Thursday, 20 May 2010

Religious prejudice

I attended some talks at an international conference on science and religious conflict. What surprised me was the lack of scientific rigour in studies of this subject.
I was less interested in conflicts with a religious nature and more interested in religious conflict with science, and whether religion leads to conflict. The theologians and philosophers can talk all they like about religious doctrine, but what matters is the feeling of religiosity in the believers.
Religiosity is an accepted term in this field, it seems, but is hard to measure. It's easy to get weighed down by academic disagreements over pet theories about whether religious feeling can be divided into different classes (questing religion, for example, hardly follows the Western concept of a religion having unquestionable doctrine at all).
I would be happy with questionnaires about how often a person attends divine worship combined with a linear scale of religious fervour on which a participant must mark a cross.
The biggest problem with the research about religion and prejudice is the definition of prejudice, a point made by a philosopher (Ingmar Persson), but in a rambling and extensive way, in which he concluded that all opinion could be prejudice.
I agree with him to an extent, that the work has not identified prejudice well, but I wouldn't be so kind as to suggest that this is because prejudice is a vague, indefinable term. Measuring the effect of religious sentiment on an individual example of prejudice gives no meaningful results (despite the authors' conclusions). The study of which I am thinking concluded that religion can both create and dissipate prejudice, as was made clear in the different attitudes of religious respondents to homosexuality and Muslims.
This sort of conclusion is almost a truism. If something in which one deeply believes tells you that certain desires are sinful, you will be prejudiced against those with such desires.
What we really need to know is whether religion increases the general (or average) level of prejudice, if we can imagine such a thing. In animals the equivalent would be the level of defensive posture in response to strangers. In humans it is harder to conceive of an unbiased indicator because in-group and out-group sentiments are more complex, and so a 'stranger' might not necessarily be regarded as fully 'out-group', thereby destroying the usefulness of any experiments trying to measure attitudes towards out-groups.
If some behavioural measure could be used, without the volunteers' direct knowledge, that would truly tell us something about how religion influences people.
In order to find such a behavioural measure, we would need to assess how religion affects people's perceptions of who is 'in-group' and who is 'out-group'. Only then can we accurately provide each participant with behavioural cues that allow us to determine his responses to each type of category.

The other aspect of the study was the use of mortality salience testing, in which people were reminded of their mortality in order to make them more uncomfortable. Mortality and existential dread affect all humans, and religion certainly offers one way of coping with these inevitable aspects of intelligence. Hence religious people were less fazed by mortality salience.
An interesting counterpoint would be to examine whether religious people could be fazed (and therefore have their behaviour negatively affected) by other cues that do not affect atheists. For example, many scientific discoveries and theories directly contradict religious doctrines. Where atheists might be comfortable with such knowledge, religious people might be uncomfortable because the source of their comfort in situations including mortality salience is undermined.
The use of false comforts and the psychological conflict between knowledge and comfort therefore helps retard the progress of science.

This issue is now returning to previous, more philosophical, musings on this subject. It is the human need for comfort and familiarity, and the subordination of reason to emotions (such as this happiness with comfort, certainty, false purpose and familiarity) that is the flaw in our species.
Religion gives us purpose and absolute certainty in a world where these things do not truly exist. The need to have bedrocks on which to build our lives ruins our species.
Even in science we cannot do things properly. Instead of probabilities or likelihoods of truth we state a result as absolute truth if the result obtained passes a specific, arbitrary boundary of improbability if the conclusion were false. This arbitrary boundary allows us to state whether a conclusion is, or is not, justified in a binary manner. We should be stating probabilities of truth.
We need to accept the way science builds truth from 'truth density clouds' of results in the same field, just as physicists accept the use of probability density functions for small particles.
Science offers us accuracy, when used correctly, with increasing precision the more we use it. Religion offers us perfect precision but with completely ungovernable accuracy. And we as a species, with remarkable disregard for the truth, choose precision of knowledge over accuracy. We choose comfort over truth, emotion over sense, familiarity over curiosity and stability over progress: we choose religion.

I buck the trend of the species. I love truth. I get a little warm glow inside every time I break apart a puzzle and get the result, be it a puzzle of data, a riddle of life or analysing the foundations of a moral or political assertion. My certainty in life comes from the joy of applying logic and rigour; it comes from the truths I have so far uncovered (given the data I have) and the certainty that although the details of knowledge might change with new data, the beliefs I hold at any moment in time are the closest that I can get to the truth at that time.

As the Bible itself (almost) claims:

Magna est veritas et praevalebit

Great is truth and it shall prevail (a bit)
(I prefer the misquotation and mistranslation to the real version)

Marriage

Someone was playing devil's advocate, and here states an argument that he's heard many people use about whether we should allow gay marriage.

Obligatory Slippery Slope Argument #1

If you break with traditional marriage, where can it lead? Can the same arguments justifying same sex marriage be used to wed three or more people? Three people and a large furry animal? A man and his sex toy (android)?

What is wrong with that?

There is no well-supported justification for the promotion of marriage, other than religious beliefs. I see no reason why arbitrary religious decisions should govern society, since we're not theocracies and the US specifically guards against such interference in public affairs.

Marriage could be said to promote child welfare, except that children grow up best in extended families with large support networks, not in 'nuclear' (two-adult) families. So we're not promoting child welfare: the focus on two adults rather than many adults is detrimental to child (and adult) welfare. People need more than one social contact to live healthy, balanced lives.

So marriage cannot be said to be best for the children (although it's not worst, either, since two adults are better than one). It has no practical worth. It is simply an artefact of religious dominance of our societies. Were we truly progressive we would discard it and promote extended support networks for children and adults.
However, the concept of devotion to one other for your whole life has such a cultural resonance in our societies that the emotional reaction to discarding marriage would over-ride rational argument. It doesn't matter that throughout history humans have typically remained with a partner for (on average) 7-10 years, and that lifelong partnership is unnatural and difficult for most people.

Marriage is sacred in our culture, even to many who do not acknowledge the existence of God. They still demonstrate the responses of those for whom things are sacred when you talk about marriage. Marriage cannot be questioned; it is an 'elephant in the room'.

The fact that if we deduce certain principles about marriage from current arrangements we find some things repugnant (not allowing gays to marry) shows that the current system is flawed.
When we try to adjust it to take into account more fundamental principles, such as equal rights, we find, as I have quoted above, that the adjusted rules of marriage lead to absurdities. This is because marriage itself is an absurdity.

Friday, 14 May 2010

Love and relationships

I was chatting to a friend who was pondering the role of love in her life. She said:
When I say I love someone, I am certainly expressing deep affection for them as well as a level of trust that I won't be made to be an idiot for having that affection.
But I am not convinced that those phenomena are some sort of Higher Plane

I asked how affection could be idiotic:
If the person were not deserving of said affection--if i were betrayed, etc.

I cannot see how affection can be betrayed. Affection is not an agreement or a promise: it's a feeling. It is my own state of feeling towards another. Betrayal needs a prior agreement; some sort of trust.
My friend's reply can be summarised thus:
I don't think I can wholly separate affection from trust. If I can't trust someone at all, there's no way I could feel that level of affection for them. I could feel some affection, but nothing more than the affection I feel for something trivial.
I don't need someone to participate in an agreement in order for my trust to be broken, which may be unfortunate, but that's how it is.
I trust that they will behave a certain way, according to what I've come to expect.

I still don't think that any betrayal can take place without an agreement, nor that trust is the right word to use about expectations. Trust is an understanding that the other person will keep his word or will perform his job well, or something similar.
I think that one's expectations of others' behaviour should be thought of as being more like the expectations one has of a computer, or a bicycle. If these fail to function normally, then it can be frustrating and annoying, but they can't betray you. On the other hand, the companies that made them might have betrayed you to some extent.
In the same way, I can't be betrayed by a complete stranger on the street. I can be surprised by one, but without the law being broken, which could be considered a common agreement between everyone, there is no trust between us that could be broken. When expectations are not fulfilled it's time to learn and re-evaluate someone, but not feel betrayed by him unless he's made a commitment that's been broken (such as marriage).
I don't think it's wrong for someone to feel betrayed, not for something that is deeply personal

My answer remains sufficient:
If I were to get upset with David Cameron for ruining the country, it doesn't matter how deeply personal my feelings are; it's wrong because he hasn't yet. Things can be wrong and be feelings. Similarly, people who feel betrayed frequently have not been, and the feeling, the resentment and any actions following from that are wrong.
I'm not denying that they might be in pain, although I do believe that the pain would be less if they didn't mix up feelings of trust and affection in the first place, but that doesn't make the justification for the pain true instead of false.

This little discussion was with only one person, but I wonder whether she is representative of many people in the world. Do many people believe that their affection is enough to warrant feelings of betrayal? Would the world be a better place if people expected nothing in return for their affection?

That sort of affection is often called love: 'true love expects nothing but gives everything' is a sentiment that is often repeated. But it seems to me that most people act as though the opposite were true: one expects nothing from one's acquaintances, but expects much from closer friends, for whom one has more love. I might even add that this is perhaps why so many people stay as my acquaintances; I do not anticipate their feelings nor respond to their expectations, but remain myself all the time.

I had another conversation this week, in which we discussed emotional closeness and courtesy. One person wanted closer emotional ties and more effusion, and as part of this expected her responses to be anticipated, and behaviour altered pre-emptively. I am of the opinion that the essence of manipulation is the anticipation of people's responses and the adjustment of one's own behaviour to control those responses. I am very much against this sort of double- and multi- bluffing and anticipation. As with any bluffing situation, it can rapidly get out of control. If I am to anticipate a response, then I must behave a certain way. And if that person is to be courteous to me, then she should anticipate that behaviour, and pre-empt it with a behaviour of her own...
and we get endless guessing games about what people mean, and whether they want something or think that you do. It's pointless and silly.

Quite apart from the risk that the ludicrous scenario that I've just described degenerates into arguments or deliberate, malicious manipulation, it makes far more sense to avoid the unnecessary complexity of multiple anticipations and behave straightforwardly.

My friends are my friends because I enjoy spending time with them and because, I assume, they do not mind me. I would not call friends people with whom I had to adjust my behaviour in order to be liked; they would then not like 'the real me', and I would be constantly alert because I would be consciously changing myself, like an actor doing his job. That's not relaxing or fun, and we'd be better off doing different things.

It's a shame that a person expects others to adjust their behaviour to account for his personal feelings, because it leads to all these different problems that I have described. The straightforward tolerance of others' actions and the acknowledgement that hopes and expectations are not the same as binding agreements would go a long way to reducing the amount of argument and disagreement that happens at a personal level all over the world.
The big problem is that I cannot break through with my attitude: people expect my behaviour to change, and if I address this expectation with this sort of direct argument, that itself often counts as offensive and against expectations. There is no way in to start change.

This issue ties in with my thoughts on speaking one's mind and adjusting speech for sensitive subjects, or avoiding jokes about such subjects.

Tuesday, 4 May 2010

Patient Satisfaction

I have for a while been annoyed by advocates of patient satisfaction. In the past my friends and I have approached this subject from the poles of objectivity and subjectivity. I dislike involving subjective ratings (feelings) in any objective outcome (promotion, success, hospital income). On the other hand, we can point to the WHO definition of health as
'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.'
This definitely includes feelings. So presumably a health service should aim to promote happiness as well as treat disease and physical infirmity. This is why the government blathers on endlessly about patient satisfaction, as though patients are customers shopping around for the best deal.
I've been into arguments about injustice before: about how a screaming person often gets seen before a quiet one (barring medical concerns about silence indicating inability), and how that punishes virtues such as patience, courtesy, consideration, self-control and the ability to wait one's turn. It's the same point I made in a recent post about achieving equality of outcome; it leads to unjust treatment of people. If you try to ensure that all children learn the same things at the same time you spend a lot of time and effort on the stupid ones and very little on the intelligent ones. Similarly with health-care, you can spend a lot of time on the needy. And in health-care that's appropriate because some things do need to be seen immediately. But the need must be objective, or else it leads to injustice.
This sort of inter-individual effect on justice seems a powerful enough argument to me, but some people would dismiss it as both insufficient to justify destroying a wonderful system of ratings, and a minor concern, since everyone does get medical care, even if the order is distorted slightly.
After all, if we weren't to use patient satisfaction, how else would we measure care? We'd have to rely on hospital inspections and outcomes, which we already do measure (and rely on to a fair extent). As we know, these are dangerous areas: hospital ratings and inspections do not reveal how a hospital really functions, with very highly rated hospitals suffering the two major health scandals of the last two years. Things can be hidden in a short inspection; inspectors don't see every aspect of day-to-day care, and outcomes depend on the severity of the cases and how the patients treat themselves.

If we aim for patient satisfaction, as now, or in a choice-driven NHS in which patients get easy choice of different providers, what will happen? The Conservatives say that care will improve, as those who provide poor care receive fewer patients and less money. They want more private companies, more choice and more market-like systems.
But the market won't be chasing good quality care. That's a little leap of faith. The leap is the logical deduction that patient satisfaction comes from better care, and better care alone. However, market systems require perfect knowledge. If every patient knew every range of possible treatments, their likely effect and could judge accurately surgeries and other procedures, then we'd be a nation of doctors and we could treat our own problems.
Just as companies distort the market by distorting what people know with advertising, publication bias (from pharmaceutical firms), false assurances and press releases, health-care providers can address patient satisfaction without improving care. This is more than a theoretical concern. Here is testimony from one doctor:
'When I first started practicing medicine, I had a lot of idealism about how I was going to improve care of patients in the ICU, and how some of my talent might even rub off on staff that were less talented. What I actually discovered was quite the opposite.

It turns out that healthcare in the US is set at a pretty low bar, and any attempts on my part to set it higher only caused widespread resentment. On the one hand, many resented the implication that a young physician like myself could offer anything of importance to older and more experienced physicians. After all, they've been doing it "this way" for years, and it's worked for them and for patients (so they believed). On the other hand, they also resented the implication that by making myself look smart, I made others look stupid. So, ironically, by trying to be the best physician I could be, I was actually putting myself in a vulnerable position. Since no one could support anything I did, I made enemies quickly.

There was a period in which I thought that even if I didn't have professional support, at least patients were better served by my care. All this changed with one experience that finally broke the camel's back. After rescuing a certain patient named M.S., I was dismissed from her care, by her family's request, because she was displeased that I did not treat her pain promptly enough. The fact that I had just saved her life didn't seem to concern her. This made me recognize that even patients don't necessarily want to get medical care. They only want certain petty concerns addressed -- usually issues of vanity. I decided that if neither the physicians nor the patients care about the quality of work that I do, why should I?

Since then, I have shifted my professional behavior markedly. Instead of trying to advance proper care, I have focused on image. Taking a cue from Machiavelli's statement that "people can see better than they can feel", I have made sure to portray the image that both patients and physicians expect, but avoiding making implications about others, even indirectly. I have found untold success in this method. In this world, it is better to look good, than be good. Since I have taken this route, my professional life has been much smoother. Because I portray the image expected of me, everyone thinks I'm their best friend. And because I don't act in a manner that appears to encroach on any other physician's territory, none of them see me as a threat. My personal life has also vastly improved. Since I don't have so much stress at work, I can remain relaxed at home. '

As the doctor notes, patient satisfaction wasn't about saving a life. Neither the patient nor her family knew that her life had been in danger, nor understood that it had been saved. What mattered was pain. Pain is quite subjective, and often treating pain is against best medical practice: there are endless people in hospital crying for better pain relief, calling the nurses torturers and so on, when any more will stop them breathing, get them addicted, interact badly with their other drugs or possibly a host of other medical concerns.
But even beyond the question of pain, the story demonstrates another truth: that satisfaction through ignorance is easier to achieve than satisfaction of the knowledgeable. If we introduce markets to health-care, then we will also introduce the typical market-failures and incentives, and one of the most damaging will be an even greater incentive to hide bad treatment, cover up failure, and generally rely on 'PR' over true ability.

My mother likes to tell the story of her inspection of two doctors in Liverpool. She was inspecting two gynaecology consultants, one of whom had some of the best post-natal survival figures in the country and one had a history of complications and problems (or something to that effect). One was friendly and liked by patients and staff, the other an aggressive man who told her that women couldn't be relied on to think clearly, especially when pregnant (and she was incubating me at the time), was disliked by staff and just about managed professional courtesy with patients. This second one had far fewer thank-you letters and gifts, but he was the one with the good survival rates.
Chasing patient satisfaction will not only get me seen much later than would be fair, but will give me poor care. I'll see a smart-looking doctor who is brisk and firm and projects an air of authority whilst explaining his decisions, and I'll feel comfortable that someone who knows his job is in charge. Actually, though, I'll be meeting someone who has more skill in acting than medicine, and who will skim over difficult decisions and problems because sounding uncertain will make me less confident and less satisfied. I'll meet someone who'll second-guess my responses as his main job, because my responses have suddenly become not just a secondary concern to his own actions, but more important than them, and the means by which his actions are judged.

If we return to what I've said in the past about leadership and democracy, we can see that this is the contrast between the popular and the sensible. In relationships it's the contrast between a reliable partner and a manipulative one. It's the clash between the subjective and objective; the hopes for absolute equality and the reality of equal rights. It's the same attitude that we decry as 'populism' but accept when it's coated with the sugary phrases of 'market forces' and 'economically sound'.
Economically sound means the same as well-evolved. People respond to incentives, just as creatures have responded to the environment. But evolved (in the biological sense) does not always mean improved, and a free market system in the NHS, or any pursuit of satisfaction over real care, will be the same.
If happiness is better, why don't we get everyone high on soma and let a ruling elite deal with unforseen problems?
Oh wait, things are going that way anyway... drugs, religion, apathy and plutocrats. Perhaps society is evolving after all.


We won't achieve benefits if people decide on the basis of satisfaction, not empirical statistics. And people do decide on that basis, which will affect my care too.
It's already affecting training: doctors are taught how to be nice. That's valuable time that could be spent on learning how to treat real conditions.
People are expecting to be made happy by many things, from the NHS to a shop assistant. Where that doesn't harm any other concern, that's fine with me. But aesthetics should contribute to good design, not detract from it. Where emotional appeal spoils something that otherwise functions well it's no longer something that the nation should invest in.

If the shop assistant takes longer to serve me because he's conversing with a customer then I've had my time wasted, even if it makes sound business sense. If a doctor does the same, then all the following patients will wait longer. That doctor might get good personal ratings, at the expense of the ward or hospital.
We could say that if the population as a whole wants this, then it doesn't matter that I don't want to waste my time waiting for other people to exchange life stories, or have my taxes pay them to do so.
But people are incapable of linking their individual decisions to mass effects. They will disagree with the mass effect and want to make the individual decision that causes it. They want everyone else to do what's right but to screw the system themselves. They can't cope with the Categorical Imperative that suggests that actions are judged by what would happen if everyone acted by such a principle.
That free markets, which are a version of mob rule, would lead to certain results doesn't mean that we actually want those results, nor that we should accept them. If we were to legalise drugs we'd get a lot of drug use, but that doesn't lead everyone to conclude that the population wants or ought to get a lot of drug use; the same applies to murder.

Do we want mob rule and the evolution of whatever panders to that best, or do we want a little bit of principle and insight? These are the things that supposedly distinguish democracy from anarchy (and mob rule). I can tolerate my local shop wasting my time, but I don't think that my government should do it. The government needs to be run by principles, not economics. The principle of 'give the people what they want' doesn't work when the people have conflicting wants. And when those wants are caused by a conflict of a principle with an immediate desire then the government should be governed by principle.

The conflict between immediate desire and long-term goals is well known:
http://www.ted.com/talks/lang/eng/dan_gilbert_researches_happiness.html
http://www.ted.com/talks/daniel_kahneman_the_riddle_of_experience_vs_memory.html
And just as well known is that giving in to immediate desire when it conflicts with long-term goals is bad for you:
http://www.ted.com/talks/lang/eng/joachim_de_posada_says_don_t_eat_the_marshmallow_yet.html

Sometimes we need government regulation to control short-term interests. We need the government to stop banks using the stock markets to take money from the economy and unbalance it. We need the government to take money from us to pay for upkeep of the infrastructure, because otherwise we'd not bother with repairs and we'd put it off indefinitely. Similarly, we need the government to prevent us from judging health care by patient satisfaction.

Female entitlement

  There is a segment of society that claims to believe in equality and fairness; and yet refuses to examine the privileges of one half of ...