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.
Asymmetric Paternalism

Asymmetric Paternalism

While writing about the book Nudge by Richard Thaler and Cass Sunstein, I have primarily focused on an idea that the authors call Libertarian Paternalism. The idea is to structure choices and use nudges (slight incentives and structural approaches) to guide people toward making the best possible decision as judged by themselves. Maintaining free choice and the option to investigate or chose alternatives is an important piece of the concept, as is the belief that we will influence people’s decisions no matter what, so we should use that influence in a responsible way to help foster good decision-making.

 

But the authors also ask if it is reasonable to go a step beyond Libertarian Paternalism. Is it reasonable for choice architects, governments, and employers to go further than gentle nudges in decision situations? Are there situations where decision-making is too important to be left to the people, where paternalistic decision-making is actually best? Sunstein and Thaler present an introduction to Asymmetric Paternalism as one possible step beyond Libertarian Paternalism.

 

“A good approach to thinking about these problems has been proposed by a collection of behavioral economists and lawyers under the rubric of Asymmetric Paternalism. Their guiding principle is that we should design policies that help the least sophisticated people in society while imposing the smallest possible costs on the most sophisticated.”

 

This approach is appealing in many ways, but also walks the line between elitism, the marginalization of entire segments of society, and maximizing good decision-making. I hate having to make lots of decisions regarding appropriate tax filings, I don’t want to have to make decisions on lots of household appliances, and I don’t really want to have to spend too much time figuring out exactly what maintenance schedule is the best for all of my cars. However, I do want to get into the weeds of my healthcare plan, I want to micromanage my exercise routine, and I want to select all the raw ingredients that go into the dinners and lunches that I cook. On some decisions that I make, I want to outsource my decision-making and I would often be happy with having someone else make a decision so that I don’t have to. But in other areas, I feel very sophisticated in my decision-making approach, and I want to have maximum choice and freedom. Asymmetric Paternalism seems like a good system for those of us who care deeply about some issues, are experts in some areas, and want to maintain full decision-making in the areas we care about, while exporting decision-making in other areas to other people.

 

Of course, prejudices, biases, and people’s self-interest can ruin this approach. What would happen if we allowed ourselves to deem entire groups of people as unworthy of making decisions for themselves by default? Could they ever recover and be able to exercise their freedom to chose in important areas like housing, retirement, and investment spaces? Would we be able to operate for long periods of time under a system of Asymmetric Paternalism without the system devolving due to our biases and prejudices? These are real fears, and while we might like to selectively trade off decision-making when it is convenient for us, we also have to fear that someone else will be making decisions for us that are self-serving for someone other than ourselves.

 

The point, according to Sunstein and Thaler, would be to maintain the freedom of decision-making for everyone, but to structure choices in a way where those with less interest and less ability to make the best decisions are guided more strongly toward what is likely the best option for them. However, we can see how this system of asymmetric paternalism would get out of control. How do we decide where the appropriate level is to draw the line between strong guidance and outright choosing for people? Would people voluntarily give up their ability to chose and overtime hand over too many decisions without an ability to get their decision authority back? Transparency in the process may help, but it might not be enough to make sure the system works.
Paternalistic Nudges - Joe Abittan

Paternalistic Nudges

In their book Nudge, Cass Sunstein and Richard Thaler argue in favor of libertarian paternalism. Their argument is that our world is complex and interconnected, and it is impossible for people to truly make decisions on their own. Not only is it impossible for people to simply make their own decisions, it is impossible for other people to avoid influencing the decisions of others. Whether we decide to influence a decision in a particular way, or whether we decide to try to avoid any influence on another’s decision, we still shape how decisions are presented, understood, and contextualized. Given this reality, the best alternative is to try to help people make consistently better decisions than they would without aid and assistance.

 

The authors describe libertarian paternalism by writing:

 

“The approach we recommend does count as paternalistic, because private and public choice architects are not merely trying to track or to implement people’s anticipated choices. Rather, they are self-consciously attempting to move people in directions that will make their lives better. They nudge.”

 

The nudge is the key aspect of libertarian paternalism. Forcing people into a single choice, forcing them to accept your advice and perspective, and aggressively trying to change people’s behaviors and opinions doesn’t fit within the libertarian paternalism framework advocated by Sunstein and Thaler. Instead, a more subtle form of guidance toward good decisions is employed. People retain maximal choices if desired, and their opinions, decisions, and behaviors are somewhat constrained but almost nothing is completely off the table.

 

“A nudge,” Sunstein and Thaler write, “as we will use the term, is any aspect of the choice architecture that alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives.”

 

Daniel Kahneman, in his book Thinking Fast and Slow demonstrated that people make predictable errors and have predictable biases. If we can understand these thinking errors and biases, then we can identify situations in which these biases and cognitive errors are likely to lead people to making suboptimal decisions. To go a step further, as Sunstein and Thaler would suggest, if we are a choice architect, we should design and structure choices in a way that leads people away from predictable cognitive biases and errors. We should design choices in a way that takes those thinking mistakes into consideration and improves the way people understand their choices and options.

 

As a real world example, if we are structuring a retirement savings plan, we can be relatively sure that people will anchor around a default contribution built into their retirement savings plan. If we want to encourage greater retirement savings (knowing that economic data indicate people rarely save enough), we can set the default to 8% or higher, knowing that people may reduce the default rate, but likely won’t eliminate contributions entirely. Setting a high default is a nudge toward better retirement saving. We could chose not to have a default rate at all, and it is likely that people wouldn’t be sure about what rate to select and might chose a low rate below inflation or simply chose not to enter a rate at all, completely failing to contribute anything to the plan. It is clear that there is a better outcome that we, as choice architects, could help people attain if we understand how their minds work and can apply a subtle nudge.
Base Rates Joe Abittan

Base Rates

When we think about individual outcomes we usually think about independent causal structures. A car accident happened because a person was switching their Spotify playlist and accidently ran a red light. A person stole from a grocery store because they had poor moral character which came from a poor cultural upbringing. A build-up of electrical potential from the friction of two air masses rushing past each other caused a lightning strike.

 

When we think about larger systems and structures we usually think about more interconnected and somewhat random outcomes that we don’t necessarily observe on a case by case basis, but instead think about in terms of likelihoods and conditions which create the possibilities for a set of events and outcomes. Increasing technological capacity in smartphones with lagging technological capacity in vehicles created a tension for drivers who wanted to stream music while operating vehicles, increasing the chances of a driver error accident. A stronger US dollar made it more profitable for companies to employ workers in other countries, leading to a decline in manufacturing jobs in US cities and people stealing food as they lost their paychecks.  Earth’s tilt toward the sun led to a difference in the amount of solar energy that northern continental landmasses experienced, creating a temperature and atmospheric gradient which led to lightning producing storms and increased chances of lightning in a given region.

 

What I am trying to demonstrate in the two paragraphs above is a tension between thinking statistically versus thinking causally. It is easy to think causally on a case by case basis, and harder to move up the ladder to think about statistical likelihoods and larger outcomes over entire complex systems. Daniel Kahneman presents these two types of thought in his book Thinking Fast and Slow writing:

 

Statistical base rates are facts about a population to which a case belongs, but they are not relevant to the individual case. Causal base rates change your view of how the individual case came to be.”

 

It is more satisfying for us to assign agency to a single individual than to consider that individual’s actions as being part of a large and complex system that will statistically produce a certain number of outcomes that we observe. We like easy causes, and dislike thinking about statistical likelihoods of different events.

 

“Statistical base rates are generally underweighted, and sometimes neglected altogether, when specific information about the case at hand is available.
Causal base rates are treated as information about the individual case and are easily combined with other case-specific information.”

 

The base rates that Kahneman describes can be thought of as the category or class to which we assign something. We can use different forms of base rates to support different views and opinions. Shifting the base rate from a statistical base rate to a causal base rate may change the way we think about whether a person is deserving of punishment, or aid, or indifference. It may change how we structure society, design roads, and conduct cost-benefit analyses for changing programs or technologies. Looking at the world through a limited causal base rate will give us a certain set of outcomes that might not generalize toward the rest of the world, and might cause us to make erroneous judgments about the best ways to organize ourselves to achieve the outcomes we want for society.
A Religious Start to Ideas of Drug Prohibition

A Religious Start to Ideas of Drug Prohibition

In his book Chasing The Scream Johann Hari briefly writes about human practices of using drugs dating back well over 2000 years ago. He uses a story about Greek rituals at the Temple at Eleusis to show how common and widespread drug use was, and how it occupied a central and almost sacred role in human life for ancient Greek civilizations. Hari writes about the downfall of the ritual use and near celebration of drugs which occurred at the temple. A downfall that doesn’t appear to have been brought about by negative consequences of drug use, but a downfall that was a deliberate power grab.

 

“The early Christians wanted there to be one rout to ecstasy, and one rout only – through prayer to their God,”  Hari writes. “The first tugs towards prohibition were about power, and purity of belief. If you are going to have one God and one Church, you need to stop experiences that make people feel that they can approach God on their own.”

 

Hari writes that drugs alter states of consciousness and can give people a new sense of wonder, of awe, and of being something more than themselves. These senses, he argues, were what the Christian Church wanted to offer people through their religious experiences. Church and drugs were competing for the same mental faculties and experiences, and the Church wanted to limit outside exposure to sources that gave people a supernatural feeling.

 

I like to think about the world in terms of the systems and structures that shape the possibilities of our lives. Institutions matter, and they can inform what we find to be immoral, just, and common (or uncommon) parts of human nature. Hari’s research suggest that human desires to change their states of consciousness with chemicals are not in fact the immoral and uncommon problematic desires that we have portrayed them. Institutions, such as religions, have shaped the ways we think about and understand drugs and chemical intoxication. There are probably some true elements of public safety and health in our drug prohibition today, but much of our policy stems from and still maintains a system of authority, power, fear, and xenophobia. Drug use can be widespread and accepted, even if it is problematic – just look at alcohol use in the United States and across the globe. It can also be prohibited and marginalized, it just depends on the institutional systems and structures we chose to attach to drug use. We can develop ways to use drugs responsibly and safely, or we can force drug use into illicit and shady corners of society, where a guarantee of safety and protection is a laughable idea.
Design Matters - Healthcare Systems Edition

Design Matters – Healthcare Edition

In his book The Opioid Crisis Wake-Up Call, Dave Chase quotes Dan Munro by writing, “The [healthcare] system was never broken, it was designed this way.”

 

I’m a fan of Debbie Millman’s podcast, Design Matters. When we are making something that other people will use and engage with, it is important to think about all the various aspects of how the thing will be used and how it can meet the needs and expectations of others. Whether what we are producing is art, a branding campaign, or a national healthcare system, design matters.

 

Unfortunately, the Untied State’s healthcare system wasn’t built on a design matters philosophy. We see inefficiencies everywhere, with some people getting care they don’t need while others can’t get routine basic care that could save their lives. Dan Munro says that the system was built this way, meaning that the inefficiencies, the inequalities, and the high costs were part of the system from the beginning, intentionally built in. The dysfunction we see in the system, according to Munro, is not so much a bug but rather a feature, helping someone make a profit or get priority access to the healthcare they want.

 

I think Munro is a little wrong. I think the system is a hodgepodge of pieces smashed together over the years. It is an incoherent patchwork of tools and players that has been haphazardly assembled over the years, with some working to truly do good, and others taking advantage of design flaws for their own aims. The system, in my argument, was never designed at all.

 

Design matters and what needed to happen decades ago was a real conversation about how the country would design a healthcare system that could innovate, that could meet the needs of citizens, that could ensure basic access to medical services, that could help provide preventative care rather than just emergency interventions, and that could be sustainable. Instead, doctors went about providing medical services, insurance companies popped up to help pay for some pieces here and there, and eventually businesses got in the mix and offered health insurance to employees. Each new step in healthcare in the Untied States has happened almost randomly, without a lot of deliberate planning.

 

Now the system is so large and complex that planning feels impossible. Legislation to address the challenges of the system is thousands of pages long, and because the most comprehensive law to restructure the program adopted the namesake of the nation’s first black president, a Democrat that became a polarizing figure, half the country derided the attempt to design something better. We can try to reshape bits and pieces of the system now, but design matters, and I understand why so many want to hit a restart button and rebuild a system from scratch.
Medical Technologies

The Problem with Healthcare Technology

In my last post I wrote about hidden costs of the healthcare system in America. I wrote about tax breaks for employers who offer health benefits, and I wrote about third party insurance preventing the healthcare system from working like a pure market. This post introduces one consequence of the hidden costs of our system and the ways in which our system fails to act like a market: the high cost of medical technologies.

 

In The Opioid Crisis Wake-Up Call, Dave Chase writes, “We ended up focusing on a certain type of high-technology, acute medical care – which we financially reward far more than lower-level preventive and chronic care – without regard for the quality of the outcomes or value of the care.”

 

When I took a healthcare policy and administration class along with a healthcare economics class for my graduate studies, I was surprised to see a critique of advancing medical technologies as part of the problem of American healthcare costs. I live in Reno, under the sphere of influence of the Bay Area, where technological solutions to global problems are hailed as the cure-all, deus ex machina that we need for a peaceful and prosperous world. I always thought that better medical technology saved lives, made us healthier, and ultimately reduced cost by being more efficient and precise than older technologies.

 

As it turns out, new medical technologies are incredibly expensive, and often times the benefits that patients receive are only marginally better than what existing technology offers. In some instances those marginal improvements make the difference between life and death, but in many instances, the new technologies might only add a few months of life to a terminal diagnosis, a few additional months lived in pain and fear. In other instances, the new technologies might add a little more comfort or certainty in a patient’s procedure or diagnosis, but it is fair to question whether its really necessary and worth the additional cost.

 

The quote from Chase reveals that when we are shielded from the costs of care, and when we remove market aspects from the healthcare system, we adopte a mindset that healthcare equals expensive interventions with high cost technology. I had clearly bought into this narrative prior to my graduate studies. The alternative that Chase highlights in his book, which we have underdeveloped in the United States, is to move upstream, and take care of people at a preventative level before they are sick and before they need expensive technological interventions. Developing systems, structures, and norms for healthy lifestyles will do more to reduce costs than the development of new magical cures and technological fixes. Our priorities and the focus of our system is flawed, and a as a result we focus on high cost interventions within a system no one is happy with. Rather than develop a system that actually supports healthy living, we have fished around for quick, high-cost technological solutions to our health woes.
Opioids and Mental Health Disorders

Opioids and Mental Health Disorders

Opioids and mental health disorders probably do not seem like a good mix in anyone’s mind. I’m sure most of the general public would find it problematic to prescribe opioids to someone with a mental health disorder, but every day, physicians across the country prescribe large numbers of opioid prescriptions to these patients.

 

Dave Chase, in his book The Opioid Crisis Wake-Up Call, writes, “According to a recent study, more than half of all opioid prescriptions in the United States annually go to adults with a mental illness, who represent just 16 percent of the U.S. population.”

 

Why do we over-prescribe so many opioids to people with mental health illnesses? I can think of three potential causal models that lead to our over prescription of opioids for people with mental health disorders. 1: our system was never set up to treat health broadly speaking, 2: mental health has always been stigmatized and hidden in America, and 3: we have sabotaged ideas of community in the United States as we pursue our own self-interests and spend unreasonable amounts of time working and commuting.

 

1: The history of the American medical system was focused on interventions and solving health problems after the problem had popped up. Insurance companies were created to help people access different parts of the medical system, and over time private insurance has become more or less the only way to reasonably access affordable medical care in the United States. Our reliance on third party payers allowed prices to profligate, and it feels as though we are at a point where we can’t turn the ship around. If you have a mental health disorder, you are less likely to have stable employment, which means you are less likely to have quality health insurance provided through your job, and less likely to establish the mental health care that you need. As a result, you probably see your primary care provider and end up with an opioid prescription during your 10 minute appointment because your doctor doesn’t have time to really work with you on addressing your mental health challenges.

 

2: There are many examples throughout history of people hiding children with intellectual disabilities. Generations before us warehoused children in mental health institutions that did little to help improve health. We are mostly beyond that today, but nevertheless, we hide anxiety, depression, learning disabilities, and other mental health challenges from our friends, families, and coworkers. We still don’t do a good job of accepting that mental health disorders are not something that people should be ashamed of, and many people do not seek appropriate care but instead life lives that are less than healthy, where ending up with an opioid prescription, or self-medicating with something worse, is a less public alternative to dealing with mental health challenges.

 

3: Tying both points one and  two together, our lack of community makes mental health management almost impossible. We don’t have a lot of friends and family members that we can truly rely on for help with physical, mental, and emotional challenges. It may take a village to raise a kid, but we have run away from our villages to hide in our suburbs. We have dis-invested in the communities where we live and as a result, people with mental health disorders lack the social support systems necessary to truly address their needs. Even if people with mental health issues have some family and friends close by, those who they rely on probably lack the support they need to care for someone with mental health challenges. We spend too much time at work, spend too much time commuting to work, and don’t have time to help those who are more vulnerable. As a result, we simply shut people with mental health disorders out of our lives and out of society, and numb their lives with opioids.

 

Our country has not set up a system that truly takes care of our health, from before we are sick or have significant health challenges through to a successful recovery. We have overloaded the system that we built which was designed for people with the means to afford care after they were ill. We have ignored mental health and pretended we didn’t know it was an issue, until now, when it is too late and we don’t have the supports we need. Our communities are non-existent, and taking the steps to care for our community feels impossible.

 

The path forward involves a shift in how we provide, pay for, and think about healthcare. The systems we turn to for health need to move up-stream, where we focus on health before people are sick. To do that, we have to be honest about things like mental health, we have to be willing to provide spaces and community so that people can engage with healthy lifestyles and behaviors. We have to break out of our 40 hour work-weeks, and find ways to work closer to where we live, to end the soul sucking commutes that so many of us have. We have to give people time, and develop communities of support so that we can take care of our health and the health of those most vulnerable people in our communities. Without making these transformational changes, we will be stuck in our default of opioid prescriptions, unable to give people what they need to live healthy and meaningful lives.
Finding Success Through Structure

What Happens When Your Day Lacks Structure

In the past I have found it incredibly helpful to have fully planned out days. To know what I have going on, what the most important priorities are for my day, and when I am going to buckle down with focus work versus when I am going to sift through emails is a great feeling. When I have thought through what to work on and know I have blocked off sufficient time, I can really do some great work.

 

Without having such planning, each day is a bit of a challenge. Things come to mind as the day passes for what I should work on, but I often float from one task to the next without a great sense for why I am working on any specific thing at any specific moment. This strategy is easy and might work fine when I am not under tight deadlines, but I have run into a real crunch when suddenly remembering a project or task that needs to be done today. Or, when fortunes change and an emergencies pops up, I have been wholly unprepared to deal with the new reality that needs my attention immediately.

 

My last post was all about finding success and finding willpower in a routine that makes you effective. Creating spaces, planning ahead, and developing rituals for deep concentrated work is the best way to ensure that you can do hard things continuously. This structure is important, and Cal Newport describes it in more detail in his book Deep Work, “without this structure, you’ll have to mentally litigate again and again what you should and should not be doing during these sessions and keep trying to assess whether you’re working sufficiently hard.”

 

Whether you work as part of an organization, lead a campaign, or work as a solo entrepreneur, you need time for deep work. You also need to think about what each day is going to entail and have a plan to get the most important work done. Spending a few minutes thinking about what is most important and what you should be focusing on at what time can help free up the mental energy and space required to get into deep work. Having to think continuously about what you should be doing at any moment is exhausting and will lead you to flutter around at a shallow level with your work. If you haven’t yet developed an effective structure to approach your day, you are missing out on being effective and finding a sense of stillness in doing the important work that needs attention.