Gawande’s Big Med: The Long Run View

Optimistically, Atul Gawande lays out a case for the future of big, standardized medicine. I think he’s right to be hopeful. His example of The Cheesecake Factory is instructive, and hospitals should be able to serve patients better by adopting some of the restaurant chain’s practices. But I also think that, in the long run, the pendulum of health care will swing away from Big Med and back toward small-scale, personalized relationships.

To explain, let me explore another analogy: to agriculture. What Gawande is really describing, with the tele-I.C.U., menu of services and standardized care, is industrialization.

Agriculture tells a cautionary tale about the promise of industrialization. Some put the blame for the sorry state of the American diet squarely on the shoulders of industrial agriculture. I know it’s more complicated than that, but the conversation – about the perils of trying to achieve quality at scale – is worth our attention.

I’m reminded of the book Oranges by John McPhee, a tireless study of -you guessed it- oranges. It was published in 1967, right around the time that orange juice from concentrate was being touted as the next best thing. “It’s so consistent! All the irregularities are removed! It’s easy to freeze!” … or something like that. It is striking to read such claims about a product that is now widely avoided. In the same way that our tastes tend more toward fresh squeezed these days, what constitutes “quality” health care may prove to be equally subjective.

This is not to advocate against the coming changes in medicine; I think they are an essential step for progress. I only wish to temper any optimism for standardization so that we are not surprised when a patient finds better, happier care outside of the “best practices.”

With this particular iteration of the health care debate, we’re witnessing the pendulum swing in one direction, toward industrialization.  As it swings, the pendulum is traveling an arc similar to the one created by the “fundamental tension between the logic of nature and the logic of human industry,” as Michael Pollan puts it in The Omnivore’s Dilemma, his take on the relationship between healthy eating and industrial agriculture.

I predict we will undergo a societal shift in our appreciation of good care and good medicine. How we define “good” will change. I don’t know how exactly, but I would venture a guess that we will do less to extend life at all costs. Maybe we can take a lesson from the industrially produced high fructose corn syrup: the sweetest medicine won’t always be the best for us. After all, as the economists say, in the long run we’re all dead.

The cloud is but water droplets

The Cybermind may be here, but we should not let it contaminate our conversations:

This curious feeling of knowing has settled over most of us. In a group, someone always seems to be “checking” something in the conversation, piping up with handy facts culled from a rapid consultation with the Great and Powerful Man Behind the Curtain. I’ve attended more than one nerdy party where everyonehad a link open and we were all talking about things we didn’t know until we were prompted by our conversation to look them up.

“We lie in the lap of immense intelligence,” Emerson wrote. If the lap these days is ever more liquid, then it is good to drink deeply but not to drown.

Iron Laws

According to an excerpt and a thoughtful review, the recent book by Christopher Hayes, The Twilight of the Elites, touches on questions of democracy and control. His general thesis contends that our current meritocracy (the purported societal reliance on smarts and ability) will ultimately be corrupted too, with its inequality becoming more, not less, fixed.

The review helpfully explains that Hayes uses the term “elites” in the stripped-down sense of merely the upper layer of an organization, not loaded with any of its typical pejorative contempt. A gulf arises between the power of those in control (the elites) and the rest. The authority becomes self-perpetuating. Hayes relies heavily on the German sociologist Robert Michels, whose “Iron Law of Oligarchy” first outlined this predicament.

Hayes renames his American observation “The Iron Law of Meritocracy,” but he seems to misplace the cause and the result. As far as I can tell, Michels was suggesting an oligarchy would occur no matter what organizational structure: “It is organization which gives birth to the dominion of the elected over the electors, of the mandataries over the mandators, of the delegates over the delegators. Who says organization says oligarchy.” Hayes on the other hand, has identified meritocracy as our current status, but that should not bump oligarchy out of the “Law of …”. The meritocracy still results in an oligarchy. If Hayes is right (which I can’t claim to know), he is just proving Michels again.

Semantic quibbles aside, it is significant that both Michels and Hayes rely on a notion that the power of the elites over others is disproportionate. This indicates a fundamental moral claim about the proportionality of power. I wonder how this is formulated, but neither the review nor excerpt went to this depth (understandably).

So why is an Iron Law a problem? The review cites figures about a declining confidence in American institutions of all stripes and sizes. “Even before the financial heart attack of 2008, a Gallup poll showed that trust in 12 out of 16 institutions had reached an all-time low.” What is the source of the dissatisfaction? I skimmed through Thinking, Fast and Slow in hope of finding some clues about cognitive biases, but I couldn’t really find any mentions of collective trust or the relationship of an individual with an institution. Instead, I’ll turn to our ever-accelerating technological progress: I wonder if access to information about the institutions (and their failures) increased more quickly than access to control or at least access to any ability to fix perceived problems. Maybe our democracy needs to catch up to our demands, however inarticulately expressed.

A Vortex of Discursive Imperatives

From The Metaphysical Club, pages 339-341:

Jurisprudential theories, like theories of literary criticism or historical methodologies, are generally categorized according to the element of their subjects they take to be essential. A legal theory that stresses the logical consistency of judicial opinions is called formalist; a theory that emphasizes their social consequences is called utilitarian; a theory that regards them as reflections of the circumstances in which they were written is called historicist. The problem with all such theories is that they single out one aspect of the law as the essential aspect. It was Holmes’s genius as a philosopher to see that the law has no essential aspect.

A case comes to court as a unique fact situation. It immediately enters a kind of vortex of discursive imperatives. There is the imperative to find the just result in this particular case. There is the imperative to find the result that will be consistent with the results reached in analogous cases in the past. There is the imperative to find the result that, generalized across many similar cases, will be most beneficial to society as a whole – the result that will send the most useful behavioral message. There are also, though less explicitly acknowledged, the desire to see the outcome most congenial to the judge’s own politics; the desire to use the case to bend legal doctrine so that it will conform better with changes in social standards and conditions and the desire to punish the wicked and excuse the good, and to redistribute costs from parties who can’t afford them (like accident victims) to parties who can (like manufacturers and insurance companies).

Hovering over this whole unpredictable weather pattern – all of which is already in motion, as it were, before the particular case at hand ever arises – is a single meta-imperative. This is the imperative not to let it appear as though any one of these lesser imperatives has decided the case at the blatant expense of the others. A result that seems just intuitively but is admittedly incompatible with legal precedent is taboo; so is a result that is formally consistent with precedent but appears unjust on its face. The court does not want to seem to excuse reckless behavior (like operating a railroad too close to a heavily populated area), but it does not want to raise too high a liability barrier to activities society wants to encourage (like building railroads). It wants the law to run in a politically desirable direction, but it does not want to be caught appearing to bend an anachronistic legal doctrine in order to compel a politically correct result.

There is also (to put the final spin on the system), within each of these competing imperatives, the problem of deciding what counts as relevant within that particular discourse and what does not. This series of problems begins with the question of what the legally relevant “facts” in the case really are; it runs though the questions of what counts as an analogous case, what counts as an applicable general legal principle, what counts as a benefit to society, and so on; and it ends with the question of what counts as a “just result.” Holmes thought that there were no hard-and-fast distinctions in any matter of degree. But he thought more: he thought that even if we were to select one imperative to trump all the others, we would still find that the consequences for any particular case were indeterminate. Principles are manipulable. Many years later, when he was on the Supreme Court, Holmes used to invite his fellow justices, in conference, to name any legal principle they liked, and he would use it to decide the case under consideration either way. “Cost benefit analysis” is as malleable as “rights talk.” When there are no bones, anybody can carve a goose.

Yet there must be bones of some sort. For cases get decided and verdicts get returned and opinions get written, and by a process that does not seem arbitrary or subjective to the people who do the deciding, returning and explaining. If the various discourses of fairness, policy, precedent and so forth are simply being manipulated rather than applied, they are being manipulated to justify an outcome which has been reached in obedience to some standard. When Holmes said that common aw judges decided the result first and figured out a plausible account of how they got there afterward, the implication was not that the result was chosen randomly, but that it was dictated by something other than the formal legal rationale later adduced to support it. Holmes announced what this “something” was in the famous fourth sentence of the opening lecture of The Common Law: “The life of the law has not been logic it has been experience.”

Clarification: Democratic Experience

In my last post I wasn’t too clear on how I wanted to interpret the point from Gordon Wood. His article noted that the founding fathers were not amateurs when it came to self-government, and he attributed some of their success to that fact. This goes against the prevailing wisdom that we have too many career politicians in Washington. It also suggests a slight conflict with the democratization of public policy that I had cited earlier.

What then, is the best balance between an open governing process (open to amateurs and anyone else) and a closed one, open only to bureaucrats who “know what they are doing” or politicians likely at the sway of narrow interests? I think it boils down to the importance of democratic experience. Such experience, broadly defined, can help bridge the gap between the people and the politicians.

We should inspire democratic experience throughout our public life in America, in a way that engenders civic participation. I admit that this is an idealistic and amorphous suggestion, but I do think it can be brought to bear on the way we structure our lives. We should seek this democratic engagement not only in the federal government, but also throughout all of our cooperative undertakings: state or local government, our other institutions and associations, and even corporations. I have no specific proposals for this, but I do know it aligns with the spirit of an organization at which I used to volunteer, Generation Citizen. We should hope and work for a more organic democracy in which all politicians are first citizens and no citizen is a Washington outsider.

Populist Experiments

Democratize public policy? That may sound redundant, but by looking at these two cases of experimentation at the local level I found surprisingly populist approaches to decision-making.

The city of Quincy, Massachusetts has opened up the urban planning process to residents with an online game platform. “The objective is to develop a planning framework for development in [the area, to] have a sustained public planning process that uses this tool,” a local official said. Similarly, a ward in Chicago is experimenting with “participatory budgeting” that has resulted in explicit changes in spending allocations. People in the ward submit can submit proposals at community meetings, which are then voted on by residents.

The first case is an example of granting greater access to public policy decisions via new technology, and it aligns with MOOCs and higher education or Shiller’s proposals and finance. The second is more an example of relinquishing control of public policy. I’m wary of such direct democracy, but the people in the ward are ostensibly happy about it.

A few years ago, historian Gordon Wood wrote an op-ed in the New York Times that explained revolutionary America’s success at self-governance (in contrast to France, for example) by the fact that our founding fathers were not amateurs. They had experience in colonial legislatures and governments before undertaking their great experiment.

Finance and … Finance and … EWCA

Yale economist Robert Shiller wants to “Democratize Wall Street, for Social Good.” Curiously to me, he calls for more financial innovation to accomplish this. I’m initially skeptical of financial innovation because things like CDSs and CDOs are what first come to mind. At the hands of humans, inventions like these were crisis-causing instruments of wealth destruction. But Shiller promotes what seem like good innovations, such as the expansion of crowdfunding.  (I haven’t read his book Finance and the Good Society so I can’t comment fully on his proposals.) An Economist article confirms financial innovation’s “dreadful image,” but places the CDSs and CDOs in a context of socially beneficial innovations like ATMs and, more recently, Social Impact Bonds. I continue to remind myself that at one point in history even coins were an “innovation.” It is clear that democratizing finance has the potential to help people live better lives.

How does this compare to the MOOCs and the democratization of higher education? Beyond the use of acronyms – the surest sign of innovation – both trends are about opening up access. A crucial difference though, is the activity to which access is granted. Humans have been pursuing higher education without negative consequences for some time now, but one can easily argue that finance is not always so benign. From my vantage point, financial interactions seem more susceptible to undue influence by greed or irrationality than many of our other societal undertakings.

The Economist writes, “… blaming the worst outcomes of financial innovation on human frailty is hardly helpful.” I disagree. If “human frailty” was part of the cause of our current crisis, we have an obligation to think carefully about finance and our relationship with it. Innovations are important in what they allow us to do. We can’t so cavalierly dismiss the human element here because we cannot separate the innovations from the humans that wield them. Both Shiller and The Economist seem too steeped in the world of finance to fully appreciate this.

Shiller does do the good deed of alerting me to the work of Walter Lippmann, who theorized about the changing role of democracy in an increasingly complex society. Shiller quotes one passage, apparently about business, from Lippmann’s The Good Society: “How else, when we pause to ponder the matter, can the human race advance except by the emancipation of more and more individuals in ever-widening circles of activity?” Ever-widening circles of activity, hereby referred to as EWCA, may be the truest mark of democratization. However, the widening is not an end in itself. In pursuit of “the good society,” we must think carefully about the nature of the activities to which any of our innovations are granting access.

The Wind of Freedom Blows: Democratizing Higher Education

“Welcome to the brave new world of Massive Open Online Courses — known as MOOCs — a tool for democratizing higher education,” reads a recent New York Times article about the slate of elite universities making their content and classes available to anyone with an internet connection. Last fall, 23,000 students from around the globe completed an Artificial Intelligence class taught by Sebastian Thrun, then of Stanford University. Stanford’s entire freshman class is typically a tenth that size. This undertaking marked unparalleled access to a Stanford professor and coursework – completely free, with no barrier to entry.

The inelegantly named MOOCs are set to disrupt the relative tranquility of the ivory towers and ivy-covered walls. Other universities are jumping in the fray too: Penn, Princeton and the University of Michigan have joined forces with Stanford as Coursera, while Harvard and MIT are cooperating under the banner of edX. The full extent of this disruption is too much to parse here, but I do think Clayton Christensen will see his theory validated again. Stanford’s president, John Hennessy, has labeled the force of online learning a “coming tsunami.”

Let us return to the matter at hand: democratization, the transfer of power from a few to the many. Democratization is not identical to disruptive innovation, although they may often be brothers-in-arms. This overlap is perhaps a topic for a different post. It is important to note that with higher education, access is being democratized, not control of the institutions themselves. The article labeled the trend correctly (in my lexicon, at least), but how or why is this happening? And what does it mean?

The MOOC does not act alone. It is riding the wave of soaring college costs (and the accompanying dissatisfaction), and is only made possible by advances in computing power, storage capability and connection speed (a.k.a. the cloud). The technology that enables successful MOOCs does not align precisely with the proverbial “cloud,” but it is a fitting mythology: dispersed and not centralized, occasionally ominous, the cloud will bring the rain. Universities have been trying different aspects of online classes (lectures and material posted online, chats and discussion boards) for at least a decade now, but only recently has it come together in a complete package. Finally, this is no guerilla insurrection. The leading names in higher education are facilitating the democratization and attempting to harness its power. Like Jerry Garcia, they are not trying to resist the trend.

In the light of history, the question of access to higher education seems trivial. I do not mean to diminish the significance of education, but a university class on artificial intelligence is a luxury next to more basic democratic liberties like free speech. That said, access to higher education is deeply intertwined with fairness and social justice. The crux of the implications may revolve around the credential that universities provide. Economists talk about the signaling value of higher education, but none of the current platforms offer anything close to a full course credit for completion.

What would any sort of credentialing mean for the dilution of the university’s brand? The word brand often connotes something meaningless or symbolic, but there is presumably real value to be gained in taking the courses. Democratization might break down barriers to power that was unfairly held by a chosen few, and it might ultimately force universities to be much leaner, and thus cheaper, in conferring degrees.

A twist on the credential issue is offered by the acting Stanford president, John Etchemendy, when he says that universities as institutions exist to perform a “bidirectional certification” on students and faculty – making sure that the faculty are capable teachers and making sure that the students are of a certain quality. The current MOOCs don’t do anything to address the student-side certification, and the students don’t contribute financially to support the professors. The financial model of both the current and future university is in question, but the value, I think, is not. The value is more nuanced than the simple credential or degree though, and I am not sure how that value will need to be articulated in the age of MOOCs. We shouldn’t be surprised that the elite universities are leading this charge themselves, tsunami or not. After all, since Stanford’s founding, its motto has been “The wind of freedom blows.”

Democratization is Old

Upon reading a David Brooks piece this weekend, I realized rather quickly that by raising the Matt Yglesias point about politicians last week, I was wading into a current of discourse on democracy stretching back thousands of years and about which I know very little. Brooks paints a broad (and on close inspection, probably inaccurate) picture of differences between European and American governance as they pertain to the degree of public autonomy. I don’t really want to dig into the specifics of his argument, but instead point out that he made me realize what seems quite obvious now: this “democratization” is nothing new. I do have a copy of The Democracy Reader, obtained on a whim at a used bookstore a few months ago, that despite its heft may be able to keep me afloat as I navigate some political theory.

In terms of keeping this conversation with myself relevant, I’ll try to explore what I see as a technological force driving democratization and decentralization. It seems that as technological change accelerates, it grows clearer how new technology can facilitate the downfall of authority (my mind is quickly brought to the role of Twitter and Facebook in last year’s Arab Spring, but also the tape recorders at Grateful Dead concerts from my first post). Also, I will try to bring more perspective on human irrationality, an essential aspect of the conversation that Brooks is content to label, perhaps a bit too simply, as “depravity.” I should note though that he gets the term from James Madison who can be forgiven for not taking into account any neuroscience.

From here, I see two promising places to look next: the decentralization of higher education via “massive open online courses” and the democratization of finance, as advocated by Robert Shiller.  Also, I’ll try to mash up The Democracy Reader with Thinking, Fast and Slow while keeping my head above water.

Democratizing, Good and Bad

Democratization is another word that perhaps better captures the trend of decentralization that I wrote about in my last post. I came across this usage once in an SSIR blog post about TEDx, the TED conference’s open-sourced branding tool for similar but independently-run events. The author, Courtney Martin, draws a connection between TEDx, the Occupy movement and even Kickstarter, calling them a part of the “renaissance of populist idea creation and distribution.” I would add Wikipedia to that list. These platforms allow the public to have a voice and even ultimately to have control over decision-making. They aren’t centralized repositories of power. She says this is good, and I think I agree.

Matt Yglesias indirectly raises a counterpoint though, when he writes of politicians that rely too heavily on voter opinions. He connects this to other industries, in which we rightly don’t democratize decision-making. E.g. “… HP doesn’t consult an opinion poll when it’s considering what kind of CPU to put in its computers.” Similarly, sometimes politicians shouldn’t be led by the polls; sometimes they need to make unpopular decisions. Is it possible to democratize too much? We don’t truly have a direct democracy here in America, which is probably good. California’s frequent struggles with voter ballot initiatives are indicative of the ways that direct democracy can hamstring good governance. How does democratization and decentralization weaken the position of experts? I think this may have to do with fundamental human irrationality – but I am not quite sure. Sometimes too, people are simply wrong.