EMCrit 246 – Philosophical & Psychological Diversions Part I – Liberterian Free Will, Blame and Shame May 2, 2019 by Scott Weingart, MD FCCM 56 Comments You are unauthorized to view this page. Username Password Remember Me Forgot Password
Just commenting that I enjoyed it and would love more on this.
Same concept, different discipline (human factors ergonomics) The natural response to an adverse incident is for the reviewer to use hindsight bias, outcome bias, attribution bias and counterfactual realities to retrospectively label a decision an error and then dole out retributive justice (what rule was broken? how badly was it broken? how much do we punish?). The trouble is, making an error is not actually a prospective choice so retribution isn’t an effective preventative tool. A cognitive de-biasing tool to avoid this is to apply the local rationality principle: assume people come to work to do the right thing. The… Read more »
George– I think you need to come on the show to talk about how you would run the ideal M&M. I’ve loved your LitFL posts on this and would love to talk. Let me know if you are game.
I really enjoyed this philosophical episode, Scott! Thoughtful and helpful. Looking forward a next show on the subject!
I liked this episode and feel I’d enjoy the two other topics as well. (That said, ultimately I listen to emcrit for tips on how to get things done in patient care.) I don’t feel like this focus on libertarian free will helps a lot though – the concept seems almost meaningless to me. Libertarian free will seems just to be enslavement to a different set of dice (that being your free will, now acting independent of everything that makes you who you are). To me, free will would represent the freedom to act on your preferences – for example,… Read more »
your preferences are built from your meat. they too are determined.
Sure. I wasn’t disagreeing so much as saying that I have no problem with being predetermined, as long as I still get to like what I’m doing.
I really enjoyed this episode. This reminds me a great deal of the arguments put forth by Sam Harris in his book Free Will. Philosophical libertarianism is very challenging to defend in a rational way. I personally alternate between compatabilism and determinism. I strongly suspect the logical arguments for determinism are much stronger than the innate “feeling” that we must have free will. I struggle to poke holes in the logic of the arguments for determinism, and it is likely the concern of drifting into fatalism that prevents a wholehearted acceptance of determinism. The fundamental attribution error is of obvious… Read more »
thanks, Dan. Think we need to do the Taoism piece as the first one we hit.
Scott! This was an incredible listen, and perfectly relevant. Keep the grade A content coming!
Definitely some good thought-provoking stuff here, and I am fortunate to work in two systems, both air and ground based, that adopted some form of the “just culture” framework. One wrinkle I see, though, is that we can’t treat something such as a medical error completely independent of the circumstances leading up to it. And when we consider those things, we need to find a line somewhere between “negligence” and “human error”. Put another way, you or I may consider ourselves experienced, up-to-date clinicians, and when we have an error in judgement, we can look back and say we were… Read more »
Think it is still a systems problem. If a system tolerates people that are just phoning it in, then it is the fault of the system when that level of knowledge causes a problem. If we tolerate unions protecting ineptitude than the unions are to blame, not the individuals.
I found this discussion refreshing and needed. Would probably enjoy it with bourbon…
well, that’s how it was recorded : )
Interesting podcast, as always. I agree with the conclusion regarding moving away from a blame based approach to error. However I disagree with some of the process of getting there, specifically the complete rejection of free will. It is interesting that the two named references of Dan Dennett and Sam Harris make up half of the “four horsemen of new atheism” and so represent a narrow perspective. The article by Cashmore certainly seems to follow in the same vein. It seems that the argument for philosophical determinism is somewhat predicated on scientific determinism which is largely out the window with… Read more »
Luke, thanks so much for commenting and offering a differing opinion. It very well may come to pass that chaos at a quantum level is what eliminates fatalism. But that doesn’t give us the ability to alter our choices via our consciousness. Our consciousness doesn’t have access to effects of randomness at the quantum level–we can’t make choices or find our ability to choose there. Those effects are included at the level of randomness in the argument I have laid out. When you say, “If scientific determinism does not exist on the micro level, then why would it exist on… Read more »
Hi Scott – thanks very much for your reply. I’m sure we are all too busy to get sucked into a vortex of the details of such things but I’ve reflected on it some more and thought it worth a reply. Perhaps I am not familiar enough with the incredibly precise semantics of the many “-isms” needed to engage with established philosophy. However, on first principles I think I probably agree with your argument about libertarian free will, as you defined it. Though I think the definition is the problem. My conception of free will would be better defined as… Read more »
Please do the other two topics.
Scott, interested can you finish the three topics.
Wow. Listening to Scott Weingart talk about free will and philosophy of mind was a surreal experience I never knew I wanted. I’m on board, good times. I think the reason we hold clinicians accountable for errors we consider below the standard of care isn’t because they should have done something differently in the moment, but because they should have prepared differently before that moment. They should have chosen to study harder, attend more classes, read more attentively, and basically hold themselves to a higher standard of competence. We all probably looked sideways at certain students in school and wondered… Read more »
the ? becomes what is the standard. Most docs out there, do their society recommended yearly CME, recert tests, and maybe a national conference a year. This is therefore the de-facto standard. Expecting more and blaming folks for error would only be fair if we make those expectations explicit and required.
Surely we can agree that the standard of care is actually higher than this? I don’t think anybody believes that the mechanisms of licensing/certification/credentialing are comprehensive (i.e. fully specific tests) for assessing competence. There would be nothing particularly incongruent about hearing a provider passed his board exams one day and then went out and committed malpractice the next. (And how about the one who took his exams 8 years ago?) Above a certain baseline, we essentially trust clinicians to uphold the standard of care on their own, and use peer review/institutional oversight/lawsuits as a second line defense to “help” them… Read more »
I understand why you wouldn’t–the viewpoint I espoused above is counter-intuitive and just feels wrong. Nevertheless it is the core of the human factors approach to error. You’ll hear more about this with George Douros when we do a podcast. Reading Dekker’s book, A Field Guide to Human Error Investigations, was entirely view changing. I highly recommend grabbing a copy from the Med Library.
I’ll try to pick it up. But I take your point to mean that our system of licensing and compliance for clinical practice implies that adherence to those requirements is both necessary and sufficient to meet the standard of care. Outside of gross negligence or malfeasance, providers who meet the requirements and yet still make errors are making errors we have endorsed. I don’t think this is how we see it currently — there is an implied standard of care above and beyond the basic requirements to practice. But I think I see your point, that it’s hard to fault… Read more »
Well sort of… Everything you say is true, but that’s not really it. Here it is in markedly reduced form. If you are a leader or a peer, and you know someone is just coming to their shifts, taking the 10 year reup test, and maybe going to a conference every 2 years or so as there only post-training con. ed; and you tolerate this situation when no error is occurring (i.e. every moment up until the error). Then you can’t change your tolerance when an error occurs. If you eliminate the error and say to yourself, if there was… Read more »
What’s the alternative, though? Of course one option is to simply say that it’s “okay” when bad things happen (that is, those errors in the gray area where we feel they might have been preventable with different care), but I’m not sure we want to do that. I think it was Nagel who used the phrase “intuition pump” to describe the goal of a lot of philosophical arguments, particularly in ethics. We want to develop rules that fit our intuitive sense for what’s “right” when we feel like we know what’s right, so that we can apply those rules in… Read more »
Intuition pumps are the work of Dan Dennett. Other than pointing that out, in answer to the rest, I would simply say that we gain v. little by blaming individuals and gain a ton by blaming the system–so even if every fiber of your body screams the reason this happened is that the person in front of you is an idiot, you will quickly see that mindset doesn’t make anything better if you really think through the consequences of going down that path. I will again recommend Dekker’s, “Field Guide to Understanding ‘Human Error'” I am going to make it… Read more »
1. Absolutely love the non-medicine podcasts, Every time. Would love to see Stoicism, Taoism, any of the ideas mentioned above. What about fasting, nutrition, exercise, hormesis. 2. I admit I have not yet listened to the podcast! Just looking at comments and the Swerve article. I had not read it before today. Please forgive me, I will listen to the podcast and repost a comment asap. 3. I am a Harris fan, have enjoyed his debates with Peterson and others. I have read End of Faith and Waking Up, but not Free Will. The free will problem seems like a… Read more »
Listened to the podcast. Love the concepts. I would have to read more about the underlying philosophical arguments. Especially the concept of “entity based free will” and “compatibilist” ideas. I do not see the logical leap of treating the anecdotal offenders differently based on the above. If libertarian free will is not real, how is the drunk driver different than the sober one, the good hearted doctor different from the one who doesn’t care? I do fully agree that physicians are generally trying to do a good job, we say this all of the time. And I do not think… Read more »
Martin, my distillation to entity-based free will is you are punishing the machine regardless of choice. Bad robot if the robot’s programming led to the action. Not bad robot if chance led to the action. The reason you punish the first case is it will change the programming of the robot and all other robots that see the punishment. That is why we punish the entities that drive drunk. They had no choice, but by punishing we make it less likely for future drunk drivers to drive drunk b/c it becomes part of the GESS that alters all future decisions.… Read more »
the word destiny is another bid to fatalism. We are not fated.
We still affect the outside word, Cashmore’s article changed my life and thinking. If he had not written it, my determined course would be different. This is true even though he was determined to write it.
I listened to it twice in quick succession. This was great, thanks Scott! Looking forward to the next two episodes.
Excellent podcast. I’m a big fan of Sam Harris and have read his book “Free Will” a few times. I am a full believer in our lack of free will and you summarized it well in a relatively short period of time. Aligning this with the practice of medicine as you did in the conclusion of this podcast was very helpful to me as I recently had a complex case with a poor outcome. It helped me not “beat myself up”. Thanks again and I look forward to more podcasts in this similar vein.
Loved this section! I had begun to come to these conclusions from my own experiences and general pondering so its great to hear them backed up by actual sound philosophical reasoning. So important to surviving and thriving in medicine. Please do a part 2! Thanks so much.
I enjoy these types of discussions and as a neurointensivist i spend an enormous amount of time thinking about consciousness. There is no good reason to believe consciousness is some variation of matter or that you can reduce consciousness to something on the periodic table of elements. It’s the ultimate mystery. The hard problem as David Chalmers described. My two cents…Consciousness exists within the electromagnetic nature of the brain. Consciousness comes and goes as the brain generates or does not generate direct current and specific rhythms that we can see on the eeg. Remember…eeg is measure of electric field’s which… Read more »
I loved this episode! A little heavy, albeit, even ion your attempt to laymen-ize, but super good stuff! It’s a nurse, I’ve made a couple med errors., one worse than the other! The shame storm to follow certainly made an indelible mark on me….. and the guilt (never helps being a Jew) is still haunting. My med error did not have any untoward consequences to the patient, thank all the gods! However, the experiences were profound. It not only effects the patient but also the provider. Though it’s hard for me to wrap my head around the philosophical concepts you… Read more »
Great topic of discussion. It’s great to slightly deviate from the typical medicine talk and nice to engage my mind in a whole different way. A way that is is still relevant in my clinical application.
I enjoyed this podcast very much – would love to hear more. Thanks!
I thoroughly enjoyed this episode, and would love to hear more like this- Regards, Austin
Scott, I enjoyed your latest podcast and look forward to more in the same vein. After practicing 35 years and seeing over 200,000 patients in the emergency setting, I find it much more fascinating to study our decision-making and our interactions with our patients rather than focusing on the disease processes we confront. In the most recent episode of my podcast (Podcastofexbem.libsyn.com) I discussed what I called the boogie man that accompanies me to work. This is the embodiment of my instinctual fear that ceaselessly argues that I protect myself while making decisions often to the detriment of my patients.… Read more »
Scott, thanks for bringing this up. Very important ideas to consider. I would love to hear more like this.
Super appropriate and fascinating discussion. I agree entirely and have a lot of interest in understanding why we do what we do, and how uncertainty affects our practice (we cannot know the future due to randomness). These are ideas that should be more explored and understood in medicine.
Great episode! I look forward to hearing the next two installments! I love that the podcasts occasionally address the issues around emergency & critical care, not just the direct medical practice. Please keep up this fantastic resource!
Scott, you lost me when, in the course of this “heady” discussion you continued – as you, and almost everyone else, seems to always do – to reference your’s/one’s “feelings” about a subject in lieu of the accurate term….”thoughts”; as in “my feelings about push dose pressers are…”. How can you conduct a meaningful philosophical/psychological discussion if you conflate “feeling” with “thinking”?
I aspire one day to have the precision of and facility with language you so adeptly demonstrate.
I think the topic of medical errors needs much more thought than just the concepts of “blame” associated with “free will” as analogized by a preventable death by drunk driving vs an “unavoidable accident”. We are in a culture of medical paternalism where while physician cognitive biases (e.g. based on overconfidence, low tolerance to risk, high tolerance to ambiguity, cognitive anchoring, racial bias, etc.) are now recognized as “reasons” for errors and poor patient outcomes, these errors continue and avoidable deaths occur despite advances in medicine, education and supportive technology. I think due to fear of blame and attribution, we… Read more »
gosh, I had stopped all my thought after that analogy, thanks for the prompting.
I enjoyed this swerve on the edge of the curve and look forward to more of the same. Dumbing it down to my mantra for the last 30 years: “always better to be lucky than smart” (clearly luck favors the prepared in most instances).
This podcast was excellent.
I would love to hear more psychology, philosophy, and medicine intertwined.
Keep on crushing it.
1. Yes, please, more episodes in this vein. 2. Would that I read as well as you and your listeners who’ve commented here. 3. To wander a bit after reading many but not all 51 comments, I continue to see patients in the ED who have a current Rx for a fluoroquinolone, prescribed inappropriately in every example (wrong indication, drug interactions, no diagnosis) and with no apparent awareness on the part of the prescriber of the near-monthly medical and general news releases regarding the need to curtail prescribing. Is fault to be assigned to a system when a warfarin-treated patient… Read more »
Will, a few points: if the physicians don’t know about the fluroquin. stuff whose fault is that. If the group thinks it is important for the group docs to know, they should have sent this info and disseminated in every possible way. If they are reliant on the individual docs to come across it, then that is bound to fail. As to counseling smokers, perhaps I was not clear not enough in the ‘cast. Doing so will absolutely change behavior. We are all subject to external persuasion. You can change the behavior of others and that is fully compatible with… Read more »
Good to hear a different podcast outside the medical field. Let me share my two cents on this. As a starting comment I would say that you should never be afraid of discussing any topic in philosophy just because you don’t have a doctorate degree in that area. Most professors of phylosophy are not philosophers, and the majority of the most important philosophers in history did not have any formal university education. That being said, let’s exam the actual problem: is there such thing as free will or not? The answer for that is yes, there is, and the reason… Read more »
I must be a poor philosopher indeed as seemingly I did not explain things well enough to be understood. Your argument is that since you made the choice to come here and comment, then there is free will… QED. Things get more interesting when we parse that statement. First of all what is YOU? I think you mean that your consciousness made the decision to come here and comment. I am willing to grant you that as I did in the podcast. Your consciousness, for the purposes of this comment, is free to think things, to decide things, and to… Read more »
This was awesome would love more!