...just like a woman

When we experience something (personally or vicariously through reading, watching TV, conversations, etc) and we get a feeling that the event can be grouped in our mind with other similar events (which is a natural tendency of our brains) and that grouping reveals a negative stereotype of a group of people, we have committed mental bias. That is not to say that what we have thought is not true, but what we have done is convert a statistic into a rule. Usually, this comes along with emotional activation within the brain, often negative.

Stereotypes are often based upon some statistical activity done inside the brain, which then get encoded as beliefs. Usually a single event is not enough to create a belief change. A person who has had several negative experiences with dogs and few positive ones will react differently to being bitten by a dog than would a dog breeder/enthusiast. Furthermore, a person taught to believe and think in a certain way will follow the worn-in pathways, right or wrong.

Everyone has latent biases. No exceptions. Trying to understand them is more important than pointing fingers at those whose latent biases leak out. Allowing people the opportunity to grow, to try to rise above their biases, to find good counter-examples, is the best way to deal with this problem. And any statistical data that is true and supports a bias should be dealt with in the real world. If a person calls an truly ugly baby ugly, fix the baby! Truth should trump political correctness, but overgeneralizations are wrong.

Free

What is free?

We hear that things should be free. Speech. Health care. But, what does this actually mean? Can things be free?

Free is limited by two obstacles.

• Principle. If there are things we value greater than what we are making free, the free thing will be limited. If we place safety as having greater value than freedom of speech, it will be wrong to falsely create fear or panic. So, you cannot claim freedom of speech if you scream "Fire" in a movie theater. We have freedom of silence as well. A person need not incriminate herself even if her silence creates fear. A woman in PA had a contract killing of her husband on the Ohio Turnpike, creating the fear that a highway murderer was on the loose in Ohio. She was eventually arrested and tried for her husband's murder, but was not charged for failing to diffuse a feeling of terror among Ohio turnpike drivers. Similarly, if health care is free, then the freedom of health care workers will be limited. Each freedom in some way enslaves others.
• Practicality. If everyone constantly spoke in the public square, no one would be listening. Similarly, resources required for health care come at a price which must be paid, confiscated or denied.

The failings of progressive thinkers, seekers of complete freedom and/or equality, are that principle and practicality often interfere with grand plans, sometimes in subtle and unforseen ways. These are the "unintended consequences" that often arise when a false principle of freedom or equality is enacted. The concept of a free and equal health care system can be visualized in the same way we can visualize travelling faster than the speed of light. Both run into basic conflicts with principles and practicalities that cannot be overcome.

The ideal physician

With everyone these days trying to redefine exactly what a doctor does (and is), I thought it was time to set the record straight. The following is my idea of what an ideal physician should do and be.

• To the best of my ability, to acquire and use my best knowledge, skills and judgment for each patient
• To try to learn as much as I can about the workings of the human body and about the diseases, injuries and other conditions that remove people from ideal health
• To try to learn as much as I can about my patient, by history, examination and diagnostic testing, to discover what maladies the patient may have.
• To try to predict, to prophesize the patient's future, based upon the expected natural history of his condition and communicate this to the patient.
• To try to predict or prophesize if there is any risk to others from the patient's condition and to work to reduce or eliminate that risk
• To intervene or advise intervention only if I can produce a better outcome than the expected natural history. Of the options available, to pick the one that has the best chance of success (greatest benefit or greatest benefit to risk ratio)
• To try to prevent, cure, or reduce the impact of the malady upon the patient, to the best of my ability, knowledge and judgment.
• To communicate effectively with the patient and with other members of the patient's health care team, including caregivers if appropriate.
• To protect the privacy of my patient, but not to withhold secrets that might lead to the harm of others.
• When appropriate, to refer the patient to others who might be better able to help.
• To direct the patient to find another physician when the doctor-patient relationship becomes irrepairably damaged.
• To try to prevent others from using the patient's illness to harm our patient based upon their own malice, avarice, retribution or other moral vices/ethical wrongs.

I do not see a role for a physician as keeper of the coffers, overseer of social justice, executioner, or legal counselor. These must be taken into account, but not by physicians. Our duty must be only to the patient and to those directly impacted by the patient.

If I can predict an impending terminal state, it becomes my duty to communicate this to the patient or his representative and must work with the patient to achieve the desired goals, providing that goal is not based upon a moral vice or an ethical wrong.

If I determine that a course of treatment is best for a patient, that patient has in good conscience purchased a health insurance policy, and the insurance company refuses to pay for the treatment, it becomes my duty to fight against the apparent avarice of the insurance company for my patient's benefit.

If I determine that a course of treatment is best for a patient and the patient does not want to pay for it or can't pay for it, I may recommend a less ideal treatment that is within the patient's budget. It is not my duty to make sure that every patient can afford every treatment. This is the job of those who insure patients, patients to be productive members of society, and social organizations to provide safety nets for those who are valued for their existence and not their current contributions to society.

My personal opinion is based upon the concept of free will. It is that those who work, those who have worked and are now retired, those who raise children, those who are too young to work, and those who are unable to work all deserve the best care we have. Those who choose not to work and those who have seriously violated our laws are entitled to whatever they can afford and whatever any private social organization wants to pay for. Those who are not members of our society (ie, illegally in the US) are entitled to emergency care and appropriate transportation back to their country of origin for further care. I believe that no one should prevent a patient from obtaining whatever care is appropriate for him that he can afford, even if it means that he will get a better care (more effective, better effectiveness/risk ratio) than the average person can afford.

Nobody does it better

There is no question that the US government can wage war better than any group of American citizens. They also seem to be able to enforce law, adjudicate innocence and guilt, all fairly well. But does that mean that they can do everything well? Can they do everything better than individuals or private enterprise?

This is where belief comes into play. There are those who believe that government is the answer to all problems. They see the ideal world has having a government in charge of everything. They see private enterprise as a way of cheating and harming others and government as the savior. Others believe that government is a necessary evil, that power corrupts and absolute power corrupts absolutely. I believe in the power of information and that as long as you have some power (ie, you are not going up against a monopoly or a government) you can change things for the better. While some do not believe that information is power, as not everyone will believe nor will everyone be able to access or understand the information, the ability of information to diffuse in society in a viral or epidemic way will lead to improvement as long as there is no force preventing change.

When some of us wanted change, they had to vote for it. We couldn't just make it happen. This is precisely why government cannot be in charge of everything, as change in government is just too hard.

Flexibility

Mental flexibility is the ability to see a situation or a set of facts from different perspectives. This is a learned trait and is influenced by both internal and external factors.

Our brains are hard wired to have limited flexibility, so the exercise of flexibility goes against the grain. If you touch something hot, you pull your hand away. This reflexive response is inescapable for most people. When Hollywood wants to demonstrate a person's complete control of himself, they will often show a person deliberately holding his hand over a lit match.

Higher cognitive processes, such as organizing thoughts and emotions into a coherent internal matrix, requires decisions...what to keep in and what to leave out; what correlation is causation, what is coincidence. Once done, viewpoints calcify, making changing perspective extremely difficult. Some see this as a virtue, others as a vice. When presented with evidence supporting your position, you accept it; evidence to the contrary is dismissed.

Mental illness is often a matter of flexibility disorders. A depressed person sees all life through the lens of depression. I remember one elderly woman, in a nursing home due to intractable depression, sitting in her room crying about how nothing good ever happens to her. A nurse opened the door and brought in a large, beautiful plant with a card identifying the giver as a long forgotten neighbor who just heard of her plight and wanted to remind her that others cared greatly for her. The old woman smiled, laughed, and was overwhelmed with happiness. Her husband told me later that the happiness lasted for about 30 minutes. She then went back to her same mantra of how nothing good ever happens to her. Patients with schizophrenia, delirium and perhaps mania have excessive flexibility, thoughts and emotions flowing without control, making it impossible to grab onto reality. A patient yesterday, in the throws of DTs, was gazing all around the room, muttering, laughing, crying, trying to make sense of the continuous flow of thoughts and perceptions, unable to find the real from the imagined.

If you are too flexible, you will be swayed by anything that comes your way. You will not have any anchors, any north stars. If you are too inflexible, you will not be open to alternatives. Since each of us is fallible, you will be most lucky if some of your errors do not seriously negatively impact your life.

What are reasonable anchors? DocBrain believes that ethics is a good place to start, perhaps with some variation of the golden rule. The second is to consider goals. Goals should be related to maximizing truth and pleasure (best seen in the long term). Data can be of some help, but all data is flawed and care needs to be taken to make sure you are not seeing things as you want to see them or as someone else wants you to see them. Lastly, you should take time to reflect on any positions you are attempting to calcify in your brain. Then, you should continue to test them for validity. While an exception does not necessarily exclude a general principle from being approximately correct, multiple exceptions should lead to a reconsideration or refinement of your theories and hypotheses of the world.

Simply put, it is healthier to have an open mind. Closed minds are the norm and the most common cause of conflict, while overly open minds are the most common cause of indecision. We probably could do with a little more indecision and a little less conflict in the world.

The Ethics of a Progressive Income Tax

In morality, the discussion usually revolves around vices and virtues. In ethics, it is about right and wrong. In either case, it is hard to come up with an argument that defends a progressive tax.

What is a progressive tax? It can envisioned as a seesaw, where those on one end receive money from the government, those at the golden mean neither receive nor pay, and those on the other end pay in an increasing rate the more they make. One can envision other solutions.

The practical underpinning of the progressive tax is that those who earn more can afford to pay more. Once basic needs are met, the rest of income can be viewed as unneeded. The government also has needs. Its needs must be met from income sources, of which taxation is the primary source. If there is a difference between the government's needs and its income, some way of getting that money must be devised. It is felt to be unfair to take needed money from citizens, so the only other choice is to take unneeded money. If you are going to do that, why not take it in some escalating way, so that the burden is borne more by those who can better afford to carry the burden? That is the argument, and it is nothing if not practical. Unfortunately, practicality runs into direct conflict with principle, and there are other solutions to the problem that are principled, making this choice wrong.

There is an ethical principle of malice. Malice is the intentional infliction of harm, which could be physical, emotional, social or economic, among others. "They can afford it" is the justification of taking, but doesn't make it ethical. For example, waterboarding a prisoner to get information may be viewed as wrong, because you actually are trying to inflict harm for your own purposes, no matter how noble those purposes might be. The defense of waterboarding is that the person is in no real danger and "can survive it". Furthermore, the defense usually is that the more a prisoner knows, the more reasonable are higher levels of intentional infliction of distress. There is no ethical construct that allows separation of financial malice from physical malice. If one is wrong, then the other is wrong. So, if you support torture of prisoners based upon some heirarchy of knowledge, you have no ethical grounds to oppose a progressive tax. And if you oppose torture, then you must oppose a progressive tax on the same ethical grounds.

There is one other point. Torture can be used to prevent further harm, but a progressive tax cannot. Torture may exact information that can be used to prevent a known upcoming malicious act. Taking of money in a progressive tax does nothing to prevent upcoming malice, unless one defines malice as the fair use of an individual's income as he sees fit. So, in this comparison, a progressive tax is worse than torture, as it provides no potential benefit. It only has ethical downside.

So, what are the ethical solutions for a government that needs money? There are several options, all of which are ethical.

• A flat percentage tax that everyone pays. From the received funds, reimbursement for basic needs is given to those below a specific poverty line.
• Reduction of government size and scope. Much of what government does could be done in the private sector. A country where people stand up and volunteer to help their fellow citizens is a more ethical society than one where largesse comes from the government.
• Ask citizens to donate to the government. Charity can flow to the government if those with money see the good in what the government does. Donations could be earmarked for different branches and services, based upon an individual's desire to give.
• Raise money from other activities. A national sales tax. Use taxes (ie, highway taxes, tolls).

Much of what our government does is not based on need, but on want, and based upon theories of governance that often run into conflict with other principles and practical limitations, thereby failing to deliver on promised results. If you want and have unlimited ability to take from others to get what you want, you have malice. Not a good way to run a free society.

Hmmmmm

Pollution is preventable, or at very least, can be limited. Some industries by nature create more pollution and these deserve higher baseline credits, but even these can use modern techniques to keep the pollution down. We really need to protect the earth from pollution. So, here is the deal. We will limit the amount of pollution a company can produce. If it produces less than the legislated amount, it can sell these to another company that pollutes more. If a company needs more than the legislated amount, it can buy from another company, or possibly even from the government. If the company cannot afford the credits, it will probably go out of business, or perhaps can work out a limited bail out program with the government while it improves its carbon footprint. If a group of people really feels sorry for the company, it can raise private funds to keep the company afloat by buying carbon credits for the company.

Chronic illness is preventable, or at very least, can be limited. Some people by nature are more predisposed to chronic illness and these deserve higher baseline health credits, but even these can use modern health care, exercise and diet to keep the chronic illness under better control. We really need to protect people from the effects of chronic illness. So, here is the deal. We will limit the amount of chronic illness we will pay for for an individual. If that person is healthy enough to spend less than the legislated amount, he can sell the additional benefits to another person who is more in need. If a person needs more than the legislated amount, he can buy from another person, or possibly even from the government. If the individual cannot afford the health credits, he will probably die, or perhaps he can work out a limited bail out program with the government while he improves his preventive practices. If a group of people really feels sorry for the person, it can raise private funds to keep the person alive by buying additional health care for the person.

Rights and duties

If you live in the USA, you are familiar with the concept of unalienable rights, which are the rights that no one can take from you, not even government, without either specific due cause, as decided by your peers (court trial) or your express and uncoerced permission. These include the big 4: life; liberty; pursuit of happiness; and property. What made them unalienable was the concept of a Creator of all things and the belief that this Creator would have wanted it no other way.

The concept of unalienable rights has been determined in other ways. Rawls demonstrated how logical process can reach the same conclusions. Recent neuropsychiatry studies with advanced imaging techniques seems to indicate that we are hard wired towards these same values. Past experiments with governments taking a different approach to any of the big 4 has usually found these governments winding up on the wrong side of history. It is an evolution of rule of law, of government, of social structures.

Grafted on top of this is the desire for a powerful leader, a powerful country. The conflict between these two impulses may lead to compromises in the unalienable rights.

Then, there is the concept of group good as opposed to individual good. One has little difficulty understanding how a person who pollutes a stream on his property adversely effects those who live downstream, but more difficulty seeing how a baker in Kansas, who sells all his bread in Kansas, effects a baker in New York, who sells all his bread in New York and has to be regulated by the Federal government.

If you award a right, you place a burden, a duty on others. One clear example is the right to a fair trial. This places a duty on citizens to serve as jurors. Courts level fines or even imprisonment on those who do not appear for jury duty. A soldier who goes AWOL is subject to penalties, which can be as high as death. If the courts found an unalienable right to eat a McDonalds hamburger, a McDonalds employee who did not show up for work might be in serious trouble with the law.

Those who accept the duties of aiding and abetting your rights, as defined by government, have themselves to some extent enslaved themselves to the government for the greater good. They are subject to penalties that do not exist for a free person.

A society where everything seems to be a right will be a society where everyone is enslaved.

One of the mottos of the revolution was Live Free or Die. As we nationalize everything in the USA, we can see how far we have come.