Tuesday, May 26. 2009
I just read a great New Yorker article on factors that influence medical system costs ("The Cost Conundrum," by Atul Gawande, June 1, 2009") I have written about health care finance in the past, largely because I'm a participant and enthusiastic fan of one of the alternatives currently available, Health Savings Accounts.
In the article, Gawande examines a particular small town in Texas in which Medicare costs are nearly twice the national average, to see if it gives any indications of what causes health care costs to grow. He systematically rules out various popular explanations – people are sicker, care is better, malpractice suits are driving up costs, etc. – and hones in on the motives of the doctors themselves. Hospitals that have the highest level of care (and, surprisingly, the lowest costs) are those which make improving patient care the number one priority, and deliberately structure the financial and social incentives for doctors to stay focused on patient care. The costliest hospitals (which, ironically, often have the lowest quality of care) are those in which doctors focus on maximizing their profits rather than making people well.
I'm glad that someone has named the elephant in the parlor. You would think that it would be obvious that health care providers have every incentive to inflate costs, at least until someone puts on the brakes and refuses to pay. I was disappointed, though, in how quickly the author dismisses the notion that changing who pays for the system (private insurers, the government, or the individual) would change the dynamic in spiraling costs. He quotes a doctor who contemptuously dismisses the thought that an individual could control the costs of their health care: "They discuss the blockages in her heart, the operation, the risks. And now they're supposed to haggle over price as if he were selling a rug in souk?"
Well, no, they probably won't haggle. But don't you think that if hospitals had to publish their price lists, and a well-rated hospital offered to do the same procedure at half the price, that an individual might decide to go to another provider? The internet has empowered patients more than ever to be informed about their conditions, their options, and (if the health-care system allowed it) the costs.
I have lots of first-hand experience of this sort of thing. When I was a young man, unemployed and uninsured and doing my Walden thing in West Virginia, I found a suspicious lump on my testicle. I saw a GP, who said it was 95% not cancerous, but referred me to a urologist to check it out. The urologist did an ultrasound, and confirmed it was a spermatocoel, a mostly-harmless blockage, which wouldn't be a problem unless it caused me pain. So far, so good. But then the urologist tried to schedule me for another ultrasound a month later. "Why do you need to do that?" I asked. "Well, it's good if we can keep an eye on these things," he said. "What do you expect might be different in a month's time? And why do we need an ultrasound to know if it's a problem?" The urologist, blustering, just kept repeating himself. "It's good to keep an eye on these things." I did not make another appointment. I didn't feel like spending $250 just to "keep an eye on things." I also noticed that I the bill had a charge for a urinalysis lab work-up, which I knew had not been done because I never gave them a urine sample. I paid my bill, minus the bogus lab fee.
This is not an isolated incident. I have had things like this come up with nearly every single health-care provider I've ever used . . . even the ones who I loved dearly and thought were the best doctors in the world. I've been asked to make an extra appointment, just to have the doctor read lab results to me, and give me the same diet advice he gave me the first time. (He could have done the same thing over the phone, or even just put it in the mail with a pre-printed explanation of the results, but then he wouldn't have been able to charge $80 for an appointment.) I have had emergency rooms and doctors try to charge me for the exactly the same service. In most instances, I have challenged the unnecessary or bogus costs and paid less . . . all because I'm the one paying for them.
If we want to control health care costs, somebody has to have a stake in controlling costs. We have a magic way of doing that. It's called a market economy. I'm perfectly happy to let the physicians have a profit motive . . . as long as I get to exercise my profit motive, too.
Monday, May 25. 2009
In the hands of any other studio, WALL-E would be unwatchable. The eco-tale would have been way too heavy-handed -- just another manifestation of our cultures' current passion for pretending to do things to save the planet. But, as it happens, this is a Pixar film, where story-telling is the number one mission, and the writers know that a mere moral is not the engine of compelling narrative. While WALL-E presents one of the most repulsive of dystopias I've ever come across, it doesn't seem to have any particular ax to grind. It tells the story, and lets the political and philosophical chips fall where they may. It is that innocence, that willingness to let the story lead us where it will, that charms me.
Had DreamWorks done this film, it would be stuffed with sly digs at current cultural figures -- we would be watching WALL-E doing impressions of George W. that he picked up from salvaged videotape. But WALL-E does not have an ironic circuit in his chassis. He doesn't despise the consumerist culture that has buried the planet in trash; rather, he marvels at the artifacts he finds, celebrating the mysteries of a Rubic's Cube, or the delight of popping bubble wrap. WALL-E loves this junk, because he senses the purpose and passions of the humanity that brought it about.
Nor does the movie vilify technology. (How could it, when its protagonists are technological wonders?) Robots are not the dehumanized, thoughtless powers of destruction, as two and a half decades of Terminator movies have taught us, but rather the builders and helpers we always wanted, as ingenious and limited as their creators. The robots, at least, have the virtues of diligence and faithfulness, a passion for the Directive. It's the humans who seem mindlessly mechanical, trapped in an endless cycle of virtual pseudo-pleasures. But even the people (always the villains of the eco-fable) are treated with gentleness and respect. For all of their ignorance and big-fat-slobdom, all the people are basically decent, sometimes even heroic, and instead of hating them for losing their humanity we find ourselves loving them for regaining it.
Having read several books about minds and machines lately (Pinker, Dennett, Hofstadter, etc.) I couldn't help but ponder over the lives of the robots. Pinker suggested that a truly intelligent robot would have to have something like emotions -- high-level, diffuse motivations -- to be able to function independently without direction. WALL-E seems to capture that vision of artificial intelligence quite well. The cleaning droid Mo doesn't just clean, he has a passion for cleaning, and the sight of WALL-E's dirty tracks excite such a furious need in him that he overcomes the other directives that usually keep confined to the flight deck. Eve doesn't just seek out life -- she is frustrated when she can't find it, overjoyed when she does find it, bitterly disappointed when she loses it. In the emotional lives of machines, we see the reflection of our own needs. People long for purpose, to strive for a goal, because without striving we are merely existing. I loved how the Captain of the Axiom saw the bleak cityscape of earth, and in spite of it said, "We have to go back." Life isn't living without struggle. To work is human.
Saturday, May 23. 2009
In response to Kenny's comments on the primacy of effort:
Tuesday, May 19. 2009
The writers at the New Yorker keep coming up with new angles on a recurring theme: talent is Out, effort is In.
I had already written previously about Malcolm Gladwell's latest book, Outliers, in which he details how effort and opportunity are more important than talent in creating super-successful people. Now, in another article, "How David Beats Goliath," (The New Yorker, May 11, 2009) he asks a seemingly simple question for a dedicated basketball fan such as himself: "Why don't more teams play the full-court press?" It doesn't take a genius to realize that a weaker team can dramatically slow down a superior team by playing the full-court press: guarding their opponents they moment they get the ball, and doing everything in their power to stop them from advancing to mid-court in the required 10 seconds. And yet, you rarely see that strategy pursued, at any level of play.
Gladwell followed up on those who did use the full-court press -- a team of 12-year-old girls in the National Junior Basketball league, and the teams of college coach Rick Pitino -- and found that they triumphed . . . at a price. The full-court press is an exhausting strategy, one that requires players to run and run and run. Few teams, it turns out, are willing to work that hard. It also makes for rather ugly basketball, a rushing and flailing of arms and legs instead of the graceful passes and shots players like to make and fans like to watch. The full-court press is stigmatized -- those who use it are met with both anger and contempt, and some officials make biased calls to discourage its use.
All this would be interesting enough on its own. But Gladwell loves isomorphisms -- he wants to see if this same phenomena maps to other sorts of struggles. And before you know it, he draws parallels with the military history, and academic studies of how underdogs prevail in battle. Lawrence of Arabia played the military equivalent of the full-court press, using the everywhere-at-once attacks of his Bedouin troops in the places his foes were weakest. They prevailed because the hustled, and refused to play by the rules that favored their opponents. Those same tactics -- small, fast, non-traditional, and out-of-bounds -- have now redefined modern warfare in an age of terrorism and insurgency. David can win against Goliath, but only by using methods Goliath finds repellant.
The triumph of effort found another voice this week in another New Yorker article ("Don't! The secret of self-control," May 18, 2009) that looked at the unexpected results of psychological research in the sixties. Some researches had created "the marshmallow test," a simple exercise to see how long four-year-olds could resist eating a treat in order to earn a greater reward later. Kids' abilities to defer gratification varied significantly, but they could also be taught cognitive tricks to make it easier. The researchers didn't realize the significance of their findings until they followed up on their subjects decades later . . . and found that the marshmallow test was profoundly predictive of success in later life. Those who passed the marshmallow test scored higher on the SAT. Those who couldn't resist the marshmallow were more likely to have behavioral problems, had trouble paying attention and maintaining friendships.
For years educators and parents have been focusing on IQ as the most important cognitive measure, when it turns out willpower was more significant. And willpower, they've found, is not some mysterious quality of character, but rather a specific skill for controlling one's attention, focusing on certain thoughts and tuning out others. Persistence of attention and effort are what ensure lifelong success.
What does this mean for our culture? I hope it signals a rejuvenation of the American meritocracy, restoring our faith that people can control their destinies, if they are willing to pay the price. The "land of opportunity" is really "the land of the opportunity to work." Effort is not omnipotent, but it's the closest thing to it.
Monday, May 18. 2009
Kenny pointed me to his essay on fantasy, which he had written after seeing Prince Caspian.
So, let me share some parts of my life that I had never shared before:
I was deeply involved in fantasy life when I was a child. From about the time I could read novels (9 or 10 years old) I would spend vast amounts of time reading fantasy and sci-fi, and then even faster amounts of time day-dreaming about those worlds. I was never merely the observer of those stories; I almost always become an active participant. I dreamed up roles for myself in the stories, or back-stories, or unwritten sequels to all those books. I developed relationships with the characters based on long conversations I had them.
To give you a sense of what this looked like from the outside, I'll tell you a story. One sunny spring day when I was nine I went outside in our back yard, climbed on a plastic faux tire swing, and began swinging back and forth. And swinging . . . And swinging . . . And swinging. I never looked around. I just stared into space, pushing off the tree again and again. At one point my mother came out into the yard and asked, "Are you ok?"
"Are you all right?"
"It's just that . . . you've been swinging on that swing for two solid hours."
I don't recall, now, what world I was in at that time. It might have Xanth, or maybe Pern. My imaginary life was totally immersive and addictive, not unlike the old Hanna-Barbara cartoon with the day-dreaming kid who was constantly losing himself in dreams, fighting arithmetic problems on the blackboard or deep-sea diving in the classroom aquarium. I eventually learned that people think you're autistic if you sit in one place while you fantasize, so I found socially acceptable repetitive things to do: weeding gardens, hitting tennis balls against schoolyard walls, biking, walking. I have always been a physically fidgety person, more comfortable moving than sitting still, so I usually needed to be moving to fully lose myself in the dream.
An imaginative life is the sort of thing that's supposed to make great artists and writers. But I didn't write, or draw, or create much of anything, other than more and more elaborate dreams for myself. I did read a lot, because my imaginative world needed the fuel of new worlds, new characters and quests. I did not play with other kids when I was in the grades, nor did I "hang out" with people as I grew older. I had only the vaguest sense of what friendships looked like. It troubles me, sometimes, when I think back on my childhood and try to remember it, and there is so little detail. I cannot write the story of my life then, because my life had no story back then. I was living in someone else's. I remember a lot of physical details. I can fly through every house I've ever lived in, and see every room in my mind's eye in perfect detail. Every road or path I walked is equally fixed in my mind. Sometimes, when I'm thinking through a problem, a part of my mind walks through those places again. There are no people in that mental space, though. It's as empty as Charn, the world of the White Witch after she spoke the Deplorable Word.
Someone might suggest that I had retreated into a fantasy world because my real life was unpleasant. I'm sure that's true for some people. But there was nothing wrong with my real life. I lived in a decent home, with good parents and brothers. I did fine in school. If anything, the causality went the other way: I didn't fantasize because I didn't have friends, but rather I didn't bother with friendships because my life was already lively and entertaining enough in my fantasy world. Were it not for puberty, and the strongly felt need to associate with flesh-and-blood females, I might never have come out.
Like the Pevensie children, I also was eventually cast out of the fantasy world. It coincided with the development of my religious life. I started reading C.S. Lewis' theology and philosophy books, at the same time that I was going to Christian youth groups and trying to interact with humanity. At some dim level, I knew that I had reached the stage when living in dreams was no longer appropriate. God did not bring me to this place just to have me dwell in a dream. But it was a secret addiction, a guilty pleasure, and I struggled mightily to overcome it. I never completely did, though I did finally find a place in this world.
Kenny makes the suggestion that people inclined to fantasy literature are also later inclined to spirituality, and that perhaps the reason for the interest in fantasy is that it appeals to some dim intuition that there is a deeper hidden reality in the world that is more real and more alive than the "real world" that most people deal with. There is definitely something to that.
I fell in love with the Narnia books, not just because they were such great fantasy books, but because they explicitly, knowingly made the connection between fantasy and spirituality. Lewis wrote the mythology of Aslan to parallel the mythology of Jesus Christ, and it resonated deeply in me. It was a good and a bad thing. It was good, I suppose, in that it created a deep desire in me to have an encounter with divinity. I had many sleeping dreams in which I finally met Aslan, and could enjoy the peace of knowing him. I was always bitterly crushed when I woke up.
The problem was, I think Lewis did his job too well. I loved Aslan more than I ever loved Jesus. Aslan was powerful and beautiful and subtle; he was most deeply personal while remaining awesome in his magnificence. Jesus was . . . Well, none those things, really. He was this guy that people seemed to perpetually take advantage of, until they finally killed him. Aslan's myth was better. That alone was enough to make me see it for what it was -- a myth, a story, something that might point to a deeper truth, but could never be taken as the Truth itself.
By then, though, the desire was too firmly planted. A life in Mundania could not possibly be enough. In this world people care about fashion, and cars, and who's going to what party, and sports. In other words, they care about things that are stupid and meaningless. (I'm sure that they would look at the things I care about -- philosophy and fiction and spirituality -- and find them equally stupid and trivial. That does not change my opinion. They're wrong.) I had seen a glimpse of life lived for something more real and true. Only now, trapped in a world without magic or miracles, I'm having to create that life on my own. One of the great strengths of the Prince Caspian movie is that it showed how hard it was for the Pevensies to live on the Outside, banished from magic.
Wednesday, May 13. 2009
I recently discovered the NetFlix Instant feature, that allows you to download and instantly view movies. I've come to think of it as "Where Commercially Unsuccessful Films Go To Die", because the vast majority of the films offered do not interest me, and with good reason. It's as if the studios said, "Aw, what the hell, we're not getting any more out of this old thing anyway, let 'em download it and see what happens. I only wish folks would start pirating the damn thing." Sometimes there are really good, really old films that are so mined out that they go to Instant -- e.g. Clint Eastwood's Unforgiven -- but mostly they are trash-films from two or three years ago, or an underappreciated gem that underperformed. Which, from a studio executive's point of view, is the same as trash.
So, I have a mixed reaction when I see a film I actually would want to see show up in the Instant section. When Joss Whedon's Serenity showed up, I thought, "YES! . . . I mean . . . Aw, that's too bad." Serenity is a really, really good movie, and it pains me to see it sitting next to Hellraiser III.
I got another one of these forsaken classics this week: The Chronicles of Narnia: Prince Caspian. Prince Caspian was one of the better Narnia books, so you think it would make a better film than The Lion, The Witch, and the Wardrobe. And you would be right. Director Andrew Adamson wins the Peter Jackson "Oh My God, That's Exactly How I Imagined It" Award with the ruins of Cair Paravel and the entire character of Reepicheep.
Adamson also succeeds at staying true to the essential nature and intent of the story, but not letting that get in the way of making a good movie. Critics had complained that the first Narnia movie couldn't sustain much action because its protagonists were so young, so it looks like the producers focused on making this one a little faster and more furious. Peter's swordplay still feels a little sluggish, though his duel with Miraz sustained the dramatic tension fairly well. Meanwhile, Susan seems to be giving Legolas a run for his money in the "Bows are so badass" category, not to mention reminding us that red fletching is the perfect accessory to a killer outfit:
Speaking of which, I imagine that C. S. Lewis, were he writing a Hollywood script instead of a Christian allegory, would be kicking himself for not using the story devices incorporated in this Prince Caspian film: "Of course! Frustrated romantic tension between Susan and Caspian! Why didn't I think of that?" The movie is full of similar innovations, which deviate from the text's literal plot but not from its mood or overall theme. Nikabrik's plot to summon the White Witch, for instance, kept all the best dialogue, but blew it up to a visually dramatic action sequence instead of just a quick brawl in the dark. I don't remember a lot about the actual war campaign from the book, which shows that the movie did a better story-telling job when it came to the failed attack on Miraz' castle and the ego-battles between Caspian and Peter. Narnia fans should rejoice; a basically faithful adaptation also turned out to be a fun movie.
Ok, now that I have the fanboy stuff out of the way, a few more thoughtful reflections.
Maybe its just that movies and games have become so much more graphically violent, that I recognize a conscious retreat back to earlier movie conventions. I have seen so many blood-smeared faces since Braveheart and Gladiator that it strikes me as singularly odd to have a full-scale battle scene where not a single drop of blood is shed. People (and centaurs, and fauns, etc. etc.) get shot with arrows, crushed under rocks, slashed with swords, and the only evidence of damage done is a short surprised grunt before collapsing to the ground. No blood. Ever. No screams, either -- howling in agony does not happen in magical fairylands. So I ask myself -- is this better? True, it's not dulling our capacity for horror by bathing us in gore . . . But do we do any better, making battle look so clean and . . . noble? C.S. Lewis, a veteran of war, believed in the just use of violence and would probably approve of his heroes and heroines being unapologetically forceful in their cause. But I wouldn't want to disconnect it from the consequences, either. My favorite scene in the whole movie, the one that showed the most depth and courage, is when Peter is standing on the bridge of the castle, gazing back at his troops trapped behind a gate, realizing that because he made the wrong decision, his friends and comrades are doomed to die. In that one slow-motion moment, we feel everything about that war -- the horror of battle, the nobility of their sacrifice, the terror of the struggle, and the awful need to keep moving through unspeakable grief. Now that is war.
Monday, May 11. 2009
But although we may use metaphors to describe our scientific theories, the science itself is not simply a collection of metaphors. And I mention this because some thinkers (C.S. Lewis and Rudolph Steiner, among others) have argued that morality is an objective fact just as science is. An intriguing thought, although I'm not sure I buy it.
I remember the first time I ran into that line of thinking. I was in high school, at some church function, and I was confessing that I didn't really understand the whole concept of why Jesus' death was supposed to redeem humanity. It just didn't make sense to me . . . God needs a human sacrifice to appease him? One guy, a visitor from some evangelical church, said that it didn't have to make sense. "It's just a brute fact." As far as he was concerned, there was no rationale to explain redemption through faith in Jesus Christ – but it was real to him, so he decided it was just an objective factor built into existence, as palpable as gravity and equally irreducible.
Steven Pinker recognized that the same sort of "well, it just is" argument could be brought to bear on the question of consciousness:
One [solution] is to say that the mysterious entities are an irreducible part of the universe and to leave it at that. The universe, we would conclude, contains space, time, gravity, electromagnetism, nuclear forces, matter, energy, and consciousness (or will, or selves, or ethics, or meaning, or all of them.) The answer to our curiosity about why the universe has consciousness is "Get over it, it just does." We feel cheated because no insight has been offered, and because we know the details of consciousness, will, and knowledge are minutely related to the physiology of the brain. The irreducibility theory leaves that a coincidence.
Like Kenny, I find that argument (and must call it an argument, because it is nothing like an explanation) to be "intriguing" but not convincing. The first time you apply it to something that baffles you (consciousness, for me) you feel particularly clever. But then when you hear someone apply the same reasoning to something you don't find baffling but merely untrue (like the cosmic necessity of Jesus' execution on the cross), you recognize that this is not reasoning at all, but merely an assertion made by someone who has run out steam on the subject. At that point, you realize that "it just is" is just a belligerent way of saying, "Heck, I don't know."
Kenny is correct that the use of metaphors in moral thinking does not mean morality is unreal. But there are better and worse metaphors to explain things . . . and I just want to be clear about which ones we're using, and what they imply.
Monday, May 4. 2009
One of the central themes of Pinker's The Stuff of Thought is that language is intrinsically metaphorical; we are constantly borrowing properties of the physical universe and applying them to more abstract concepts and ideas. For instance, we often use the metaphor "TIME IS SPACE" when talking about a sequence of events: "We just passed the early registration deadline; we are coming up on the final deadline." In our language we treat time as if it was space that could be travelled through. Even when we are talking about non-material things, our language uses metaphors that are, as Pinker puts it, "thuddingly concrete." Some common conceptual metaphors:
ARGUMENT IS WAR (e.g. "he attacked the weak point in my argument")
LOVE IS A JOURNEY (e.g. "Where is this relationship going? I feel like we've hit a dead-end.")
GOALS ARE DESTINATIONS (e.g. "When we reach our monthly quota we'll have a party.")
Once you get the hang of it, you start seeing the metaphorical underpinnings of language and thought everywhere. You start parsing every statement by asking the question: "What metaphor underlies this statement? And what assumptions are made as a part of that metaphor?"
So, when we ask the question, "How good is good enough?" I can't help but ask, "what metaphor are we using to describe morality?" We couldn't ask the question unless we were using some sort of model where there can be "enough" goodness, whatever that means. "Enough" implies sufficiency to meet some need or end. Whatever model is being used, there is some need or end implied: "enough" really means, "Enough for something". Enough for what?
Based on the conversation thus far, I think most people would answer something like this: "Good enough to still be considered a good person." Or, "Good enough to not feel guilty about it." Or maybe even, "Good enough to be rewarded by God in heaven."
Hmmm . . . Ok. So let's try this metaphor:
MORALITY IS A TEST. When a test is applied, it is usually to determine whether the properties of someone or something are sufficient to a particular purpose. We test buildings to make sure they are strong enough to withstand an earthquake; we test students to see if they learned their lessons sufficiently well to use their knowledge in a practical manner. In this metaphor, being "good enough" means you pass the test for goodness. The metaphor carries some implicit assumptions: someone is doing the testing, and that someone has a specific purpose or end in mind for applying the test. For a religious person, the tester is God, who is testing to see if you are worthy to enter his heavenly kingdom. For the non-believer, the tester is Society, who is testing to see if you are someone with whom we can safely and profitably associate.
If we accept this metaphor, what does it mean to be "good enough?"
If you believe, as most Christians do, that morality is God's test for humanity, then I guess you should consult the scriptures and make your best guess. I would warn you that Jesus is kind of a hardass on this subject; when asked on one occasion, he said, "Sell everything you have, and give it to the poor, and follow me."
I'm fairly certain that Pinker and his fellow evolutionary psychologists would support the idea that Society is the tester. Their theory is that our moral instincts evolved as a means towards reciprocal altruism: helping others so we can in turn be helped by them. That theory would certainly require we be very sensitive to how we are perceived by our peers and neighbors, and give us a strong desire to have the community regard us as trustworthy, fair, and generous -- all the qualities that would make us good partners in mutually beneficial cooperation. So, "passing the test" in this context is dependent on the needs and expectations of the community. It would be graded on a curve, since you are competing with other members of the community to be the most desirable partner in collaboration. There would also be a failing grade, a level below which no one would want to have anything to do with you. Evolution would encourage the development of people who are as generous as they can afford to be without compromising their own well-being or security -- so, generous but not too generous. And that model does a pretty good job of describing the way people actually behave.
The question is: are any of these metaphors the ones that I was actually using? And do I believe the underlying assumptions of them?
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