Fatal Flaws Don't Have To Be Fatal

For each of us, some of the most important truths are things about ourselves that seem like bad news—though usually they are not news at all to anyone but ourselves. And they are only bad news to me or you because you and I have been in denial.

Overcoming denial about one’s own flaws is crucial for becoming a better person. But it is hard. I have two hacks to make it a bit easier. First, I tell myself in that crucial moment when denial is a strong temptation that facing the truth doesn’t mean I have to do anything about it. Some people might be shocked at the idea that one could see something egregious and do nothing about it, but that seems a much smaller danger to me than refusing to see something. If you use this hack, there might be a bit of delay between facing the truth and doing something about it—and sometimes a long delay—but after you get used to that hard truth you will probably be able to gingerly begin thinking if you want to do anything about it.

The second hack is repeating to myself the maxim above: “Fatal flaws don’t have to be fatal.” In saying this, I am consciously using the word “fatal” in two different senses. A “fatal flaw” is used loosely to mean a very serious flaw. The very serious, genuinely bad, shameful flaws you have might seem they could do you in, or make you unworthy of a spot on this planet. But (knowing my readers), however bad they seem, I claim that they are, in fact, unlikely to do you in, and unlikely to make anyone else think you unworthy of a spot on this planet.

Lately, while doing my nightly stretches in my study, I have been listening to Jordan Peterson on YouTube. Jordan Peterson has been slandered by some who put political projects ahead of other values. Disregard those slanders. He has a lot of important things to say and is good at making his case. I recommend listening to some of his talks and Q&A sessions. My experience has been that going to the YouTube video randomly except for whatever help YouTube’s algorithm gives me works fine to get to good stuff. One of Jordan’s big themes is a tragic view of life, in the deep sense of “tragic.” He argues for example, that based on what actually happened under Hitler—an in particular how many ordinary people went along with the evil—that almost all of us, in the same situation would act as the concentration camp guards did. We have that potential for evil within us.

Fortunately, most of us are not in situations that encourage us in evil to the extent that the Third Reich did. But almost all of us do quite bad things even in the situations we are actually in. Jordan emphasizes that we have badness within, but we can become better by working at becoming better. Those who have spent a long lifetime trying to become better almost always in fact become better than those who just stay as they are.

Albertus Magnus emphasizes the trio of goodness, truth and beauty. There is a general regularity that almost all desirable things are positively correlated in the cross-section; and there are causal relationships between goodness, beauty and the knowledge of truth; but they are distinct concepts. We need them all:

“Goodness and beauty without truth are doomed.

Goodness and truth without beauty are grim.

Truth and beauty without goodness are cold.”

Truth is the particular responsibility of scientists. I wrote “Virtues for Economists” with that in mind.

I have two thoughts on beauty. First, I highly recommend the Zen koan practice in the “Waking Up” meditation app. Koans—carefully crafted, seemingly paradoxical statements—are, I believe, a way of gaining fuller access to the beautiful, holistic way of seeing that the right hemispheres of our brains are putting together all the time. Second, my personal value on beauty is such that I have decided to relatively freely retweet what I consider beautiful art on my Twitter feed. In between the tweets trying to seek truth, there are many trying to seek beauty.

As for goodness, in practice the best way I know to foster goodness is the approach I describe in “How Economists Can Enhance Their Scientific Creativity, Engagement and Impact.” (Also see “Reactions to Miles’s Program For Enhancing Economists’ Scientific Creativity, Engagement and Impact.”)

If you pursue all three of goodness, beauty and truth, you will become better and your life will get better. In the meanwhile, remember that fatal flaws don’t have to be fatal.

Don’t Miss These Posts Related to Positive Mental Health and Maintaining One’s Moral Compass:

On Critical Race Theory

I argue in “The Right Amount of Wokeness” and “Getting the Best from Wokeness by Having the Right Mean, Reducing the Variance and Mitigating the Losses from Extreme Values” that shifting the mean of the wokeness distribution toward greater wokeness would be a good thing because the horrors currently arising from too little wokeness are more terrible than the horrors currently arising from too much wokeness. Overall, I think an increase in wokeness is in order. If it went too far, that would be bad, but unlike those on the Right, I think the probability that extremes of wokeness will take over is relatively small.

But let there be no mistake: extremes of wokeness would be bad. It is only because I believe the majority of Americans will see how bad those extremes are that I don’t worry too much about extremes of wokeness taking over.

Though not a clear and present danger to America as a whole, extremes of wokeness are not a figment of the imagination either. They are clearly evident in important pockets of American universities and in a few other places in American culture.

On problem with Critical Race Theory is the same as the problem with many enthusiasms: it focuses on one things to the exclusion of other things that are also important. In his July 19, 2021 Wall Street Journal op-ed, Lance Morrow reminds of Isaiah Berlin’s distinction between “foxes” and “hedgehogs”:

In a famous essay, published as a book in 1953, Berlin suggested that the world is divided between hedgehogs and foxes—between those who believe in One Big Thing (one all-sufficient super-explanation), and those who are content with a more modest, irrational and even incoherent idea of history’s unfolding.

Then, Lance applies this distinction to describe Critical Race Theorists:

Hedgehogs are thick on the ground, all of them advancing One Big Thing or another—each peering through the lens of a particular obsession. At the moment, the biggest One Big Thing is race—the key, it seems, to all of America, to the innermost meanings of the country and its history.

It isn’t really true. Race is one of many big things in America. It is hardly the most important. Americans need to desanctify the subject of race—to mute its claims, which have grown absolutist and, as it were, theological in their thoroughness, their dogmatism.

Then Lance compares those who use Critical Race Theory to take wokeness to the extreme to Joe McCarthy:

It was said in the era of Joe McCarthy that he and his followers saw a communist under every bed. The single-minded ideology of critical race theory sees racism in every white face—a racism systemic, pervasive, inescapable, damning. All white people are racists. The doctrine devolves to the crudest form of what might be called racial Calvinism: Americans are predestined—saved or damned, depending on the color of their skin. This doctrine merely reverses the theory of white supremacy, which damned black people—and consigned them to oppressive segregation—because of the color of their skin.

In “How Adherents See ‘Critical Race Theory’” (July 13, 2021) and “A Deeper Look at Critical Race Theory” (July 20, 2021), William Galston provides more detail about Critical Race Theory. Small doses of Critical Race Theory likely have quite a good effect, but large enough doses could be corrosive of what the human race has laboriously built to protect itself from a war of all against all. In the first of those two op-eds, William writes:

… critical race theory is … originated in law schools in the 1970s and has since become a sprawling movement. To find out more about it, I turned to “Critical Race Theory: An Introduction,” co-written by one of the movement’s founders, Richard Delgado. He writes that critical race theory “questions the very foundations of the liberal order, including equality theory, legal reasoning, Enlightenment rationalism, and neutral principles of constitutional law.

He also points out that that Critical Race Theory says explicitly that “Incrementalism is a bankrupt strategy; ‘everything must change at once.’”

In the second of the two op-eds, William Galston gives some bullet points about Critical Race Theory. Giving my own selection from those points in a numbered list, here are some quotations:

  1. Critical race theory denies the possibility of objectivity.

  2. it aims to “recover and revitalize the radical tradition of race-consciousness,” a tradition “that was discarded when integration, assimilation and the ideal of colorblindness became the official norms of racial enlightenment.”

  3. Critical race theory rejects the principle of equality of opportunity. Its adherents insist that equality of opportunity is a myth, not a reality, in today’s America, and that those who pursue it are misguided. The real goal is equality of results, measured by black share of income, wealth and social standing. Critical race theorists reject the idea that sought-after goods should be distributed through systems that evaluate and reward “merit.”

  4. [Critical Race Theory argues that] “conceptions of merit function not as a neutral basis for distributing resources and opportunity, but rather as a repository of hidden, race-specific preferences for those who have the power to determine the meaning and consequences of ‘merit.’”

The typical American notion of “merit” is quite shallow. (I address this a bit in “Virtues for Economists.”) But that doesn’t mean we can get by without some notion of merit. To get outcomes we want, we need what Jordan Peterson calls “hierarchies of competence.”

The need for hierarchies of competence is matched by our need for police as well. It is hard for me to tell just how literally various people took the slogan “Defund the police.” With enough creativity and poetic license, it might be possible to come up with some meaning for that slogan that is actually a good idea. But anything close to the literal meaning is a very bad idea.

Indeed, one of the more dependable approaches to making policing less racist—only hiring people into the police force who have college degrees—would cost significantly more money. Note how this would use the wokeness of colleges and universities to good effect. Without taking things to extremes, we definitely want our police to be at least somewhat more woke than they are. Requiring college degrees for new police can help achieve that goal.

No doubt many of the pillars of our civilization have been corrupted by racism. But simply discarding those pillars would bring the whole edifice crashing down. We need to:

  • reform our judgements to be more objective;

  • become more truly and deeply colorblind, while recognizing whatever burdens people bring from their backgrounds and the strengths it took to deal with those burdens well;

  • provide more equality of opportunity by providing more slots in charter schools and allowing construction of more housing in heretefore exclusionary neighborhoods;

  • deepen our notions of merit; and

  • more thoroughly recognize the temptations and corruptions of power. What we shouldn’t do is totally abandon the hacks we have used to raise ourselves up from where we were as a species 500 years ago.

One of the most important lessons of history is how unimaginably bad things used to be. The human race has endured and perpetrated many evils on its own for thousands of years. To take one very important example, if one takes the entirety of human history since the rise of agriculture, the (still not 100% complete) abolition of slavery in the last century or two stands out as the exception, while slavery as an institution was the rule. We have made progress by abolishing slavery. That progress depended crucially on the pillars of our civilization that Critical Race Theory evinces too little appreciation for.

Standard Cholesterol Tests are Substandard; Better Cholesterol Tests are Available

Cholesterol has a big hold on medical practice because it is so easy to measure. Unfortunately standard medical practice hasn’t kept up with advances in the measurement of cholesterol. The total amount cholesterol in LDLs (low-density lipoproteins)—so-called “bad cholesterol”—and the total amount of cholesterol in HDLs (high-density lipoproteins)—so-called “good cholesterol”—are routinely reported. but there is much more to the story.

Somewhat confusingly, within the category of low-density-lipoprotein (LDL) particles, it is the small, dense ones that are most dangerous. A 13-year follow-up report on the Québec Cardiovascular Study (“Low-density lipoprotein subfractions and the long-term risk of ischemic heart disease in men: 13-year follow-up data from the Québec Cardiovascular Study”) summarized its conclusions thus:

These results indicated that estimated cholesterol levels in the large LDL subfraction were not associated with an increased risk of IHD in men and that the cardiovascular risk attributable to variations in the LDL size phenotype was largely related to markers of a preferential accumulation of small dense LDL particles.

In other words, big LDL particles that hold a lot of cholesterol aren’t associated with extra risk of blockage of blood to the heart; small dense LDL particles that may not hold that much total cholesterol account for pretty much all the risk of reduced blood flow to the heart that we associate with LDL cholesterol.

Unless you are quite lucky, your doctor is unlikely to do tests that distinguish between the small, dangerous LDL particles and the large, relatively innocuous LDL particles unless you ask for them. I have no idea how it stacks up with other testing companies, but the Quest Diagnostics webpage I show below is one that you could refer your doctor to for general orientation about a variety of more sophisticated tests of cardiovascular risk, including tests that better distinguish different subtypes of cholesterol particles.

I recommend that you get these more modern tests. You definitely should get these tests if your doctor is recommending any treatment for cholesterol. But you also should get these tests to make sure you aren’t lulled into a false security by the standard cholesterol test.

I learned about these more sophisticated tests of cardiovascular risk from Peter Attia’s podcast. As I have on other occasions let me strongly recommend Peter Attia as a very thoughtful and well-informed source for health knowledge.

For organized links to other posts on diet and health, see:

Richard Feyman on the Centrality of Scientific Disrespect

“Science is the belief in the ignorance of experts.”
— Richard Feynman

Related Links:

Also, relatedly, in “Biological Evolution Right Before Our Eyes” I say:

I get annoyed often these days reading or hearing people express their devotion to science but treating science as if it were an authoritarian enterprise. Saying one should believe in the scientists as if they were some kind of high priests is contrary to the spirit of science. The spirit of science is pointing to the evidence.

The Federalist Papers #35 B: Alexander Hamilton on Who Can Represent Whom

In recent years, it has become common for authors to be criticized for having central characters in their fiction who come from racial or ethnic groups they don’t belong to. Such authors often argue in response that it is the job of authors to try to empathize and understand other human beings—even those from quite different backgrounds.

The question of who can represent whom comes up not only in literature, but also in politics. Can a politician from a different racial or ethnic group effectively represent the interests of that group? This is a controversial question, but when given the choice, voters of one racial or ethnic group often vote for someone of a different racial or ethnic group. (This happens in both group-power-gradient directions.)

Though he is thinking about differences in occupation rather than differences in racial or ethnic group, in the second half of the Federalist Papers #35, Alexander Hamilton takes the position that one can be a good representative for someone from a different occupation—and likely would agree that one can be a good representative for someone who is different in other dimensions.

Alexander Hamilton also points out the sheer impracticality of trying to insist that an individual always be represented by someone else who is very similar. When asked, many people point to their membership in their own family as their primary identity—much more important to them than the racial or ethnic group they belong to. Should we then say that because that identity as a family member is so near and dear to their hearts that each can only be represented by someone else from their own family? That would be a lot of representatives in Congress!

Somewhat contrary to the general drift of what Alexander Hamilton is saying, I really would like to be represented by an economist in Congress (especially if I could have some choice among economists). But agreeing with Alexander Hamilton, I can see that it is impossible to satisfy my desire along those lines and everyone else’s corresponding desires.

The smaller the group, the more likely it is that—without especially good fortune in the vagaries of talent—they will need to hope for representation from someone outside the group—whether literary representation or political representation.

Across occupations, Alexander Hamilton makes some claims about who can reasonably represent someone who is in a different occupation. He says:

  • merchants can do a good job representing mechanics and manufacturers

  • “the learned professions” (professor, doctors and lawyers??) might well be able to represent almost any other group

  • landholders can represent other landholders in relation to their interests as landholders

”Cultural appropriation” is an issue because some people perform quite badly at understanding those who are unlike them. But the right remedy is not to ban people from writing about or politically representing those who are unlike them, but to encourage and support those whose empathetic understanding is strong (regardless of their background) and correct those whose whose empathetic understanding is weak. This includes letting people know that their empathetic understanding is weak on one area even though it is strong in another.

One reason rules against cultural appropriation or against political representation by someone from a different racial or ethnic group are a bad idea is that reducing conflict in our society depends so heavily on encouraging the development of empathetic understanding of those who are different. Declaring empathetic understanding of those who are different to be impossible—or to be somehow automatically second-rate—is not a good way to encourage such understanding. Pointing to actual failures of understanding in detail is a much, much better way to help people course-correct and further their understanding. In this context, it is especially harmful to treat people too much as if they “should have known” already that they were misunderstanding. The “should have known” attitude might be appropriate to the extent that embarrassment is the penalty for not having known. But at the cost of serious embarassment, people should be allowed learning opportunities as they make their mistakes.

Below is the full text of Alexander Hamilton’s argument in the second half of the Federalist Paper #35 that it is possible to effectively represent someone who is quite different.

Let us now return to the examination of objections.

One which, if we may judge from the frequency of its repetition, seems most to be relied on, is, that the House of Representatives is not sufficiently numerous for the reception of all the different classes of citizens, in order to combine the interests and feelings of every part of the community, and to produce a due sympathy between the representative body and its constituents. This argument presents itself under a very specious and seducing form; and is well calculated to lay hold of the prejudices of those to whom it is addressed. But when we come to dissect it with attention, it will appear to be made up of nothing but fair-sounding words. The object it seems to aim at is, in the first place, impracticable, and in the sense in which it is contended for, is unnecessary. I reserve for another place the discussion of the question which relates to the sufficiency of the representative body in respect to numbers, and shall content myself with examining here the particular use which has been made of a contrary supposition, in reference to the immediate subject of our inquiries.

The idea of an actual representation of all classes of the people, by persons of each class, is altogether visionary. Unless it were expressly provided in the Constitution, that each different occupation should send one or more members, the thing would never take place in practice. Mechanics and manufacturers will always be inclined, with few exceptions, to give their votes to merchants, in preference to persons of their own professions or trades. Those discerning citizens are well aware that the mechanic and manufacturing arts furnish the materials of mercantile enterprise and industry. Many of them, indeed, are immediately connected with the operations of commerce. They know that the merchant is their natural patron and friend; and they are aware, that however great the confidence they may justly feel in their own good sense, their interests can be more effectually promoted by the merchant than by themselves. They are sensible that their habits in life have not been such as to give them those acquired endowments, without which, in a deliberative assembly, the greatest natural abilities are for the most part useless; and that the influence and weight, and superior acquirements of the merchants render them more equal to a contest with any spirit which might happen to infuse itself into the public councils, unfriendly to the manufacturing and trading interests. These considerations, and many others that might be mentioned prove, and experience confirms it, that artisans and manufacturers will commonly be disposed to bestow their votes upon merchants and those whom they recommend. We must therefore consider merchants as the natural representatives of all these classes of the community.

With regard to the learned professions, little need be observed; they truly form no distinct interest in society, and according to their situation and talents, will be indiscriminately the objects of the confidence and choice of each other, and of other parts of the community.

Nothing remains but the landed interest; and this, in a political view, and particularly in relation to taxes, I take to be perfectly united, from the wealthiest landlord down to the poorest tenant. No tax can be laid on land which will not affect the proprietor of millions of acres as well as the proprietor of a single acre. Every landholder will therefore have a common interest to keep the taxes on land as low as possible; and common interest may always be reckoned upon as the surest bond of sympathy. But if we even could suppose a distinction of interest between the opulent landholder and the middling farmer, what reason is there to conclude, that the first would stand a better chance of being deputed to the national legislature than the last? If we take fact as our guide, and look into our own senate and assembly, we shall find that moderate proprietors of land prevail in both; nor is this less the case in the senate, which consists of a smaller number, than in the assembly, which is composed of a greater number. Where the qualifications of the electors are the same, whether they have to choose a small or a large number, their votes will fall upon those in whom they have most confidence; whether these happen to be men of large fortunes, or of moderate property, or of no property at all.

It is said to be necessary, that all classes of citizens should have some of their own number in the representative body, in order that their feelings and interests may be the better understood and attended to. But we have seen that this will never happen under any arrangement that leaves the votes of the people free. Where this is the case, the representative body, with too few exceptions to have any influence on the spirit of the government, will be composed of landholders, merchants, and men of the learned professions. But where is the danger that the interests and feelings of the different classes of citizens will not be understood or attended to by these three descriptions of men? Will not the landholder know and feel whatever will promote or insure the interest of landed property? And will he not, from his own interest in that species of property, be sufficiently prone to resist every attempt to prejudice or encumber it? Will not the merchant understand and be disposed to cultivate, as far as may be proper, the interests of the mechanic and manufacturing arts, to which his commerce is so nearly allied? Will not the man of the learned profession, who will feel a neutrality to the rivalships between the different branches of industry, be likely to prove an impartial arbiter between them, ready to promote either, so far as it shall appear to him conducive to the general interests of the society?

If we take into the account the momentary humors or dispositions which may happen to prevail in particular parts of the society, and to which a wise administration will never be inattentive, is the man whose situation leads to extensive inquiry and information less likely to be a competent judge of their nature, extent, and foundation than one whose observation does not travel beyond the circle of his neighbors and acquaintances? Is it not natural that a man who is a candidate for the favor of the people, and who is dependent on the suffrages of his fellow-citizens for the continuance of his public honors, should take care to inform himself of their dispositions and inclinations, and should be willing to allow them their proper degree of influence upon his conduct? This dependence, and the necessity of being bound himself, and his posterity, by the laws to which he gives his assent, are the true, and they are the strong chords of sympathy between the representative and the constituent.

There is no part of the administration of government that requires extensive information and a thorough knowledge of the principles of political economy, so much as the business of taxation. The man who understands those principles best will be least likely to resort to oppressive expedients, or sacrifice any particular class of citizens to the procurement of revenue. It might be demonstrated that the most productive system of finance will always be the least burdensome. There can be no doubt that in order to a judicious exercise of the power of taxation, it is necessary that the person in whose hands it should be acquainted with the general genius, habits, and modes of thinking of the people at large, and with the resources of the country. And this is all that can be reasonably meant by a knowledge of the interests and feelings of the people. In any other sense the proposition has either no meaning, or an absurd one. And in that sense let every considerate citizen judge for himself where the requisite qualification is most likely to be found.

PUBLIUS.

Links to my other posts on The Federalist Papers so far:

Forget the Money Supply, It's the Interest Rate, Stupid

The only sensible view on monetary policy is to be a hawk when the situation calls for it and a dove when the situation calls for that. Anyone who is always a hawk or always a dove is off-base. However, there might well be political benefits to being always a hawk or always a dove. And there can be a pecuniary benefit to being always a hawk: it can be a good way to gin up gold sales by scaring everyone about inflation.

Lately inflation has jumped way up. There is a debate about whether that rise is mostly temporary or has a big permanent component. And this is in a context where the Fed has decided it wants somewhat higher inflation than it had before the pandemic. The Fed’s current monetary policy framework is meant to be ill-defined enough to not tie the Fed’s hands—contrary to the desire of some economists, including me, for more of a monetary policy rule. (See “Next Generation Monetary Policy.”) But I interpret the Fed as shifting from an implicit target of about 1.5% per year up to an implicit target of 2.5% per year: going from not being fully willing to do what it would take to get inflation back up to their nominal 2% per year target to being willing to exceed their 2% per year target somewhat for quite some time.

Whatever one’s take on how tight or how stimulative monetary policy should be, the money supply is no longer very relevant to monetary policy on the margin. The Fed now has what is sometimes called a “floor system.” The Fed tries to keep the monetary base—paper currency plus reserves held in electronic accounts at the Fed—large enough that banks have nothing better to do with the last dollar of reserves than leave it earning interest as excess reserves in a reserve account—or earning interest in the Fed’s overnight facility based on Treasury bill repurchase agreements. Those reserves held as excess reserves or funds earning interest from repurchase agreements are economically idle and don’t stimulate the economy. They are part of the money supply, but one can say they aren’t part of the active money supply. Being inactive matters: for example, idle reserves only add 1-for-1 to other money supply measures. I explain all of this in greater detail, with graphs, in “Supply and Demand for the Monetary Base: How the Fed Currently Determines Interest Rates.”

In their July 20, 2021 op-ed “Too Much Money Portends High Inflation,” John Greenwood and Steve Hanke claim the size of the money supply matters, contrary to what Jerome Powell says:

In his Feb. 23 testimony to Congress, Fed Chairman Jerome Powell said that the growth in the money supply, specifically M2, “doesn’t really have important implications.” The experts, the press and the bond vigilantes were as quick to unlearn monetarism, if they ever had learned it, as Mr. Powell. Reporting about U.S. inflation rarely contains the words “money supply.” …

Wrong. The inflation upticks aren’t temporary and were predictable, driven by an extraordinary explosion in the money supply. Since March 2020, the M2 has been growing at an average annualized rate of 23.9%—the fastest since World War II. There is so much money out there that banks don’t know what to do with it. Via reverse repurchase agreements, banks and money-market funds are lending money to the Fed to the tune of $860 billion. That’s unprecedented.

Notice how they say there is so much money sloshing around that a lot of it sits idle in the overnight facility based on repos that I mentioned above. But they don’t seem to understand that money idled like that doesn’t add to economic stimulus. It doesn’t lower the interest rate because the interest rate on reserves has put a floor under interest rates. (For technical reasons, the floor on interest rates is a tad lower than the interest rate on reserves itself, but not much.)

To see that the money supply is no longer crucial in a floor system where the interest rate has been disconnected from marginal changes in the monetary base, consider the following policy shift:

  • The Fed raises its target rate and the interest rate on reserves by 500 basis points (= 5 percentage points, where a percentage point is a per annum rate).

  • The Fed doubles the monetary base.

I assure you, this would be quite contractionary. The high interest rate on reserves would reduce the active part of the monetary base even though the entire monetary base doubled.

Money doesn’t matter any more on the margin. But that isn’t to say money doesn’t matter. A floor system only works when the total size of the monetary base is kept quite large. So a large monetary base is a precondition for the kind of logic I laid out above. Friedman’s dictum “Inflation is always and everywhere a monetary phenomenon” is not lost, as John Greenwood and Steve Hanke claim; rather, money—and in particular, “Supply and Demand for the Monetary Base,” is what is enabling the Fed to set interest rates.

It is certainly reasonable for John Greenwood and Steve Hanke to be arguing that the Fed should be tightening sooner than it is saying it will (that is well within the range of reasonable disagreement), but they should leave their money supply rhetoric behind and argue forthrightly for the Fed to raise its target rate and to reduce long-term asset purchases in order to put other rates on a higher track.

Hormone Replacement Therapy is Much Better and Much Safer Than You Think

Link to the Amazon page for Estrogen Matters, by Carol Tavris and Avrum Bluming

Link to the Amazon page for Estrogen Matters, by Carol Tavris and Avrum Bluming

Health care for women has been affected in many ways by our societies lack of full respect for women. This is true for Hormone Replacement Therapy. (Outside of the quotations from Estrogen Matters below, I will use that phrase to cover both estrogen only and estrogen plus progesterone treatments.) The conventional wisdom about Hormone Replacement Therapy beginning around the time of menopause has been affected by at least 4 forces: commercial incentives and suspicion of those commercial incentives, scientists who twist scientific evidence to further their preexisting views, ideological dogmas about “natural” being good, and underweighting of the importance of women’s quality of life.

The conventional wisdom is that Hormone Replacement Therapy (HRT) causes breast cancer. The big study on which the HRT-causes-breast-cancer conventional wisdom is based actually said something quite different. It said that even when a woman has been in menopause for many years without HRT, so that starting HRT up is a wrenching adjustment for the body, the effect on breast cancer can be precisely bounded as small. And there is no evidence that HRT begun smoothly at perimenopause causes breast cancer. Indeed, there is a lot of evidence that HRT begun smoothly at perimenopause has many positive health effects.

Avrum Bluming and Carol Tavris lay all of this out in their hard-hitting book, Estrogen Matters: Why Taking Hormones in Menopause Can Improve Women's Well-Being and Lengthen Their Lives -- Without Raising the Risk of Breast Cancer. One powerful analogy is that avoiding HRT in order to avoid breast cancer is like getting an unnececessary radical mastectomy in order to avoid a recurrence of breast cancer. Both are based on fear rather than on sound evidence of efficacy. They write:

Randomized trials and observational studies continue to show that breast-conserving surgery is almost always at least as effective as mastectomy. Yet rates of radical mastectomies, especially bilateral mastectomies, for treatment of localized breast cancer have been rising since 2006—another manifestation of the fear associated with breast cancer.

The idea that estrogen causes breast cancer is doubtful for many reasons. Here are some of them, as discussed in Estrogen Matters:

  • Estrogen goes down at menopause, but breast cancer doesn’t go down. (Note that menopause is statistically distinguishable from age.)

  • Estrogen is actually an important treatment for women with breast cancer.

  • Early menarche and late menopause do not predict breast cancer.

  • The endometrium is much more sensitive to estrogen than breast tissue. But no one is successfully claiming that HRT is related to endometrial cancer.

  • “in most breast cancers, estrogen-receptor-positive cells are not the ones proliferating.” If a breast cancer cell is estrogen-receptor-positive, that is an indication that it is more like a normal breast cell than cancer cells that are estrogen-receptor-negative.

  • Pregnancy, which dramatically raises estrogen levels, is not a risk factor for breast cancer.

The false belief that Hormone Replacement Therapy begun as usual around the onset of menopause causes breast cancer is extremely damaging because HRT has many powerful benefits. Here is Avrum Bluming and Carol Tavris’s summary of those benefits near the beginning of Estrogen Matters, with my emphasis added in bold:

Estrogen not only successfully controlled menopausal symptoms in most women but also significantly reduced the risks of heart disease, hip fractures, colon cancer, and Alzheimer’s. A 1991 New England Journal of Medicine editorial, “Uncertainty About Postmenopausal Estrogen: Time for Action, Not Debate,” reported a 40 to 50 percent reduction in atherosclerotic heart disease, which was responsible for the deaths of more than eight times as many American women as breast cancer. The long-running Framingham study reported a 50 percent drop in osteoporosis-associated hip fractures, which were linked to as many deaths every year as breast cancer. Two studies, one from the University of Wisconsin and one from the American Cancer Society, reported a 50 percent decrease in the risk of developing or dying of colon cancer. And a USC study reported a 35 percent decrease in the risk of Alzheimer’s. Among women with no history of breast cancer, studies found that estrogen did not increase the risk of developing it, even among women who had been taking estrogen for ten to fifteen years. Most remarkable, women taking estrogen were living longer than women who were not taking hormones. A 1997 report in the Journal of the American Medical Association stated that “HRT should increase life expectancy for nearly all postmenopausal women by up to 3 years.” Their analysis concluded that up to 99 percent of current postmenopausal women would benefit from taking HRT as measured by decreased rates of disease and improved longevity.

Even if, contrary to the evidence, Hormone Replacement Therapy begun as usual around the onset of menopause did have any substantial effect on breast cancer, that should not overrule all the other benefits. It is difficult to do, but breast cancer should be kept in perspective. As Avrum and Carol write:

The often repeated statistic that one woman in eight (12 percent) will develop breast cancer at some point in her life should be understood in a broader context: That’s a woman’s risk of getting it, all right, but only if she lives to be eighty-five. As Patricia T. Kelly explained in Assess Your True Risk of Breast Cancer: • A thirty-year-old woman has a risk of developing breast cancer in the next decade of 1 in 227 (0.4 percent). • A forty-year-old woman has a decade risk of 1 in 68 (1.5 percent). • A fifty-year-old woman has a decade risk of 1 in 42 (2.4 percent). • A sixty-year-old woman has a decade risk of 1 in 28 (3.6 percent). • A woman over seventy has the highest risk, 1 in 26 (4 percent).1 So where did that one-in-eight risk come from? It’s obtained by adding together the risks in each age category: 0.4 plus 1.5 plus 2.4 and so forth. But if you are a woman who has reached age sixty without a diagnosis of breast cancer, your risk in the coming decades is only 7.6 percent (12 percent less each decade’s risk that you have passed); the risk of breast cancer in any given decade of life never exceeds one in twenty-six. Yet by far the most important statistic is this one: over 90 percent of women currently diagnosed with early breast cancer will be cured, and most will not need disfiguring mastectomies or chemotherapy.

Dangers surround us, and death is coming for us all. We need to choose our battles out of a much larger set of concerns than breast cancer alone.

Every woman and every man who cares about a woman should read Estrogen Matters. (I listened to it on Audible.) Even if you are already convinced that HRT is the way to go, you are going to need to be armed with a fairly detailed knowledge of the science in order to stand up to your doctor, who is likely to adhere to the conventional wisdom on HRT. Note that Avrum Bluming is just as much an MD as your doctor, and for most of us, much smarter than our own doctor. And he and Carol Tavris lay out the evidence and logic in a much more detailed way than your own doctor is likely to be able or willing to do.

Note: HRT is an important enough issue, I expect to return to this topic and discuss more of what is in the book Estrogen Matters in future posts.

For organized links to other posts on diet and health, see:

Virtues for Economists

Introduction

There is much debate these days about “meritocracy.” One problem with the 21st Century American version of meritocracy is that by “merit” it means only intelligence and other dimensions of talent and skill. It gives short shrift to whether someone is good or not. As one consequence of this version of meritocracy that pays little attention to virtue, our public policy does a lot more to make people like those chosen by the meritocracy feel good about themselves and have the opportunities they value than it does to help those whom the meritocrats don’t care much about—such as poor people they might actually have to deal with personally, or poor people who don’t otherwise belong to a category of concern for the meritocrat. (On “don’t otherwise belong to a category of concern,” I am thinking here particularly of the folks Anne Case and Angus Deaton focus on in their book Deaths of Despair and the Future of Capitalism.) Another example is my complaints in “False Advertising for College is Pretty Much the Norm” against college and university administrators chosen according to such narrow meritocratic criteria. But there are many, many other bad consequences of non-virtuous meritocrats.

In this post, let me spell out what I consider key virtues for economists. I’ll focus on virtues for economists as economists, and even more specifically on virtues for their role as researchers. (Virtues for economists for their role as teachers deserve their own future post.) I am only addressing here those who feel some calling to research. Some economists feel other callings as primary.

There are key virtues in each of the three stages of research: (A) preparing the ground; (B) planting; then (C) irrigating, weeding and harvesting.

Preparing the Ground

  1. Hone Your Skills and Knowledge: Although having good genes for being smart is not itself a virtue, working hard to gain skills and knowledge in order to be able to do a good job is a virtue. If you are an Economics PhD, unless you have suffered a terrible health shock, buckling down to decades of additional reading, study, deep thought and attempts at application will be enough to give you formidable powers to do good in the world.

  2. Master Time Management: Some of you have many heavy responsibilities. But it is unlikely that you can’t find 5 hours a week to do research. I am far from being an expert on time management, but many excellent books exist. One well-known book on this topic that I recommend is Stephen Covey’s book First Things First (with A. Roger Merrill and Rebeca Merrill).

3. Avoid Getting Discouraged: Research can be difficult. It might make you feel stupid. Some parts of it are boring—such as doing the 15th revision. Other parts are frustrating, as when a statistical estimation fails to converge or when a beautiful mathematical conjecture turns out to be false (as you may see from a simple counterexample that you missed early on). You may feel a version of imposter syndrome, thinking “Who am I to try to say something on this topic, when some economists much smarter than I am have addressed it?”

Discouragement and other forms of disillusionment of economists with economic research are so common that I started a program to help. Take a look at these posts:

Of course, a program like this can also help economists who are doing great with their research. Take a look!

Planting

4. Care: To choose important topics, tap into your values. What do you care deeply about? Two key guides to the importance of topics are contribution to social welfare and scientific beauty. Don’t think you need to be limited to topics that have traditionally been the purview of economics. Economists have great skills for addressing most topics in the social sciences and even great skills for addressing some topics in the natural sciences, such as topics in nutrition. On the breadth of what I think economists should be doing, and my toddling forays into nutrition (which may some day lead to formal research on my part) see:

5. Cultivate Good Judgement: In addition to judging the contribution to social welfare or scientific beauty of a project, good judgement about research projects requires making good estimates of the cost of doing a research project. Is it easy, hard or pretty much impossible? You won’t always know just how hard a project is, and you don’t want to give up too easily, but you also don’t want to underestimate the cost in a foreseeable way.

Of course, social welfare impact depends not only on the potential social welfare contribution of a project, but also on how much it is likely to affect the work of other economists (and of other scientists and policy-makers). It is good to think about what other researchers need in order to do their work better. There is nothing wrong with choosing to do something ahead of its time that may not have much impact until half a century from now, but you should be aware that you are making that choice.

It is easy to get help with good judgement. Most of you will know someone you respect who will be happy to tell you their judgement about the potential impact of a research project and how difficult and costly it is likely to be. But you don’t have to rely on one person. It is easy to poll 10 economists you know about how important a project seems and how hard it is likely to be.

Note that judging cost requires introspecting about your own preferences as well as counting the hours (and dollars). If doing the research would be as fun as playing a videogame, the cost could be low even if it will take a huge number of hours!

6. Don’t Be Too Careerist: There are strong social pressures in Economics to do research that will advance your career. As an advisor, I tell my students to go along with those social pressures in choosing their job market paper and in what they do while putting together a tenurable record if they have a tenure-track job. But you need to keep your soul so that you can return to choosing projects based on deeper considerations after you get tenure—or are otherwise unlikely to be fired. Some people may need to worry about being able to move. But do you really want to do trendy, but unimportant research just to get a bit higher salary?

Remember also that many of the most renowned economists did research that was very much unappreciated when they first did it. Being “careerist” is often a version of putting the short run over the long run—even if you were only out for money and fame. And you aren’t just out for money and fame!

(Economists don’t get all that famous anyway. Just try asking your non-economist friends and family to name five economists they don’t know personally. They will almost all have a really tough time. But within the level of fame that economists get, economists who have taken risks often have some degree of triumph even in their own lifetimes.)

Irrigating, Weeding and Harvesting

7. Seek the Truth: In empirical or mathematical investigations, first try to figure out what you really believe based on the data and theoretical results. That means being responsive to the data and theoretical results and thinking through what they mean—at first without any regard to your audience.

8. Tell the Truth. Do your best to communicate what you learned from doing the research. You probably spent a lot of time thinking about it. Try to get across that understanding. That will require distinguishing your most important results from less important results that you have fallen in love with. This is where you should think a lot about your audience.

After I got tenured, I was given a document with excerpts from some of the letters evaluating me. I remember most the excerpt saying “Miles often overestimates his audience.” In other words, my papers and presentations were sometime impenetrable and hard to understand. One of my problems in my career is that I have a (faulty) gut feeling that it is bad form to act as if I know a lot more than other economists. But each of you, like me, in your particular area of research do, in fact know a lot more than the vast majority of other economists. They don’t expect themselves to know everything about your area of research, so they don’t feel bad about knowing less than you do on that topic. Why shouldn’t you face the truth that you know a lot more than others on your specific topic and will need to hold their hand and lead them along for them to understand what you learned?

9. tell the truth. You have an overall perspective on your research and want to get across that vision. But you don’t have the right to lie or deceive about the small-t truths—specific facts or statistical analyses or detailed interpretation of results—even when those very specific truths run contrary to the capital-T Truth you want to get across. You are not infallible. You need to give readers the raw material to construct their own arguments based on your data or results, even if their arguments run counter to the Truth as you see it.

There are a set of common statistical practices that to me constitute the moral equivalent of a lie—unless they are made in genuine, abject ignorance. (p-hacking/not reporting all the tries you made to get something with a nominal 5% level of significance is first and foremost among these practices.) Don’t commit these crimes, wittingly or unwittingly. To better avoid them, see:

You have a duty to know what ways of using statistics could mislead a reader, and avoid them.

In public advocacy based on yours and other economists’/scientists’ research results, the burden shifts somewhat. In your own research, your truthful and full reporting is the only way anyone can know key facts, short of getting your data and analyzing it themselves. At the other extreme, if there is a fact everyone knows that you don’t acknowledge in your op-ed, you may look stupid, but you aren’t deceiving anyone. Or if there is a fact your opponents in a public debate are loudly trumpeting, your not mentioning it won’t be depriving everyone of that information. But you aren’t a lawyer. If you make an argument that is vitiated by a counterargument you are well aware of that your opponents in the debate have never mentioned before, you should probably mention that counterargument yourself. To do otherwise is to pay too little respect to the truth. And to the extent that your readers are in informational bubbles and are only likely to see your side of the argument, your responsibility for informing them of counterarguments goes up.

Conclusion

The word “virtue” makes me think of Stoicism. Ideas from the philosophical school of Stoicism are, in fact, an aid to cultivating virtue. Although the daily bits get somewhat repetitive over time, I highly recommend subscribing to the Daily Stoic. It’s free. Ryan Holiday is behind the Daily Stoic. I like his books, too. Beyond that, the ways I know to help economists strive to be better as well as smarter are in the Positive Intelligence training I give, as detailed in the blog posts I linked to above and will again here:

Don’t Miss These Posts Related to Positive Mental Health and Maintaining One’s Moral Compass:

Fighting Statistical Illiteracy

Link to the article shown above

Link to the article shown above

Our culture looks on inability to read as a grave disability, but treats inability to do arithmetic as a minor weakness—something people admit without embarrassment and even laugh at. This doesn’t show causality, but as Jo Craven McGinty writes in her June 11, 2021 Wall Street Journal article “What Are the Odds? Even Experts Get Tripped Up by Probabilities,”

According to the research of Ellen Peters, an expert in decision making at the University of Oregon and author of “Innumeracy in the Wild,” the lack of skill can have consequences for your wallet and your health. People who are less numerate adopt fewer healthy behaviors; they are 40% more likely to have a chronic disease; they end up in the hospital or emergency room more often; and they take 20% more prescription drugs, but are less able to follow complex health regimens.

Our culture pays even less attention to statistical illiteracy than it does to general innumeracy. Part of the problem is that the traditional math curriculum hasn’t changed in a long time, and has its roots before the rise of modern statistics. We should be integrating a little bit about probabilities into the math curriculum even in grade school. And at the advanced high school level, my view is that AP Statistics is more important than AP Calculus. My son took that advice, and never regretted it as he went on to graduate Phi Beta Kappa in Economics at Ohio State University.

A lot needs to be done to help people understand probabilities better—especially small probabilities. Here is an example of the sort of thing that might help, from Jo Craven McGinty’s article:

Dr. Anagnostopoulos, who has helped develop a probability-based dice game called Borel, offered this example.

“Let’s assume that the risk for a certain group of people was that 1 in 50,000 would get a clot after having the vaccine,” he said. “If instead you were told you need to roll six dice and get all of them to be a one, would it be easier for you to make a decision?”

The odds of simultaneously rolling six ones, he said, are also 1 in 50,000. 

People’s lack of understanding of probabilities is an important issue for “Cognitive Economics.” Let me mention three things of interest for economics research:

  1. In Behavioral Economics, it is always important to know whether what people say that violates the standard axioms is due to nonstandard quirks of their genuine preferences or to difficulties in understanding things cognitively—which might be accompanied by standard preferences. (It matters for Normative Behavioral Economics, for example.) I have noticed that a large fraction of the evidence against expected utility theory involves choices with small probabilities that people may not understand. I consider it an important agenda to reexamine the evidence and isolate what evidence against expected utility theory remains when looking only at choices that had a 50/50 probability. I don’t trust the typical person to intuitively understand any probability more complex than a 50/50 probability. (Talking about rolling six dice and getting six ones could help, but I still worry about people’s level of understanding.)

  2. My University of Michigan colleague Bob Willis found that, in the Health and Retirement Study, a simple index based on how often someone rounds a probability they are asked for to 0, 50% or 100% can predict many things, including their portfolio choices. Someone’s level of probabilistic sophistication predicts a lot!

  3. For someone (or some team) with the right qualifications who is willing to do a very ambitious survey experiment, I could see myself collaborating on this:

    • There is a way to make correctly reporting probabilities incentive-compatible.

    • Using true/false quiz questions for which an experimental subject reports probabilities that they got it right, it should be possible to train them to report probabilities more accurately.

    • Randomizing this intervention, one could then look at what the effects of this probability training were:

      • effects on survey responses (say being more informative about important probabilities in their life)

      • effects on how they play experimental games

      • effects on their real life (as judged by a follow-up survey)

    • I think it would be possible to do all of this on MTurk

    • It would require some nontrivial programming.

Math education in general needs a lot more attention. And within math education, early statistical education especially needs a lot more attention. If you are aware of good things for statistical education on free websites, please let us know in the comment section!

Other Posts about Learning Math and Doing Math

I wrote a follow-up column "How to Turn Every Child into a "Math Person" that gives links to some of the reactions to "There's One Key Difference Between Kids Who Excel at Math and Those Who Don't" and many resources for math learning. Here are some links to posts on math learning that didn't make it into that column:

Also, here are some Twitter discussions on math learning:

Finally, on learning more generally, don’t miss: