Anecdotal Versus Systematic Thinking

Anecdotal Versus Systematic Thinking

Anecdotes are incredibly convincing, especially when they focus on an extreme case. However, anecdotes are not always representative of larger populations. Some anecdotes are very context dependent, focus on specific and odd situations, and deal with narrow circumstances. However, because they are often vivid, highly visible, and emotionally resonant, they can be highly memorable and influential.
Systemic thinking often lacks many of these qualities. Often, the general reference class is hard to see or make sense of. It is much easier to remember a commute that featured an officer or traffic accident than the vast majority of commutes that were uneventful. Sometimes the data directly contradicts the anecdotal stories and thoughts we have, but that data often lacks the visibility to reveal the contradictions. This happens frequently with news stories or TV shows that highlight dangerous crime or teen pregnancy. Despite a rise in crime during 2020, we have seen falling crime rates in recent decades, and despite TV shows about teen pregnancies, those rates have also been falling.
In Vices of the Mind, Quassim Cassam examines anecdotal versus systematic thinking to demonstrate that anecdotal thinking can be an epistemic vice that obstructs our view of reality. He writes, “With a bit of imagination it is possible to show that every supposed epistemic vice can lead to true belief in certain circumstances. What is less obvious is that epistemic vices are reliable pathways to true belief or that they are systematically conducive to true belief.”
Anecdotal versus systematic thinking or structural thinking is a useful context for thinking about Cassam’s quote. An anecdote describes a situation or story with an N of 1. That is to say, an anecdote is a single case study. Within any population of people, drug reactions, rocket launches, or any other phenomenon, there are going to be outliers. There will be some results that are strange and unique, deviating from the norm or average. These individual cases are interesting and can be useful to study, but it is important that we recognize them as outliers and not generalize these individual cases to the larger population. Systematic and structural thinking helps us see the larger population and develop more accurate beliefs about what we should normally expect to happen.
Anecdotal thinking may occasionally lead to true beliefs about larger classes, but as Cassam notes, it will not do so reliably. We cannot build our beliefs around single anecdotes, or we will risk making decisions based on unusual outliers. Trying to address crime, reduce teen pregnancy, determine the efficacy of a medication, or verify the safety of a spaceship requires that we understand the larger systemic and structural picture. We cannot study one instance of crime and assume we know how to reduce crime across an entire country, and none of us would want to ride in a spaceship that had only been tested once.
It is important that we recognize anecdotal thinking, and other epistemic vices, so we can improve our thinking and have better understandings of reality. Doing so will help improve our decision-making, will improve the way we relate to the world, and will help us as a society better determine where we should place resources to help create a world we want to live in. Anecdotal thinking, and indulging in other epistemic vices, might give us a correct answer from time to time, but it is likely to lead to worse outcomes and decisions over time as we routinely misjudge reality. This in turn will create tensions and distrust among a society that cannot agree on the actual trends and needs of the population.
Case Explanations Versus Structural Explanations

Case Explanations Versus Structural Explanations

In Vices of the Mind Quassim Cassam asks whether we can understand the behaviors of an individual based on individual characteristics or if we have to rely on larger structural and systemic explanations for their behavior. The question is important for Cassam because his book focuses on epistemic vices, which are vices that get in the way of knowledge. If such vices change people’s thoughts and behaviors in predictable ways, then they are something we should think about and work to change in ourselves and others. If, however, they don’t make a difference in people’s behaviors because larger structural explanations exist, then they are not worthy of our attention.
Given that Cassam wrote an entire book about epistemic vices, it is not surprising that he believes that they are useful in explaining behavior. He writes, “Epistemic vices are obstacles to knowledge that can in appropriate cases explain how people think and what they do. Sometimes, though, structural or systemic explanations are better.” This sentence feels a little weak, as though Cassam is admitting that epistemic vices can take a back seat to structural factors. However, the sentence is a useful summation of how we should think about individual level factors and larger structural and systemic factors.
Our lives are shaped to a great degree by large structural and systemic forces that are beyond our control. Family structures drive specific types of behaviors. Markets produce predictable outcomes. The rules of a sport determine what actions can and cannot be taken. However, within these larger structures and systems there is room for individual variation. Cassam’s argument is that we can understand some of the individual variation within larger structures by understanding epistemic vices.
Case explanations can include individual choices, characteristics, and epistemic virtues and vices to help us understand behavior. These explanations can be built on top of structural and systemic explanations which shape the range of possibilities and narrow some of the individual variations. We cannot entirely define someone by their individual choices and differences, but we can view them within a system and ask how their choices within a system differed from others, whether their differences were positive or negative, and why.
Systematically Obstructing Knowledge

Systematically Obstructing Knowledge

The defining feature of epistemic vices, according to Quassim Cassam, is that they get in the way of knowledge. They inhibit the transmission of knowledge from one person to another, they prevent someone from acquiring knowledge, or they make it harder to retain and recall knowledge when needed. Importantly, epistemic vices don’t always obstruct knowledge, but they tend to do so systematically.
“There would be no justification for classifying closed-mindedness or arrogance as epistemic vices if they didn’t systematically get in the way of knowledge,” writes Cassam in Vices of the Mind. Cassam lays out his argument for striving against mental vices through a lens of consequentialism. Focusing on the outcomes of ways of thinking, Cassam argues that we should avoid mental vices because they lead to bad outcomes and limit knowledge in most cases.
Cassam notes that epistemic vices can turn out well for an individual in some cases. While not specifically mentioned by Cassam, we can use former President Donald Trump as an example. Cassam writes, “The point of distinguishing between systematically and invariably is to make room for the possibility that epistemic vices can have unexpected effects in particular cases.” Trump used a massive personal fortune, an unabashed bravado, and a suite of mental vices to bully his way into the presidency. His mental vices such as arrogance, closed-mindedness, and prejudice became features of his presidency, not defects. However, while his epistemic vices helped propel him to the presidency, they clearly and systematically created chaos and problems once he was in office. In his arrogance he attempted to bribe the prime minister of Ukraine, leading to an impeachment. His closed-mindedness and wishful thinking contributed to his second impeachment as he spread baseless lies about the election. 
For most of us in most situations, these same mental vices will also likely lead to failure and errors rather than success. For most of us, arrogance is likely to prevent us from learning about areas where we could improve ourselves to perform better in upcoming job interviews. Closed-mindedness is likely to prevent us from gaining knowledge about saving money with solar panels or about a new ethnic restaurant that we would really enjoy. Prejudice is also likely to prevent us from learning about new hobbies, pastimes, or opportunities for investment. These vices don’t always necessarily lead to failure and limit important knowledge for us, as Trump demonstrated, but they are more likely to obstruct important knowledge than if we had pushed against them.
Consequentialism

On Consequentialism

In his book Vices of the Mind, Quassim Cassam argues that patterns of thoughts and mental habits that obstruct knowledge are essentially moral vices. Ways of thinking and mental habits that enhance the acquisition, retention, and transmission of knowledge, according to Cassam, are moral virtues. Cassam defends his argument largely through a consequentialist view.
Cassam is open about his consequentialist frame of reference. He writes:
“Obstructivism is a form of consequentialism. … Moral vices systematically produce bad states of affairs. … The point of systematically is to allow us to ascribe moral virtue in the actual world to people who, as a result of bad luck, aren’t able to produce good: if they possessed a character trait that systematically produces good in that context (though not in their particular case) they still have the relevant moral virtues.”
I think that this view of epistemic vices is helpful. I know for me that there are times when I fall into the epistemic vices that Cassam highlights, and they can often be comforting, make me feel good about myself, or just be distractions from an otherwise busy and confusing world. However, recognizing that these vices systematically lead to poorer outcomes can help me understand why I should stay away from them.
Epistemic vices like scrolling through Twitter to look at posts that bash on someone you dislike are structurally likely to produce bad outcomes by wasting your time, making you more prone to distractions, and prejudicing yourself against people you don’t agree with. What you spend your mental energy on matters, and in the case of Twitter scrolling, you are allowing your mind to indulge in shallow quick thinking, closed-mindedness, and biases. It plays off confirmation bias, giving you the ability to only see posts that confirm what you believe or want to believe about a person or topic. It feels nice to bash on someone else, but you are reinforcing a limited perspective that might be wrong and rewarding your brain for being shallow and inconsiderate. In the moment it is rewarding, but in the long run it will lead to worse thinking, shorter attention spans, and biased decision-making that is hard to get away from once you have closed the Twitter tab. Consequentialism helps us see that the epistemic vices involved in Twitter scrolling, which feel harmless in the moment, are more likely to result in negative outcomes over time. The systematic nature of these epistemic vices, the consequences and outcomes of indulging them, is what defines them as vices.
Consequentialism, Cassam’s argument shows, can be a useful way to think about how we should behave. People who try to do good but experience bad luck and don’t produce the same good outcomes as others can still be viewed as morally virtuous. Even though in their particular situation a good result did not occur, those who practice moral virtues can be praised for behaving in a way that is systematically more likely to produce good. Conversely, people who behave in ways that systematically produce negative outcomes can be deterred from their negative behavior through social taboos and norms, even if a poor behavior might provide them with an opportunity to succeed in the short term. It is hard to take absolute stances about any position, but consequentialism gives us a frame though which we can approach difficult decisions and uncertainty by recognizing where systematic patterns are likely to lead to desired or undesired outcomes for ourselves and our societies.
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.
Value in Healthcare

Value in Healthcare

A common complaint about healthcare in the United States is that it has traditionally operated on a fee for service (FFS) based model. It is a natural and easy to understand system, and generally the type of system that both patients and providers prefer. The idea is that you pay for the services you receive from a healthcare provider. So if you need a tooth extracted, you go and have the tooth extracted and pay for the extraction. If you need a skin check, you go and get a skin check and pay for it. However, this FFS model can encourage a lot of waste through unnecessary medical procedures, and the value in healthcare is sometimes lost when we wait until someone has a problem before we help them with their health.

 

A lot of government programs, employers, and insurance companies are making efforts to push against FFS in an effort to provide greater value in the healthcare services we pay for, but it is worth asking, what is value and how can healthcare systems provide it? Is value just better health? Is it services that a patient said they were happy about? Is it care that saves a life or can it just be care that makes a life somewhat more comfortable? Dave Chase helps explain one aspect of value in healthcare in his book The Opioid Crisis Wake-Up Call, “Value is defined as the ratio of quality to cost. Value increases as the quality of the care increases or the cost of care decreases.”

 

FFS encourages short appointments where doctors cram as much as they can bill for into the shortest possible time before moving on to the next patient to do the same. Value based models, on the other hand, seek to improve the quality of the care provided without adding more costs to the patient and their insurer. As opposed to simply cramming in more tests, treatments, and procedures to get more money, value based systems that increase quality focus on improving health outcomes while keeping costs stable.

 

Alternatively, value based models might seek to keep quality the same, but reduce overall costs. This can wade into territory we don’t necessarily want to support, such as cutting nurse management staff to keep overhead low, but it could also look like more comprehensive care to reduce costly re-admissions after a procedure. When we think about value and try to build systems around value, we ultimately have to think about quality and cost, and how those are related. We can cut pieces out of the system that are just meant for signaling and cut pieces out that might be unnecessary without diminishing quality. But at the same time, we really need to examine whether the pieces we want to cut really do help with the quality of the care, especially over the long run.

 

Thinking about value in healthcare isn’t entirely new, but it is receiving increased focus, which is important if we want to have a healthcare system that people actually trust and are willing to engage with when necessary.
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.