Conditional Knowledge

Conditional knowledge subject to relentless reassessment in light of new data. That's what comes to mind when I think of the scientific way of knowing. Progressive approximations of reality. Only those approximations that can account for known facts, predict new ones, and accommodate established uncertainties get to be called facts. It's a harsh standard. It usually doesn't fit with how we might wish the universe to be. Ironically it's that failure to bend to our wishes and desires that speaks to its truth.

What Weight Evidence?

In order to control my blood pressure I've had to refrain from a couple of my usual blog haunts because I'm pretty sick of the same old tired apologetics delivered either with sheepish smugness (like the Family Circus) or increasing condescension. Some are skillful at debate - kind of master debaters you might say. To bad they aren't so concerned with facts. The problem is that debate does not require facts to be compelling. It can become something with the sole goal of gaining approval, often through some sort of slight of hand approach. Debate, like the law, is adversarial and, though ideally based in logic, may or not be factual. I keep coming back to this - Logic is not the same thing as truth. Take a recent example in a logic test. I smiled to my self when I read this because the authors (intentionally or not) created a false logic - something I accuse them of frequently...

• All ducks bark
• Donald is a duck
• Therefore, Donald barks

This is logically valid. It's also factually false. This one is easy to dismiss because we know ducks don't bark, but think about how often people confound debate with essentially identical arguments from logic. If the basic assumptions used in the logical argument are false the result is false logic. We waste so much time on this sort of thing because it can be convincing in a superficial sort of way and when confronted the master debater will often run off and hide in the realm of metaphysics where almost anything goes - even barking ducks. Philosophers may debate whether we can dismiss this logic out of hand. The apologist will say that because we haven't examined every duck or haven't tested them in the right manner to determine if they might all bark that we can't completely reject this logical claim.

But is that really true? Since the logic implies a positive statement, we can in fact, reject it using empiric methods. We just need one duck that can't bark. That won't convince the master debater because he'll just claim that the duck barks when we aren't looking. We have no evidence that ducks bark. We have never encountered a barking duck. The agbarkic may say that he or she doesn't know if a duck can bark or not. But among other things this is a cognitive bias called neglect of probability if nothing else. Since we have vast experience with quacking ducks and none with barking ones we might logically propose the following:

• No ducks have ever been observed to bark
• Donald is a duck
• Therefore, Donald does not bark

The master debater will be correct in saying that this is an example of overstepping the bounds of what can be concluded through logic, but so what. Do we really want to waste any more time on the notion of barking ducks? The master debater may consider it a win if he or she can get the skeptic to admit that all they can really say is that Donald probably can't bark. Within that tiny reed of uncertainty the master debater can continue their guerrilla war against rationality. With such an admission they can loudly proclaim that we cannot exclude the existence of a barking duck! Soon they'll leap to claim that this means that superpowerful ducks rule the universe, while chiding us for any lapses in logic... Our counter should be simple - Show me a barking duck or shut the heck up about it already. Absent the proof (or woof...) the logic statement becomes nothing more than intellectual amyloid that can be ignored. The overwhelming preponderance of evidence trumps the need to spend any more time on it. Reality has many examples of quaking ducks and not yet a single barking one. So the possibility (tiny) of a barking duck is of no practical importance. Find one and we'll talk.

What about this one?

• Reality can always be described through logic
• A particular master debater is always logical
• Therefore, the master debater can always describe reality

Why is this invalid in fact? Our courts are a good place to see one reason why it's not truthful (in an absolute sense). In the case of two opposing mutually exclusive logical positions, one must be false - unless truth is a quantum phenomenon... Reality may be amenable to logical description but that doesn't in any way mean that a particular human (or any of them for that matter) can accurately describe the baseline logic that is factual. People can, have, and continue to create false assumptions as to the baseline of reality and happily run off in some completely logical, albeit false, direction.

Take one of Zeno's famous paradoxes (created originally to mess with other people's minds) to see how we get caught up in this nonsense. One paradox (the dichotomy paradox) talks about traveling a fixed distance. It posits that before a traveler can get somewhere, he must get halfway there. Before he can get halfway there, he must get a quarter of the way there. Before traveling a quarter, he must travel one-eighth; before an eighth, one-sixteenth; and so on. Basically it says that he can never reach his fixed destination. The math can get quite cumbersome if one wants to refute this formally. But the practical minded person can just step back and say, " I have to cover ten meters of distance and my stride is half a meter. Therefore I will reach that fixed point in 20 strides. I won't get caught in an infinite regression because that's not how I walk. I can prove that empirically. No one else I know walks that way either so buzz off." By simply walking across the room the paradox is dispelled by a single exception.

That's one reason that many apologists hate science. It has this nasty habit of demonstrating that their philosophical emperor has no clothes. Rather than wasting time on logic constructs why not let the preponderance of evidence be our guide? When exceptions are proven, then revise the model. What might we call such an approach? Science perhaps?

So as for logic I must confess the following:

• The overwhelming preponderance of empiric information usually points toward the truth...
• I seek truth...
• Therefore as a practical approach, I will look in the direction created by the overwhelming preponderance of empiric data...

Or said another way - from now on I'm from Missouri...

WMD's: Words of Mass Destruction

The unintended consequence of a recent post has gotten me thinking yet again - most unfortunate. I used a word in a post that has a particular meaning to me but a very different one to another person whose wit, insight and personality makes our little niche of cyberspace all the more enjoyable. For that I am truly sorry. I am not trying to be PC here (I am not good at that anyway). I started again to wonder about the enormous number of Words of Mass Destruction that linger out there ready to do harm, often with out that harm being the user's intent.

Some might say that having to carefully chose ones' words is ridiculous and that 'they' (insert whomever is contextually appropriate) shouldn't be so sensitive and should just ignore it. Easy to say when the word does not carry steel for you.

So much of our language - at least our idiom, comes from dubious historical contexts that we usually don't remember. Much like our genome, our language is saddled with a bunch of old stuff that isn't particularly useful to modern discourse. For example, I still chuckle on those rare occasions when the high and mighty NYT crossword includes 'snafu' in a puzzle. I'm pretty sure that's the only way that word is going to get in there for a while. Think of these seemingly innocuous and common phrases: sacred cows, the pot calling the kettle black, retarded, rule of thumb, tar baby, etc. It's not just the words that have known negative meaning. It can also be ones like handicapable. Intended to be an improvement but usually just cloying and condescending. How often have each of us used these and other phrases without a thought. And shouldn't language be about thought?

Celebrating an Immoral System: Some More Teaparty Nonsense

I'm moved to submit this post for two reasons: 1) the immoral Right wing grandstanding that 'symbolically' repealed the Health Care Reform bill yesterday, and 2) the hidden impact this could have on people within our little discussion circle who struggle with chronic conditions that are poorly understood and largely ignored by our proud capitalist health care system.

I am a doctor. I don't play one on TV. I have been a trauma surgeon for over 2 decades. I have been involved in health care systems efforts for most of that time. I am an expert on the delivery of healthcare. I have great respect for many of my colleagues who do their best to provide comfort and care. And I have no doubt that ours is an immoral system based upon one's ability to pay or the portability of one's healthcare coverage. The poor get care, but it's care from people like me. At the end of the line when injured or too sick to not come to the ED. No prevention, no wellness, no early detection of disease. The immoral Right wingers celebrate a system that learned through science that early detection of disease and good management saved lives, yet is governed by a payment system that penalizes those who access those same services. They call it actuarial tables to limit risk, but I know it prevents our nation from realizing the benefits of our best medical science. We spend more than 2x times on care in the US compared to the next highest nation, yet rank 32nd (tie) in life expectancy and 40th (tie) in infant mortality. [World Health Organization, “World Health Statistics Mortality and Burden of Disease ", 2008]. Yes, there are many factors that cause this but ignoring prevention while dispensing erection pills in baskets isn't helping. Republican 'law makers' (wow there's an irony...) are really good at catch phrases - I wish they were half as good at actual leadership but hey. So Mr Speaker - when you trot out 'Job killing Health Care Legislation', those of us who actually know about such things know that the real job killer is the fact that we don't get value for our health care dollar and nothing kills a new job like being saddled with the burden of a pre-existing condition that makes it impossible to change coverage.

What's worse, we are spending this much even though we are largely ignoring huge segments of health care need. There are many places one could point to that illustrate why I use such a strong word as immoral. But a short description of our 'mental health services' works all too well.

Every night I cover the ED, any number of poor souls is brought in by EMS. They are homeless. Many are mentally ill. They have no advocates. They can access no benefits. Mental health resources have been slashed in the last few years as the States have struggled to make do with less. The mentally ill disappear into the shadows. Hospitals hate admitting the mentally ill because it almost invariably means that they will eat a huge bill and the length of stays are very long since there are few places to send them post discharge. With the costs associated and the fact that hospitals are graded by length of stays (affects payments) it doesn't take long to understand how a hospital in LA used a van to dump homeless mentally ill patients in another area where some other hospital would have to take care of them the next time. It's a dreadful and immoral game of musical chairs. And no hospital wants to be left standing when the music stops. A system based upon payment for expensive and glitzy procedures has little to spare on unpopular chronic problems.

So those in need are swept under the carpet. The average Joe doesn't have to concern themselves with their plight unless offended by some poor guy muttering to himself on a street corner in the throws of untreated schizophrenia. No, this is much better than a national health system where we'd all have some skin in the game to figure out how to provide care to all Americans. I believe Oregon has not executed any criminal for aggravated murder in the last 14 years - in the last 14 months I know of at least three mentally ill persons who died at the hands of the Portland criminal justice system. Now, don't get all offended for the Portland police. I'm not blaming them. Our national unwillingness to face the music puts them in a no win situation. But it is sad that schizophrenia and mania are ending on our streets because the police , ill equipped and untrained to address mental illness (why should they be the only ones when the rest of the system has washed its hands) are being forced to deal with mental illness with a gun.

Yeah a lot of the usual do gooders rant about the horror of it all, but there are no initiatives on the ballot to address any of it. They just want the police to be more gentle - or quieter about it I suppose. High profile shootings make it harder to ignore the problem. Though I am impressed with how even then, nothing really gets better.

This is just one example of the problems we face. The right and moral thing to do is to band together as a nation to address these challenges. Or stop pretending that we care.

Discourse is most productive near the very limits of civility

Did Sara Palin, et al. contribute to an environment that could incite marginal individuals to violence? I don't know. But for a moment I'll ask that we consider only this - why did her actions lend themselves so easily for people to make such an accusation? Some no doubt don't need much of an excuse to think badly of her. After all she was a big promoter of the flagrant 'death panel' lie and, until recently, had a lot of pictures with cross hairs in them on her website. So she can't really pass herself off as a voice of moderation.

But if nothing else, I'd like our leaders to look at the lessons of Arizona and realize that all of them are putting themselves on the line every time they go out into public. Leaders are lightening rods for argument and disagreement. To lead among the people one must put oneself at some risk. Crazy people need little encouragement and therefore can't really be avoided. What can be avoided is inflammatory rhetoric that intentionally blurs the line between reasoned disagreement based upon enlightened debate, and demonization of any and all who might legitimately and with principle, disagree.

A lot less entertaining no doubt, but also a lot more productive.

The True Death Panels

No, I'm not talking about the reprehensible scare tactics used by the Republicans prior to last year's health care bill. I'm talking about the closed door sessions in corporate board rooms of payers, political strategy sessions, and PAC planning meetings. You know - a lot of the people who opposed health care reform. The real death panels are those that want to preserve the status quo. Hopefully, this will make sense after you read the rest of this post.

What follows are some indisputable facts. How they get used in Washington is up to us.

1. Prevention, wellness, and early disease detection strategies are the best methods to provide both improved care and reduced costs.
2. All of these strategies depend upon; a) ready access to care, b) profiling strategies to identify those most at risk, and c) low cost lifelong support for chronic problems.
3. Our current system denies ready access, penalizes those identified with risk factors, and denies continuity of care caused by job changes, relocation or aging, for example.
   
4. Economic disincentives to prevention and early detection exist for both patients and care providers.
5. Disincentives include nonexistent or low reimbursement for prevention, fee increases or canceled coverage for pre-existing disease, life-long exclusions for pre-existing disease or risk factors with changes in coverage, etc. All of which make individuals reluctant to seek preventive care.
   
6. These disincentives are most acute for the poor or those generally described as working class.
7. Lack of prevention and early detection results in failure to prevent or recognize early stage disease which increases preventable mortality, particularly amongst the poor and working class families.

So, the real death panels; the ones that ultimately make decisions that cost people their lives; aren't the ones giving end of life counseling in a clinic. They are the shadow groups that oppose the reforms that can improve care and extend life for all. Those that oppose reform out of financial gain or political gamesmanship. Can one sink any lower than that?