Central to the problem
of how best to live in a world that we cannot understand is how to regard:
“The
Extended Disorder Family (or Cluster): (i) uncertainty, (ii) variability, (iii)
imperfect, incomplete knowledge, (iv) chance, (v) chaos, (vi) volatility, (vii)
disorder, (viii) entropy, (ix) time, (x) the unknown, (xi) randomness, (xii)
turmoil, (xiii) stressor, (xiv) error, (xv) dispersion of outcomes, (xvi)
unknowledge. (Nassim Nicholas
Taleb, Antifragile, London: Allen Lane, 2012)
To this impressive list,
I would add seventeenth and eighteenth items: failure and death.
All of these characteristics scare and frighten most of us, and so we do
our best to avoid them.
Despite the popularity
of self-help books emphasizing the pursuit of happiness, a vocal minority has
advocated embracing all of the above negative items in order to live fully and
successfully.
Eric G. Wilson perhaps
provides the best overview of this minority report when he observes that
“To
desire only happiness in a world undoubtedly tragic is to become inauthentic,
to settle for unrealistic abstractions that ignore concrete situations.”
And
“Our
passion for felicity hints at an ominous hatred for all that grows and thrives
and then dies.” (Eric G. Wilson, Against Happiness, New York: Sarah Crichton Books, 2008)
To be alive and to
realize that you are going to die means being insecure and vulnerable. According to Martha Nussbaum one should
embrace this uncertainty.
“To
be a good human is to have a kind of openness to the world, an ability to trust
uncertain things beyond your own control, that can lead you to be shattered in
very extreme circumstances for which you were not to blame. That says something
very important about the ethical life:
that it is based on a trust in the uncertainty, and on a willingness to
be exposed. It’s based on being
more like a plant than a jewel: something rather fragile, but whose very
particular beauty is inseparable from that fragility.” (Oliver Burkeman, The
Antidote, New York: Faber and
Faber, Inc., 2012).
The Stoics may have been
the first to realize that embracing the negative can be a useful tool for human
beings attempting to lead a meaningful life. William Irving in A Guide to
the Good Life: The Ancient Art of Stoic
Joy describes their negative visualization as imagining that the worst
possible outcome may occur. And if
bad things do happen that is the way it is supposed to be. Marcus Aurelius advised us to
“constantly regard the universe as one living being, having one substance and
one soul. (http://classiclit.about.com/od/aureliusmarcus/a/aa_maurelius.htm) Whatever happens at all happens as it
should; you will find this true, if you watch
narrowly.” (http://en.wikiquote.org/wiki/Marcus_Aurelius)
By concentrating on this
glass half full philosophy, the Stoics solved two of the more vexing problems
that humans encounter when they pursue happiness. The hedonic treadmill effect where sources of pleasure last
only a short period of time is minimized when one meditates on the likely
negative outcome of everything in life.
Negative visualization also decreases the anxiety associated with the
irrational fears that our minds come up with when worrying about the unknown
future.
Oliver Burkeman in The Antidote describes how Albert Ellis, the
second most influential psychotherapist of the twentieth century, advocated a
similar negative approach to life.
He differentiated become a terrible outcome and a merely undesirable
outcome, and he argued that it could always be worse. In advising an anxious and ambivalent woman trying to decide
if she should move to be with her boyfriend, Ellis shouted:
“So
maybe he turns out to be a jerk, and you get divorced! That would be highly
disagreeable! You might feel sad! But it doesn’t have to be awful. It doesn’t have to be completely
terrible.”
One of the things that
troubles me most about the current American fascination with happiness is how
self-absorbed and superficial the entire enterprise can become. Those that are most concerned with
happiness often appear to be ignoring much of reality. Taleb in Antifragile
defines via negativa as focusing on what something is not and he recommends
using it as recipe for what to avoid, what not to do. He also observes that we know what is wrong with more
certainty than we know what is right.
Applying these concepts to happiness, he believes the subject is best
dealt with as a negative concept:
“Instead,
they should be lecturing us about unhappiness (I speculate that just as those
who lecture on happiness look unhappy, those who lecture on unhappiness would
look happy).”
Which brings us to Alan
Watts who in The Wisdom of Insecurity makes
two very important points. The
first is that
“There
is a contradiction in wanting to be perfectly secure in a universe whose very
nature is momentariness and fluidity.”
His second key
observation in this important book about our inability to control events in a
world that we truly do not understand is his fascination with the law of
reversed effort.
“When
you try to stay on the surface of the water, you sink; but when you try to
sink, you float…Insecurity is the result of trying to be secure…contrariwise,
salvation and sanity consist in the most radical recognition that we have no
way of saving ourselves.”
This realization that
the world we live in is essentially insecure and that denying this reality
makes us unhappy is the message of Pema Chodron. She writes, “Things are not permanent, they don’t last,
there is no final security.”
What does the
realization that we will never truly understand the world we live in mean for
those of us who are physicians?
Should the discussion above change the way we view medicine? David Agus in the End of Illness and Taleb in Antifragile
provide us with guidance about medicine in a complex emergent system world.
Having graduated from
Case Western Reserve School of Medicine in 1980 and having trained at UCSF as
an academic anatomic pathologist, I am steeped in the traditional approach to
health care where we assume we can understand the world of medicine. The biomedical model reduces every
illness to a biological mechanism of cause and effect, and physicians diagnose
diseases and then treat them.
Health is defined as absence of disease. The patient story and experience is subjective and
untrustworthy in comparison to the test results emanating from my pathology
laboratory, which are objective and true.
Generalists are replaced by specialists who regard cure as the only
important goal. And pathologists
are the most important of the specialists because treatment selection and
administration has to await the diagnosis rendered in the pathology
laboratory.
Agus labels the
traditional approach “the germ theory of disease, which dominated, and in many
ways defined, medicine in the twentieth century.” “The treatment only cared about the invading organism…it
didn’t care to define or understand the host (the human being).”
Agus, an academic
oncologist and founder of both a proteomics and a genomics biotech start up
company, replaces the medical status quo with a system biology approach. “It is
important to approach your health in general from a lack of understanding. Honor the body and its relationship to
disease as a complex emergent system that you many never fully comprehend.” His conclusion that one does not need
to understand cancer to treat it is controversial.
Taleb’s Antifragile provides an approach to living in
a world we do not understand by applying his study of the statistics of random
events and his experience as an options trader. Taleb compares and contrasts a fragile and antifragile
approach to everything from science, business, errors, systems, and Greek
mythology. In science for example,
the fragilista who thinks he understands everything causes fragility by depriving
variability loving systems of variability and error loving systems of errors;
he favors directed research and grand theories. The opposite scientist is a practitioner who tries to
understand how things react to volatility and errors, and he favors stochastic
tinkering or bricolage to grand overarching theories.
The French biologist
Francois Jacob used the term bricolage to describe the trial and error way that
nature exploits optionality. Jacob
gives the example of how half of all embryos undergo spontaneous abortion in
the uterus, which is easier than designing the perfect baby by blueprint. Another example of bricolage would be
the way that genes that work in simple animals are retained and utilized for
similar functions in higher animals.
This concept of “trying to make do with what you’ve got by recycling
pieces that would be otherwise wasted” illustrates how nature substitutes
optionality for intelligence.
Saras Sarasvathy’s study
of 45 successful entrepreneurs shows how the bricolage approach can be applied
to start-up companies. In Sarasvathy’s
effectuation system causally minded people (fragilistas in Taleb’s book) favor
a directed plan to achieve their goal.
Effectually minded people, on the other hand, take a trial and error
approach to see what they can make out of the means and materials that are on
hand. Applying the bird in the
hand principle and the principle of affordable loss, effectually minded people
forge ahead to see what happens.
Sarasvathy found that most successful entrepreneurs were effectually
minded. (www.effectuation.org)
A conclusion that would
please Taleb.
When Taleb focuses on
medicine, he concentrates on the problems of iatrogenics and the agency
problem. Iatrogenics literally
means caused by the healer as iatros means healer in Greek.
“Every
time you visit a doctor and get a treatment, you incur risks of such medical
harm, which should be analyzed the way we analyze other trade-offs: probabilistic benefits minus
probabilistic costs.”
The agency problem is
when the agent has personal interests that are different from those of the
principal who uses the agent’s services
“An
agency problem, for instance, is present with the stockbroker and the medical
doctor, whose ultimate interest is their own checking account, not your
financial and medical health, respectively, and who give you advice that is
geared to benefit themselves.”
Taleb notes that
Montaigne recognized the agency problem when he wrote, “No doctor derives
pleasure from the health of his friends, wrote the Greek satirist, no soldier
from the peace of his city.”
Taleb develops simple
decision rules for dealing with health and wellness. Using his concept of via negativa that we encountered above
when we discussed happiness, his first rule is “only resort to medical
techniques when the health payoff is very large (say, saving a life) and
visibly exceeds its potential harm, such as incontrovertibly needed surgery or
lifesaving medicine (penicillin).
Taleb believes “we do
not need evidence of harm to claim that a drug or an unnatural via positiva
procedure is dangerous.” To
emphasize that harm can be difficult to appreciate, he notes that harm often
occurs in the future and that the past does not tell one much about rare random
events. The Turkey Problem makes
this point.
“The
turkey is fed by the butcher for a thousand days, and every day the turkey
pronounces with increased statistical confidence that the butcher ‘will never
hurt it’ – until Thanksgiving, which brings a Black Swan revision of belief for
the turkey.”
Following Taleb’s advice
would have avoided the harm caused by Thalidomide (birth defects) and
Diethylstilbestrol (delayed cancer in daughters).
“Iatrogenics,
being a cost-benefit situation, usually results from the treacherous conditions
in which the benefits are small, and visible – and the costs very large,
delayed, and hidden. And of
course, the potential costs are much worse than the cumulative gains.”
Another Taleb rule is
“we should not take risks with near-healthy people; but we should take a lot, a
lot more risks with those deemed in danger” because iatrogenics has a
nonlinearity response.
“This
means that we need to focus on high-symptom conditions and ignore, I mean
really ignore, other situations in which the patient is not very ill.”
Taleb also recognizes
that the paucity of medical articles reporting negative results has contributed
to the problem of overtreatment with sometimes disastrous results.
“What
made medicine mislead people for so long is that is successes were prominently
displayed, and its mistakes literally buried -- just like so many other interesting stories in the
cemetery of history.”
Ben Goldacre in the New York Times recently discussed this point
when he wrote about the recall of a Johnson and Johnson artificial hip that
experienced a 40% failure rate:
“The best evidence shows that half of all the clinical trials ever
conducted and completed on the treatments in use today have never been
published in academic journals. Trials with positive or flattering results,
unsurprisingly, are about twice as likely to be published — and this is true
for both academic research and industry studies.” (http://www.nytimes.com/2013/02/02/opinion/health-cares-trick-coin.html)
Perhaps the best way to
end this discussion of how to live wisely in a world that we can never truly
understand is to give Taleb the final word:
“If
there is something in nature you don’t understand, odds are it makes sense in a
deeper way that is beyond your understanding. So there is a logic to natural things that is much superior
to our own. Just as there is a
dichotomy in law: innocent until
proven guilty as opposed to guilty until proven innocent, let me express my
rule as follows; what Mother Nature does is rigorous until proven otherwise;
what humans and science do is flawed until proven otherwise.”
