Geriatrics: The Grim Good Magic of Setting Priorities in Old Age

Economics is about tradeoffs. People want many things and care about many things. Indeed, we want so many things and care about so many things that it is extremely unlikely we will ever get them all. We have to choose.

Professionals in any area become enamored of the particular outcomes they focus on improving. This is as true of medicine as any other professional area. Because death, despite its inevitable, seems like the ultimate defeat to doctors, they face the temptation of pushing people toward prolonging life at the expense of other things people value. This can steer doctors wrong toward the end of patients lives, when patients often value the freedom to do some things they want to do in their remaining time more than a few extra months.

Atul Gawande’s wonderful book Being Mortal is on this theme: people rightly rebel at being told they must always play it safe and always put medical concerns first in their final years. (All the quotations in this post are from that book.)

There are other issues with medical judgment for older patients. Even within strictly medical outcomes, doctors not trained in geriatrics (old-age medicine) often have trouble setting clear priorities. For example, avoiding falls is crucial. Atul Gawande writes:

Each year, about 350,000 Americans fall and break a hip. Of those, 40 percent end up in a nursing home, and 20 percent are never able to walk again. The three primary risk factors for falling are poor balance, taking more than four prescription medications, and muscle weakness. Elderly people without these risk factors have a 12 percent chance of falling in a year. Those with all three risk factors have almost a 100 percent chance.

I think often about the danger of falls in my future; I regularly do balance exercises. (See “Learning to Do Deep Knee Bends Balanced on One Foot.”)

Specialized training in geriatrics helps doctors do a much better job in making the lives of older patients better:

Several years ago, researchers at the University of Minnesota identified 568 men and women over the age of seventy who were living independently but were at high risk of becoming disabled because of chronic health problems, recent illness, or cognitive changes. With their permission, the researchers randomly assigned half of them to see a team of geriatric nurses and doctors—a team dedicated to the art and science of managing old age. The others were asked to see their usual physician, who was notified of their high-risk status. Within eighteen months, 10 percent of the patients in both groups had died. But the patients who had seen a geriatrics team were a quarter less likely to become disabled and half as likely to develop depression. They were 40 percent less likely to require home health services.

These were stunning results. If scientists came up with a device—call it an automatic defrailer—that wouldn’t extend your life but would slash the likelihood you’d end up in a nursing home or miserable with depression, we’d be clamoring for it. We wouldn’t care if doctors had to open up your chest and plug the thing into your heart. We’d have pink-ribbon campaigns to get one for every person over seventy-five. Congress would be holding hearings demanding to know why forty-year-olds couldn’t get them installed. Medical students would be jockeying to become defrailulation specialists, and Wall Street would be bidding up company stock prices.

Instead, it was just geriatrics. The geriatric teams weren’t doing lung biopsies or back surgery or insertion of automatic defrailers. What they did was to simplify medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.

Unfortunately, geriatrics gets low reimbursement, low pay and little respect. The government has mismanaged its price. This puts us in a crisis as the population continues to age. Here is the situation and remaining hope:

I asked Chad Boult, the geriatrics professor, what could be done to ensure that there are enough geriatricians for the surging elderly population. “Nothing,” he said. “It’s too late.” Creating geriatric specialists takes time, and we already have far too few. In a year, fewer than three hundred doctors will complete geriatrics training in the United States, not nearly enough to replace the geriatricians going into retirement, let alone meet the needs of the next decade. Geriatric psychiatrists, nurses, and social workers are equally needed, and in no better supply. The situation in countries outside the United States appears to be little different. In many, it is worse.

Yet Boult believes that we still have time for another strategy: he would direct geriatricians toward training all primary care doctors and nurses in caring for the very old, instead of providing the care themselves.

In dealing with older folks, what doctors with no geriatrics sensibility is to try to fix everything. But every fix has potential side effects. Tradeoffs mean that patient preferences have to be consulted. But, interestingly, experience Atul recounts in Being Mortal by those who are especially good at working through decisions with patients makes it clear it is better to ask people about their preferences in general terms (“What is important to you?”) before talking in detail about the particular decision a patient faces. Indeed, the recommended type of interaction with patients sounds for all the world like what I do (totally non-medical contexts) as a part-time Co-Active Coach. (See “Co-Active Coaching as a Tool for Maximizing Utility—Getting Where You Want in Life” and the other links at the bottom of “Zen Koan Practice with Miles Kimball: 'I Don't Know What All This Is')

Optimizing-subject-to-constraint needs the right objective function, which for most people is much more complex than simply maximizing lifespan. Optimizing-subject-to-constraint also needs a clear recognition and understanding of the constraints. Admitting to ourselves the doom of mortality that hangs over our flesh-and-blood bodies—and the bodily breakdown likely to presage that end—is an important part of seeing the constraints clearly.

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

Zen Koan Practice with Miles Kimball: 'I Don't Know What All This Is'

I have heard that instruction in Zen is often hardcore. Some Zen instructors may well be like drill sergeants, but Henry Shukman’s course within Sam Harris’s “Waking Up” app is wonderful. I highly recommend it. Henry Shukman does give some instruction on proper Zen posture, but I simply ignore that, and pay attention to everything else.

A Zen koan is a word, a phrase, a sentence or a little story designed to have a revelatory effect on the mind, without necessarily making any literal sense. Paradox is a way to knock the mind out of its accustomed ruts without ever needing to find a solution to the paradox.

Henry Shukman is great at explaining some of the principles of Zen that are reasonably easy to explain. For example, Zen encourages you to identify with your entire sensorium—everything they see, hear, taste, smell or feel at any given moment—rather than the human-shaped object within your sensorium. (“Who Am I?” is a koan that gets at that fairly directly.) That is only a fraction of what Zen reveals; that much all by it self is a great liberation. What seems to be “out there” is really inside your mind—not because there are no “things-in-themselves,” but because what you actually perceive are highly processed in-your-mind representations of those things. “Mind is nothing but the rivers, the mountains, and the whole wide earth; the sun, the moon and the stars.” Rather than being isolated Cartesian minds, our minds naturally connect us to all of the things around us that matter to us, where what matters to us (both animate and inaminate) has a long evolutionary history going back through millions of years of interaction.

Another key principle of Zen is “ordinary mind” and its emphasis on the transcendent beauty of ordinary objects. As such, Zen can easily fit within one’s regular life: whatever your days are like already, in any outward sense, there is transcendent beauty to be seen within that day.

Closely related to the principle of “ordinary mind” is the principle of “beginner’s mind.” I used to think “beginner’s mind” referred to the kind of openness I discuss in “Open Skepticism and Closed Skepticism.” It is something else. It is experiencing each moment as if it were the first time you had ever experienced anything like it. Instead of anticipating what is coming a second ahead of it’s happening and overlaying that expectation on what is happening, just see what is there. It may be much different, much more intricate and hence much more beautiful than anything you had imagined. (This might be hard to do without listening to some instruction in Zen from someone like Henry Shukman.)

“Beginner’s mind” reminds me of a principle I learned in a Landmark Education Communication Course of listening to someone like you don’t know what they are going to say. That simple practice can be surprisingly powerful.

In addition to listening to Henry Shukman’s course in the “Waking Up” app for the 3d time now, and buying one of the many collections of koans out there (I bought Entangling Vines), Henry is so clear in explaining how koans work that I feel I can invent koans of my own. Fortunately, as far as I know, Colorado has no occupational licensing laws for an upstart internet Zen master :)

The koan I have in mind today is one that works great when you are out and about doing whatever you normally do in your life. I have been using it on my daily walks, but you could use it during many other activities as well. It is an encouragement to beginner’s mind. I say to myself repeatedly:

I don’t know what all this is.

A variation on the theme of trying to see everything new that I also say to myself is:

I know what my feet should do, but I don’t know where I am.

With Zen koans, you don’t have to try to think or feel any particular way, just say the koan to yourself repeatedly and see what happens. These particular koans are intended to go along with other activities rather than to be used in any kind of sitting meditation. They are working for me, but I don’t know whether or not they will work as entry-level koans, without other koan practice first. Try them and see!

Posts on Positive Mental Health and Maintaining One’s Moral Compass:

An Altruism Paradox in Our Attitudes toward Foreigners

As I discuss in “What is a Supply-Side Liberal?” and “Inequality Aversion Utility Functions: Would $1000 Mean More to a Poorer Family than $4000 to One Twice as Rich?” Most Americans have an inequality aversion above two. That means that they assess a dollar to a family twice as rich as making only a quarter the difference to the lives of those in the richer family. Conversely, to a family living on a tenth the income, a dollar would make one hundred times the difference to their lives that it would mean to a family ten times richer than they are. Even if we decided that foreigners should have a welfare weight only one hundredth as big as an American citizen (something I call “The Aluminum Rule” because it is a far cry from the Golden Rule of loving one’s neighbor as oneself), there are many foreigners so poor that they would matter a lot in welfare calculations. As far as I can tell, our policies don’t follow the Aluminum Rule. They seem to follow something more like the “Dirt Rule” of treating poor foreigners like dirt when they show up at our borders, with a welfare weight far below .01 times the welfare weight of an American citizen.

So it comes as a surprise that as a nation we slow-walked booster shots for Americans in order to free up more vaccination shots for folks abroad. (I talk about this more in “Lying is Bad.”) Unlike dollars, that are worth more to people who have fewer of them, life versus death counts about the same for a rich person as a poor person. So if we had that attitude for citizens and then followed the intermediate Aluminum Rule of a .01 welfare weight on non-citizens, we wouldn’t be shipping vaccine doses abroad when there are supply shortages. However, it seems that rather than following this logic, people have much more sympathy for folks abroad who might die from Covid-19 than folks abroad who face an elevated risk of dying from abject poverty and a lot of poverty misery along the way who just want a chance to work in a decent country like ours. We are getting closer to the Golden Rule than to the Aluminum rule for getting vaccines to poor folks in other countries, but follow the Dirt Rule when poor folks in other countries want to immigrate to the US. What is going on?

For more on the moral dimensions of immigration policy, see:

Processed Food is Our Evil Overlord

Most of what we as a nation eat is processed food—or technically “ultra-processed food”—to use the nutritionists’ term that allows for the fact that, for example, even triple-washed spinach is technically “processed.” This is pretty much anything that is in a package or can and has a nutritional label on it. Matthew Rees’s November 3, 2021 review of The End of Craving by Mark Schatzker summarizes it this way:

58% of calories in the American adult diet come from ultra-processed foods, 67% among children and adolescents. Such foods—prepared meats, potato chips and other snacks, really almost anything in a package—are high in sugar, salt or fat. Many also contain a witch’s brew of ingredients that make nutrition labels unintelligible: sucralose, methylcelluloses, saccharin, microparticulated protein, Solka-Floc, maltodextrins, carrageenan.

Other than transfats which are very unhealthy, I tend to think dietary fat isn’t as bad as all that, and that even salt has been overly demonized. But sugar is a slow poison. I have often pointed out that, as things stand, it isn’t easy to distinguish between going off of sugar and going off of processed foods because such a high fraction of processed food has sugar as a major ingredient. (And the most common nonsugar sweeteners in processed foods are pretty bad, too. See “Which Nonsugar Sweeteners are OK? An Insulin-Index Perspective.”) And many of the other ingredients in processed food are suspect, if only because they haven’t had a chance to be tested by time in the way things humans have eaten for centuries have been tested by time. The objective function of trying to hook people on the particular processed foods a given company is making is also likely to push processed food toward extremes one should worry about.

The End of Craving has an additional hypothesis about how processed food could mess us up. As Matthew Rees summarizes it:

Consuming foods and beverages that have been designed to fool the brain into believing that it has received nutrition when it hasn’t, says Mr. Schatzker, stimulates a desire to consume more of them. Cravings follow, and they’re satisfied with the supersize concoctions that have become a defining—and depressing—feature of America’s food landscape…. The portion size of entrées at U.S. fast-food outlets, in roughly the past three decades, has grown 24%.

Could it be that fake food—a.k.a. processed food—often isn’t very satisfying? Mark Schatzker goes there:

For inspiration, he travels to Italy to determine why people there have a healthier relation to food—and a lower obesity rate (under 8% in the north). There’s no simple explanation, but he approvingly quotes a chef in Bologna who says: “It comes down to the difference between feeding and eating. . . . Italians don’t want just to feed themselves, they want to eat. . . . They want an experience.”

Mark Schatzker also has a more out-there theory:

In Mr. Schatzker’s telling, dietary deceptions are not the only reason for Americans’ girth. In the 1940s, he notes, the U.S. government began mandating that enriched flour be fortified with B vitamins. The policy continues today, resulting in Americans ingesting niacin and thiamin at levels that are well beyond what’s needed. Mr. Schatzker describes these vitamins as essential to calories being transformed into fuel, but he cautions that their excessive consumption results in the body metabolizing a higher share of calories. “With great obesity,” writes Mr. Schatzker, “comes great B vitamin intake.”

This sounds as if it assumes a simple calories-in/calories-out model. If more B vitamin intake means more calories are absorbed, that might be more satiating and then people would adjust the amount they ate. On the other hand, enriched flour is high in easily-digested starches that are quickly broken down by the body into sugar, and many baked products have sugar added to boot. Sugar causes an insulin spike that can mess up the appetite. So enriched flour could easily mess us up, but I’m doubtful that it is the vitamin enrichment that is messing us up.

I have inveighed against processed food before. See:

I attack sugar in these posts among many others:

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

The Federalist Papers #42: Every Power of the Federal Government Must Be Justified—James Madison

The most important message of the Federalist Papers #42 is subtext: James Madison shows he believes that each individual power of the federal government in the proposed constitution needs to be justified. Not only is the federal government limited to a small, finite list of powers, the rationale for each power needs to be carefully examined.

Actually, that is a bit of an overstatement: James Madison felt certain powers for the federal government were uncontroversial. Separating quotations from the Federalist Papers #42 with added bullets, here are what James Madison thought were uncontroversial powers:

  • The powers to make treaties and to send and receive ambassadors, speak their own propriety.

  • … The power to define and punish piracies and felonies committed on the high seas, and offenses against the law of nations, belongs with equal propriety to the general government

  • The regulation of foreign commerce, having fallen within several views which have been taken of this subject, has been too fully discussed to need additional proofs here of its being properly submitted to the federal administration.

  • All that need be remarked on the power to coin money, regulate the value thereof, and of foreign coin, is, that by providing for this last case, the Constitution has supplied a material omission in the articles of Confederation.

  • The punishment of counterfeiting the public securities, as well as the current coin, is submitted of course to that authority which is to secure the value of both.

  • The regulation of weights and measures is transferred from the articles of Confederation, and is founded on like considerations with the preceding power of regulating coin.

  • The power of establishing uniform laws of bankruptcy is so intimately connected with the regulation of commerce, and will prevent so many frauds where the parties or their property may lie or be removed into different States, that the expediency of it seems not likely to be drawn into question.

  • The power of prescribing by general laws, the manner in which the public acts, records and judicial proceedings of each State shall be proved, and the effect they shall have in other States, is an evident and valuable improvement on the clause relating to this subject in the articles of Confederation.

  • The power of establishing post roads must, in every view, be a harmless power, and may, perhaps, by judicious management, become productive of great public conveniency.

    Nothing which tends to facilitate the intercourse between the States can be deemed unworthy of the public care.

James Madison considered some of these so uncontroversial that he had to make the case that they were still important:

… the most minute provisions become important when they tend to obviate the necessity or the pretext for gradual and unobserved usurpations of power. A list of the cases in which Congress have been betrayed, or forced by the defects of the Confederation, into violations of their chartered authorities, would not a little surprise those who have paid no attention to the subject; and would be no inconsiderable argument in favor of the new Constitution, which seems to have provided no less studiously for the lesser, than the more obvious and striking defects of the old.

By contrast, James Madison felt certain other power were quite controversial:

  • It were doubtless to be wished, that the power of prohibiting the importation of slaves had not been postponed until the year 1808, or rather that it had been suffered to have immediate operation. But it is not difficult to account, either for this restriction on the general government, or for the manner in which the whole clause is expressed…. [James Madison then goes on to make a “Half a loaf is better than none” argument.] …

    Attempts have been made to pervert this clause into an objection against the Constitution, by representing it on one side as a criminal toleration of an illicit practice, and on another as calculated to prevent voluntary and beneficial emigrations from Europe to America.

  • The defect of power in the existing Confederacy to regulate the commerce between its several members, is in the number of those which have been clearly pointed out by experience. [James Madison follows this with an extensive and detailed argument.]

  • [There is also a long argument supporting this claim:] The new Constitution has accordingly, with great propriety, made provision … authorizing the general government to establish a uniform rule of naturalization throughout the United States.

Of course, the design of limited enumerated powers that helped the framers of the US Constitution get that constitution ratified has not survived the centuries that have passed since then. The power to regulate interstate commerce, for example, has become close to an unlimited power. Very occasionally, the Supreme Court has put some limit on this power, but almost anything the federal government wants to do domestically is considered a legitimate regulation of interstate commerce. The now eliminated requirement for everyone to get health insurance in the original Obamacare legislation was one exception. Nonpurchase of insurance was deemed not “commerce” by the Supreme Court. The penalty for nonpurchase of insurance was, however, justified as an exercise of the power to levy a wide variety of taxes ever since the 16th Amendment was ratified.

The currently ascendant “Public Meaning Originalism” in constitutional interpretation maintains that the words of the US Constitution should be interpreted according to what those words would have meant to the people who ratified the Constitution, and the words of each amendment should be interpreted according to what those words would have meant to the people who ratified that amendment. Because it is the meaning of the words to those who read them and ratified them, not the meaning of the words to those who wrote them, it doesn’t require any psychologizing of those who wrote them.

I have a lot of sympathy for Public Meaning Originalism. It is important that we have a Constitution that is treated as constraining government actions rather than having a meaning so flexible that the government is allowed to do anything it decides to do. Without some fidelity to the original public meaning, it seems unlikely that that Constitution can keep constraining government actions.

Of course, there is the difficulty of knowing what the words in the Constitution and its amendments would mean to those ratifiers in relation to new things that have arisen since then if a representative sample of ratifiers were transported hundreds of years into their future, to the year 2021. For example, how would they want to apply those words to computer activities?

And what about cases in which the ratifiers would think they understood something that arose long after their deaths, but in fact wouldn’t understand it very well? I am thinking here of the Fed as the US central bank. Folks transported from the past might think of it as a version of the Bank of the United States. But the Fed is a dramatically different creature.

One more big issue in constitutional interpretation is that whenever the Supreme Court has gone against original public meaning in the past, it creates a conflict in the present between the original public meaning and the desire for continuity embodied in the principle of following precedents. Do we really want to make ourselves worse off by destroying key institutions we have been used to for a long time through declaring them unconstitutional? Yet there is a lot of wisdom in the original constitutional design that should presumably have some gradually-applied influence even as against precedent.

All of these issues of constitutional interpretation come up when thinking of enumerated powers since that is an area where, arguably, what we do now has strayed the furthest from what people thought they were ratifying when they ratified the US Constitution and what people thought they were ratifying when they ratified relevant amendments to the US Constitution.

Below is the full text of the Federalist Papers #42:

FEDERALIST NO. 42

The Powers Conferred by the Constitution Further Considered

From the New York Packet
Tuesday, January 22, 1788.

Author: James Madison

To the People of the State of New York:

THE SECOND class of powers, lodged in the general government, consists of those which regulate the intercourse with foreign nations, to wit: to make treaties; to send and receive ambassadors, other public ministers, and consuls; to define and punish piracies and felonies committed on the high seas, and offenses against the law of nations; to regulate foreign commerce, including a power to prohibit, after the year 1808, the importation of slaves, and to lay an intermediate duty of ten dollars per head, as a discouragement to such importations. This class of powers forms an obvious and essential branch of the federal administration. If we are to be one nation in any respect, it clearly ought to be in respect to other nations. The powers to make treaties and to send and receive ambassadors, speak their own propriety. Both of them are comprised in the articles of Confederation, with this difference only, that the former is disembarrassed, by the plan of the convention, of an exception, under which treaties might be substantially frustrated by regulations of the States; and that a power of appointing and receiving "other public ministers and consuls," is expressly and very properly added to the former provision concerning ambassadors. The term ambassador, if taken strictly, as seems to be required by the second of the articles of Confederation, comprehends the highest grade only of public ministers, and excludes the grades which the United States will be most likely to prefer, where foreign embassies may be necessary. And under no latitude of construction will the term comprehend consuls. Yet it has been found expedient, and has been the practice of Congress, to employ the inferior grades of public ministers, and to send and receive consuls. It is true, that where treaties of commerce stipulate for the mutual appointment of consuls, whose functions are connected with commerce, the admission of foreign consuls may fall within the power of making commercial treaties; and that where no such treaties exist, the mission of American consuls into foreign countries may PERHAPS be covered under the authority, given by the ninth article of the Confederation, to appoint all such civil officers as may be necessary for managing the general affairs of the United States. But the admission of consuls into the United States, where no previous treaty has stipulated it, seems to have been nowhere provided for. A supply of the omission is one of the lesser instances in which the convention have improved on the model before them. But the most minute provisions become important when they tend to obviate the necessity or the pretext for gradual and unobserved usurpations of power. A list of the cases in which Congress have been betrayed, or forced by the defects of the Confederation, into violations of their chartered authorities, would not a little surprise those who have paid no attention to the subject; and would be no inconsiderable argument in favor of the new Constitution, which seems to have provided no less studiously for the lesser, than the more obvious and striking defects of the old. The power to define and punish piracies and felonies committed on the high seas, and offenses against the law of nations, belongs with equal propriety to the general government, and is a still greater improvement on the articles of Confederation. These articles contain no provision for the case of offenses against the law of nations; and consequently leave it in the power of any indiscreet member to embroil the Confederacy with foreign nations. The provision of the federal articles on the subject of piracies and felonies extends no further than to the establishment of courts for the trial of these offenses. The definition of piracies might, perhaps, without inconveniency, be left to the law of nations; though a legislative definition of them is found in most municipal codes.

A definition of felonies on the high seas is evidently requisite. Felony is a term of loose signification, even in the common law of England; and of various import in the statute law of that kingdom. But neither the common nor the statute law of that, or of any other nation, ought to be a standard for the proceedings of this, unless previously made its own by legislative adoption. The meaning of the term, as defined in the codes of the several States, would be as impracticable as the former would be a dishonorable and illegitimate guide. It is not precisely the same in any two of the States; and varies in each with every revision of its criminal laws. For the sake of certainty and uniformity, therefore, the power of defining felonies in this case was in every respect necessary and proper.

The regulation of foreign commerce, having fallen within several views which have been taken of this subject, has been too fully discussed to need additional proofs here of its being properly submitted to the federal administration. It were doubtless to be wished, that the power of prohibiting the importation of slaves had not been postponed until the year 1808, or rather that it had been suffered to have immediate operation. But it is not difficult to account, either for this restriction on the general government, or for the manner in which the whole clause is expressed. It ought to be considered as a great point gained in favor of humanity, that a period of twenty years may terminate forever, within these States, a traffic which has so long and so loudly upbraided the barbarism of modern policy; that within that period, it will receive a considerable discouragement from the federal government, and may be totally abolished, by a concurrence of the few States which continue the unnatural traffic, in the prohibitory example which has been given by so great a majority of the Union. Happy would it be for the unfortunate Africans, if an equal prospect lay before them of being redeemed from the oppressions of their European brethren!

Attempts have been made to pervert this clause into an objection against the Constitution, by representing it on one side as a criminal toleration of an illicit practice, and on another as calculated to prevent voluntary and beneficial emigrations from Europe to America. I mention these misconstructions, not with a view to give them an answer, for they deserve none, but as specimens of the manner and spirit in which some have thought fit to conduct their opposition to the proposed government. The powers included in the THIRD class are those which provide for the harmony and proper intercourse among the States. Under this head might be included the particular restraints imposed on the authority of the States, and certain powers of the judicial department; but the former are reserved for a distinct class, and the latter will be particularly examined when we arrive at the structure and organization of the government. I shall confine myself to a cursory review of the remaining powers comprehended under this third description, to wit: to regulate commerce among the several States and the Indian tribes; to coin money, regulate the value thereof, and of foreign coin; to provide for the punishment of counterfeiting the current coin and secureties of the United States; to fix the standard of weights and measures; to establish a uniform rule of naturalization, and uniform laws of bankruptcy, to prescribe the manner in which the public acts, records, and judicial proceedings of each State shall be proved, and the effect they shall have in other States; and to establish post offices and post roads. The defect of power in the existing Confederacy to regulate the commerce between its several members, is in the number of those which have been clearly pointed out by experience. To the proofs and remarks which former papers have brought into view on this subject, it may be added that without this supplemental provision, the great and essential power of regulating foreign commerce would have been incomplete and ineffectual. A very material object of this power was the relief of the States which import and export through other States, from the improper contributions levied on them by the latter. Were these at liberty to regulate the trade between State and State, it must be foreseen that ways would be found out to load the articles of import and export, during the passage through their jurisdiction, with duties which would fall on the makers of the latter and the consumers of the former. We may be assured by past experience, that such a practice would be introduced by future contrivances; and both by that and a common knowledge of human affairs, that it would nourish unceasing animosities, and not improbably terminate in serious interruptions of the public tranquillity. To those who do not view the question through the medium of passion or of interest, the desire of the commercial States to collect, in any form, an indirect revenue from their uncommercial neighbors, must appear not less impolitic than it is unfair; since it would stimulate the injured party, by resentment as well as interest, to resort to less convenient channels for their foreign trade. But the mild voice of reason, pleading the cause of an enlarged and permanent interest, is but too often drowned, before public bodies as well as individuals, by the clamors of an impatient avidity for immediate and immoderate gain. The necessity of a superintending authority over the reciprocal trade of confederated States, has been illustrated by other examples as well as our own. In Switzerland, where the Union is so very slight, each canton is obliged to allow to merchandises a passage through its jurisdiction into other cantons, without an augmentation of the tolls. In Germany it is a law of the empire, that the princes and states shall not lay tolls or customs on bridges, rivers, or passages, without the consent of the emperor and the diet; though it appears from a quotation in an antecedent paper, that the practice in this, as in many other instances in that confederacy, has not followed the law, and has produced there the mischiefs which have been foreseen here. Among the restraints imposed by the Union of the Netherlands on its members, one is, that they shall not establish imposts disadvantageous to their neighbors, without the general permission. The regulation of commerce with the Indian tribes is very properly unfettered from two limitations in the articles of Confederation, which render the provision obscure and contradictory. The power is there restrained to Indians, not members of any of the States, and is not to violate or infringe the legislative right of any State within its own limits. What description of Indians are to be deemed members of a State, is not yet settled, and has been a question of frequent perplexity and contention in the federal councils. And how the trade with Indians, though not members of a State, yet residing within its legislative jurisdiction, can be regulated by an external authority, without so far intruding on the internal rights of legislation, is absolutely incomprehensible. This is not the only case in which the articles of Confederation have inconsiderately endeavored to accomplish impossibilities; to reconcile a partial sovereignty in the Union, with complete sovereignty in the States; to subvert a mathematical axiom, by taking away a part, and letting the whole remain. All that need be remarked on the power to coin money, regulate the value thereof, and of foreign coin, is, that by providing for this last case, the Constitution has supplied a material omission in the articles of Confederation. The authority of the existing Congress is restrained to the regulation of coin STRUCK by their own authority, or that of the respective States. It must be seen at once that the proposed uniformity in the VALUE of the current coin might be destroyed by subjecting that of foreign coin to the different regulations of the different States. The punishment of counterfeiting the public securities, as well as the current coin, is submitted of course to that authority which is to secure the value of both. The regulation of weights and measures is transferred from the articles of Confederation, and is founded on like considerations with the preceding power of regulating coin.

The dissimilarity in the rules of naturalization has long been remarked as a fault in our system, and as laying a foundation for intricate and delicate questions. In the fourth article of the Confederation, it is declared "that the FREE INHABITANTS of each of these States, paupers, vagabonds, and fugitives from justice, excepted, shall be entitled to all privileges and immunities of FREE CITIZENS in the several States; and THE PEOPLE of each State shall, in every other, enjoy all the privileges of trade and commerce," etc. There is a confusion of language here, which is remarkable. Why the terms FREE INHABITANTS are used in one part of the article, FREE CITIZENS in another, and PEOPLE in another; or what was meant by superadding to "all privileges and immunities of free citizens," "all the privileges of trade and commerce," cannot easily be determined. It seems to be a construction scarcely avoidable, however, that those who come under the denomination of FREE INHABITANTS of a State, although not citizens of such State, are entitled, in every other State, to all the privileges of FREE CITIZENS of the latter; that is, to greater privileges than they may be entitled to in their own State: so that it may be in the power of a particular State, or rather every State is laid under a necessity, not only to confer the rights of citizenship in other States upon any whom it may admit to such rights within itself, but upon any whom it may allow to become inhabitants within its jurisdiction. But were an exposition of the term "inhabitants" to be admitted which would confine the stipulated privileges to citizens alone, the difficulty is diminished only, not removed. The very improper power would still be retained by each State, of naturalizing aliens in every other State. In one State, residence for a short term confirms all the rights of citizenship: in another, qualifications of greater importance are required. An alien, therefore, legally incapacitated for certain rights in the latter, may, by previous residence only in the former, elude his incapacity; and thus the law of one State be preposterously rendered paramount to the law of another, within the jurisdiction of the other. We owe it to mere casualty, that very serious embarrassments on this subject have been hitherto escaped. By the laws of several States, certain descriptions of aliens, who had rendered themselves obnoxious, were laid under interdicts inconsistent not only with the rights of citizenship but with the privilege of residence. What would have been the consequence, if such persons, by residence or otherwise, had acquired the character of citizens under the laws of another State, and then asserted their rights as such, both to residence and citizenship, within the State proscribing them? Whatever the legal consequences might have been, other consequences would probably have resulted, of too serious a nature not to be provided against. The new Constitution has accordingly, with great propriety, made provision against them, and all others proceeding from the defect of the Confederation on this head, by authorizing the general government to establish a uniform rule of naturalization throughout the United States. The power of establishing uniform laws of bankruptcy is so intimately connected with the regulation of commerce, and will prevent so many frauds where the parties or their property may lie or be removed into different States, that the expediency of it seems not likely to be drawn into question. The power of prescribing by general laws, the manner in which the public acts, records and judicial proceedings of each State shall be proved, and the effect they shall have in other States, is an evident and valuable improvement on the clause relating to this subject in the articles of Confederation. The meaning of the latter is extremely indeterminate, and can be of little importance under any interpretation which it will bear. The power here established may be rendered a very convenient instrument of justice, and be particularly beneficial on the borders of contiguous States, where the effects liable to justice may be suddenly and secretly translated, in any stage of the process, within a foreign jurisdiction. The power of establishing post roads must, in every view, be a harmless power, and may, perhaps, by judicious management, become productive of great public conveniency.

Nothing which tends to facilitate the intercourse between the States can be deemed unworthy of the public care.

PUBLIUS.

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

Why I Am a Capitalist Roader

There are many things that are messed up in our economy and in our society. These things often get blamed on “Capitalism.” But it is the fundamental principles of Capitalism that are keeping things from being worse—much worse—than they are. Let me give you my version of the fundamental principles of fostering prosperity, among which the principles of Capitalism are an important part.

Making Benefitting Society the Only Way to Get Rich. The most fundamental principle for fostering prosperity is to develop institutions that make benefitting society the only way to get rich:

  • Property rights are an obvious part of this: if you are allowed to steal, then you have an obvious path to trying to get rich that doesn’t benefit society.

  • The same goes for prohibitions on extortion: if you can get paid by saying “I’ll torch your store if you don’t pay me protection money,” there is again an obvious path to trying to get rich that doesn’t benefit society. (Muggings are a simpler version of the same thing.)

  • Prohibiting lying is also important. Lying can be a way of getting rich at someone else’s expense instead of getting rich by benefitting society.

  • Note also that it is hard to have secrecy without being driven or tempted to lie to protect that secrecy. To the extent secrecy is allowed, it should be closely regulated in order to avoid bad consequences from deceptive secrecy that exceed benefits of secrecy. My own personal opinion is that our society is a bit too pro-secrecy. We act as if people have an inherent right to keep secrets without asking them to make the case that the right to keep secrets in a particular context is going to make the world a better place. A right to keep secrets in some contexts makes the world a better place. A right to keep secrets in other contexts makes the world worse—sometimes much worse.

  • In a complex economy such as ours, there are many other highly technical things we need to get right to make benefitting society the only way to get rich. As a society, we have been neglectful of this design problem in the last 50 years. An important chunk of criticisms of “Capitalism” are criticisms of this neglect. I give some examples in “Odious Wealth: The Outrage is Not So Much Over Inequality but All the Dubious Ways the Rich Got Richer.”

(Note that an indirect way to benefit society to enhance the rewards for people who directly benefit society. For example, family members play an important role here; many people have worked a lot harder because they had a family to support.)

The Free-Market Principle. The next principle for fostering prosperity is the free-market principle of staying close to allowing any two people who want to make a trade (often of money for work, a good or a service) to make a trade. The reasoning behind this is that if both people want to make the trade, it suggests they think that trade will make each of them better off. Why not let them both become better off?

Any departure from this free-market principle should bear a heavy burden of proof that it does enough good to warrant the harm of preventing pairs of people who want to trade from both becoming better off. The need for tax revenue to provide public goods combined with concerns about poverty can provide an adequate justification for some departure from this free-market principle (I discuss those concerns in my inaugural post “What is a Supply-Side Liberal?”) In practice, many departures from the free-market principle that people advocate and many that get enacted are quite ham-handed. (For example, I think there are better approaches than the minimum wage. See “Inequality Is About the Poor, Not About the Rich” and “Oren Cass on the Value of Work.”)

Interestingly, anti-trust and anti-monopoly policies are part of this free-market principle. The government often discourages mutually beneficial trades by policies such as anti-construction policies that keep house prices high and occupational licensing rules that ‘Keep the Riffraff Out!’ Private companies also often discourage mutually beneficial trades by making it costly for people to switch to buying from a competitor. This should be (and to some extent is) discouraged by law. A good example is that tech companies acting to make interoperability and portability difficult violates the free-market principle. Another example is noncompete agreements that try to prevent an employee from going to a competitor. (It is often claimed this is necessary to protect trade secrets. But noncompete agreements have been proliferating far beyond what is needed to protect trade secrets. And letting companies protect trade secrets has to be justified, as I mentioned above. Letting companies protect trade secrets is in the same category as letting companies get patents, copyrights and trademarks, which all raise non-trivial policy questions.)

Even immigration restrictions are a way of blocking mutually beneficial trades; excessive immigration restrictions badly violate the free-market principle. For example, one has to put a very low weight on the benefits immigrants get from coming to the United States to oppose a big increase in legal immigration that includes appropriate provisions for encouraging assimilation. (Note that this is about economic participation of immigrants. Rules for political assimilation of immigrants are a different question. On that question, experience suggests it is unwise to have a group permanently have second-class political status as is true for immigrants in many countries. I think, however, it is possible to have up to an 18-year delay in getting voting rights without having the harms that come from a group permanently having a second-class political status.)

The Magic of the Price System. In practice, even a quite imperfect application of the free-market principle leads to a price system emerging. Any trade of money for work, a good or a service has an obvious price. If there is any freedom in choosing the price at which trades happen, those prices will carry a lot of useful information. (This is true even when prices are legally set but people make blackmarket transactions ignoring those laws. The legally fixed price doesn’t carry much useful information, but the blackmarket price does.)

Justin Lahart’s October 15, 2021 Wall Street Journal article “At Times Like These, Inflation Isn’t All Bad” confuses relative price changes—some prices going up more than others—with inflation, which is all prices and wages going up in lockstep. But change “inflation” to “the price system giving smart signals to the economy through relative price changes” and his article becomes a wonderful paean to the price system. Relative price changes tell the economy which way we want it to adjust. Let me quote a few examples from his article, with different passages separated by added bullets:

  • The pandemic has brought about changes in what we want to spend our money on and where we want to live and work that could prove persistent. Appliance prices aren’t up just because of supply snarls, for example, but because the Covid crisis increased the appeal of suburban living. So even if supply chains get fixed, demand could still be hard to meet, with prices continuing to rise as a result.

  • … the pandemic brought on was a massive increase in demand for goods, versus services. At first, this seemed entirely temporary: People were buying more stuff like videogame consoles and groceries because they were hunkered down at home. But even though the vaccine rollout and the easing of Covid restrictions has increased demand for services such as restaurant meals, demand for goods has shown staying power.

    … That change in preferences is helping drive a divergence in inflation as well. Wednesday’s inflation report showed prices for consumer goods were up 9.1% from a year earlier, while services prices were up 3.2%. [That is, on average the prices of goods went up 5.9% relative to the prices of services.]

  • If more people keep working from home some of the time, for example, they will spend less money at lunch joints near their offices, and more on groceries.

    Similarly, if businesses continue to hold many client meetings virtually, they will spend less on travel, and more on tech equipment. Personal-computer makers are betting that a higher number of workers will need more than one computer as a result of remote-work arrangements, translating into higher PC demand post-pandemic.

  • More people moving to the suburbs or smaller cities, and people who live in the suburbs working from home more often, could equate to more demand that suburban and smaller-city businesses need to meet. There does appear to be a divergence in what is happening with prices depending on population size: Overall consumer prices in areas with over 2.5 million people were up 4.8% from a year earlier in September, while prices in areas with 2.5 million or fewer people were up 5.9%. [That is, on average prices in suburbs and smaller cities have gone up 1.1% relative to prices in large cities.]

  • Demand-driven price increases carry an important message to businesses that are benefiting from them: You can make even more money if you can supply more. That entails buying new equipment, opening new locations and, most important, hiring additional workers. Meanwhile, businesses that experience weaker demand often can’t lower prices, in part because cutting worker wages isn’t feasible.

  • … [relative price changes] can help facilitate the economy’s response to shifts like the current one because it encourages expansion where demand is rising. It also helps draw workers away from moribund businesses where wages aren’t rising because inflation is cutting into how much those workers’ paychecks can buy.

Capitalism: The Price System Operating Over Time and Across Projects. Capitalism proper is an extension of the price system across time. “Capital” means the things needed in advance for production and sales that will only be completed later. “Capital” can also mean the funds used to buy those things needed in advance for production and sales that will only be completed later. Occasionally, an entrepreneur will be able to provide those funds themself. But entrepreneurial talent and already having a pile of ready funds do not always go together. So typically an entrepreneur looks for investors to help fund a project. Some investors simply loan money (which might not get paid back if the borrowing company or individual goes bankrupt). Others buy stock so that they have an equity stake that is worth more the better the project does and worth less the worse the project does.

The great thing about capitalism is that investors will work hard to figure out which are the best projects to invest in. Projects that are likely to succeed financially and therefore provide investors the best return are more likely to be of substantial value to society than projects that are likely to fail financially.

So far, I have talked about new projects. Capitalism is also crucial for directing funds to things that should be scaled up and denying funds to things that should be allowed to gradually scale down.

Finally, a form of Capitalism I call “Vulture Capitalism” is extremely useful in helping to wind down outmoded activities that should be wound down more quickly. As I say in “Odious Wealth: The Outrage is Not So Much Over Inequality but All the Dubious Ways the Rich Got Richer,” being a vulture capitalist and firing a lot of people is so painful to most emotionally normal people that you might not want hang out with someone who finds this an attractive career, but vulture capitalists serve a very important social function of sending workers looking for jobs that are more valuable for society than the outmoded job they were in.

Vulture capitalism is something we do relatively effectively in the United States. Many other countries impede this winding down of outmoded activities by government regulation and their economies suffer for it. One of the key examples of this was the transformation of retail led by Walmart. The US economy grew a lot because of that transformation of retail. Other countries didn’t see the same growth and productivity improvements because they had policies that tried to prevent existing retailers from going under.

Getting Interest Rates Right. In addition to getting the right projects funded, a Capitalist economy needs to make sure that the total volume of funds demanded for projects equals to total volume of funds supplied at the relatively full level of employment called the “natural rate of employment.” The relevant set of prices are interest rates, including the extra “premia” that are added to safe short-term rate to compensate for risk and for funds being committed for a long term. (The interest rate implicit in stocks is sometimes called “the required return.” It includes a risk premium and a premium for a stock representing a long-term investment.)

In theory, getting interest rates right takes care of itself in the long run, but in the short run, getting the overall level of the whole panoply of interest rates right is the job of the central bank: the Fed in the US, the European Central Bank in the euro-zone, the Bank of England in the UK, the Bank of Japan in Japan, etc. Thus, as things have evolved and improved, central banks have become a crucial part of the workings of a Capitalist economy.

Even Partial Capitalism is Valuable. Nothing here is directly about politics. China is not a democracy. But China benefits from deploying many of these principles for fostering prosperity. It usually protects property rights. It allows people to get rich by benefitting Chinese society. It allows a lot of economic exchanges to take place quite freely. It benefits from the magic of the price system. Even though China does a lot of politically directing funds run through state-owned banks to state-owned firms, it does allows private firms to raise funds. So China doesn’t allow as much scope for Capitalism, but it gets a lot of mileage from the Capitalism that it does allow. China does have a central bank, the People’s Bank of China, but it also tries to get the total amount of funds demanded to equal the total amount of funds supplied at relatively full employment by ordering more or fewer loans by state-owned banks. Capitalism is so powerful that a little bit can go a long way. And the US benefits from having even more Capitalism. Although China’s population is enough bigger than that of the US that the total size of its economy might exceed the total size of the US economy sometime in the next few decades. (See the graphs in “Benjamin Franklin's Strategy to Make the US a Superpower Worked Once, Why Not Try It Again?) However, China is unlikely to match US GDP per person any time in my lifetime or yours.

Evaluating the Idea that Estrogen Replacement Therapy Causes Breast Cancer against the Bradford Hill Criteria

One false thing in the world is that the conventional wisdom says estrogen replacement therapy and the closely related hormone replacement therapy cause breast cancer on the basis of quite dicey evidence. It matters for women’s lives, especially because estrogen replacement therapy and hormone replacement therapy (which also has estrogen as a key ingredient) have many health benefits, as well as quality-of-life benefits. I have two previous posts on this:

These previous posts explain why the experimental evidence doesn’t say what the conventional wisdom seems to think it does.

As for non-experimental evidence, the Bradford Hill criteria are often used in medicine and other areas as a way to think about evidence for causality. The excellent book Estrogen Matters by Avrum Bluming and Carol Tavris (shown at the bottom of this post) contrasts how strong the Bradford Hill criteria look for the idea that smoking causes lung cancer and how weak they are for the idea that estrogen causes breast cancer. You can see a list of the 8 Bradford Hill criteria at the top of this post; Avrum Bluming and Carol Tavris use a somewhat different version of the Bradford Hill criteria, which also adds the ruling out of alternative explanations as a 9th criterion (about which they don’t have much to say). I’ll intersperse indented quotes from Estrogen Matters with my own commentary after each of the other eight points:

… Using Hill’s framework, is the link between estrogen and breast cancer supported?

Strength: The link is unsupported. Most of the correlations published by the WHI and other investigators were neither strong nor statistically significant by conventional standards.

Let me say here that there is also a lot of p-hacking going on to try to get to bare statistical significance or close.

Consistency: The link is unsupported. Most published reports find no consistently increased risk of breast cancer associated with ERT. On the contrary, the results could not be more inconsistent: Between 1975 and 2000, forty-five published studies examined the relationship between breast cancer and ERT. Of these, 82 percent found no increased risk; 13 percent found a very small increased risk; and 5 percent found a decreased risk. In that same twenty-five-year period, of twenty published studies of HRT, 80 percent found no increased risk, 10 percent found an increased risk, and 10 percent found a decreased risk.

This point speaks for itself.

Specificity: …

The link is unsupported. The overwhelming majority of breast cancer patients have never taken estrogen, and the vast majority of women who have taken hormones have never developed breast cancer.

The link isn’t specific, but specificity is mainly a test of causality when there is one main cause of something. When something is one cause among many, we should still worry about it even though it is not a “specific cause” in the Bradford Hill sense. So unlike the lack of statistical significance (“strength”) and consistency, I don’t see the lack of specificity as totally damning. However, many women may make decisions about estrogen replacement therapy based on the idea that the link with breast cancer is much stronger than indicated by “The overwhelming majority of breast cancer patients have never taken estrogen, and the vast majority of women who have taken hormones have never developed breast cancer.”

Temporal relationship: The link is unsupported. Taking estrogen does not always, or even frequently, precede the onset of the disease. The risk of breast cancer increases with age—even after menopause, when estrogen declines, and even among women who never took estrogen.

Here we have a natural experiment: estrogen goes down after menopause. The drop is often steep enough to make a regression-discontinuity analysis reasonable. Breast cancer risk shows no quick drop at menopause.

Dose-response relationship: The link is unsupported. Study after study finds no consistent increased risk of breast cancer in women who have taken ERT or HRT for five years, ten years, or fifteen years. If cumulative exposure to estrogen is a risk factor in breast cancer, why did the Nurses’ Health Study and the Million Women Study find that risk only among current users rather than past users? Some investigators assert that early menarche and late menopause, which would provide a woman with more exposure to estrogen in her lifetime, are associated with an increased risk of breast cancer. But they are not. Four separate studies have examined the breast cancer risks to women who started their periods between the ages of twelve and seventeen as compared to the risks for women whose periods started at age eleven or younger. In two of these studies, no differences in risk were found. In the other two, a significant reduction in risk was found only among women who started their periods at age seventeen and older; but they, like those whose menarche began before age eleven, represent a very small outlying percentage of the population. None of the comparisons for any of the other ages resulted in differences that were significant in any of the four studies.

Lifetime exposure to estrogen doesn’t seem to matter, which is strange, given that cancers often develop slowly.

Plausibility: The link is unsupported. Surely, the most disconfirming evidence for the claim that estrogen causes breast cancer is this: the administration of estrogen has been shown to have beneficial effects even in women with advanced breast cancer. For example, in 1944 Sir Alexander Haddow, director of the Institute for Cancer Research at the University of London, reported that 25 percent of his patients with advanced breast cancer improved when given high-dose estrogen,64 and other researchers subsequently have gotten the same or better results. Oncologist Bruno Massidda and his team at the University of Cagliari, Italy, reported remission in 50 percent of advanced breast cancer patients treated with estrogens, and so did Reshma Mahtani and colleagues at the Boca Raton Comprehensive Cancer Center. Gabriel N. Hortobagyi and colleagues at the MD Anderson Cancer Center reported that the most effective therapy for metastatic carcinoma of the breast was combined estrogen-progestin. James Ingle and colleagues at the Mayo Clinic demonstrated better survival among breast cancer patients treated with diethylstilbestrol (DES), a form of estrogen, compared to tamoxifen, as did Per Eystein Lønning and colleagues at Haukeland University Hospital in Norway. And the pioneer cancer researcher V. Craig Jordan and his research team demonstrated that both high and low doses of estrogen can shrink cancerous breast tumors.

Estrogen is actually a treatment for breast cancer!

Coherence: The link is unsupported. Using the mosaic method of knowledge, the more pieces we add, the clearer the overall image should become. That is what happened in confirming the relationship between smoking and lung cancer, and it is precisely what has not happened in the persistent efforts to confirm a relationship between estrogen and breast cancer.

The evidence just isn’t coming together. One can go too far by saying only one type of evidence (however equivocal) is worth paying attention to. Eventually, one should be able to make sense of the great bulk of the evidence—more complex evidence as well as cleaner evidence.

Experiment: The link is unsupported. In 1999, breast cancer rates began to decline. The WHI investigators claimed credit, maintaining that thanks to their 2002 warning that HRT was a cause of breast cancer, the number of women taking hormones plummeted—and thus did not develop breast cancer. However, their claim had several fundamental flaws. First, the decline began three years before the WHI published anything. Second, in Sweden and Norway, women stopped taking HRT at about the same rate that American women did but had no additional drop in rates of breast cancer. And third, because breast cancer usually takes years to become clinically detectable, how could a drop in the rate of breast cancer be related to stopping HRT one year prior? The WHI authors responded by saying that’s because when women went off estrogen, they removed a stimulus to the growth of already present but not yet detectable (subclinical) breast cancer. If that were so, however, the decreased incidence should have been confined to small, early, noninvasive breast cancers; it was not. It occurred almost entirely with invasive breast cancers.

Let me contrast this with a result that really did show something for another cancer. After the discovery that Helicobacter pylori caused stomach ulcers, the incidence of stomach cancer around the world went way down. That was a good piece of evidence that Helicobacter pylori can cause stomach cancer: the new treatment for stomach ulcers by antibiotics to kill Helicobacter pylori had the right timing to have reduced stomach cancer if Helicobacter pylori sometimes causes stomach cancer.

If estrogen causes breast cancer at all, it isn’t at all in the way that most people imagine. The way most people imagine has been clearly disproven.

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

A Spiritual Autobiography—Miles Kimball

Miles Kimball as a young man

I am a Unitarian-Universalist lay preacher. I gave 12 sermons—annually from 2005 to 2016—to the Community Unitarian Universalists in Brighton. This post is my April 3, 2011 sermon “A Spiritual Autobiography.” This brings to 11 those that are posted on this blog. The others are:

Below is the newly edited text. This sermon only gives my spiritual journey from my birth in 1960 to 2011.

At the bottom of this post are links to some of my other posts on religion. I began blogging in 2012; a large part of my spiritual journey since I gave this sermon is laid out here on my blog.

In line with the democratic spirit of Unitarian-Universalism, I believe that it would be a good thing for Unitarian-Universalist congregations to increase the number of opportunities, and the encouragement, for members of the congregation to speak to the congregation. In addition to giving everyone a chance to hear many viewpoints, this has the benefit of allowing everyone to get to know each other better. 

One problem with this idea of rotating speaking opportunities and assignments among congregation members is that many people are terrified of public speaking. So it is important to develop patterns for talks that are both reasonably interesting and easy to prepare and give. One example of an easy form of talk to give is the “spiritual autobiography”: a more or less chronological account of one’s religious quest that draws a few morals along the way. At least, as long as one’s memory is reasonably intact, a spiritual autobiography does not require a lot of outside research! And so many Unitarian-Universalists are refugees from some other religious tradition, or have faced deep soul-searching within this religious tradition, that there are many fascinating stories to be told.

In giving an account of my own spiritual journey, there are at least four thematic threads to follow along the way: us versus them, mystical experience, the spiritual affects of ambition, and the quest for hidden wisdom. 

I grew up in Madison, Wisconsin, far from the center of the Mormon Church to which my family belonged. When I was young, I had only a dim awareness of any religious difference between my family and others in Madison—partly because, outside of church, people didn’t talk about religion very much.  I remember being surprised when listening to “Jesus Christ Superstar” at my friend’s house to learn that, as a Jew, he didn’t believe in Jesus Christ as the Son of God. It simply hadn’t occurred to me that not everyone believed that. 

One practical religious difference was that, as Mormons, we had more meetings than most other religions. I remember being embarrassed to explain to my friends about a weekday children’s meeting, not because it was religious, but because I felt I was almost too old to be going to that meeting. 

I would not make it very far on American Idol, but I was not very old when my mother got me to sing a solo in Church. The song was called “A Mormon Boy,” and it had the refrain “I might be envied by a King, for I am a Mormon boy.” Of course there was no reason for any king to envy a Mormon boy, since Mormons would welcome any king who wanted to convert to Mormonism. When I look back, the interesting thing about that song is the sense of social inferiority it hints at. Mormonism is considered a weird, fringe religion that most Americans look down on, however much they may like individual Mormons. The awareness, at some level, that others look down on Mormons causes Mormons to have an inferiority complex they are not fully aware of, and to be very proud of those Mormons who are successful in the world at large, especially celebrities. If you don’t believe me, you only have to Google the website famousmormons.net, which scratches this itch. 

When I was eight years old, my father, who like almost all Mormon men, had been ordained a Priest and Elder of the Mormon Church, baptized me by dunking me totally under the water off of Picnic Point, a thin peninsula in Madison’s Lake Mendota. Since that was my chance to get my sins washed away, I felt I could safely steal some cheese from our refrigerator before that, but not after. After I was baptized, my father laid his hands on my head along with several other men to confirm me a member of the Mormon Church and give me the Gift of the Holy Ghost. In Mormonism, all members of the Church can get personal messages from God through the Holy Ghost. Also, in the Mormon scriptures, it talks of one reward of righteousness as having the Holy Ghost as a constant companion. So I was brought up to believe, and did believe, that I had the moral equivalent of a personal genie following me around to answer my questions and give me guidance. Indeed, Mormon scriptures explain in some detail how to do this. With God speaking, they say “… you must study it out in your mind; then you must ask me if it be right, and if it is right I will cause that your bosom shall burn within you; therefore, you shall feel that it is right.  But if it be not right you shall have no such feelings, but you shall have a stupor of thought that shall cause you to forget the thing which is wrong …”   In other words, as I understood it, if I prayed and asked God a question, all I had to do was to keep talking about different aspects of the question and asking the question in different ways until I either felt a warm sensation in my heart—which meant YES or felt a little stupid and confused, which meant NO.  Or if there were two possible courses of action I was thinking about, I could talk about each alternative in my prayer and notice which one left me feeling warm and good and which one left me feeling confused and not-so-good. 

A great deal of the first 40 years of my spiritual autobiography was determined by the fact that this procedure for asking God questions seemed to work very well for me.  Mormon teenagers are very strongly encouraged to “get a testimony,” which means to have a spiritual experience that confirms that Mormonism is the one true religion. For me, getting a testimony was a straightforward matter of reading the Book of Mormon and following its advice to pray and ask God if it was true.  Precisely as predicted, I felt a burning in my heart on cue. I interpreted that spiritual experience as telling me that the Book of Mormon and Mormonism in general were both true. Not only that, I could essentially reproduce that experience if I prayed and asked the question again. I didn’t just grow up in Mormonism. I believed it, through and through, because of my own spiritual experiences, of this type. 

When I was thirteen, my family moved from Madison Wisconsin to Provo, Utah.  Just a few months after we moved to Utah, my grandfather became the head of the Mormon Church—analogous to the Pope, except that there a lot fewer Mormons than there are Catholics. My grandfather became President of the Mormon Church by being appointed as one of the twelve apostles of the Mormon Church at a reasonably young age and then living a long time so that he became the most senior apostle. He had been appointed as an apostle when he was working as an unpaid local church leader while making a living selling insurance and real estate in southern Arizona. As President of the Mormon Church, often called “The Prophet,” millions of people would listen with rapt attention to his speeches at church conferences that occurred twice a year, looking up to him as God’s representative on the Earth. Without my fully realizing it, watching all of this happen to my grandfather nurtured an outsized ambition in my heart. Since my grandfather had been, I thought, chosen by God out of relative obscurity to be an apostle, I imagined God having some great task for me to do someday, and resolved to be prepared. Since any great religious task would have to wait on God’s appointment, I needed to do something else in the meantime and decided to be some sort of scientist like great uncle Henry Eyring, who was a world-renowned chemist and had an equation named after him, though he didn’t quite win a Nobel Prize. 

During my thirties, this outsized ambition caused me a lot of psychological pain, and a fair amount of anger, when my relatively successful career as an economist was not as successful as I thought it should be. As a result, I returned to psychotherapy, and have been in psychotherapy most of the time ever since.  (An earlier stint of psychotherapy had been occasioned by the death of one of our baby girls.) I think of psychotherapy as its own kind of religion and an important step on my religious quest.  More particularly, I think of helping people to get the right amount of ambition as a key service that religion should provide.  Too little ambition, and you don’t reach your potential. Too much ambition, and you are in great danger of either cutting ethical corners, ignoring your family and friends, or making yourself miserable. I don’t claim to be cured of my outsized ambition, but I am no longer in such great psychological pain on that front.

I encountered at least two other quasi-religions in my thirties. My sister got me into Transcendental Meditation, which I still try to find time to do at least once every day.  As a form of meditation, the great virtue of Transcendental Meditation is that it is easy—much easier, for example, than the Buddhist Insight Meditation that I later took a class in. The way I do it, all I need to do is to sit in a chair for twenty minutes and say a mantra—or not—as my mind wanders. I think of it as some combination of cleaning out the closets of my mind and just plain resting. 

The other quasi-religion was the courses of the Landmark Educational Corporation.  My friend Kim Leavitt got me into those. The Landmark Educational Corporation has a set of personal growth workshops that use Existentialist philosophy and Deconstruction in a pragmatic way to teach how to let go of grudges, repair relationships, and envision and work toward a positive future for one’s life and for the world. I found those workshops quite powerful and valuable and persuaded many friends to do them as well. Most of them had a good experience. The Landmark courses I took have helped me to have a can-do attitude in my life, and gave me great models of how to be a good teacher and to be persuasive. But I have found most valuable the philosophy they taught about life as something that has the meaning we decide to give to it. 

[We tried to get a video of this sermon, but only got the last third, from about here on. See immediately below.]

My last thematic thread is hidden wisdom. Let me backtrack some.  For a young boy, Mormonism has a lot of cool ideas in it that sound like Science Fiction: other worlds, God living in the Kolob solar system, and God creating the world by scientific means. It is not an accident that Utah is a Mecca for Science Fiction.  I had the sense growing up that there were endless things to be learned and discovered in Mormonism. As a teenager, I was fascinated by the work of Hugh Nibley, who managed to read Mormonism into ancient documents, including Egyptian papyri. That was heady stuff. I later dated Hugh Nibley’s daughter Martha Nibley briefly but intensely before she went on to marry my friend John Beck, write several best-sellers and write a column in Oprah’s magazine, among many other adventures she has chronicled. She has the same kind of free-wheeling intellectual creativity that her father had. (Here is her Amazon page.)

When I arrived at college, I realized that my classmates knew so little about Mormonism that Mormonism to them was whatever I told them it was. So without stretching things too much, I tried hard to make my account of Mormonism as attractive and as consistent with scientific and historical facts as I could. Later on, in my thirties, every other week I got together with a group of Mormon men who were, by and large, quite skeptical of Mormonism. At first, I imagined myself to be a missionary to these skeptics, and continued my efforts to give an attractive account of Mormonism consistent with scientific and historical facts. Over time, we exhaustively discussed the relationship of Mormonism to every relevant scientific and historical fact we could think of. In order to continue to make sense of Mormonism, I had to gradually modify my idea of Mormonism, but I was still able to believe. During this same time, I was happily teaching an adult Sunday School class in the Mormon Church as well as periodically teaching some of the adult men in what was called a “Priesthood Meeting.” The modified version of Mormonism I had come up with crept into this teaching, but even more, I delighted in letting those who came to my Sunday School class talk freely about what they thought and their concerns, including Mormonism’s unequal treatment of women.  By the time I was almost forty, local Mormon leaders had stopped me from teaching Sunday school and finally stopped me from teaching in “Priesthood Meeting” as well. To put it bluntly, I felt I could defend Mormonism in the face of scientific and historical and social issues, but by the time I had modified Mormonism enough to feel good about defending it, many other Mormons didn’t recognize it as Mormonism anymore. 

One of the luckiest things in my life is that while very different in its details, my wife Gail’s religious journey and my religious journeys were synchronized well enough that we left Mormonism together in 2000. At that time I began my association with Unitarian Universalism. It is nice to be able to be myself and say what I think without any fear in Unitarian Universalism.    

Psychologically, leaving Mormonism was quite wrenching. I had to rethink a lot of things.  For one thing, without any need to try to make sense of Mormonism any more, I decided in fairly short order that I didn’t believe in God. That made it hard to believe in an afterlife either, which was a real blow. Like most Americans, I had assumed I would go to heaven, so nothingness after death was a great come-down.  I grieved the afterlife I now believed I would never have.

After the difficult adjustments of leaving Mormonism, my spiritual life has revolved around my men’s circle in the First Unitarian-Universalist Congregation of Ann Arbor, my annual visits to the Community Unitarian Universalists of Brighton, my study of happiness as an economist, my psychotherapy, and continuing to wrestle with the reality of death. 

Besides the double-edged sword of ambition, and the irrational sense I still have of a personal genie watching out for me, two big legacies of my experience in Mormonism are the desire for hidden wisdom and the love of talking about religion. At this point, I don’t think I know what religion is all about. Most of the time these days I think of religion as a grab-bag of many different things, some incredibly valuable and some utterly worthless or even harmful. But if we can sort through the items in the grab-bag carefully enough, we can keep the good and throw away the bad. I believe that if talk to one another about our views on each item in the grab-bag, we can do a better job of sorting than if we try to do our sorting alone. Each person’s spiritual autobiography can give us extra insight in that task. Thank you for giving me this chance to share mine.

Don't miss these posts on Mormonism:

Other Posts on Religion:

Posts on Positive Mental Health and Maintaining One’s Moral Compass:

Helen Czerski: Behind the Spooky Eyes of Cats

I think the tweet above should get you past the paywall. Here is the paragraph I love in this article:

A cat—like its fellow nighttime predators—effectively has a narrow pupil in the horizontal direction but a wide pupil in the vertical direction. So anything along the horizontal plane is in beautiful sharp focus, and the image is more blurred in the vertical direction. But at the right focal length, the image will be perfectly in focus in both directions, and that gives the cat an extra way of judging distance.

Lying is Bad

The idea that lying is bad is surprisingly controversial these days. Many people now treat lying as if it were a bit of an ethical minus (easily overridden by other concerns), without serious practical consequences. But lying, even when it can be ethically justified, has serious practical consequences. I might or might not be OK with you misleading others, but I am unlikely to be OK with you misleading me. Exceptions to that rule do exist, but they are uncommon.

What that means is that, regardless of how well you think you can justify lying ethically, you might get only one or two shots at successfully deceiving people, so you had better carefully save up those very limited opportunities.

In line with the last paragraph, for those who bristle at my use of the word “lying” in this post, let me define “lying” for my purposes here as anything you say that—if a listener came to know the whole truth later on—would make them trust your words less thereafter.

What has happened in public affairs over my lifetime is that those in power have lied quite freely, leading people to trust them less and less. Fortunately, there are some people I still trust not to lie too much. For example, still to this day I think the typical rank-and-file economist and the typical rank-and-file lab scientist will tell me the truth about what they found scientifically about narrow questions, other than some statistical fudging that is predictable enough that I can adjust for it. (I inveigh against that statistical fudging in “Let's Set Half a Percent as the Standard for Statistical Significance” and “Adding a Variable Measured with Error to a Regression Only Partially Controls for that Variable.” Also see “Adam McCloskey and Pascal Michaillat: Calculating Incentive Compatible Critical Values Points to a t-Statistic of 3 as the 5% Critical Value after Accounting for p-Hacking.”)

However, when it comes to interpretations of data behind recommendations made to the general public, I have very little confidence that those in power will tell me what they actually believe as opposed to what was decided by some highly politicized committee as the particular way they should try to shade things to get me to do what they want me to do.

Before I get more specific, let me admit up front that I will focus my ire on those from whom I expect better behavior. There are others in public life who lie so often, in such varied ways, that I have gotten used to it, and my anger that once burned hot about their lying has to some degree burned itself out.

In the area of diet and health, those in power still won’t tell the hoi polloi forthrightly just how bad the evidence suggests sugar is.

In the area of fighting global warming, they won’t tell the hoi polloi forthrightly which policy measures will have a big effect and which will only have a token effect, and are eager to pretend there is a unanimity of evidence behind the appropriately governing mainstream view instead of the reality that the appropriately governing mainstream view (of magnitude of effects as well as direction) is only based on a preponderance of evidence.

In economic policy, rather than focusing on their cogent arguments that are politically less convenient, politicians are happy to call on voters’ economic misconceptions when it favors their policies. Paul Rubin’s October 5, 2021 Wall Street Journal op-ed “The Woke Left’s Primitive Economics” and letters responding to it give a decent rundown of some of these misconceptions.

From the op-ed itself, here is one aspect of people’s economic misconceptions:

Folk economics is the economics of people untrained in economics. It is the economic view of the world that evolved in our brains before the development of the modern economy. During this period of evolution the economy was simple, with little specialization except by age and sex, no economic growth, no technological change, limited trade, little capital, and warfare between neighboring tribes.

Zero-sum thinking was well-adapted to this world. Since there was no economic growth, incomes and wealth didn’t grow. If one person had access to more food or other goods, or greater access to females, it was likely because of expropriation from others.

Paul Rubin also notes in the op-ed that “Frequent warfare encouraged xenophobia,” and then goes on to be very partisan in saying that our primitive xenophobia is called on in identity politics without making the obvious point that our primitive xenophobia is also called on in attacks on immigration.

(John Wight’s letter in response to Paul Rubin’s op-ed is fascinating, though somewhat off-topic for this post. He writes:

Paul Rubin writes about the zero-sum thinking of the left and primitive societies. I noticed this attitude while serving as a Peace Corps volunteer in South America: If the pie is not equally divided, those with a bigger slice got theirs from someone else’s share.

…

… there are two negative aspects to this zero-sum, peasant attitude, beyond those identified by Mr. Rubin. First, there is enormous social pressure not to succeed, because if you do, you are taking some one else’s share. The corollary is that if you are successful, try to hide it …

Second, if you prosper, your neighbors will think you are a crook. So, why not be one? I can’t prove it, but I think this accounts for some of the corruption endemic to underdeveloped societies.

He also mentions that an upside is pro-equality attitudes.)

Finally for this post, in the area of pandemic policy, there has been a lot of shading of the reading of evidence in order to manipulate the public. To address this issue, let me draw first on Gary Saul Morson’s op-ed “Partisan Science in America.”

Early on, when masks were scarce, instead of saying “Masks are helpful but right now we need to save them for medical workers,” those in power talked as if it was unclear that masks were helpful. On that, Gary Saul Morson writes:

Dr. Fauci admitted that he first stated that masks were ineffective in part because there was a shortage of masks and he wanted to preserve them for medical workers, who needed them most. He doesn’t seem to have considered: Once he shades the truth for a reason of policy, why shouldn’t reasonable people assume his other statements are based on policy considerations rather than science?

Decisions about lockdowns were represented as being clear from natural science, when at a minimum they involved economics to evaluate tradeoffs, as well as values questions involving ethical philosophy to choose the objective function. Gary writes:

When President Biden, or a politician from any part of the political spectrum, claims he is only “following the science,” one can be sure that he isn’t. Should we lock down? Lockdowns, like any other policy, entail costs as well as benefits. How do we weigh them? Not by epidemiology, which has nothing to say about the costs to children, small businesses, performing artists and human enjoyment generally. Science can inform a policy decision, but whatever judgment one makes, it cannot be based wholly on the science.

On the issue of boosters, let me point you to one of my tweets:

And early on, for rankly political reasons, epidemiologists prematurely (and with substantial probability wrongly) rejected the idea that the coronavirus behind Covid-19 might have originated in a Chinese lab. Gary writes:

It is now regarded as an open question whether the Covid virus escaped from a laboratory in Wuhan, China. But when the virus first appeared, dozens of scientists published a statement in the Lancet expressing “solidarity” with Chinese colleagues. “The rapid, open, and transparent sharing of data on this outbreak is now being threatened by rumors and misinformation around its origins,” the statement declared. “We stand together to strongly condemn conspiracy theories suggesting that COVID-19 does not have a natural origin.”

Gary Saul Morson also has these more general comments to make about how science works and why lying is bad. I add bullets to separate different passages:

  • Scientists don’t experience divine revelations, they propose hypotheses that they and others test. This rigorous process of testing gives science the persuasiveness that mere journalism lacks. If a scientific periodical expels editors or peer reviewers because they don’t accept some prevailing theory, that process has been short-circuited. Those who call for such expulsions have missed the whole point of how science works. They are the true deniers, far more dangerous to science than a religious fundamentalist who believes the world is 6,000 years old.

  • When researchers fear losing a grant or being subject to personal attack if they question a predominant belief, that belief no longer rests on scientific grounds.

  • By the end of the Soviet Union, almost no one trusted government statements about natural disasters or man-made catastrophes like Chernobyl. How will we handle the next crisis about which scientific understanding has something to contribute when scientists are known to base statements on policy preferences? That is part of the cost of the Lancet scientists’ accusation and of Dr. Fauci’s lack of candor.

In addition to people feeling OK in lying to further their preferred politics or policies, there is always the danger that politics will cloud people’s judgment in the first place. I worry that was the case for a “whistleblower” who significantly delayed our utilization of the very helpful anti-Covid drug molnupiravir. The story is in Alyssia Finley’s October 10, 2021 Wall Street Journal op-ed “Who Slowed Merck’s Covid Remedy.”

Here is Alyssia’s account of what happened when Rick Bright was demoted for opposing a fast-tracking of this promising, though still unproven, anti-Covid drug:

Mr. Bright then filed a complaint accusing Trump officials of pressuring him to fast-track unsafe drugs and award contracts “based on political connections and cronyism.”

He claimed that even before the pandemic, they were inappropriately pressing Barda to fund clinical studies of molnupiravir, which had shown promise against other viruses in lab experiments at Emory University. Mr. Bright’s complaint alleged that George Painter, CEO of Drug Innovation Ventures at Emory, and Trump HHS official Robert Kadlec had urged Barda in November 2019 to “invest millions of dollars into their ‘miracle cure.’ ” It noted that “similar experimental drugs in this class had been shown to cause reproductive toxicity in animals, and offspring from treated animals had been born without teeth and without parts of their skulls.” But similar effects hadn’t occurred with molnupiravir.

If a Hillary Clinton administration had urged the fast-tracking of the same drug, with the same scientific evidence at the time of decision, would Rick Bright have opposed it? And to the extent that he had reason to expect skullduggery that an investigation concluded wasn’t there in this instance, was it because of frequent lies by high officials in other contexts, that were especially suspicious to Rick Bright in those who were politically other?