Tuesday, November 29, 2016

A Few Philosophical Reflections On Dreamland: The True Tale of America's Opiate Epidemic

I just finished reading Sam Quinones's astonishing book Dreamland. Dreamland tells the story of the story of America's recent opiate epidemic, but it is also about a million other things like modern American culture, the ethics of health care, late capitalism, the role of government, the nature of pain, and the timeless dilemma of human existence: can you make things better for people without also, somehow, making them worse?

This post isn't an overview of important themes from Dreamland. For that you'll have to read the book. And you should read the book. If you're not sure, start by listening to the author talk about it on the WTF podcast or check out more info here.

Anyway, this is just a discussion of a few things I personally found philosophically interesting, relevant, and thought-provoking.

1. Philosophy of science: evidence and social epistemology

One of the central aspects of the epidemic was the sudden rise in prescriptions for opioid pain relievers and particularly Oxycontin. For a long time it was part of health care orthodoxy that opioids are highly addictive and thus dangerous, and so should only be prescribed in special circumstances like after surgery or when someone is near death. But Oxy tried to change all that.

Oxycontin was formulated as a time-release pill made up of the opioid oxycodone intended to eliminate the euphoria and make the drug non-addictive. It is not surprising that Oxycontin was aggressively marketed as non-addictive: in the nature of things, the makers of the drug stood to make more money the more it was prescribed, and this is what companies do.

What is surprising, and indeed utterly shocking, is how many people went along with it -- with a belief that challenged everything they thought they knew -- on the basis of virtually no evidence. Doctors believed it, med school profs started to teach it, massive health care decisions were made on its basis. And, of course, it turned out to be wildly false. So: what the hell?

As with so many things, it turns out that the answers are complex. The drug arrived in the middle of a shift away from thinking of pain as something to be endured no matter how awful and toward thinking of pain as something that ought to treated. That shift probably would have been a good thing, except that at the same time, insurance companies didn't want to pay for the multidimensional treatments known to help with pain. The producers of Oxy spent a fortune conducting huge conferences that trained drug reps and reinforced the message.

These reps were trained to cite, as evidence, a text known as "Porter and Jick." This text, which was refereed to as a study and sometimes described as a large or important study, was supposed to show that opiods aren't so addictive after all. But Porter and Jick isn't a study at all. In fact, it turned out to be a one-paragraph letter to the editor, written in 1980, to the New England Journal of Medicine, in which a doctor with a taste for data wrote out an informal observation of patients at the hospital where he worked. Not only wasn't it a study, it described patients in a highly controlled environment receiving drugs before the rethinking of pain treatment was underway.

No one questioned "Porter and Jick" -- at least for a long time. People shared the info, passed it along. Quinones points out that everyone thought everyone else had read it; before the journal archives were put online in 2010, finding out what Porter and Jick really was would have required going to the library and looking it up -- something doctors just didn't have time to do. Interestingly, when I tried to use PubMed to view Porter and Jick, I saw the image at the top of this post -- no associated abstract even! -- and Google Scholar offers only a citation. It is still not an easy text to find!

Don't you find it profoundly disturbing that people can cite something crucial, and build on it, and teach it, and share it, without really knowing what it is? I do. And yet, I expect that this -- or something like it -- happens a lot. We know that science proceeds in a highly social way, and that scientists trust one another. People appropriately subject some beliefs to much more crucial scrutiny than others, because they are relying on a sense of what is, and isn't, already known and what is, or isn't, important to revisit. You couldn't require everyone to check everything going back all the way at every stage, or nothing would move forward. It's complicated.

Of course, when it comes to actual pharmaceuticals, you could build in specific checks on things. This article points out that the current US scheme -- in which advertising has to be submitted to, but not reviewed by, the FDA before it can be used -- is a big part of the problem.

2. Capitalism and philosophy of economics

The story of the opiate epidemic is, in some ways, the story of capitalism going where capitalism had never gone before. If you leave out the "people dying in droves" problem, the story of Oxy is a story of business success. And Dreamland describes how a guys from one town in Mexico create a kind of pizza-delivery model for black tar heroin, where you call and there's a guy, and there's quality control and customer service and so on.

I'm constantly trying to convince people that economics is not value-free: that our definitional choices affect our conclusions, that this process is not value-neutral, that assumptions about what is and is not important are hidden behind seemingly objective principles.

The opiate situation is a perfect illustration. The story we always hear about capitalist exchange is that when A and B  make a voluntary transaction, overall well-being improves: since A and B are both getting what they prefer, they are both better off.

As Adam Smith well knew, this is true only in certain contexts and against certain backdrops, and ethical questions and economic ones are deeply intertwined. If you allow that people buying Oxy and black tar heroin, becoming addicted, and often dying is a "bad thing," then you immediately face several deep questions: How is this exchange unlike others? What is the theory of "well-being" in which Coca-Cola makes you better off but Oxy doesn't? What is the theory of "voluntary" that makes addiction incompatible with free choice?

In her wonderful 1962 book Economic Philosophy, the economist Joan Robinson uses the example of addiction to showcase the problems with the standard economic view in which the theory of revealed preferences -- whatever the person chose must, tautologically, be what they wanted -- comes together with the theory of well-being as preference-satisfaction -- whatever the person preferred must, tautologically, have been what would improve their well-being.

"But [addicts] should be cured," she writes, "[and] children should go to school. How do we decide which preferences should be respected and what restrained unless we judge the preferences themselves"

Sure, highly addictive drugs are an extreme example. But you can't rule them out without a some thinking about what preferences matter and why, that is, about what is good for people and what isn't. And once you're going down that road, well -- pretty soon you're asking what is a good life and what matters and why. You're far from rational choice theory and revealed preferences, and there's no telling where you'll end up.

3. Is the human experience essentially a pain?

When it comes to the pains of human existence, there are two types of people in the world. There are people who think things are naturally OK and only become fucked up when bad things happen, and there are people who think that the human experience itself is essentially a problem. In case you haven't noticed, I'm the second type.
In Dreamland, Quinones talks about the dilemma of all attempts to kill pain: can you have the heaven of pain-killing without the hell of addiction? The thing I'm talking about is related to that but goes beyond pain and pleasure into general human existence questions.

As the opiate crisis deepened, many of the people who got addicted were young privileged white people from well-to-do families -- kids growing up in leafy suburbs, with their own bedrooms and cars and TVs and so on. In some cases they started because of sports injuries, but a lot of them were just looking for a good time.

If you think things are naturally OK and become fucked up only when bad things happen, it seems difficult to explain these kids deciding to take drugs. Why take those risks? For what? But if you think human existence is naturally difficult, exhausting, irritating, and boring, it makes all the sense in the world. People are constantly trying to escape their own consciousness, and they always have.

What this ultimately shows, I think, is that while freedom and autonomy are wonderful things, desires don't just come out of nowhere, and most people aren't going to do very well when left alone to their own devices.

Tuesday, November 22, 2016

Guest Post: The Movie 'Arrival' Made Me Sad And Angry

This guest post is by my former co-blogger at Commonwealth and Commonwealth, Captain Colossal aka Felix Kent.

I saw two movies this weekend and one of them was Arrival and it made me hopping mad, like walking-out-of-the-theater-with-my voice-getting-louder-and-louder mad. I was angry because I thought it was stupid, because I thought if I was going to see a stupid movie I wanted at least the pleasures of a stupid movie (montages! explosions! breakthroughs!) and also I had thought it was going to be good, partly because I think Jia Tolentino is a certified genius (see this for example) and she really liked it and partly because the first hour or so was really good.

Many of the reasons I didn’t like Arrival, by the way, involve what could be termed “plot-twists” or “surprises,” so, you know. Don’t read this if you haven’t seen Arrival but think you want to see Arrival and also care about not knowing in advance what happens.

In the movie Amy Adams learns to write an alien language in order to communicate with actual aliens who have come to Earth. One thing that the many positive reviews of the movie are right about is that it is, in fact, really really beautiful, and the aliens are cool-looking and convincingly alien. But. Learning this alien language allows Amy Adams to experience the world the way the aliens do, which involves, to put it crassly, seeing the future. Mostly her vision of the future involves a very narrow swath of her personal life, but also it takes in a future meeting with a Chinese general who is (in the movie’s present) the leading global voice for bombing the aliens. And she doesn’t want the aliens bombed, and in this vision of the future the general tells her that she convinced him to change his mind by calling him on his private number and saying to him the dying words of his wife. And he gives her that number and whispers the words to her. And then Amy Adams pops back into the present and calls him on said number and tells him those words and so he decides not to bomb the aliens and also all the governments across the land decide to work together and she teaches other people to write the alien language and, presumably, see the future.

And the problem I have with that set-up seems like maybe a small or nit-picky problem, equivalent to the fact that Amy Adams has security clearance as a result of having been asked to translate Farsi for the United States government two years earlier, which is odd, because you would think that the United States government would have a whole stable full of native Farsi speakers with pre-existing security clearances and would not need to turn to a random linguistics professor. But the Farsi problem I am prepared to ignore as plot-set-up hand-waving. The problem of the Chinese general goes deeper. Because the movie imagines that once we know the magic code — the right phone number, the right words — we can wipe out all the stubborn competing interests that make this world such a complicated place to navigate. But of course, that’s the opposite of true. The general wants the aliens bombed because he thinks that they are offering a weapon to different sectors of humanity, hoping to lead us to fight amongst ourselves. It does not seem to me that learning that the aliens can also see the future — and train us to do the same — will wipe out those suspicions. That is assuming that her use of his private number and the dying words of his wife does anything other than convince him that American intelligence is more efficient than previously supposed.

I don’t think it is possible to write anything these days without thinking about the incredibly horrifying choice that the United States made in its most recent election. I am an American and a proud one and also I am sick to my stomach not just over what is to come but also about what the choice itself says about my country, how loudly it proclaims our worst-kept secrets. And day after day I thumb through my deck of narratives explaining what happened, hoping to find one I can live with, exasperated by the explanations of others which, for various dark psychological reasons, work like nails on the chalkboard of my mind. But one thing that I believe really deeply is that it is not a matter of finding a magic word or the right phone number. That what is required is a lot of arduous painful work of resistance that will happen day after day and that may, in the end, succeed or fail, but will not do either miraculously.

The other movie I saw this weekend was Moonlight and I walked back from that movie along the river to my house and the water in the river seemed like it was almost too high to be held by the banks and the world seemed brand-new and my heart was constricted with fear for the characters of that movie, and so there was that, also.

Tuesday, November 15, 2016

The Election And Modern Education Priorities

Like so many people, I am still reeling from the election. As an American living in Canada, my emotions take on a particular complexity: while I feel so lucky to be here, I also feel weird being "away from home" at this moment, if you know what I mean. I don't really have anything original to contribute in an overall way, beyond OMFG, but it seemed wrong to ignore the election all together, as if it hadn't happened at all. So I'll just try to say something particular to my tiny corner of experience.

Not surprisingly, a lot of people here in Canada have expressed shock and horror at Trump's success, for all the reasons: his association with white supremacist and racist people and organizations, the likelihood of policies that will trample long-protected rights in the name of law-and-order and so on, his disbelief in climate change and commitment to undermining environmental efforts. All of this is mostly straightforward.

What's interesting to me, though, is to think about these expected sentiments in light of something else I sometimes hear in Canada, which is a particular take on priorities in Canadian higher education. Those priorities value STEM and business savvy, sometimes at the expense of humanities and social science. We hear a lot here about the importance of innovation and tech industries, sometimes with the implication that the humanities and social science are kind of luxury add-ons -- "nice" things you can do, if you can afford it, but not essential in tough times.

To which I'd just like to register a gentle reminder: if you disagree with the incoming approach to US-problem-solving, you really need to support humanities and social sciences in education at all levels.

For one thing, as we've discussed on this blog before, most of the difficult problems of modern life are not science and tech problems at all, but are actually problems of social coordination and values. Meaningful solutions to the refugee crisis, to global war and violence, to providing health care in a rational way -- these are all problems of how to live together, problems you can't solve without studying history, sociology, economics, politics, and so on.

Even problems like global hunger and climate change, while they are often treated as science problems, are also primarily social problems. The world produces enough food to feed everyone. You don't need new biotechnologies: you need new ways of organizing how food moves around. Sure, we need green energy, but we also need to think differently about how environmental action comes from social changes.

For another thing, if you're worried about keeping alive the flames of democracy and liberty, you have to be able to think for yourself and express your own ideas. As we've discussed on this blog before, if you can't think for yourself and assess the evidence, you're a pawn of someone else's interests. Sure, that requires some scientific knowledge and numeracy skills, but it also crucially involves developing the habit of actual thinking -- a habit we all know is easily lost.

Getting the citizens out of the habit serves some political interests. It should give people pause that getting rid of philosophy and literature departments is a goal both of ISIS and of some US politicians.

Finally, you can't even talk about what is wrong with the kinds of policies the incoming administration is likely to pursue without getting immediately in to social and ethical matters. When does protecting the citizens become trampling over liberty rights? How much should we spend or sacrifice to ameliorate climate change, and who pays? When does free speech become threats and harassment?

In the rush of think-pieces about the election, one thing I've read again and again from Trump supporters is "He's a businessman; he'll know how to run things."

Maybe you agree with me that being a businessman is not the right preparation for dealing with massively complex social problems where "making money" is not the main goal. Maybe you also think that understanding human motivation and culture and expression and rights and values are all essential to solving these kinds of problems.

If you do, don't forget to keep a dose of skepticism handy next time someone seems too excited about innovation, tech, and STEM, and how they're all going to save the world.

Tuesday, November 8, 2016

My Encounter With A Creepy Guy At A Bar, Or, How Is It That Other People Structure Our Experiences?

I was in Connecticut visiting my mother this past weekend, and when I'm visiting my mother I always stay at the same hotel, and when I stay at that hotel I always go at least once for dinner at the nice Italian restaurant that's about thirty feet away from the hotel.

So on Sunday night, after hanging out 'til early evening with my mom, I went over there to eat. It was late for a Sunday evening dinner, probably around 8:15. This place has a bar area as well as a restaurant; it's a small bar and the whole place is set in a kind of down-market suburban town, on one of those roads where you can't walk there from anywhere else -- except the hotel. So -- it's not a very "bar-like" atmosphere. There are TV's, though, and a bartender, and sometimes people drinking.

I like to sit at the bar when I'm eating alone at a restaurant. In fact, I'd go so far as to say I often like to sit alone at a bar and eat and drink. I bring something to read or I watch TV or I just zone out while I drink my wine. I listen to the chit chat. I'm usually pretty good at just doing what I want and being impervious to people's judgments so I almost never feel embarrassed or ashamed or weird for being out alone and eating and drinking at the bar.

On this occasion, there were two guys also at the bar -- guys who seemed not to know one another from before but who were deep in conversation. There was a regular-seeming guy and a creepy guy. I say he was a creepy guy because at one point he said something about how awful it was having to do his line of work which required doing awful things to people and the regular guy said, very tentatively, well you could quit and do something else, couldn't you? and the creepy guy said no, he couldn't, because "the wife" needed her nice things.

He then told a story about how, because the wife didn't like car shopping, he'd brought home a Mercedes, an Audi, an Accord, and something else and let her pick one. He asked the regular guy to guess which one the wife had chosen and the regular guy guessed "Mercedes." It's what I would have guessed too, but no, the creepy guy said she'd chosen the Accord. The regular guy said, "Well .. the Accord is a nice car." And the creepy guy said, "I thought she'd pick the Mercedes too."

I was avoiding glancing over at them because while I'm not averse to a bit of chit chat at the bar I could tell that the creepy guy was not a guy who would have light chit chat with a woman alone but would obviously try to turn it into something creepy. I was concentrating on reading my book on my iPhone -- (don't knock this method of novel reading 'til you have tried it, BTW).

Then the creepy guy started in. He was saying something about women and he said ".. and then there's this type here. Beautiful but totally unapproachable." I didn't look up. The regular guy must have looked uncertain because the creepy guy said, "This one, over here. Looking at her iPhone." The creepy guy said something under his breath to the regular guy and they both started laughing loudly.

Then the creepy guy turned to me and said "So. You live around here?" I don't want to be rude, I just want to read my book and avoid too much creepy conversation. So I turned to them and said, "I'm here visiting my mother." The creepy guy started in with more questions, but I decided it would be best to just convey my point of view unambiguously. So I read my book and didn't answer.

Not surprisingly, this caused the creepy guy to become agitated. In a tone of indignation verging on anger, he began a long disquisition on how outrageous it is that while he's "just trying to strike up a conversation" someone could be so rude as to not answer him back.

I struggled to concentrate on my book as I finished my dinner, and I thought about this whole experience, which I've had a few times over the years, and why it is so troubling. For me, it's not a feeling that it's somehow wrong to try to talk to or flirt with strangers at a bar. I am in favor of talking to and flirting with strangers at bars, when it's the right context and circumstance and tone. In fact, just a few weeks before, when I'd been in the same exact bar, the woman bartender and a guy client were deep in conversation about horses and horse-back riding, and they included my briefly in the conversation, and the guy may even have asked, "So, you live around here?" and I would have said "No, I'm visiting my mother." We definitely chatted briefly and it was absolutely fine and not weird because it was a normal conversation.

A conversation at a bar with a guy like the creepy guy is never a normal conversation. You know, and he makes it known, that he is there to make a point, and to make you feel uncomfortable, and that no matter what you do he will use it against you somehow. If you're too nice you'll be a trashy slut; if you're not nice (like me) you're a bitch, and if you're nice but not nice enough you're a tease and a manipulative bitch to boot.

As someone who is, as I've said, pretty impervious to things, it's always interesting to me that there are ways that other people can structure my experience. I was reading my book, but I was no longer happily reading my book and enjoying my food. I could ignore the creepy guy, but I couldn't go back to the same carefree mood I'd had before. Even though I don't care about what that guy thinks, and even though I didn't feel in literal danger, he can still get under my skin, which is interesting in and of itself.

Eventually the regular guy proposed going out for a smoke. I learned from their conversation they were both staying at the hotel next door as well. They paid, and walked out, and I figured they were gone. I enjoyed the rest of my dinner and got ready to go myself.

As I walked out, I saw they were sitting on a bench outside the restaurant, smoking. I walked right past them, and they watched me go. As I walked, I felt a surge of gratitude for being in this particular place and time, where hotels have locks and it's considered reasonably normal for a women to staying in a hotel alone. 

Tuesday, November 1, 2016

Miscellaneous Thoughts About Clothing, Sex, Food, and Capitalism

As regular readers know, there is a health problem in my family (mom, congestive heart failure, in a rehab place trying to regain her strength to go home. Stressful and time-consuming!). I didn't have the mental energy for a regular post. But here are some things that are on my mind this week:

1. Free love and politics

I just finished reading the Oryx and Crake trilogy by Margaret Atwood and I thought it was really good and full of interesting things. In case you don't know, it tells the story of a dystopian future where biotech has run amok, much of the environment is ruined, and society is divided into safe and bland "compounds," where wealthy educated people live and work, and the "pleeblands" where people are poor are things are violent and shady and unpredictable.

One of my favorite things in this book is the way Atwood depicts the "God's Gardeners," who are a gang of animal-loving, anti-materialistic, anti-technologist zealots. The Gods Gardeners are basically the heroes of the story, and there's no question they are "right" about things in some deep and important way. But Atwood also goes out of her way to say how they're also kind of dull and moralizing, insisting on drab clothing and low-key social life.

I was glad to have this pointed out. Contrary to the "harmony myth of human nature," things like making your own soap can be both really boring and the right thing to do.

At one point there's a discussion of why Katrina, who runs a fancy pleebland sex club, can't escape trouble by going to live with the God's Gardeners. The answer is that "it wouldn't have worked out" because "wrong wardrobe preferences."

I never highlight things in novels, but I highlighted that -- because it captures something deep and real and sometimes very puzzling, namely, that "free love" rebels and other kinds of political rebels often can't get along. Really: why can't you be pro-environment and pro-equality in a miniskirt and heels?

2. The cultural and personal aspects of meal skipping

After I read The Obesity Code by Dr. Jason Fung I put into practice some of its recommendations, and I started skipping breakfast and avoiding snacks. Not only did I lose weight and start to feel better physically, I also experienced other surprising positives.

Though I think of myself as someone who isn't easily seduced by nutrition orthodoxy, I had somehow really bought into the commandment to "eat frequent small meals." Only now do I realize how ridiculously and pointlessly stressful this made my life. Being out and about all day and trying to find healthy food to eat four or five times a day? It's impossible. The standard advice -- to prepare and carry food around -- was unworkable for me.

I can't believe how liberating it is to just ... not eat when it's not convenient. My god. Yes, you get a bit hungry. But honestly, once I started separating the feeling of "hungry" from the anxiety of "not eating! unhealthy!" I found being hungry is not really a big deal.

On top of everything else, it saves money, it's consistent with environmentally friendly eating, and it requires no consumer products. Dr. Fung points out in his book how much standard nutrition advice is influenced by corporations need to make money. Skipping meals is like the opposite of that - it's like the food equivalent of buy-nothing-day.

3. How is late capitalism so strange?

It's fascinating to me how many of the things that we need most for happiness and well-being are things late capitalism is proving terrible at providing. Job security, time to care for children and others, time to cook food, opportunities for moving around and being outside, basic health care -- all things we need most, all things late capitalism seems to be eroding.

Sometimes it seems like the aspects of life that other societies are most focused on providing are just the ones we somehow expect people to deal with in the corners of their lives, as things they'll have to find a way to work out. Things like who is going to watch the kids when a parent gets sick -- it's like such a basic, basic thing, and yet somehow in late capitalism it gets treated like some kind of personal problem that everyone has to solve on their own.

I'd like to say I saw this coming, but I didn't. I was young during the days of middle-capitalism, when it really looked like with a bit of planning you could have it all kind of work. You could have the pleasures of technology and fashion without rampant inequality and with environmental protections and with structures in place to make all the difficult things work the way they should. Somehow, though, that's not how it all seems to be going.