Fixing Healthcare in 3 parts: Part 1 the Diagnosis The Medical Industrial Complex

“We don’t have a deficit problem; we have a health care expenditure problem.”

Aaron Carroll*

What’s wrong with American health care?  To paraphrase James Carville, the problem is “the cost stupid”. ** In 2016 we spent $3.3 Trillion on health care. This is twice as much per capita as any other developed country on health care.  In those countries access is not an issue because no one is uninsured.  In those countries medical bills are not the cause of bankruptcy as they are more than half the time in the United States because no one is under insured.  If our health care system were as efficient as any other developed country we would cover everyone and currently be saving $1.6 trillion per year.

If we a spending $1.6 trillion more than we should, where is that money going?  Well, Consumer Reports looked at the growth of health care spending in the United States from 1970 to the 2008.*** (This report is dated but I think the statistics hold up for another decade.) They found that the biggest growth went first to hospitals and then to doctors.  This was followed by pharmaceutical sales.  The lowest increase was in insurance administrative costs.  Therefore, most of the inordinate increase in the cost of health care goes to care.  Since we are not twice as sick or live twice as long as people in other countries why do we spend so much more on care?

The answer is multifactorial but it starts with the perverse fee for service payment system.  The problem with fee for service is not that doctors are rewarded for providing service; it is that they are rewarded for creating service.  From the extra office visit, to the extra test, to the extra procedure or surgery, doctors have an almost limitless capacity to create service and in doing so drive up costs.  The fee for service system rewards providers for the quantity of the service without regard to its utility.  If America is to cure its ailing health care system it must abandon the fee for service system once and for all. 

A second problem coming from providers, that is doctors and hospitals, is that there are no financial consequences for inefficiency.  The following is a trivial example. It had been pro forma to order 2 liver tests when following a patient who had been placed on a statin for high cholesterol.  These tests are usually done semi-annually. About ten years ago the American College of Cardiology determined that these tests were unnecessary after the tests done at the initiation of therapy.  I stopped ordering the test as soon as I read this but virtually every cardiologist with whom I share patients still orders these tests at an average of $64 for the two tests.  If this is the norm throughout the country then tens of thousands of these tests are being performed by professionals whose organization says they are of no value.  I am not sure if this is just force of habit or an “It can’t hurt” mentality but it is unnecessarily wasteful.

While the lion’s share of wasteful spending comes from providers, others share in the problem including . . .

Insurers get a lot of heat for the mess that healthcare is but their contribution to high healthcare costs is indirect. Competition in our “free market” health care system is among insurers. Since they don’t directly control the delivery of care the only things they can do to hold down costs are to limit care and to select for the healthiest panel of patients. This is inefficient and adds to higher administrative costs to providers – the estimate being an additional 10% (remember of a very big number) to the cost of health care.

Pharmaceuticals cost about twice what they do in other developed countries.[i] They spend more on marketing than they do on research which is a complete waste of money (but we all pay for it). More importantly Medicare is blocked by law from negotiating prices as part of the Medicare prescription Drug Law of 2005[ii] (sometimes referred to as the Big Pharma Relief Act of 2005).

There is controversy about how much malpractice laws drive up the cost of medicine. I think malpractice laws significantly impede best medical practices and I will discuss this in a later entry. However, if it is driving up the use of unnecessary medical services as part of defensive medical practice that is still money being spent on providers and is going into their pocket.

As I move in to my later years of practice as a physician, my biggest embarrassment is that I have been a participant in and benefactor of this wildly inefficient system that is a chronically debilitating disease impeding the health and well being of the rest of society and the responsibility for that falls largely on the people (like me), organizations, and institutions providing the care.

That said, there are no bad actors here in the sense that the players in this game are not cheating.  Providers, insurers, pharmaceutical companies, and personal injury lawyers are all doing what the system pays them to do. If you want better outcomes from your system you have to change the system and that is not going to be easy to do. Every one of these players has a huge stake in this very big pie so they have fought and will continue to fight changes that affect their share of this market.

Since the 50’s when President Eisenhower coined the phrase we have talked about the military industrial complex but no one talks about the medical industrial complex even though it is 5 ½ times bigger than the military budget. When I talk to people about this they seem to have a hard time getting their head around this probably because spending on medicine is seen as helping people and that must be a good thing. All I can say in response is, “Trust me. I'm s doctor.”

Next blog I will propose the cure.

* More dogma – not sure if this is his original quote or he is quoting someone else

** https://www.nytimes.com/2018/01/02/upshot/us-health-care-expensive-country-comparison.html?_r=0 This article antedates my comments and corroborates them. However, the article cited in the 4^th paragraph predates my thoughts on this. However, I did not plagiarize the title of the article cited.  I am not that well read to have been aware of it.

---

[i]https://www.aarp.org/health/drugs-supplements/info-2017/rx-prescription-drug-pricing.html

[ii] https://www.aarp.org/health/drugs-supplements/info-2017/lower-rx-prices-drug-costs.html

THE Simple Complete Market-based Solution to Climate Change

The earth is round, it rotates on its axis, it revolves around the sun, it is getting warmer as a result of humans burning fossil fuels, and if we don’t change course the results will range from catastrophic to apocalyptic. This is settled science that can be demonstrated with a 5^th grade experiment[1], and is shown to be reliably predictable by advances in computer modeling[2]. We are well past the point of defending the science of climate change and it is past time to implement solutions.

Responding to an Op-Ed piece that appeared in the Providence Journal (“Fight, Harvard, against global warming” 11/8/2014) I wrote the following response which encapsulates a solution I have been working on as a member of a group referenced below.

Charles Miller is troubled by the fact that his alma mater, Harvard, won’t divest itself of its investments in the fossil fuel industry. While I share his concern over global warming, I think his targets—both Harvard and the fossil fuel industry—are misplaced. Companies like ExxonMobil, Arch Coal, and Chesapeake Energy merely take the carbon out of the ground, but it’s we the people who cause global warming by putting that carbon into our atmosphere. To solve this fundamental problem we must find a way to wean all of us off fossil fuels. There are all sorts of smaller steps we can take to get there, but the urgent fact is we need to start taking bigger ones.

The enormity of the global warming crisis demands common-sense market-based solutions that shift the market itself without critically damaging our economy. Too often we see the path towards independence from fossil fuels and the road to economic prosperity as inevitably divergent. Fortunately, they don’t have to be. Enacting a revenue-neutral carbon fee and a flat-rate dividend program is a market-friendly approach that would help us change course on fossil fuels without placing undo economic burden on consumers. 

A carbon fee works by placing a charge of $15 per ton on carbon at its source. Though the fee is charged to the fossil fuel industry, of course this cost is passed directly on to consumers. To mitigate this added cost, 100% of the collected fees would be rebated back to consumers at a flat rate. In the first year, for example, the fee would generate roughly $81 billion dollars in revenue, and each American could expect an annual dividend of $250. The carbon fee would increase by $10 per ton every year until carbon mitigation targets are met. Therefore, both the amount of the fee and the dividend would grow annually; at the end of 20 years the expected annual dividend paid out to each American would be approximately $1600.

While every individual receives the same dividend, it’s you—the consumer—who determines how much in fees you actually pay out. The dividend is essentially a refund check for the average American consumer’s carbon fee. If you are an above-average consumer of fossil fuels, the $250 only offsets part of your total fees. If you are average in your consumption, you break even. If you are below average in your consumption, you come out ahead. As a result, everyone has an incentive to reduce their carbon footprints, not out of the goodness of their hearts but out of goodness to their wallets.

Citizens Climate Lobby (CCL) has been promoting just such legislation since 2007. We recently commissioned a non-partisan firm, Regional Economic Models Inc., to evaluate our proposed legislation to determine the comprehensive economic impact of such a plan. Regional Economic Models took the CCL’s model legislation and carried it out over a 20-year period, evaluating its economic, environmental, and social impact compared to a business-as-usual model. 

The study found that enacting a carbon fee and flat-rate dividend program would lead to positive effects on GDP throughout the entire span of the study. In particular, for every year of the study, personal income and job growth was projected to outpace the business-as-usual model. At the 10-year mark, an estimated 2 million new jobs would be created, and 2.8 million new jobs were forecast by the 20-year-mark. Meanwhile, the study projected a 33% decrease in carbon emissions at 10 years, and a 52% decrease in emissions at 20 years compared to a relatively flat business-as-usual baseline.

If we take this step toward comprehensively divesting ourselves of fossil fuels in a gradual, steady, and predictable manner, we can take truly consequential steps towards developing cleaner energy sources without throwing our economy into a tailspin. Carbon fees paired with a flat-rate dividend program will create predictable markets for clean, renewable energy and shrink market share for fossil fuels. As that happens, the issue of divestiture in the fossil fuel industry will solve itself.

++++++++++++++++++++++++++++

One final note, if we want America to continue to be great leaving our head in the sands over climate change is the last thing we should be doing.  To begin with the entire world understands that climate change is taking place as witnessed by the fact that every nation on earth signed the Paris Climate Accords except Syria (who tragically are otherwise occupied) and they are looking for solutions.  America has always been at the forefront of new technologies (think automobiles, airplanes, computers) and that has served us well.  We want to be at the forefront not playing catch up.

Furthermore, remaking our entire energy infrastructure based on clean domestically produced energy sources would be a massive job creator for decades to come.

---

[1] https://www.youtube.com/watch?v=3v-w8Cyfoq8

[2] https://www.ted.com/talks/gavin_schmidt_the_emergent_patterns_of_climate_change#

Death and other harmful side effects

Before I move on to my last book report I wanted to offer my views on the topic of death and how to manage what you can of it.

Usually at some point you will have the opportunity to fill out a living will and a durable power of attorney. The living will gives you the opportunity to leave some general instructions for how you want your health to be handled in the case that you become incapacitated.  However, these instructions may be unhelpfully vague (no extraordinary measures) or inappropriately restrictive (no feeding tube, no intubation, no CPR) in many situations that you cannot foresee in your current state of normal health.

With the durable power of attorney you entrust someone with the authority to make medical decisions on your behalf in the event that you become incapacitated and are incapable of making those decisions. This is far and away the more valuable of these documents because here you take the opportunity to clarify the vague and say specifically under what conditions potentially lifesaving measures become unacceptably extraordinary and therefore should be withheld or withdrawn.

The power of attorney goes into effect when you become intellectually impaired to the point that you can’t make or articulate rational decisions.  This incapacity can come in a variety of ways over a variable period of time. The most important question that needs to be asked if that happens is, “Is this incapacity permanent?” The answer to that question can be yes or no but at the outset the answer is usually we don’t know. If the answer to that question is no or we don’t know then life saving procedures should be implemented.

To be clear, there can be a common misconception that once implemented these interventions cannot be withdrawn and the case of Terry Schiavo comes to mind.  However, this case better illustrates what can happen when there is no clear power of attorney and there is a conflict between loved ones over what should be done. Someone with proper power of attorney can withdraw life support at any time.

The second question that needs to be asked and clearly answered is what is the nature of the permanent incapacity that would render lifesaving measures meaningless. 

People become physically incapacitated over time and that in fact is the trajectory of life beyond the age of 25. We soldier through that and carry on until at some point we may decide that the paralysis or the pain or the labor of breathing with recurrent set backs is not worth the effort so any life saving measure would not be worth the effort. However, as long as the individual is not mentally incapacitated this decision is up to the individual. Because they are mentally competent they have agency in this sort of decision. 

However, as is frequently the case, the individual permanently loses their mental capacity along with their physical capacity so the burden for making decisions about life saving measures falls on the person with power of attorney. This is the same decision as above but must be made before the fact and communicated clearly from the individual to the power of attorney designee.

These kinds of decisions are of course highly personal and everyone will have their own take on them but I am going to give you mine.

If I were to become mentally incapacitated I would want all measures implemented until it was established that this incapacity was permanent.  If it were deemed that I was to be permanently mentally incapacitated them I would consider any lifesaving measures extraordinary and I would only wish to have comfort measures.

What defines permanent mental incapacity? For me it would be my permanent inability to make medical decisions for myself. My belief is that I am my rational conscious self and once that no longer exists and cannot be reconstituted I no longer exist even if the body I inhabit continues with its vegetative and impaired cognitive function. 

Again, this incapacity can come in a variety of ways over a variable period of time. It can come suddenly as with a massive cerebral hemorrhage or gradually as with dementia.  In either case at some point the ability to rationally process information is lost and passed on to another and it is at that point that any even life prolonging measures (in addition to lifesaving measures) for me would be inappropriate because it is no longer my life you are prolonging.  I have ceased to exist.

With sudden and severe and permanent incapacity life prolonging measures are not an issue. However, patients with dementia can have other comorbidities such as high blood pressure, diabetes, or high cholesterol.  Treatment of these conditions are life prolonging and for me I would want my power of attorney to withhold these treatments. Vaccinations would be appropriate for their public health benefit, especially if I were institutionalized. Treatment of underlying conditions if that treatment provided comfort (for example, oxygen if I were short of breath or diuretics if I had edema) would be for me appropriate as well. 

This sort of gradual decline can and often does go on for years. Quite often it is more burdensome for the caregiver than the patient. If I were the patient my existence need not be uncomfortable but it need not be prolonged.

Quite frankly, I think this is a relatively radical way to deal with this problem. Therefore it is clearly not for everyone or even anyone but me.  Perhaps that is the most important point.  These are questions are highly personal and you really need to think about them and clearly communicate them with the person who is going to be your power of attorney.  As important as it is to have your wishes carried out the person who is entrusted with the power of attorney carries the burden of responsibility for doing what you think would be best.  If at any time after the fact they think they have had to guess and guessed wrong that can be a burden of guilt they may carry for the rest of their lives.

Thinking Immortal but Being Mortal

Being Mortal by Atul Gawande is an important book for those who have thought about the death of themselves or a loved one; it is an essential book for those who never considered the question.

Although not specifically delineated that way the book can be thought of as divided into three parts.

Part 1: “Life is a non-winning proposition.” Russell Berg

The first part deals with how we die. I tell patients that we peak between 20 and 25 and then it is a down hill course to oblivion*. Gawande discusses how this takes place and uses the aging of teeth as an example.  Even this most inert part of our body is not immune to the ravages of time. He discusses various theories as to why this happens but favors the notion that we are complex self-correcting machines where eventually the mistakes over take the corrections and we end with overall system failure.

For all of previous human history that end was usually fairly sudden and usually the result of an infection.  Pneumonia was referred to as the old person’s friend. The downhill course to oblivion ends at a cliff.

Now, for the most part, the downhill ride is punctuated by a series of events that permanently reduce our capacities but, because of modern medicine, it becomes a drawn out affair. We aren’t dead but we must learn to live with what we have lost.

Part 2: Don’t live free and don’t die

Gawande goes on to discuss how society has had to come to grips with this extended twilight world that the moderately to severely debilitated aged live in.  He traces the history of the development of the nursing home industry as a well-meaning solution for dealing with people who are unable to care for themselves. He notes that the quality of care is orders of magnitude better than the poor houses they replaced but their principle problem is that there, patients lose their autonomy.  He notes that like the military and prisons nursing homes are the institution in which the individual’s schedule – when you get up, when you eat, when you wash, when you socialize - is completely directed by someone else. This loss of autonomy results in a loss of a sense of self.

There are movements afoot that Gawande talks about to give more autonomy to the client.  The assisted living arrangement was started to give individuals the opportunity to decide when they want to get up, eat, socialize, etc. However, many of the questions revolving around autonomy raise questions about safety.  Can an individual live alone, go out by themselves, without a walker or cane, drive? The important point he addresses here is the interpersonal nature of this problem. This is often a point of conflict between the elderly individual and their loved ones.  While these sorts of issues must be dealt with on a case-by-case basis, being able to frame the problem in this way makes it easier for both sides to come up with solutions to their differences.

Part 3: What are your hopes and what are your fears

In the last part of Being Mortal the author talks about what happens when that decades-long downhill course turns into a rapid rush punctuated by modern medicines valiant but ultimately futile attempts to prevent the inevitable. He deals with this issue objectively quoting authorities and citing statistics; professionally how he dealt, both well and badly, with the problem with patients: and personally in dealing with the prolonged illness and death of his father. 

He feels the medical profession is understandably overly directed toward cure and the patient, equally understandably, is overly optimistic for a cure.  The result can be a futile pursuit of doing too much for too long to the detriment of the patient.

He favors taking a step back, realistically assessing a prognosis, and then trying to optimize everyday that the individual has left to them.  Once an estimate of a prognosis has been determined the first and foremost question, which is straight out of hospice care, is:

What are your hopes and what are your fears; what are you willing to do to realize your hopes and avoid your fears? *

The object is to think as clearly as possible about how to optimize the measurably finite time you have left and make each day a blessing. Gawande’s personal and professional recollections give tangible examples as to how this can work out in practice to the benefit of the patient, their family, and even the provider. 

Being Mortal gives the reader an opportunity to think through these issues before they come to the fore so that the individual can be better prepared when the inevitable comes.

It has not only been beneficial for patients but has been widely read in the medical community resulting, at least in the circles I run in, with a more ready embrace of palliative and hospice care.

*I go on to tell patients that there are 3 things and only 3 things you can do to keep the slope as flat as possible.

1.     Don’t put bad things into your body. (Heroin, nicotine, high fructose corn syrup, etc.)

2.     Put good things into your body. (Fruits and vegetables)

3.     Exercise.

** “What are your hopes and what are your fears; what are you willing to do to realize your hopes and avoid your fears? The object is to think as clearly as possible about how to optimize the measurably finite time you have left and make each day a blessing.”

This should probably be the guiding principle of our entire finite life. But for most of us it isn’t and that is probably because while our life is, of course, finite it is not measurably so in any meaningful way for us. We are all going to live forever until we’re not.

Democracy in America I then Everywhere II Illuminated

A few years ago I went on a Brown (University) excursion to Concord Massachusetts led by Brown Professor of history Kenneth Sacks. He trained in the classics but teaches their influence on American history.

In a brief conversation I had with him he said that de Tocqueville was the Thucydides of American history. If you have an argument about Greek history and can defend your position by quoting Thucydides you win the argument. He said that the same can be said of American history with de Tocqueville.

Alexis de Tocqueville’s seminal text is, of course, Democracy in America, which is in fact, like Don Quixote, two books. De Tocqueville was a French aristocrat who in 1831 traveled to the United States ostensibly to study the American prison system. He was here for 9 months and took extensive notes.  In 1835 he published Democracy in America (what turned out to be Volume I) which was a comprehensive survey of the new republic’s origins and its political, and social institutions.

De Tocqueville first considers the substrate out of which the United States grew.  He considers the geography, the Anglican predispositions and temperament, and the social conditions that gave rise to the democratic intuitions that spread through the colonies.  He makes the case that it was the unique contribution of all three of these factors that allowed democracy to take root here.

He then goes on to describe how government at the local then state then federal level works not merely as a sterile civic lesson but in the real world as American responded to and shaped these institutions.  What was striking to me about this was how we interface with these same institutions as our forefathers did 180 years ago.  For the most part de Tocqueville is quite impressed with what he sees and I for one come away with a sense of pride in this nation of which I am a part.

However, he ends Volume I with a chapter, The Present And Probable Future Condition Of The Three Races That Inhabit The Territory Of The United States, which could be subtitled America’s Dirty Little Secret. In this chapter, the longest in either volume, he delineates our deplorable relations with blacks and Indians, the enormity of the problem, and its intractability. With copious notes and statistics and poignant anecdotes the lays bare the problem at the time and presciently predicts the future that awaited our country. 

Volume II was written five years later in 1840 with an entirely different purpose and an entirely different format.  De Tocqueville firmly believed that democracy was coming to a country you will be living in.

“ . . . the democratic revolution which we are witnessing is an irresistible fact against which it would be neither desirable nor wise to struggle . . .”[1]

That said there are downsides as well as upsides to this inexorable march of democracy and the purpose of Volume II is, using America as an example, to outline how democracy will both positively and negatively effect the thoughts, feelings, and manners of people who adopt democracy.

Volume II is laid out in four Books, each with as many as 26 chapters.  However, each of these chapters is no longer than 12 pages (most 5 pages or less) and each is really a self-contained essay that gives a rather accurate snapshot of some aspect of the how life will change when democratic institutions are adopted.  He predicts “fake news”. He describes the “Rat Race”.  He worries that we will reach a place where people end up “talking without speaking; hearing without listening”. Nearly all of the changes good and bad are the result of moving from societies that are static and hierarchical to ones that are ever changing and egalitarian (or at least perceived to be so by those who live in it.)

He is not trying to denigrate democracy he is trying to paint an honest picture of it. As he says, “ . . . it is because I am not an adversary of democracy, that I have sought to speak of democracy in all sincerity.

I was persuaded that many would take upon themselves to announce the new blessings which the principle of equality promises to mankind, but that few would dare to point out from afar the dangers with which it threatens them. To those perils therefore I have turned my chief attention, and believing that I had discovered them clearly, I have not had the cowardice to leave them untold.”[2]

De Tocqueville is a brilliant writer and thinker and particularly in Volume II he is so accessible because you can pick nearly any chapter and in a few pages treat yourself to the writing of a great thinker and get new insights into how the world we are living in works and how we got here.

Below is a link to to the entire text as well as a partial list of chapters, all in Volume II, I found most illuminating.

http://xroads.virginia.edu/~hyper/detoc/toc_indx.html

Book 1 Chapter XL

Book 1 Chapter XVII

Book 2 Chapter XIII

Book 3 Chapter I

Book 4 Chapter VI

---

[1] Democracy in America Alexis de Tocqueville Author’s Preface To The Second Part

[2] Ibid

The Righteous Mind - The Self-Righteous Mind

Jonathan Haidt begins his book, The Righteous Mind, with the late Rodney King’s famous quote, “Why can’t we all get along?” Haidt then goes on to explain quite the opposite phenomenon; the uniquely human capacity for people to form large non-kin groups and work together in more or less harmony to achieve common goals.

According to Haidt the key that unlock this capacity for cooperation are humankind’s evolved ability to create moral systems which he defines as “interlocking sets of values, virtues, norms, practices, identities, institutions, and technologies that mesh well with evolved psychological mechanisms and thereby enable the community to suppress or regulate selfishness and make cooperation possible.” Humans have evolved a set of intuitive moral reflexes or appetites that help us to jointly protect our mutual and individual interests so we can get along in groups and collectively protect ourselves from other groups. There are three aspects to this theory.

First, moral judgments arise from innate instinctive reflexes; they are not derived from reason.  In fact reason is almost always used to create post hoc rationales for the moral decision we have already made.

Second, these innate moral intuitions or appetites seem to fall into six categories, care/harm, fairness/cheating, freedom/subjugation, community/anarchy, authority/insubordination, and sanctity/degradation.  Different groups tend to value these moral appetites differently. Haidt points out that, universally, liberals put far more weight on the appetites of care and fairness whereas conservatives give more balanced weight to all six appetites.

Third, moral appetites evolved not only to motivate individuals to protect self-interest, but also to motivate individuals to respond to threats and protect group interests. Haidt calls institutions that support these moral appetites moral capital.   They are particularly morally compelling because they give us the opportunity to become part of something bigger than ourselves. They almost exclusively fall into the category of community (Support the troops), authority (Respect the president), and sanctity (respect the flag). 

Haidt acknowledges that conflict can arise within groups (liberal vs. conservative Americans) or between groups (secular humanist west vs. Islamist middle east), but, for the most part, he attributes these conflicts to differences in emphasis on the various moral appetites.  He implies that if we understood these differences more completely we could all get along a lot better. He concludes the book with the following hopeful advise.

“We are deeply intuitive creatures whose gut feelings drive our strategic reasoning.  This makes it difficult – but not impossible – to connect with those who live in other (moral) matrices which are often built on different configurations of the available moral foundations.

So the next time you find yourself seated beside someone from another (moral) matrix, give it a try. Don’t just jump right in. Don’t bring up morality until you’ve found a few points of commonality or in some other way established a bit of trust.  And when you do bring up issues of morality, try to start with some praise, or with a sincere expression of interest.

We’re all stuck here for a while, so let’s try to work it out.”

However, if one looks a little more closely at conflicts both within and between groups these conflicts are far more intransigent and morality is precisely the problem.

Alexis de Tocqueville pointed out in Of honor in the United States and in democratic communities from volume II of Democracy in America that conflicting values can arise within groups when a set of rules is implemented as a means of suppressing one group to advance the interest of another. He doesn’t call this a moral code but instead uses the term honor which he defines as, “ . . . the aggregate of those rules by the aid of which . . . esteem, glory, or reverence is obtained.” 

In aristocratic, that is hierarchical societies a small group of people at the top of the hierarchy had to maintain power over those they ruled. They created this particular form of morality so that their class could maintain power over all others.

As de Tocqueville puts it, “A class which has succeeded in placing itself above all others, and which makes perpetual exertions to maintain this lofty position, must especially honor those virtues which are conspicuous for their dignity and splendor and which may be easily combined with pride and the love of power. “

De Tocqueville sees morality in more conventional liberal terms. The basic function of this system is to bring people together and is based on care and fairness. “It is the general and permanent interest of mankind that men should not kill each other . . .” He further notes that  “It often happens that these two standards differ; they sometimes conflict” as when;

“Some actions have been held to be at the same time virtuous and dishonorable; a refusal to fight a duel is an instance. “

“To debauch a woman of color scarcely injures the reputation of an American; to marry her dishonors him.”

Nonetheless, this honor code “at the periods of its greatest power sways the will more than the belief of men . . .” That is, it precisely fits Haidt’s definition of moral thought; it is a . . . deeply intuitive . . . gut feeling that drives strategic thinking.”

If what de Tocqueville calls honor then is a value system evoking the same emotions and the same neural pathways as morality, then what it really is is morality by another name but used for other purposes, namely as a means to separate people for the purpose exerting power over them.

DeToqueville believed that as society became more egalitarian this brand of morality would gradually disappear and this for the most part is true.

However, this same dynamic takes place when we consider conflicts between groups.  Furthermore, it is probably far older, stronger (hardwired), and more prevalent today than the moral conventions that separate class. Where this value system has been rampant throughout history is in religion.  It is in fact codified in western monotheistic religions where Jews, Christians, and Muslims have some variation of, “Love thy neighbor as thy self.” (Binding Morality) and “Though shalt have no other God but mine.” (Honor/Separating Morality)

As a result, you love your neighbor as long as they do or don’t believe in the pope, do or don’t believe God gave the land to you, or do or don’t ever print pictures of the prophet. In all those cases you kill your neighbor. 

While religion has been the conventional system for creating lethal group distinctions for most of human history, eliminating God doesn’t solve the problem and the lack of a God may only exacerbate the problem.  Nazi’s killed millions and communists killed 10’s of millions in the name of racial and ideological purity respectively.

Where a value system is invoked to separate rather than bring people together the moral stand is one that is based on either authority or purity and very occasionally community. The point of invoking this value system is to exert power over another person or group.  I can harm you, cheat you, take away your freedom, or exclude you from my group because you are immoral on grounds of either authority (who you do or don’t revere) or purity (you don’t adhere to rituals that defines my group).

However, eliminating moral appetites based on authority and purity would be both impossible (like eliminating taste and touch) and harmful. As Haidt points out in the third part of his book it is in the cultivation moral capital that man finds meaning in shared group practices.  It gives man the opportunity to become part of something bigger than himself and can motivate him to some of mankind’s highest endeavors. Gandhi, Mother Theresa, and Martin Luther King created meaning for themselves and the world, motivated by their adherence to their values of authority and religious ritual (purity).

On the other hand the quest for meaning through adherence to exclusionary authority and ritual can lead to the worst excesses of human depravity. We see it today when thousands young men and women, sensing the culture they live in bankrupt of moral capital, leave their comfortable lives in the west and travel to the middle east to commit the most heinous moral atrocities in the name of well - morality.

As Haidt comprehensively makes the case, morality is the answer to why we can get along at all.

Unfortunately, it is also the answer to the question, “Why can’t we all get along?”

Geoffrey Berg MD

References:

The Righteous Mind: Why Good People Are Divided by Politics and Religion,

Jonathan Haidt First Vintage Books 01/2013

 

Democracy in America Volume II section 3 Chapter XVIII Of honor in the United States and in democratic communities Alexis de Tocqueville,

http://xroads.virginia.edu/~HYPER/DETOC/ch3_18.htm

A summary of Food for Thought up to now

My previous entries have fallen into the following four categories:

1.     Caveats

2.     Economies and Government

3.     Capitalism and democracy

4.     The modern world blessing or curse

Caveats

I started on a cautionary note about what we know and why we accept what we know.  Often what we profess to be true we believe to be true because “they” said it.  In addition and probably more importantly we believe certain things because of our emotional predisposition.

The take home is to be humble (as he dishes out platitudes) about what we think we know and why we are so willing to accept those “facts”. As an example of this, in a recent book discussion, I, being a hopeless romantic, came to a very optimistic view of the prospects of the protagonist at the end of the book. Another reader who is well known to be a hopeless, heartless cynic came to a very different conclusion.  My first reaction was to dismiss that person’s view because of course it was distorted. However, after further consideration of that point of view and realizing my own propensities, I changed my view to one that was much more guarded.  By taking a minute to consider the point from a different predisposition I got a fuller understanding of the reading.

Economies and government

Economies start when people barter and trade. As soon as that happens they have make/buy decisions. As economies mature people decide to buy much more than they decide to make.

Governments start as a means of protecting property.  Property is life liberty and physical possessions. When people form governments they trade freedom to (do as they please with their life liberty and physical possessions) for freedom from threats to their life liberty and physical possessions by others.

At first those “others” are people in other groups but as groups get bigger they need protection for their life liberty and physical possessions from people within the group. As a result laws, standards, and regulations are promulgated to protect property from others in the group.

The take home is that as labor divides and each person becomes more specialized, we overwhelmingly make buy decisions over make decisions.  As the system fosters this specialization we resort to a massive regulatory system to give us freedom from having to decide if the transactions we are making are fair – from the weight of a loaf of bread to the safety of the toaster we use. Subjecting ourselves to (and paying for) the laws, standards, and regulations of government we liberate ourselves to use our life liberty and physical possessions as we see fit within those constraints.

Capitalism and democracy

The economy is the game we all play and government makes the rules by which we play. At the current moment of history capitalism is the name of our game and democracy is the structure of the government that does the rule making. Most public policy debates revolve around how strictly should government call the game. Since its democracy, we all have a say in who gets to decide and enforce the rules. 

The take home here first is capitalism is not the problem.  Capitalism is descriptive of how people respond to property as soon as they start to barter and trade. Capitalism is never unbridled because it always operates within the constraints of government.

Problems arise when certain players either make the rules or can pay people to make the rules to favor them. Hereditary governments and communism are both inherently flawed in this respect because the rule makers are always in a position to make rules that favor themselves.  Democracy should theoretically be able to solve that problem because at least theoretically we all ought to have equal opportunity to make the rules or influence the selection of the people who will be making the rules for us.  Unfortunately, as it is practiced in the United States, the process is flawed because the more money you have the more you can pay to have the game called in your favor.

The modern world blessing or curse

In the last 250 years there has been an exponential spread and growth in the material wealth of mankind with most of this coming since the last half of the 20^th century.  This is clearly the result of capitalism providing markets for new technologies powered almost exclusively by fossil fuels.  This has created unprecedented wealth for unprecedented portions of the world’s population. In addition, because we no longer have to earn our bread by the sweat of another man’s brow or in most cases by anyone’s sweat, slavery and male gender domination are no longer normative behavior as they have been for most of human history.

For all the prosperity and refinements civilization has to offer, we feel something is oddly amiss.  In the time before history when we lived as hunter/gatherers we were more connected to our clan and to nature although we were much more likely to be at war with the clan or tribe that lived nearby.  We had a sense of agency that everything we did made a difference and the differences mattered because they were often the difference between life and death.  It has been suggested that since this is the way we had lived for most of mankind’s existence, perhaps the epidemic of depression, suicide, drug addiction, and child abuse we find ourselves in today is because we have not evolved as quickly as our cultural patterns have changed.

For most of human history man evolved while living on the brink.  Surviving on the brink gives man a sense of meaning even today.  According to Victor Frankl the search for meaning is man’s principle driving instinct.  And where did Dr. Frankl come to this revelation; living on the brink in Hitler’s concentration camps for more than four years.

“Society never advances. It recedes as fast on one side as it gains on the other. It undergoes continual changes; it is barbarous, it is civilized, it is christianized, it is rich, it is scientific; but this change is not amelioration. For every thing that is given, something is taken. Society acquires new arts, and loses old instincts.”

Ralph Waldo Emerson Self-Reliance

The take home is that we have spent the last ten millennia moving away from the brink and we have in the last 2 centuries been wildly successful at it and we are not going back in large numbers, voluntarily, any time soon.  If for no other reason moving from the brink promotes survival with which we have also been wildly successful. That said meaning is important if not essential to life and finding it in the midst of our prosperity can be difficult and may explain some of the bizarre choices we see people in civilized society making.