

“The point here,” write Simler and Hanson, “is that whenever we fail to uphold the (perceived) highest standards for medical treatment, we risk becoming the subject of unwanted gossip and even open condemnation. Our seemingly personal medical decisions are, in fact, quite public and even political.”

 

The kind of medicine we pursue and the lifestyle we live are never going to be restricted to just ourselves. We will at the very least be judged by others for our health and medical decisions. Our choices may or may not have major financial implications for other people, but that doesn’t mean that we can make our choices in a vacuum.

 

What is important to remember here is how complex the line is between personal and societal responsibility. Our individual decisions can have bigger impacts than we realize, and it is hard to keep something just within our own bubble. Added to that are questions about liberty and the authority of the state. It is not an easy question to ask if your diet should be controlled by anyone other than yourself, or if you should be forced to exercise and sleep a certain amount. Approach questions about healthcare understanding that these questions don’t have clear answers, and whichever choice we make is going to have strange consequences as a result of these complex inter-dependencies.