Month: August 2019

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America remains in the grip of an opiate* epidemic. Over 70,000 Americans died from legal and illegal drug overdose in 2017 alone, more than four times higher than in 1999.

The tragic history of this crisis was carefully documented by investigative journalist Sam Quinones in his 2015 work, Dreamland: The True Tale of America’s Opiate Epidemic.1 Cast members in this drama represent a cross section of human society, from Mexican laborers to executives of multinational corporations. A sobering element of this story is that the American medical community bears much responsibility for the crisis. This example serves as both a lesson and a reminder that sometimes the scientific community can err en masse. In previous posts we examined pitfalls in belief formation and the perils of overconfidence from a theoretical perspective. This story underscores the dire consequences of ignoring these principles—in this case by highly educated professionals. We will focus on two salient biases: information cascade and confirmation/disconfirmation; and two nonrational contributors to belief formation: moral grandstanding and economic self-interest

Information Cascade

Experts once widely accepted the notion that opiate narcotics were highly addictive. However, some people questioned the idea in the early 1990s as a movement gained traction to treat pain with aggressive medication. A powerful new belief ignited and sustained the boom in narcotics; namely, that addiction from prescribed opiates was actually quite rare. Yet, there was never any evidence for this belief, and considerable evidence to the contrary.

The wildfire was unwittingly sparked by an innocuous five-sentence letter to the editor in the 1980 New England Journal of Medicine.2 The authors commented that new addictions seemed to be rare in hospitalized patients receiving low doses under direct supervision with no prior history of addiction. In ensuing years, this source was repeatedly cited, then those sources were cited, snowballing into a widespread false consensus regarding the low risk of addiction.

By early 2017, over 400 scientific papers had cited the letter as evidence that addiction from prescribed opiates was rare.3 It was a classic information cascade. Physicians were not basing their opinion on the evidence but on what other experts said, who were themselves biased by earlier opinions. Almost no one, it seemed, knew or gave much thought to what the original citation actually said. (And it was a letter, not a clinical investigation!)

As a consequence, almost 218,000 Americans died from prescription opioids between 1999 and 2017, while the annual fatality rate rose 400% over the same period.

Confirmation/Disconfirmation Bias

Throughout my medical training and early years in practice, physicians generally agreed that narcotics were potentially addictive and should be used with restraint. This belief wasn’t necessarily based on hard data, but the stream of addicts passing through the healthcare system left little room for doubt. That was anecdotal evidence, but it was evidence, nonetheless.

But physicians were not emotionally invested in withholding narcotics; in fact, quite the opposite. Restraint was the path of greater resistance. Liberal prescribing took less time, gratified patients, and left one with a sense of accomplishment. The new paradigm—we could dispense without concern—was liberating. But how could we justify it scientifically?

Confirmation bias is the tendency to favor evidence in support of one’s own position. If a doctor wanted to prescribe opiates freely, scientific papers in support of that position were proliferating due to the previously mentioned information cascade. As we noted, it was faulty yet adequate evidence if someone really wanted to believe it.  

Disconfirmation bias is the tendency to dismiss evidence against one’s belief. What about all the addicts? In the case of opiate addiction, physicians began to argue that opiates didn’t cause the addiction; rather, those who were already addicts sought out the opiates. That was a false dilemma between two partial truths, which is why the deception was so persuasive.

Moral Grandstanding

A powerful driving force behind the rise in prescription narcotics emerged from the belief that too many patients suffered unnecessary, easily treatable pain. Convinced that the risk of addiction was low, there was no downside to liberal use of narcotics. If narcotics were safe, it was virtuous to prescribe them and heartless to withhold them.

Interns and residents were taught that these drugs were now not addictive, that doctors thus had a mission, a duty, to use them.4

Once framed in moral terms, the stage was set for moral grandstanding and ramping up. Consequently, physicians and health care organizations competed in expressing their zeal for pain remediation. By 1998, over 1000 multidisciplinary pain clinics had been established. They vanished almost as rapidly, as the increasing use of narcotics effectively eliminated the need for multiple disciplines.5 Other social influences kicked in. As the epidemic unfolded, physicians faced increasing pressure from patients while accreditation agencies demanded proof that they were relieving pain—and that meant more narcotics.6

Economic self-interest

One particular drug occupied the epicenter of the prescription drug crisis: OxyContin, a slow-release preparation of oxycodone. This was a proprietary product of Purdue Pharma, privately held by the Sackler family. Upon the release of OxyContin in 1996, Purdue unleashed a sales and marketing juggernaut to aggressively promote it. According to Quinones:

Purdue set about promoting OxyContin as virtually risk-free and a solution to the problems patients presented doctors with every day.7

Eleven years later, Purdue Pharma pled guilty for, among other things, misrepresenting OxyContin’s abuse potential, for which it was fined over $600 million.8

Complicit physicians, driven by greed, began and continue to run prescription mills in some of our most vulnerable communities. Many have been caught, convicted, and sent to prison. But it’s a lucrative business and demand is virtually unlimited. In April of 2019, the biggest crackdown to date charged 60 healthcare providers in rural Appalachia with the illegal distribution of narcotics.9 As many as 32 million pain pills were distributed, and at least five patients died.

Inside each of us runs a highly tuned excuse factory, efficiently manufacturing plausible beliefs to justify our own behavior.

At this point, some may object, “What does belief have to do with it? They knew they were doing wrong and did it just for the money.” This may indeed be true for genuine psychopaths but is otherwise a one-dimensional view of human nature that overlooks our compelling need and skill for self-rationalization. Inside each of us runs a highly tuned excuse factory, efficiently manufacturing plausible beliefs to justify our own behavior. According to the science of human nature—and ancient scripture (“Every way of a man is right in his own eyes” Proverbs 21:2, KJV)—most perpetrators probably believed they were not doing wrong.

A lesson for us all

While science is our best source for understanding the physical world, physicians and scientists are subject to the same cognitive pitfalls as everyone else. In certain circumstances, they err communally with potentially disastrous consequences. Familiarity with the science of belief can help us to discern when a prevailing consensus should be questioned. Is there emotional investment? Moral grandstanding and ramping up? Peer pressure? Information cascade? Economic self-interest? We all must endeavor to avoid these traps.

In this case, silence was complicity. Had more people been willing to speak up and challenge the paradigm, the false consensus surrounding opiates might have been thwarted, sparing thousands of lives. It takes courage to stand against the crowd—after clearing the logs from our own eyes—but sometimes it is morally necessary.

Beliefs have consequences. False beliefs have worse consequences. Intellectual humility is the first line of defense. After all, just because we think doesn’t necessarily mean it’s true.

*Note: for purposes of this article, “opiate,” “opioid,” and “narcotics” are basically synonymous. For precise definitions, click here.

Endnotes

[1]. Sam Quinones, Dreamland: The True Tale of America’s Opiate Epidemic (New York: Bloomsbury Press, 2015).

2. Jane Porter and Hershel Jick, “Addiction Rare in Patients Treated with Narcotics,” New England Journal of Medicine 302 no. 123 (January 10, 1980): doi:10.1056/NEJM198001103020221.

3. Pamela T. M. Leung et al., “A 1980 Letter on the Risk of Opioid Addiction,” New England Journal of Medicine 376 (June 1, 2017): 2194–95, doi:10.1056/NEJMc1700150.

4. Quinones, Dreamland, 95.

5. Quinones, 109.

6. Quinones, 98.

7. Quinones, 127.

8. Barry Meier, “Origins of an Epidemic: Purdue Pharma Knew Its Opioids Were Widely Abused,” New York Times, May 29, 2018, https://www.nytimes.com/2018/05/29/health/purdue-opioids-oxycontin.html.

9. Terry DeMio, Dan Horn, and Kevin Grasha, “Ohio, Kentucky Doctors among 60 Charged in Pain Pill Bust Acted ‘Like Drug Dealers,’” Cincinnati Enquirer, April 17, 2019, https://www.cincinnati.com/story/news/2019/04/17/opioid-pain-pill-federal-prescription-bust/3482202002/.

Most of us think we’re smarter than most of us! In a recent large survey, 65% of Americans rated themselves more intelligent than average.[1] [Sounds of unrestrained laughter, barking, and howling – the Spaniel and pals]. Believing we’re very smart, we assume we’re usually right. But is that confidence warranted?

“Do you see a man wise in his own eyes?
There is more hope for a fool than for him.”

Proverbs 26:12

In the course of my medical career, I have known brilliant physicians of many different faiths. Among the most committed adherents, it is safe to say that all were quite sure regarding the truth of their particular faith. But each tradition contradicts all others in one or more matters. They could all be wrong in part or in whole; they cannot all be right. Logically, we must conclude that not only is it possible to be brilliant, certain, and wrong, but that it is common.

In the previous post, we looked at several nonrational factors that can lead to false beliefs: heuristics and biases, emotions, and social influences. We noted that education and intelligence are unreliable predictors of rational thinking.

Yet false beliefs comprise but one side of the coin. The other side, of equal or even greater importance, is the level of certainty attached to those beliefs. Confidence is our estimate of the probability that we are correct. It is a belief concerning our belief—metacognition, in psychological parlance.

The Illusion of Certainty

Ideally, our confidence should be roughly proportional to the mathematical probability that we are correct. In other words, if we are 90% certain, we should be right 90% of the time. But studies repeatedly show that our degree of certainty consistently exceeds our accuracy. For example, people who are “99% sure” are wrong 50% of the time. This disparity both defines and demonstrates the phenomenon of overconfidence. Our unwarranted certainty could be blamed on misplaced trust; that is, by placing too much credence in an unreliable source. However, since we tend to favor sources we already agree with (confirmation bias), excess certainty usually reflects an excessive faith in ourselves (pride).

In his 2009 tome On Being Certain, neuroscientist Robert Burton argued that certainty is not a state of reason but of feeling, influenced by unconscious physiologic processes.[2] Certainty is mostly illusion, Burton argues, and there is considerable evidence supporting this hypothesis.

Overconfidence has been demonstrated and measured in many domains besides intelligence: driving ability, economic forecasting, and medicine, for example. In almost every domain studied to date, significant majorities express a confidence in their abilities far beyond what is warranted, or even mathematically possible. [“Like my distant cousin who somehow still thinks he can catch a car” – the Spaniel].

Sometimes, the least competent people are the most confident, whereas the most skilled and knowledgeable people slightly underestimate their ability. This phenomenon has been dubbed the “Dunning-Kruger” effect, after the original researchers whose landmark paper, “Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments,” not only opened a new avenue of research but has prompted many a smile from those who sensed its ring of truth.[3]

The Intelligence Trap

Highly intelligent people constitute another group with an elevated risk of overconfidence. Intelligent people know they are intelligent, making them less likely to doubt themselves, respect other opinions, or change their minds. They are also every bit as attuned, if not more so, to social influences that motivate belief.[4]

Highly intelligent people can and do believe crazy things. Sir Arthur Conan Doyle, creator of the ruthlessly logical Sherlock Holmes, was a devout believer in spiritualism and fairies. [“I once knew a Border Collie who claimed he’d been abducted by penguins” – the Spaniel]. Albert Einstein expressed a naïve and unshakeable optimism concerning Lenin, Stalin, and the Soviet Union:

I honor Lenin as a man who completely sacrificed himself and devoted all his energy to the realization of social justice. I do not consider his methods practical, but one thing is certain: men of his type are the guardians and restorers of humanity.[5]

In The Intelligence Trap, science writer David Robson informs us that:

  • College graduates are more likely than nongraduates to believe in ESP and psychic healing
  • People with IQ’s over 140 are more likely to max out on their credit
  • High IQ individuals consume more alcohol and are more likely to smoke or take illegal drugs[6]

While the popular perception is that intelligent people are naturally skeptical, in fact all humans are believing machines. We drift with the cultural tides, embracing popular ideas on the flimsiest of evidence, then clutch those beliefs tenaciously to protect our egos, strut our virtue, justify our actions, and advertise loyalty to our in-group. This view may seem cynical, but it is well-validated.

There are many strategies for overcoming the “intelligence trap.” They include cognitive reflection, actively open-minded thinking, curiosity, emotional awareness and regulation, having a growth mindset, distrusting the herd, and consistent skepticism. However one habit of mind undergirds all others: an attitude of intellectual humility.

Knowing Our Limits

Intellectual humility could be defined as merely having a realistic view of our mental processing; viz., that our knowledge is inevitably limited, our thinking is unavoidably biased, and that even the smartest among us are prone to error.[7]

In recent decades, psychology has embraced a model of personality based on the “big five”: openness, conscientiousness, extraversion, agreeableness, and neuroticism. The more recent version adds a sixth measure: HH, for honesty-humility. Researchers have demonstrated that HH shows a consistent negative correlation with all three elements of the “dark triad”: psychopathy, narcissism, and Machiavellianism.[8] [“We just call that ‘being a cat’” – the Spaniel]. On the other hand, HH correlates positively with healthier traits such as cooperation and self-control.

In a 2018 paper from UC Davis, researchers showed that intellectual humility is associated with openness during disagreement, and that promoting a growth mindset served to enhance intellectual humility.[9] Intellectual humility also helps to reduce polarization and conflict.[10] In one study, it was even superior to general intelligence in predicting academic achievement.[11]

Research Affirms Scripture

According to most theologians in the Judeo-Christian tradition, pride is the deadliest sin. Humility is its opposite. It may be tempting to assume this peril concerns only the skeptic, but it’s not just about “them.” It’s about all of us. And the greater the visibility or the higher one’s position in Christian circles, the greater the problem is likely to be.

“Do not be wise in your own conceits.”

romans 12:16, KJV

Scripture repeatedly warns against unwarranted confidence in our own wisdom. Decades of research in cognitive science shows this to be a common human problem that only worsens with intelligence. The antidote begins with intellectual humility, an ancient virtue whose wisdom has been validated by the latest empirical data.

Article also posted (without canine commentary) at Reasons to Believe on August 9, 2018

Endnotes

[1]. Patrick R. Heck, Daniel J. Simons, and Christopher F. Chabris, “65% of Americans Believe They Are above Average in Intelligence: Results of Two Nationally Representative Surveys,” PLoS ONE 13, no. 7 (July 3, 2018): e0200103, doi:10.1371/journal.pone.0200103.

2. Robert Burton, On Being Certain: Believing You Are Right Even When You’re Not (New York: St. Martin’s Press, 2008).

3. Justin Kruger and David Dunning, “Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments,” Journal of Personality and Social Psychology 77, no. 6 (January 2000): 1121–34, doi:10.1037//0022-3514.77.6.1121.

4. Dan M. Kahan, “Ideology, Motivated Reasoning, and Cognitive Reflection,” Judgment and Decision Making 8, no. 4 (July 2013): 407–24.

5. Lewis Samuel Feuer, Einstein and the Generations of Science 2nd ed. (New Brunswick, NJ: Transaction Publishers, 1989), 25. [JA10] [SW11] 

6. David Robson, The Intelligence Trap: Why Smart People Make Dumb Mistakes (New York: W. W. Norton & Company, 2019).

7. Peter C. Hill et al., “A Few Good Measures: Colonel Jessup and Humility,” in Everett L. Worthington Jr., Don E. Davis, and Joshua N. Hook, eds., Handbook of Humility: Theory, Research, and Implications (New York: Routledge, 2017).

8. Joseph Leman et al., “Personality Predictors and Correlates of Humility,” in Worthington, Davis, and Hook, eds., Handbook of Humility.

9. Tenelle Porter and Karina Schumann, “Intellectual Humility and Openness to the Opposing View,” Self and Identity 17, issue 2 (August 9, 2017): 139–62, doi:10.1080/15298868.2017.1361861.

10. Porter and Schumann, “Intellectual Humility.”

11. Bradley P. Owens, Michael D. Johnson, and Terence R. Mitchell, “Expressed Humility in Organizations: Implications for Performance, Teams, and Leadership,” Organization Science 24, no. 5 (February 12, 2013): 1517–38, doi:10.1287/orsc.1120.0795.



Feeling blue? Tried therapy and medication? Here’s a radical thought: try visiting your local church next Sunday.

A new study adds further evidence to what we have known for quite some time: going to church is good for your mental health. Last Thursday, the Irish Longitudinal Study on Ageing issued a press release announcing its latest findings. Following over 6000 adults aged 50 and over for six years, they found that regular church attendance (mostly Catholic in this group) was strongly associated with a lower incidence of depression.

“Although we did not find longitudinal evidence for a causal effect between religiosity and mental health, we found a robust association between religious attendance and lower depressive symptoms at baseline.”

The researchers found that this benefit could be partially, but not entirely, attributed to higher levels of social engagement. Religiously minded individuals who did not attend services were actually worse off. (The study design was unable to determine why that might have been so, leaving ample room for speculation but no evidence).

Human behavior and religious faith are both highly complex matters, making it nearly impossible to tease out the exact connection between religion and mental health. Is it merely the social engagement? In this study, that only partially explained the benefit. Would this apply to every church? Probably not, considering that many are admittedly dysfunctional. Should one “embrace a lie” just to enjoy the benefits? Be honest. There’s plenty of good evidence for God. To believe or not is a matter of choice. How about non-Christian faiths? A few studies show similar benefits; though again, it probably depends on the details.

Despite the complexity of the matter, the accumulated research is sufficiently compelling that psychologists can conclude:

“The amassed research indicates that higher levels of religious belief and practice (known in social science as “religiosity”) is associated with better mental health. In particular, the research suggests that higher levels of religiosity are associated with lower rates of depression, anxiety, substance use disorder, and suicidal behavior. “

Religious faith could even save your life. There is a powerful connection between church attendance and reduced risk of suicide. Writing in the July 2019 Wall Street Journal, Erika Andersen reported:

“A 2016 study published in JAMA Psychiatry found that American women who attended a religious service at least once a week were five times less likely to commit suicide…. It’s true that correlation doesn’t prove causation, but there’s strong evidence that people who attend church or synagogue regularly are less inclined to take their own lives.”

Our most current understanding regarding the cause of depression offers further explanation why religious faith – particularly Christian faith – may be protective. The most effective and enduring treatment available is cognitive therapy. In its simplest terms, this means learning to break through mental habits of despair, self-absorption, and self-abasement. Strange as it may seem to some, this means thinking Biblically:

Rejoice in the Lord always. Again I will say, rejoice!

Philippians 4:4
  • Instead of despair we find hope. (Romans 5:2)
  • Instead of self-absorption, we are to embrace humility and concern for others. (Philippians 2:3)
  • Instead of self-abasement, we find unconditional forgiveness and can stop comparing ourselves to others. (Romans 4:7)

So, if you’re attending regularly, good for you! Look out for new visitors and make them feel welcome. Pay them a visit, or at least a phone call. Haven’t been in a while? It’s never too late to go back. Everyone will be happy to see you. Tried and it didn’t work? Try a different church. Never been and wouldn’t know where to start? Ask someone you know, or look for one with a lot of cars in the parking lot. Someone may greet you, or no one may, but fill out that little card and you may get a friendly call or visit.

[“Speaking of mental health, aren’t you forgetting someone?” – the Spaniel. “Never, little buddy” – me.]

The secret is out. Going to church is good for your health!