A brief observation about Max Weber (hottest of takes) — July 29, 2018

A brief observation about Max Weber (hottest of takes)

There’s a weird disconnect between the most widely read of Max Weber’s works, and what I understand to be the most influential. Granted that I’m not a professional sociologist, but most of what I see cited among Weber’s works are “Politics as a Vocation,” containing Weber’s famous definition of a state as a human community claiming a monopoly over legitimate violence in a defined area; and “Bureaucracy,” which contains Weber’s description of the modern civil service and contrasts it with older forms of government where people claim office through, for instance, family relationships. (By the way, I’m not sure if I ever endorsed Francis Fukuyama’s The Origins of Political Order and Political Order and Political Decay. They take those two essays of Weber’s as their starting point, and they’re really exceptional books—the first more than the second.)

All of which is to say that the works of Weber’s that people still care about are those which map out the functioning of modern government in industrial democracies, whereas the main work of Weber’s that everyone is expected to know is The Protestant Ethic. The thing about The Protestant Ethic is that it’s not very good. At best it feels like an observation about a historical curiosity: this particular thing (the Industrial Revolution) happened in these specific societies (Protestant ones), but not in these others (Catholic ones, or in Asia) during this specific window of time (the early 1800s). So what? Other nations (Japan and South Korea, say) have also industrialized, with vastly different backgrounds. Protestant Ethic has some things going for it, among them that it contrasts the intentions of the individual actors with the aggregate outcome of their behaviors: early-modern Protestants practiced thrift and worked hard for religious reasons, and as an unintended side effect they produced the Industrial Revolution. Even if the substance of the argument is wrong, there’s some value in that way of thinking—the same way we often hear that even if Freud is wrong, it was still novel to discover a subconscious. On the other hand, Adam “Invisible Hand” Smith was already contrasting the intentions of the actors with their aggregate outcomes, so this alone wouldn’t be novel in The Protestant Ethic.

In any case, my sense is that Weber’s real long-lasting impact comes from his mapping the structure of modern bureaucratized industrial democracies, not from a (seems to me) rather fanciful story about the origins of the Industrial Revolution. Yet when I told a friend recently that I was reading the classic sociologists, including Weber, but that I was specifically not reading the Protestant Ethic (having read it previously), he arched his eyebrow and gave me a funny look. My hunch is that sociologists would support my approach.

Something similar, it seems to me, is the case with Kafka: the word “Kafkaesque” is normally used to describe interactions with a faceless nightmare state, because the Kafka that people are thinking of there is his story “The Trial”. But the only Kafka that people are assigned in school is “The Metamorphosis”. I wonder how often this sort of mismatch between popularity and import happens.

A quick note on what seems like a misuse of history — July 8, 2018

A quick note on what seems like a misuse of history

I’m working backwards through my podcast queue, having for a couple reasons developed quite a backlog, so I just got to Ezra Klein’s discussion with Yascha Mounk about whether American democracy is in decline. The discussion is worth listening to, but Klein makes an argument that I’ve heard often and that just seems wrong. The argument is basically that if you’re looking at this period in American history and calling it out as singularly bad (because Trump, say), you’re ignoring the vast swathes of American history that have been much worse. Even going back to the 60s, says Klein, we had political leaders (JFK, MLK, Malcolm X, Medgar Evers) being assassinated, we had riots in the streets, and we had Nixon elected in part on a promise to fight lawlessness.

Now, what do you do with this argument? One approach is to ask: if American democracy is in decline, what is that decline relative to? If it’s relative to the 1960s, then maybe we can argue that it’s not in decline, because it’s never been particularly strong. Maybe, in fact, it’s stronger than it was back then.

Sort of a corollary to that argument is: times have been bad before, and we survived those. We’re supposed to infer from this that we’ll survive this particular era of badness.

This sort of reasoning always rubs me the wrong way, and I hear variants on it a lot. George W. Bush was bad, say, and there were those of us (I was certainly among them) who believed for a time that he and Cheney wouldn’t allow themselves to be removed from office. In retrospect that was a paranoid view. Now here we are under the Trump administration, which certainly feels like an era when the U.S. could turn authoritarian. “But you thought the same thing in the Bush Administration,” the argument goes, “and you were wrong then. Doesn’t that make you think you’re wrong now?”

Well, maybe. If nothing else, maybe it should make me question my authoritarian-dar. But there’s no historical law that says “When the level of authoritarian badness is below some threshold x, we have nothing to fear.” And there’s no historical law that says “If our political leaders aren’t being assassinated, U.S. government will survive.”

Maybe you can assemble some notion of historical law, by which when x, y, and z happen, then outcome O is really likely. I’m not sure I reject the possibility of historical law altogether—maybe I do, maybe I don’t—but I certainly have strong doubts that we finite humans know what those laws are. And normally when people advance the “it was worse in the past, and we got through it” argument, as Klein did, they’re not even reaching for a historical law. They have no causal reason to believe that circumstances x, y, and z always (or even often) lead to outcome O. They only have correlation to point to: x, y, and z happened, and as it happens our government also survived it. That’s a very slender reed upon which to support the notion that we’ll get through this era unscathed.

As time has gone on, I’ve come to expect less “use” from history. History is what the mathematicians call an “existence proof”. For instance: we lived through an era when African-Americans fighting for basic access to American democracy were being murdered with impunity in the South, when political leaders were being assassinated with frightening regularity, and when it felt like the political consensus that had bound the United States for decades was coming apart at the seams—and we survived it. Conclusion: it’s possible to survive those things. It’s not guaranteed that we’ll survive those things. The fact that we survived those things doesn’t even make our survival in the future more likely. It just makes our survival possible.

All that said: if you need to treat history as a machine that deterministically churns toward your desired outcome, because that’s what you need psychologically to make it through the day, by all means use that. For me, though, the uses we put history to often feel like facts about our own brains rather than facts about the way the world works.

Recent Reads, 2018-07-04 — July 4, 2018

Recent Reads, 2018-07-04

  • Enrico Moretti, The New Geography of Jobs

    Combines a popularization of some economic theory—of the sort that you’d read in Fujita, Krugman, and Venables, for instance—with the sort of boilerplate that you’d expect out of any popular work of economics nowadays. The author has to travel to see how Innovation is being done in various cities, for instance. This is all just filler. The author is an economist in good standing, and Krugman himself seemed to like it, so who am I to say that it’s underwhelming?

    The basic premise is that we’re being sorted into thriving cities and failing cities, and that this sorting is self-reinforcing: people move to where other college graduates are, for instance, which only reinforces the strength of cities that already contain a lot of college graduates. As a big Boston booster, I’m happy about this. I’m unsure in a couple directions, though. First, the book makes some pretty strong conclusions about San Francisco, Boston, and New York, and on the other side about Detroit and Flint. But what about cities whose economic future is less certain, like Pittsburgh? Other than that these cities are teetering on a knife’s edge, which could lead them to either of two disparate futures, I don’t know what to conclude. As Moretti mentions at one point, economists have a term for this: “multiple equilibria”. For our purposes, this just means that self-reinforcing processes can either lead to self-reinforcing success or self-reinforcing failure. It’s probably good that Moretti didn’t try to make any predictions about the Pittsburghs of the world; predictions are above his pay grade.

    A second question concerns what we’re to do with his Seattle-versus-Albuquerque example. Microsoft was established in Albuquerque but soon moved to Seattle, with fateful consequences for the economic success of the latter city. Albuquerque continues to linger in the doldrums. Seattle rose from a backwater to where it is today.

    So what does that all tell us about Detroit? Is Detroit today like Seattle before Microsoft?

    Maybe the answer is ¯_(ツ)_/¯.

  • Timothy Snyder, The Road to Unfreedom: Russia, Europe, America

    The main thing I took away from this book is that we can only have a functioning democracy if our institutions support a basic respect for the truth. Putin succeeds by destroying the very concept of an objective reality, and by brazenly lying in front of everyone. The connection with Donald Trump is clear, and terrifying.

    This book also pretty firmly cemented for me the idea that Trump is directly in the thrall of the Russian government.

  • Norbert Wiener, God & Golem, Inc.

    I didn’t really understand what was going on here. I also didn’t really understand what was going on in Wiener’s more-technical book Cybernetics. The thing about Wiener is that he’s one of the 20th century’s most brilliant scientists and mathematicians, with a beautiful Victorian style. Ideas that are seemingly quite obvious to him are not obvious at all to his readers, or at least this one.

  • Tim Weiner, One Man Against the World: The Tragedy of Richard Nixon

    I’ve read quite a number of books about Nixon now: All the President’s Men, of course, about the Watergate coverup, and then the same authors’ The Final Days, about the collapse of the Nixon White House that followed on the final Watergate revelations; and then John Dean’s yeoman-like The Nixon Defense, which gets down to the nitty-gritty of what Nixon said exactly when, on which tapes.

    No book before Weiner’s, in my experience, even approaches his skill at connecting the Vietnam War to Watergate. The paranoia of the Nixon White House comes through on every page, and we see the bombing of Indochina escalate in lockstep with the man’s rapid mental decay. I can’t recommend this book strongly enough, both for its important historical clarifications and because it’s written with the driving force of a novel.

  • Kate Manne, Down Girl: The Logic of Misogyny

    This is an astoundingly poorly written book. That’s a shame, because the fundamental premise deserves to be more widely understood: misogyny isn’t about individual people being misogynists. Misogyny, in Manne’s telling, is about what happens when men believe that women owe them something—for instance, affection, or sexual favors, or housework—and that expectation is violated. To quote her list of gender-coded possessions:

    Hers to give (feminine-coded goods and services): attention, affection, admiration, sympathy, sex, and children (i.e., social, domestic, reproductive, and emotional labor); also mixed goods, such as safe haven, nurture, security, soothing, and comfort; versus His for the taking (masculine-coded perks and privileges): power, prestige, public recognition, rank, reputation, honor, “face,” respect, money and other forms of wealth, hierarchical status, upward mobility, and the status conferred by having a high-ranking woman’s loyalty, love, devotion, etc.

    Manne takes this very expansive definition and lets it encompass even such seemingly trivial behaviors as mansplaining. She also counts it as misogyny if your wife cheats on you and you attack the other man:

    when this sense is challenged, thwarted, violated, or threatened, this is often the trigger for misogyny toward her—or, in some cases, violence against male rivals who have trespassed on his supposed property. He might also seize what he thinks he is owed by her: that is, what he is supposed to have been given by a woman, and what is then supposed to be his for the taking.

    Call that misogyny if you will. Whatever it is, it doesn’t seem like misogyny. Manne would probably deny my right, as a male, to tell her what is and isn’t misogyny, so do what you will with this.

    Only if you really enjoy reading lifeless academic prose should you bother with this book. I expect that Manne, in making the rounds of the book-tour circuit, will either talk about this book on a podcast or write up a blog post about it; it would be better to find one of those and save yourself the aggravation of reading this book.

  • G.A. Cohen, If You’re an Egalitarian, How Come You’re So Rich?

    Cohen charts his migration from Marxist to Rawlsian and back to a position that nicely mixes Christianity with Rawls. He argues that you can’t be as indifferent to the individual moral behaviors of individual humans as Rawls would have it—that you need to take something from Christian teaching, and care about the inner life of the human as well. Merely building a basic structure, à la Rawls or Marx, isn’t enough. Merely building a just society isn’t enough; you need to give away much of what you own, as well.

    There’s also something to Cohen’s argument structure that I find enjoyable here. He’ll periodically stop to sketch out an argument of Rawls’s or Marx’s, and write it down in precise “if A then B” form. He intersperses this blueprint-drawing with delightful anecdotes from his own upbringing in Canada and the U.K. This is one of the nicer combinations of abstract philosophizing and real human-interest story that I’ve ever read.

    I moved on from here to Cohen’s Marx’s Theory of History. Somewhat similar structure, but certainly more rigorous and less breezy. I’ve found it slow going.

  • Abraham Pais, Subtle is the Lord: The Science and the Life of Albert Einstein

    I barely understood a word of this. It’s a hardcore scientific biography. If you’re not clear on what a covariant and a contravariant tensor are (and I’m not), then this book will make no sense to you. I’m sure it’s great if you have the right background.

  • Quinn Slobodian, Globalists: The End of Empire and the Birth of Neoliberalism

    As Slobodian tells it, neoliberalism wasn’t born to remove the shackles of government from the market. Instead, it was born to build a protective shield around the market—to protect the market from the twin ravages of nationalism and democracy. As the World Wars ended, empires fell, and a new order had to be established by which free trade would be allowed to function between the newly established states. Meanwhile, the people demanded protection from the market. How could capitalism continue to function when subjected to these new stresses? The market needed to be walled off from democracy. It needed a constitution, by which the people’s ability to interfere with economic order would be strictly controlled.

    This book should probably be read alongside Eichengreen’s brilliant Globalizing Capital. That book maps out what happens to governments as democracy ascends; they no longer have the power to defend exchange rates at all costs, and now must use some of their resources to provide for their people. The gold standard fell away precisely because governments had to listen more to their people. I suspect Slobodian would say that exactly this sort of populism is what scared Hayek and the other fathers of neoliberalism.

  • James Comey, A Higher Loyalty

    Worth reading, if only because everyone talks about it and few people read it. It’s good to be one of the people who actually knows what he or she is talking about.

    I certainly left the book feeling a lot better about Comey than I did before I went in. He paints his career with the FBI as being essentially about preserving the agency’s reputation at all costs. He’s an institutionalist, and he asks us to judge all his actions relative to that goal. The main reason everyone hates him is that he announced to the world, mere days before the election of 2016, that the FBI would be reopening its investigation into Hillary Clinton’s emails. In his telling, he had no choice: had he not told the world about the reopened investigation, after having previously declared that investigation closed, the FBI would be accused of having withheld important information from the American public just before an election.

    If nothing else, it certainly seems that Comey was in a no-win situation. So if nothing else, I have sympathy for the position the man was in.

  • Tim Wu, The Attention Merchants: The Epic Scramble to Get Inside Our Heads

    This is an enjoyable history of 20th- and 21st-century media, framing radio and television and the Internet as, essentially, technologies that trade in a limited currency called “attention”.

  • Bill Browder, Red Notice: A True Story of High Finance, Murder, and One Man’s Fight for Justice

    This is the story of how Browder became the largest foreign investor in Russia and got himself kicked out of the country. We know Browder today because the Russian government tortured and killed Browder’s tax accountant, Sergei Magnitsky. Browder spent months fighting the Obama administration to pass the Magnitsky Act, by which those involved in Magnitsky’s death lose their assets held abroad.

    This book tells the story of Browder’s rise to wealth, the agonizing death of his friend, and of Browder’s fight to ensure that his friend’s death wasn’t in vain. I couldn’t put it down.

Friedrich A. von Hayek, The Constitution of Liberty —

Friedrich A. von Hayek, The Constitution of Liberty

The plainest book cover imaginable: the author's name in black, above the book's title in white, all those words surrounded by three thin white ovals, everything on an orange background

I go back and forth on whether there’s a valuable core to this book, or whether the whole thing is as objectionable as its worst parts. Partly the answer will depend upon whether the book is a prolonged shaggy-dog story, whose useless punchline is something to do with price controls.

Giving the man his due: he uses the word “constitution” advisedly. A constitution isn’t just a set of laws; it’s an outline of the basic structure of a society. It tells us where the government cannot go; it defines a sphere of liberty around each citizen. So if we were building a government that maximally honored the dignity of each citizen, how would we constrain that government?

Among the first constraints we’d impose is the rule of law: when the legislature makes a law, it doesn’t know the specific people upon whom that law will be enforced. In that sense, laws cannot be arbitrary; they must apply to everyone equally. To enforce this impartiality, the people who execute the laws, and those who decide whether laws are constitutional, must be separate from those who write the laws. The legislature writes the laws; the executive branch enforces them; the courts measure legislation for conformity with the capital-L Law.

A world in which the laws are non-arbitrary is a world in which people can make plans. There will still be arbitrariness—a tornado can still flatten your house—but at least there’s order in this corner of the world.

But wait. There are lots of terrible laws which nonetheless allow people to make plans. What if the law says that it’s illegal to be Jewish, or to marry someone whose gender is the same as yours? Those are non-arbitrary, in the sense that they don’t single out anyone in particular. You can certainly plan around that sort of law: just stop practicing Judaism, or leave the country, or marry someone you don’t love. Simple! But surely we would consider such laws unjust. How does Hayek feel about such laws? The answer seems to be: not so bad. Witness:

The enforcement of religious conformity, for instance, was a legitimate object of government when people believed in the collective responsibility of the community toward some deity and it was thought that the sins of any member would be visited upon all. But where private practices cannot affect anybody but the voluntary adult actors, the mere dislike of what is being done by others, or even the knowledge that others harm themselves by what they do, provides no legitimate ground for coercion.

So he seems to have no problem with laws that are non-arbitrary in this sense, so long as they pursue an end that, in some broad sense, is reasonable in that time and place.

We might grant him this, because the reason he goes into great detail about his definition of the rule of law is that he wants to show how broad a definition it is. It should be easy, implies Hayek, to adhere to the rule of law, and yet—by his lights—much modern economic policy is a violation of the rule of law.

This is probably granting him too much, though. I want to interpret him as defending a certain narrow definition of the rule of law, and a narrow definition of coercion, purely for the sake of argument, which would then allow him to show that something which we all object to is a violation of even this narrow idea of coercion. If he were doing that, we’d expect him to say something like “Surely it’s bad if people are coerced in lots of different ways. But let’s assume for the sake of argument that ‘coercion’ just means a monopolistic power, like a government, forcing you to carry out its will rather than your own. This is the least we can expect out of a definition of coercion. Obviously the definition of coercion I actually believe in is much more expansive than that, but follow along with me.” Hayek gives us no reason to believe that he would prefer a broader definition. Witness:

Provided that I know beforehand that if I place myself in a particular position, I shall be coerced and provided that I can avoid putting myself in such a position, I need never be coerced. At least insofar as the rules providing for coercion are not aimed at me personally but are so framed as to apply equally to all people in similar circumstances, they are no different from any of the natural obstacles that affect my plans.

He’s defining coercion this narrowly because it’s the only kind of coercion that concerns him. Yet it immediately invites a lot of questions that, so far as I can tell, he never answers. If I can’t enter a given neighborhood because it’s dominated by mobsters who demand a bribe in exchange for keeping my kneecaps intact, is that coercion? After all, I can choose to not live in that neighborhood. One version of Hayek’s argument says that that is coercion:

True coercion occurs when armed bands of conquerors make the subject people toil for them, when organized gangsters extort a levy for “protection”

I can leave, though; so why is this not coercion, by his “Provided that I know beforehand” idea above?

Likewise, the sexual coercion of a boss over his subordinates wouldn’t concern him, because the only sort of coercion he’ll admit is that of a monopolist in a strict sense:

The individual provider of employment cannot normally exercise coercion, any more than can the supplier of a particular commodity or service. So long as he can remove only one opportunity among many to earn a living, so long as he can do no more than cease to pay certain people who cannot hope to earn as much elsewhere as they had done under him, he cannot coerce, though he may cause pain.

If you don’t like your boss’s advances, why don’t you just quit? Here Hayek gives us the “notably rare exceptions” of employment law:

in a competitive society the employed is not at the mercy of a particular employer, except in periods of extensive unemployment.

(emphasis mine)

The argument is incoherent. The problem lying at the root of this incoherence is that Hayek contorts himself to define “coercion” as exactly—and only—the narrow type of coercion that he cares about:

In the sense in which we use the term, the penniless vagabond who lives precariously by constant improvisation is indeed freer than the conscripted soldier with all his security and relative comfort. But if liberty may therefore not always seem preferable to other goods, it is a distinctive good that needs a distinctive name.

The final sentence here tries to give him an out, namely: yes, maybe other sorts of coercion are problematic, but let’s just keep our types of coercion separate. Yet nowhere in The Constitution of Liberty does Hayek come back around to opposing these other sorts of coercion. They just don’t concern him.

But let’s ride along with him for a bit about the sort of coercion, and the sort of rule-of-law, that he cares about. If the goal is just to have laws that are exercised uniformly against all people, and to allow people to make plans, then a lot of the modern welfare state seems to be admissible. For instance, why not establish a guaranteed minimum income? To quote Hayek:

There is then the important issue of security, of protection against risks common to all, where government can often either reduce these risks or assist people to provide against them. Here, however, an important distinction has to be drawn between two conceptions of security: a limited security which can be achieved for all and which is, therefore, no privilege, and absolute security, which in a free society cannot be achieved for all. The first of these is security against severe physical privation, the assurance of a given minimum of sustenance for all; and the second is the assurance of a given standard of life, which is determined by comparing the standard enjoyed by a person or a group with that of others. The distinction, then, is that between the security of an equal minimum income for all and the security of a particular income that a person is thought to deserve.

This seems to say that he’d be perfectly okay with a Universal Basic Income. We view him as the arch-conservative, and in many ways he is, but by modern lights many of his views would count as very left-wing.

Much of the time I don’t understand which left-wing bogeyman he’s setting himself up against. What is “the security of a particular income that a person is thought to deserve”, for instance? Is there some version of the welfare state in which we each are given a specific allotment based on various details of our lives? Even if so, on what grounds could Hayek object? Suppose we pass a law according to which African-Americans, specifically, are entitled to tens of thousands of dollars off their taxes every year as reparations for centuries of bondage? Which principle of Hayek’s would this violate? Surely it allows people to make plans; it treats people as classes, not as individuals, so it seems consistent with the rule of law. Yet I get the sense that Hayek would oppose it.

I can only really say that I “get the sense” here, because Hayek’s engagement with facts on the ground is fairly limited. The final third of the book is a grab-bag of attacks on various parts of the regulatory state, taking as its foundation the fundamental theoretical attack from the book’s first third. The final third is where, for instance, he attacks something so fundamental as progressive taxation. (See the big chunk starting on page 431.) Here he sets himself against virtually everyone, including the sainted Adam Smith:

The necessaries of life occasion the great expense of the poor. They find it difficult to get food, and the greater part of their little revenue is spent in getting it. The luxuries and vanities of life occasion the principal expense of the rich; and a magnificent house embellishes and sets off to the best advantage all the other luxuries and vanities which they possess. A tax upon house-rents, therefore, would in general fall heaviest upon the rich; and in this sort of inequality there would not, perhaps, be any thing very unreasonable. It is not very unreasonable that the rich should contribute to the public expense, not only in proportion to their revenue, but something more than in that proportion.

At root, he opposes progressive taxation mostly because much of the welfare state, by his lights, is driven by envy:

When we inquire into the justification of these demands, we find that they rest on the discontent that the success of some people often produces in those that are less successful, or, to put it bluntly, on envy. The modern tendency to gratify this passion and to disguise it in the respectable garment of social justice is developing into a serious threat to freedom.

That’s why the book feels mostly incoherent: the first third lays down a moderately respectable portrait of what his ideal government would look like, and then the second and final thirds try to pretend that they’re logical consequences of the first third. But they’re not. He opposes the welfare state for reasons that seemingly have little to do with any claim that it violates the rule of law.

I could get into much of the rest of the book—for instance, Hayek’s claim that modern welfare-state liberalism (as opposed to classical Adam Smith-style liberalism) mostly derives from the French Revolution, and has thereby proven wrong in every particular—but it hardly seems worth the effort. He uses this patient logical apparatus to set up a series of straw men. If the welfare state doesn’t aim to make every citizen happy, and instead just tries to get rid of egregious suffering, Hayek has nothing to say. Hayek’s grand pronouncements, like these, fall flat:

The proper answer is that in a free system it is neither desirable nor practicable that material rewards should be made generally to correspond to what men recognize as merit

Perhaps he’s right. But it hardly seems to matter. Suppose I’m born into this world to impoverished parents, without access to quality education and nourishing food. Suppose my home is crawling with roaches, and cold air blows in through visible cracks between the floorboards. Do we as a society have an obligation to do something about that? Must the child suffer just because she was born into these conditions?

Mostly I think Hayek would say yes. To the extent that he would say no, it’s because he’s arguing with a non-existent version of the welfare state. I just don’t see the point.

I’d like to get Hayek and Popper in a room together. They might agree on a lot. They might even agree on method: both were adamantly against social engineering, and Popper wanted to bring science to his social engineering: solve a problem at the smallest scale possible; observe the results; change your methods; scale up to a larger social unit; repeat. I’m just not sure about the moral core within either Hayek or Popper. Would either man describe his motivations the way Russell did?

Three passions, simple but overwhelmingly strong, have governed my life: the longing for love, the search for knowledge, and unbearable pity for the suffering of mankind.

I’d have an easier time stomaching Hayek if I felt as though, back of his cold libertarian theorizing, there were the beating heart of a human.

Recent adventures with the medical system — June 29, 2018

Recent adventures with the medical system

I’ve spent a significant fraction of my mental energy in recent weeks dealing with the U.S. medical system, and I’ve taken away from all of it a very solid conclusion: unless you’re

  • reasonably knowledgeable about biology and medicine
  • assertive in a way that many people (and certainly I) are not always prepared to be
  • able to commit lots of time to the task
  • free of significant cognitive impairments
  • surrounded by a solid social network
  • well-fed and so forth—meaning not just able to afford food, but able to prepare it for yourself, etc.
  • reasonably affluent
  • lucky enough to have a doctor in the family
  • able to understand insurance, particularly things like how to choose among Medicare plans, how and whether to buy a Medigap plan, etc.

then I really suspect you’re going to have a hard time navigating the medical system. And to be clear: the logical connective joining all of those bulleted items is AND, not OR. I think you need all of those things.

My mom started losing vision in her left eye late last year. She underwent the usual spate of tests, to no avail. Somewhere in here she was put on prednisone, I believe to fight off an autoimmune disorder that they thought might be causing the vision loss. While scanning her head to look for problems in her optic nerve and such, they found an aneurysm. They decided to repair the aneurysm, and made the first attempt in January, using a pretty remarkable technique whereby they run a coil from her hip all the way up to her brain, stuff the aneurysm with that coil, and thereby prevent it from growing any larger. The first attempt only half-worked, so they stopped midway through and waited a few months to complete the second half. It took her at least eight weeks to feel like herself again, and soon thereafter she underwent round 2; this happened in mid-April.

This one went much worse than the first round. After the first round, she was able to leave the hospital the day after the surgery; after the second she was hospitalized for four or five days. After the second round they found fluid building up in her lungs, and oxygen-saturation levels in her blood that were well below where they should have been. Upon examination, a pretty clear reason for the slow recovery speed came out: they discovered she has emphysema, a result of decades of smoking up to three packs a day. (She quit 30-plus years ago.) Not long after the surgery, she also developed, for the first time in her life, really severe depression. This is apparently not terribly uncommon after surgery: it’s classified in her record as ‘Adjustment disorder with depressed mood’.

Meanwhile the prednisone continued. Eventually one of her doctors pointed out two things: first, that she would never keep a patient on prednisone that long, and second, that a significant fraction of patients on prednisone end up experiencing some form of psychosis. (Google for it; it’s fun.) After something like six months on prednisone, her doctor expected that her adrenal glands would have stopped producing adrenaline altogether. You can imagine the sort of effect this would have on her mood.

Throughout this process, each doctor blindly felt his part of the elephant, but it was exceedingly rare for any one of them to see the whole animal. I thought it was her PCP’s job to coordinate care, and in a certain sense he did: he farmed out tasks to specialists, then washed his hands of it. The surgeon who handled the aneurysm surgery saw that the aneurysm would never again pose a problem, declared his work done (as it probably was, in a sense), and backed away. Her ophthalmologist was the one who originally prescribed prednisone, which sounds like the standard approach to such problems, but I don’t really understand why he kept it going as long as he did; it took a rheumatologist to raise the red flag about health effects of long-term prednisone use.

Nowhere in this process, from what I can tell, did anyone introduce risks to the patient. Are there downsides to performing aneurysm surgery on an elderly patient? Life expectancy for the average 73-year-old non-Hispanic white female is another 14.3 years; is the aneurysm expected to burst in 14.3 years? In 20? As for the prednisone, I don’t think anyone told her about the significant psychosis risk, or the risks of long-term use.

Even if they’d told her the surgical risk, I can imagine how that would have registered. Imagine being told you have a Sword of Damocles hanging over your head, which might not drop during your lifetime. Do you leave the sword alone and hope it never falls? Or do you try to do something to stop it from ever falling, risks be damned? I don’t really know the liability calculus on the doctor’s part, but I imagine it cuts in a similar direction.

Many elderly patients can’t be expected to make complicated risk tradeoffs—especially right when they’re in the middle of a stressful health event. If you’re lucky, you rely for help on the people around you. But many people don’t have a knowledgeable network around them. Many people don’t know doctors. In my mother’s case, her husband suffers from Parkinson’s, and his ability to help is, by everyone’s understanding (including his, and including hers) diminished. So their network is smaller than we’d like. I’m helping where I can, but it’s a struggle.

This latest depressive episode introduces its own complexities. Now my mother is simply unable to make decisions for herself. And it’s not clear, from a distance, that my parents are feeding themselves well, are getting even a minimal amount of exercise, etc. Here’s where we need to bring in community organizations like Meals on Wheels. Those organizations have their own stigmas; but if we can overcome those, there’s at least someone checking in on my parents a couple times a week to make sure that the non-medical portions of their lives are okay. Step out a tiny bit, though: who’s going to request Meals on Wheels? The patient and her husband are not in a place to manage this for themselves. My parents have children who can help them, but not all elderly people do. Even many children who are willing to be involved in their parents’ care may not be able to be involved: work may not allow them the time to handle family care. In my case, I’m lucky to have an employer who will give me the time to place some phone calls on behalf of parents who need help. Not everyone will be so lucky.

I’ve only found one doctor throughout this process who’s seen the big picture, including the weakness of the underlying social supports. This doctor has gone out of her way to send visiting nurses, check in on my mother’s mental health, and even prescribe Ensure to get a few more calories into her diet. Doctors, in my experience, are at worst focused on their specialty to the exclusion of all else; if you’re lucky, they can scale out to all purely medical issues. It’s the rare doctor who can think about nutrition, home care, and even what “informed consent” means for a patient who’s in no position to make decisions for herself.

I’ve started having to fight with insurance in recent days, thereby opening up a new and delightful front in the proceedings. My favorite of my mother’s doctors prescribed Cellcept to combat possible auto-immune attacks on her optic nerve; the drug could literally keep my mom from going completely blind, so it seems rather important to cover it. They’ve been dragging their feet on granting approval. It’s possible the insurer rejects Cellcept for this particular use (namely preventing blindness, I guess), so now we need to file a Letter of Medical Necessity, etc., etc. And on it goes. Imagine trying to navigate this while you’re suffering through post-operative depression, not eating well, deferring to authority figures, in no mood to fight, and with no one around to help or guide you.

My parents are understandably concerned about the medical bills that will result from all of this surgery. So a couple natural consequences of all of this will be some discussions of finances, and some discussions of health-insurance choices. I consider myself a reasonably sophisticated consumer of health information, but even my heuristics here are pretty simple: pick the insurance plan that minimizes the maximum total financial hit I’ll take in a year, when premiums and out-of-pocket max are factored in. For elderly people, this turns into choices among classic Medicare, Medicare Part C, Medigap, and so on. It’s complicated. Many elderly people are vulnerable to scams. Family can help, but eventually the involvement becomes total: is the rest of the family expected to intervene in every financial, technological, and health decision which could lead to the patient’s being scammed? The honest answer may be “yes”, but few people are going to have the time to get that involved in someone else’s life; we have our own financial, technological, and health decisions to worry about.

In the midst of all this, I had my own fun run-in with the health system. Radically abbreviating the whole thing: I picked up a nasty infection six days ago and got a urine culture right away, but it took until last night for the culture to come back. Had it come back sooner, I could have avoided two fruitless courses of antibiotics. I don’t know why it took 5 days to get back cultures which were, as was known at the beginning, urgent. (The pain was unbearable for at least a couple days.) Maybe it just takes that long to culture for the specific types of bacteria at issue?

I consulted a specialist in the middle of the week, who told me that at some point a specialist like him would have to schedule imaging for me. “Aren’t you one of those specialists?” I asked. He said that he wasn’t able to urgently schedule scans for his patients; should the urgency increase, he said I should call the ER, which could take care of the urgency. Consider for a moment how busted the incentives are if specialists are making referrals to the ER.

Sure enough, that night my temperature spiked, and I went to an ER within the same medical group. Our first glimpse at the ER showed that it was overcrowded, serving a largely poor population. Not to be too short about it: it was the kind of hospital that you wouldn’t go to if you had options. Our friends, who are more familiar with D.C. hospitals than we are, all endorsed Sibley, so we called a Lyft and drove the half hour between the two ERs. The contrast could not have been more stark: Sibley was virtually empty and felt boutique. It felt like a hotel, in fact, which made the literal “Marriott Reception Area” all the more…glaring? Hilarious? I don’t know. In any case, I want someone like Sarah Kliff to explain to me why anyone would go to the Washington Hospital Center when Sibley is that close by. Yes, I understand the obvious answers: WHC is the neighborhood hospital in a poorer neighborhood, so it’ll be the hospital for ambulances in the surrounding catchment area, and not everyone can afford a Lyft. Is that most of the story?

This is my second recurrence since 2015 of this sort of infection, and I was told in 2015 that even one was concerning and unexpected. So I’ve been reading up on the chronic appearance of this sort of infection, and when this immediate outbreak is over I’m going to spend a good long while (I already forecast) trying to get doctors to answer my calls and solve a long-term problem even when the short-term crisis has passed. No one cares more about my life than I and my immediate family do, so I need to badger and badger and badger until others grudgingly give me a minute of their time.

David Rieff, In Praise of Forgetting: Historical Memory and Its Ironies — March 26, 2018

David Rieff, In Praise of Forgetting: Historical Memory and Its Ironies

Yellow background. All text in black, other than the word 'Forgetting', which is in silver

I don’t really understand why this book was written. I’m entirely open to the possibility that I’m a bad reader, but it feels to me like this book has a very simple premise that was monstrously over-written. On the ‘simple premise’ angle: the premise is that there’s a difference between “history” (the stuff that happened), and “memory” (how we think about history, particularly how we think about it as a society), and that it may be better for us if we could learn to forget about our historical grievances. Not only that, but we often misuse history in dangerous ways, such that there’s no necessary connection between history and memory.

On the ‘monstrously overwritten’ side:

And regardless of whether we completely accept Freud’s generalization, we hardly need a profound insight into human nature to understand that to remain productive—and possibly even to stay entirely sane—we human beings need to behave as if the era in which we are fated to live and die and, after we have been extinguished forever, a relatively short period of the future to come about whose essential characteristics we feel that the present allows us to foresee would be recognizable to us were we to be resurrected at some more far-off point in the future.

That sentence needed an editor. So does a lot of the book.

It’s not hard to argue that a little selective amnesia about our history, and a little reframing of our memory, would help everyone. The most striking examples of mis-framed history in Rieff’s book are Osama bin Laden’s declaration that the modern West’s war on Islam is just a continuation of the Crusades, and the Israeli government’s habit of identifying any opposition to the current Israeli government as objectively pro-Holocaust. The past has been weaponized in defense of a modern ideology. As Rieff puts it:

And on the other side there is Tony Judt’s far more pessimistic suggestion: “Maybe all our museums and memorials and obligatory school trips today are not a sign that we are ready to remember but an indication that we feel we have done our penance and can now begin to let go and forget, leaving the stones to remember for us.” Judt recalled that during a visit to Berlin’s Memorial to the Murdered Jews of Europe, he saw “bored schoolchildren on an obligatory outing [playing] hide-and-seek among the stones.” And he argued, “When we ransack the past for political profit—selecting the bits that can serve our purposes and recruiting history to teach opportunistic moral lessons—we get bad morality and bad history.” To which one should add: we also get kitsch.

The nut of the whole book, I think, comes when Rieff writes that “remembrance is about self-love, and self-recognition, which means more often than not that it is little more than the present in drag.” Everyone loves that Santayana quote about remembering the past, but Rieff’s point—and I think it’s a correct one—is that too often we’re not remembering history; we’re remembering what we want to remember to serve ideological ends. So by all means let’s study history; but let’s be careful about the uses to which we’re putting our memory.

Duff Cooper, Talleyrand — March 21, 2018

Duff Cooper, Talleyrand

Portrait of Talleyrand, presumably when he was at the peak of his fame, power, etc.

This book is entertaining in its way, if the sort of entertainment you enjoy is watching 18th-century French gentlemen have a lot of sex with other 18th-century French gentlemen’s wives. In a word, it’s catty. So when Cooper tells us that “Napoleon was quick to realise that there was one man in Paris whose support was precious and whose advice was invaluable,” implying that Talleyrand was that man, we have no reason to believe him; we’ve spent the book up to that point merely watching a man examine French society with amusement and, we gather, keep most of his thoughts to himself.

Of course Talleyrand must be an amazing character: he wore all manner of different hats under all manner of different régimes, during the most tumultuous decades of France’s existence, without once nearing the guillotine. He represented the clergy when the Estates-General were reconvened for the first time in 161 years, and arranged the Civil Constitution of the Clergy that did so much to divide France and—along with his marriage—did much to alienate Talleyrand from his Church. As the Revolution was happening he was part of the French diplomatic mission to England, then was expelled and left for the United States, now a man without a home. He returned and orchestrated Napoleon’s coup of 18 Brumaire, then served as Napoleon’s Foreign Secretary. Napoleon eventually soured on him—in Cooper’s telling, mostly because Napoleon became an autocrat who couldn’t tolerate Talleyrand’s differing views—and eventually Talleyrand worked to undermine the Emperor and arrange his defeat before the assembled might of the European powers. When the great powers met at the Congress of Vienna to rearrange the map of Europe after the Napoleonic Wars, Talleyrand represented France, and—according to Cooper—did much to ensure that his nation wasn’t dismantled. Under Louis XVIII, Talleyrand was effectively the Prime Minister. In retirement, he was the wise old man of French diplomacy, all-seeing, all-knowing, dropping witty apothegms hither and thither. Moments before his death, he re-established ties with the Church, apologizing for the folly of his youth during the Revolution.

Such is the outline that most everyone would have going into this book; and with this outline in mind, you can’t help but expect some plasticity of morals on Talleyrand’s part. How else do you explain his ability to please so many diverse masters? The easiest answer is probably that he unerringly knew which way the wind was blowing, and always remained one step ahead of the latest calamity. Was this just the luck of the draw? Was Talleyrand just one of those men who, through some inexplicable fluke, got more than the usual portion of foresight? Cooper is not really the man to answer these questions. Instead he seems driven to counter what I imagine is the historical image of Talleyrand, namely the amoral practitioner of realpolitik. In Cooper’s telling, instead, Talleyrand is a veritable rock of principle: from the reign of Louis XVI, through Napoleon and the Congress of Vienna, and on through the Restoration of the Bourbons, his fixed star is a broad European peace. This is why he consistently (says Cooper) advises Napoleon against European conquest, but eventually the inertia of the Emperor’s string of victories becomes too great to resist.

Maybe this is all true. And maybe, in the same vein as A People’s History of the United States, the existing story of Talleyrand’s scheming and duplicity is so widely and unquestioningly believed that someone like Cooper needs to, at least, put a thumb on the other side of the scale. Like Zinn’s book, though, Cooper’s can’t be used as your sole historical source; it’s too obviously got a story to tell, and is too obviously unwilling to admit deviations from that story.

It’s a shame, because when he sets his sights on explaining some abstruse matter of foreign policy, Cooper can do very well. Witness this description of Talleyrand’s advice to Napoleon as the latter negotiated terms with Austria after the latter’s defeat:

Austria must be compensated in the east for all she forfeits in the west. Moldavia, Wallachia, Bessarabia, and part of Bulgaria will increase rather than diminish the power and prestige of the Habsburg Empire, which in the future will stand with its back towards Europe and its face to the East, thus acting as a bulwark to protect western civilisation from the aggression of Russia. The latter, faced by so powerful an antagonist on her western frontiers, and knowing that behind that antagonist there stands her still more formidable ally, will also be driven to look eastward for expansion, where she will find herself hampered by the oriental possessions and ambitions of Great Britain. So Russia and Great Britain, the two most dangerous enemies of France, would be set to grapple with one another in Asia, and Europe would be left in peace.

Incidentally, I’ve always found the great-power calculus hard to understand. For reasons that I also don’t understand, the calculus of “If we do this, then Austria will react in this way, which will trigger Russia to react in this way, [etc.]” always seems more intricate than the present-day diplomacy calculus. I don’t know why that might be, or even whether it’s true; it might be a bias in favor of believing that today’s situation is inherently less complicated than a more-distant thing that I would have understood perfectly well had I lived it.

In any case, Cooper does a great job on the occasions when he chooses to explain this calculus. But the quoted passage is one of the few where he really tries. Much of the rest of the book is either the clear-eyed Talleyrand seeing what others don’t, effortlessly parrying every challenge, or he’s seducing another mistress. And for Cooper, that is basically that.

We’re left with no real knowledge of psychology, or of the precise mechanics of surreptitious language. Take this, for instance:

‘Sire, it is in your power to save Europe, and you will only do so by refusing to give way to Napoleon [said Talleyrand to Czar Alexander]. The French people are civilised, their sovereign is not. The sovereign of Russia is civilised and his people are not: the sovereign of Russia should therefore be the ally of the French people.’ He went on to explain and develop this statement.

A natural question for any reader is how Talleyrand decided to take such a risk with a foreign power. This was arguably treason, and one imagines that Napoleon would have beheaded his Foreign Secretary for such an insult. So what preparations, exactly, did Talleyrand take to ensure that these words stayed between him and the Czar? Cooper doesn’t say.

I don’t think that’s accidental. Cooper is at his happiest when he’s presenting Talleyrand as preternaturally gifted at the art of subterfuge. I find it maddening. Maybe it is, indeed, a pure gift, but Cooper never gives us reason to believe so. It’s asserted, essentially, without being defended, which is the recipe for much of the book.

I think Cooper is in it for the naughty bits. He could have dug deeper on those parts, while still providing his reader with a psychological education—here, for instance:

Caroline Murat, who was probably Metternich’s mistress at this time, seems to have been his informant.

Well, that’s interesting. It raises a load of questions. For one: if everyone is having sex with everyone else, and (seemingly) everyone knows this, and if even great statesmen are apparently not immune to sexual persuasion, then how does that change what people say to each other? This only reinforces my question from above: how does Talleyrand know whom to trust? How does he know that, say, Alexander isn’t sleeping with someone who’s sharing the goods with Napoleon? Again, Cooper doesn’t say. He walks right up to a great opportunity to paint the backdrop of early-19th-century politics, then steps back.

On the other end of the spectrum from this Cooper book is, say, the three-volume Otto Pflanze biography of Bismarck, who is a comparable historical character in many ways. Pflanze’s biography maybe goes into excessive detail about the exact choice sets available to Bismarck at a given moment, though his leitmotif is that Bismarck always consciously left two or more options available to him in any given scenario. So at least Pflanze has a structure to hold together the map of Bismarck’s delicate schemes. More like Cooper is Steinberg’s more-psychological biography of Bismarck. Both Pflanze and Steinberg are worth reading in their own ways.

I guess Cooper is good for the outline, but I’m going to look elsewhere for a real biography of Talleyrand.