Friday, May 17, 2013

Tricking Thanatos or kidding ourselves

What a pleasure it is to wake up from a deep dream.  Life seems so full of possibility afterward.

Earlier in the week it felt anything but.  I was exhausted from lack of sleep.  Then I tend to fixate.  Someone had posted to a listserv I follow occasionally with a recommendation for people to take risks in their work lives.  I wanted to respond that unless you're Jason Bourne or Jack Bauer you don't want to drive on the wrong side of the road.  I normally have the urge to post thoughts, but I suppressed it this time out of fear of regretting it later.  Evidently, there are some risks you don't want to take.

Another object of fixation was on the question of whether someone close to the deceased should control themselves at the funeral and bottle up any emotions they have.  The first funeral I attended was in 1971 after my Uncle Dan passed away from Leukemia  My father and he were partners in a law firm.  My dad did break down at the funeral.  My Aunt Gertrude got quite angry at this.  She was a cold fish.  We never liked her very much.  I broke down at each of my parent's funerals when I was to say a few words to those in attendance.  With my dad I didn't anticipate it.  Though I'm entirely areligious, with my mom I wanted a Rabbi at the funeral, armed with the memory of the prior experience.  It was the right call. 

Earlier this week there had been the funeral of Marianne Ferber, a former colleague in the Economics Department and a near contemporary of my mom.  All the relatives who spoke were quite gracious in their remarks, and there was an especially humorous letter read from Bob Ferber to Marianne, his wife, written in 1980, a tongue in cheek pose as a member of the Moral Majority, urging passage of the ERA immediately, before women take over entirely and after which men will have nowhere to turn.  For me what was most noteworthy at the service is that each of these presenters maintained full composure.  I wonder if that is the norm at funerals in spite of strong feelings about the deceased.

Then there have been so many disparate things in the news recently either about life shortening or life prolonging activity.  Among these are the rapid increase in the suicide rate since 2000, particularly among people who are approximately my age, and it's relationship to the economic downturn and austerity in fiscal policy.  Add to that the Angelina Jolie thing and the Chris Christie thing.  And a high school classmate pointed out that quite recently Vermont has passed Aid In Dying Legislation

I wanted to provide a framework with which to be able to consider all these experiences in one fell swoop, in order to render some opinion on them.  It's hubris, no doubt, but I felt uniquely positioned to do that.  I have been in the avelut phase of mourning since the end of December, so I have been grappling with related issues for quite some time.  Further, I have the inclination to come up with framing questions and from that perform an analysis that has eluded others and offers them some insight.  Alas, while I did have a couple of framing questions I failed to do anything with them.  These experiences ultimately seemed too disparate to put under one umbrella.

But I think the framing questions useful in themselves so I will pose them here.  First, whose decision is this to make, only the individual and the immediate family, or is there a significant social interest as well?  The piece I linked to about austerity and its connection to suicide certainly makes it seem like there is a social interest in that case.  What about in the other cases?  Second, do we make good decisions or are we apt to make serious mistakes?  Here I have in mind Daniel Kahneman's Thinking Fast and Slow, where he argues we have a tendency to come to quick decisions based on our intuition and not go through the mindful and more deliberate process of fully working our way to the conclusion.  We are frequently guilty of WYSIATI (What you see is all there is).  In Angelina Jolie's case, the memory of the early passing of her mother at age 56 quite possibly trumping other information in coming to the conclusion she did.  And we are particularly poor in reasoning through information where randomness is an important part of what we observe, attributing too much causality the normal mistake we make.

Further, the statistical information available in the health arena should often be taken as highly contingent, and the best opinion based on that information might be overturned when new data are available.  For example, on the same day as the Angelina Jolie Op-Ed, there was this Editorial about Salt, the benefits of consuming it in contrast to the "conventional wisdom" to restrict its consumption lest it lead to a heart attack.  My brother, who is an MD and a PhD, used to joke that in the even numbered years consuming eggs was good for you and in the odd numbers years it was not, presumably a knock on clinical research.   I'm afraid that even well train physicians can be guilty of WYSIATI and that short of having a PhD in Statistics and perhaps not even then, the issue of what the data show and what to do as a consequence is quite challenging, perhaps too challenging for the vast majority of us. 

With those caveats out of the way, let me discuss each of the pieces individually and my connections to them. I suspect that most of us have some sort of connection to several of these pieces, if not all of them.  Though I can't provide a uniform framework, perhaps discussing these connections will help others think through theirs.

On the increase in suicide rate, in thinking about this one will soon turn to the labels we have from the abortion issue, either pro-choice or pro-life, and realize that these labels prove highly ironical or entirely dysfunctional, with the correlation that pro-choice people tend to be for more fiscal stimulus and pro-life people tend to be for austerity.  The labels Liberal and Conservative get the correlations right but they don't say much at all on the underlying principles for why the correlations occur.   

On this matter I think Paul Krugman is quite helpful.  I'm a regular reader of his NY Times column and especially since the start of The Great Recession, I have been in pretty much agreement with what he says.  Abstracting from the uber rich, who have financial reasons to want austerity - they are creditors holding a lot of debt, the real value of which would erode if there were substantial inflation - the Average Joe Conservative is motivated in support of austerity for quite different reasons.  A big one is that it is a kind of penance that the nation must go through for the over indulgence of the previous decade.  On a personal level, I'm all for penance.  The problem, of course, with this as a policy prescription given that the economy is performing poorly is that austerity has this mysterious Keynesian multiplier effect in reverse - the none-to-healthy economy grows at an anemic rather than robust rate because aggregate demand is too weak.  Further, the pain is borne disproportionately by the unemployed.  Among those who are long term unemployed, have spent down their entire savings, and who had higher aspirations because they were once part of the middle class, the situation is desperate.  No matter your political leaning, one can agree that suicide for a physically healthy person is an act of desperation, somebody unable to see a path of return to the good life.

Conservatives might agree with that last sentence, yet vehemently deny the Keynesian multiplier or, even if they concede on that point might argue that overall it is still good to slash the social safety net, because by and large people get what they deserve.  We tend to think the gridlock in Washington is a consequence of the truculence of the politics of our representatives and the lobbyists who manipulate them like mannequins.  On guns, this seems to me a correct view.  On fiscal policy, I think otherwise.  If the contrast between the students to whom I've taught intermediate microeconomics (the last time was spring 2011), who on the whole were far more Conservative than I am, is any indicator of the national picture, then the gridlock in Washington is a consequence of a lack of consensus among the populace on the matter.  If that is right, I'm not sure what to do about it.  One might hope that thoughtful Conservatives would come around to a Keynesian view here, but I wouldn't hold my breath on that one.  And for that to happen, Krugman (and Brad DeLong) are the wrong messengers to achieve this end.  There is too much animus built up over a very long time to expect them to generate some meeting of the minds.  Further, leading serious Conservative economists, like Greg Mankiw and John Taylor, simply don't agree. 

This is probably too much economics, especially given the subject matter of this post, so let me turn to a personal view and stick with it for the remainder of what I have to say, much of which is about my relationship with my mom and some of it is about me directly. 

My mom had a radical mastectomy when I was a kid.  My memory on this is not perfect but I believe it happened in spring of 1961.  The following summer my parents took a world-wind tour visiting relatives in Denmark, England, Israel, and South Africa.  If the date is right, at the time I was six and my mom was thirty eight.  She lived to be ninety two, so in that sense it definitely worked.  Yet it had many indirect consequences, some of which impacted me in a profound way and not always for the good.  Here are two.  A couple of years later, when I was in the third grade, I got to play the Sheriff of Hokum County in Bandit Ben Rides Again and sing a song in front of an audience of people I did not know, probably the last time I ever did that. I learned from my mom many years later that the teacher was onto the fact that she had cancer and I got the role not for my prodigious talent as a thespian but rather to give a warm moment to my mom, who deserved a few of those.  This one is totally benign and, I think, every teacher who knew the facts would do likewise.   Yet it also was an indicator of things that followed.

Sometime afterward, my mother became convinced that she was near death.  The cancer would return and that would be that.  That conviction became the basis of much else that she did.  One of those things was to cajole me some years later into having a faux Bar Mitzvah.  I didn't go to Hebrew School so there was no chance of a real ceremony, but there was nothing to prevent having a big party to celebrate my thirteenth birthday, whether I had become a man or not.  I wasn't particularly enthusiastic for this, but I wasn't dead against it either.  As a thing itself, it was probably the right thing to do.  But the way it came about was not good and it had a significant impact on what followed.

Probably every kid who goes through adolescence has some period of rebellion in them, but mine hit particularly hard.  A big part of the reason is that my mom saw it as her role to make important life decisions on my behalf and I disagreed with them.  Here I'm talking about which school to attend and how I should go about being a good student.  This impacted me so negatively that after her funeral this time period is what I'm focused on rather than on the thirty plus years that followed where I'm an adult and she is retired and I have quite a different and happy relationship with her.  It took kind of an epiphany to get past that experience from my teen years and focus on what came later. 

Now let me return to the Angelina Jolie piece.  My immediate reaction to it was not based on this experience as a kid.  Rather I tied it to last fall when I spent 5 days in the hospital for an infection in my shoulder (but fortunately not in the bone).  I had previously had rotator cuff repair and this was a complication that followed.  There  was a bit of a fiasco near when I was to leave the hospital.  It concerned my care thereafter.  Would the infection be treated by a pill or intravenously via a PICC line?  The confusion arose out of lack of communication between the various doctors.  It eventually got resolved but the experience frightened me a great deal and I needed to get it out of my system, so I wrote a post in Facebook called The Fear of God, available only to my Facebook friends.  One of them, herself having survived a bout with cancer, wrote a comment:

You have taken a very powerful step with the help of your wife - advocating for yourself. Be strong.

There was a very similar line in the Angelina Jolie piece.  I reacted strongly to it.  It's what made me think about good decision making.  I wonder if this line or something like it has become a mantra for cancer patients who are not terminal.  I don't know but it seems possible.  My health threat is not ongoing.  The infection is long gone and I've been out of physical therapy for a while.  So I have not taken this line for my own.  It may be absolutely necessary for someone who does experience cancer.  But here's the thing, it is not sufficient to conclude that a resulting important decision will be a good one.  Being strong is not the same as thinking it through.  

Anybody who knows me well is aware that I second guess myself.  I certainly did about my relationship with my mom during the teen years.  But I've also done quite a bit of this about my work life, particularly when I was a campus level administrator,  and I continue to do so about decisions I made 10 to 15 years ago, even now having been retired for almost three years.  If volume of activity leads to expertise in an area then I'm an expert in regret.   You can't know all the derivative things that will happen as the consequence of an important decision at the time you make it.  But you can, having come to the choice via WYSIATI, reflect more on some of the consequences and see if there is possibly another path that might be tried so as to avoid the more pernicious outcomes.  

My mom had breast cancer at the time she had the procedure, so there was no other path.  In the case of Angelina Jolie, she made an elective choice. My goal here is not to Monday morning quarterback that choice.  It is only to point out that to know whether it was a good choice or not we'll likely have to wait to read the memoirs by one or two of her kids, after they've grown up. 

Let me turn to the Chris Christie thing.  I don't believe he has a Yiddish bone in his body, but he and I have something significant in common.  We're both fressers.  We grew up with overeating a source of pleasure.  Sometime later we "learned" to use eating the way little kids use a blanket for security.  Aside from the pleasure eating afforded, it was a way to manage stress.  If eliminating the stress itself is not an option, the question is whether there are other more healthful ways of dealing with stress.  Exercise always pops to the the top of the list when this issue is discussed.  I think it is part of the solution.  Writing might well be another part - to get the worries that are bottled up outside oneself.  

The first step in moving to a healthier life style is a serious diet.  I did that between college and grad school, losing about 60 pounds that summer.  I did that on my own without any doctor's supervision and no medication to curb the appetite.  My younger son did something similar last summer before he became a freshman in college, but he was part of a well supervised diet run by our healthcare provider and while he did that my wife also participated.  In my case, I was able to maintain a healthier approach for about 25 years and stay at a normal weight.  After that my weight drifted upwards till I again became obese.  There were are variety of reasons.  

The first, probably, was lack of sleep.  Being a young parent is wonderful in many respects, but there is a zombie-like aspect to it because the baby needs to be fed or have a diaper change in the middle of the night.  Anybody can deal with that for a short period of time but when it happens over a few years your defenses wear down and your worst instincts can emerge again.   Then I had to stop jogging, which had been a great stabilizer for me.  My knees eventually hurt too much to jog.  My mistake at that point was not to find something else to substitute.  I never liked swimming that much, particularly as an adult, because without my glasses the world is one big blur.  But I could have taken up power walking or used the equipment at the Gym (there was a rowing machine, for example) and gotten some aerobic workout that way.  Instead I went cold turkey, a blunder for sure.  

The third factor was switching from being a professor to a campus level administrator, seeing my workload explode with everything seemingly having to be done immediately, and with my role much more visible to others so that I constantly felt responsible to produce reasonable outcomes.  As a consequence the stress was ever present.  At the same time much of this work I enjoyed because there was novelty for me so I learned a great deal and I seemed reasonably good at it.  It certainly wasn't all doom and gloom.  It was, however, on the weight front.  

I have now reached the point where I'd like to see if I can replicate in some way what I went through after college.  For me this would not be about prolonging life.  I have "good genes" in that my cholesterol numbers are excellent and now my blood pressure is normal too.  But I've got pretty bad arthritis in the hips.  Taking the weight off would obviously ease the pain there quite a bit.  I've vowed to myself to do this once the pain in my shoulder subsides a bit more.  There is no pain at rest.  But when I do my stretching exercises it hurts still, not as much as it used to, but certainly it's noticeable.  When I'm a little closer to normal, the diet will be the next step in the agenda.  

What is one to make of the lap band procedure that Christie had?  In my way of thinking it is like imposing a diet when the will isn't quite ready to do so.  Once the procedure has occurred the discomfort from eating too much then serves as a ready reminder to eat less in the immediate future.  In that sense it has an eerie resemblance to A Clockwork Orange.  So one wonders whether it is treating only the symptom, not the cause.  The real issue then is not just diet, though that is important.  Equally important are what other things Christie changes in his lifestyle to manage the stress and become healthier.  On this front, the sensible thing in my view would be for him to take a year off after his current term as Governor concludes and devote that year to his physical well being.  During that time he'd get out of the spotlight entirely.  Perhaps he'd hire a personal trainer and a diet coach.  The goal would be to reach a normal weight before resuming any of the politics.  Who knows if that will happen?  But I think it next to impossible to try to do this in parallel, while he is making a bid for the Presidency.  Changing deeply ingrained habits is not like flipping a switch.  It's difficult and takes a lot of time. 

Finally, let me discuss the Vermont thing.  I found it instructive to do a Google search on "Hospice and Medicare" (without the quotes) after which the first document you find is this one, a pdf from the Government on what opting for Hospice means and how the Medicare coverage for it works.  It is a choice for somebody who is near end of life.  It is not the only possibility.  One can continue with regular Medicare coverage as an alternative and try to fight the illness till the end.  In this way of thinking, the Vermont thing offers a third alternative.  It is available only to people who have their marbles (so not to dementia patients like my mom).  That third alternative might be best if the person has lost control of bodily function and doesn't want to experience the indignity of that or if the person is in pain so intense that the alternative is to be mind numbed by drugs to endure.  It seems an entirely different animal to suicide out of desperation from poor economic circumstance.  As such it seems humane, not a cop out. 

Unfortunately, it doesn't help in the situation my siblings and I experienced with my mom, when the dementia has progressed far enough that there are no more lucid moments yet at a biological level end of life is not imminent.  When I was cleaning out her condo I found a longish document from a doctor written in the mid 1990s that there was evidence of dementia then.  I hadn't seen that document before.  I previously thought the episode she went through at the time - she was out of it for about a month but then did return to normal - was entirely due to too much medication and what she showed then was in essence an allergic reaction to that.   I was wrong in my belief.  

After my dad passed away my mom had a couple of years of normalcy - although she would repeat the same thing over and over - and then the dementia gradually took over.  By 2007 when I'd visit she would not know who I was, couldn't speak, and would have a stupefied look on her face.  The health issue for us was this.  She was prone to get skin cancers.  If those were treated early they would not be life threatening.  If left to fester they would spread and cause other problems.  What was the right course of action to take?  Whose decision was this to make?  My mom passed away in December 2012.  Based on that you can get some sense as to how those questions were answered. 

In discussing the rise in the suicide rate among my contemporaries, many experts have pointed out that the stress on baby boomers is something new, because in addition to worrying about the welfare of their own families they have to worry about the well being of their parents who are still alive.  For previous generations, the parents would have already been gone.  Our laws and our sense of ethics give insufficient guidance on what to do when the parent can no longer make the decisions.  This is the issue of our time that we need to talk about a lot more and then come to some sensible meeting of the minds rather than have each of us individually reinvent the wheel, which is what we seem to have now.

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