Unpredictable Patterns #36: Diagnosis as a tool for thinking
Diseases of the body politic, health, second opinions, finding Jack the Ripper and learning from doctors
Dear reader,
We are back in the thick of it, and it is quite nice. There is something about work that is really quite extraordinary, and I remember once hearing a Swedish author note that the wish to be constantly on vacation really was just a death wish, thanatos in its purest form, because vacation is a lot like any utopia - it is a place without time, and so in a sense without future or past, like death. Work, however, is embedded deeply in time - and that is both its curse and blessing. Ha! Work or death, then, it is; or, well, I am exaggerating, but you will know what I mean. I think.
Anyhow - this week we will discuss medical tools of thinking, and diagnose the body politic!
Medical investigations
The medical profession is focused on solving problems in a unique way. As outlined by Jerome Groopman and Lisa Sanders in their books, doctors engage in diagnosis and prognosis - the act of assembling patterns of fact, distributing weight overt the different facts and then matching these weighted patterns to a pre-defined set of categories - diseases - with possible therapies and treatments.
Medical thinking is a form of problem solving that is highly structured and focused on individual cases as understood from carefully constructed histories - anamneses - that recollect the patients individual history.
This skill is at least partly transferrable to other domains. Sherlock Holmes was, for example, based on a brilliant doctor that Arthur Conan Doyle had studied under - Joseph Bell - and the detective’s mindset very much reflects the medical mindset. Bell was - according to some sources - even consulted to find Jack the Ripper. He studied the handwriting of the murderer and other details and delivered a name to the Scotland Yard. The name was never made public, however, so we still don’t know what Dr Bell’s conclusion was.
Just as in the detective novel a medical investigation is helped by a differential diagnosis. Simplified, this is a list of the possible diseases the patient may have. Most doctors, notes Groopman, have 3 or 4 such diagnoses in mind when they visit a patient and then slowly try to determine which one is the right one. Just like a list of suspects in the detective novel, the possible diseases are then eliminated one by one and the remaining one - however unlikely - is identified as the culprit.
Applying this mode of thinking to public policy and government affairs may seem bizarre, for several reasons. First, most companies or organizations are embedded in complex networks of causes that do not allow for easy identification of any specific cause behind their challenges. Second, the work of diagnosing what ails a company or society seems to suggest that a company’s reputational and political problems can be cured much like a diseases. Surely this is not the case?
Well, any modern medical expert would suggest that diseases are the products of complex network interactions in the body and environment, and as for a cure - sometimes the cure is a combination of things - like medicine against high blood pressure and a change in diet. Maybe, just maybe, the analogy could at least be generative in exploring the problem?
The concept of disease
What is a disease? If we want to extend the analogy of medical investigation to government affairs we need to understand what kinds of diseases that can infect a company and how to categorize them. And more importantly we also need to understand the concept of health.
The WHO has a definition of health that is breathtakingly broad: ”a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity” and this - translated to a company - would seem to imply not just a company that has no policy challenges, but also has a happy and healthy workforce, great revenues, slim costs and an innovation function that cranks out new solutions to demands all the time (it is an interesting question if a healthy company necessarily innovates - if we define health for companies, do we then say that a healthy company needs to also innovate or can there be healthy companies that do not innovate?).
Some scholars - like RP Hudson - has suggested that this definition is unlikely to ever apply to any actually existing human being (he is known to have quipped that is ”more realistic for a bovine than a human state of existence”) and it is easy to agree that this description of health is so broad as to become meaningless. But it does capture something of what we mean when we talk about health - it captures that health at least requires the absence of disease.
Disease then becomes an almost primary concept as we discuss health - and so we have to understand disease to understand health.
And this is hard, even for doctors. Take osteoporosis. As detailed in the essay ”What is a disease” by Jackie Leach Scully, osteoporosis has alternately been classified as a disease and as a consequence of normal aging. Indeed, aging in itself is defined by some as disease, and by others as a normal condition not just to be tolerated but lived out fully within the limitations of that particular life form (here aging becomes a bit like a meter in poetry, the trick is to be creative within the limitations of the metric structure and create your life to the fullest in that frame - and, yes, some would argue that this is why death is important: it is the ultimate human metric).
So how should we define disease? The answer we will use is this: carefully and in a coarse-grained way. We will abide by the definition given by Oxford languages:
”a disorder of structure or function in a human, animal, or plant, especially one that produces specific symptoms or that affects a specific location and is not simply a direct result of physical injury.”
This is enough for us, recognizing that we have but a blunt tool, to proceed. What we will be interested are disorders of structure of functions in companies that produce specific symptoms and signs.
Diseases also have causes - like a virus - and can be treated. We would not call a disorder without a cause or treatment a disease - and this is also important; diseases are disorders that we can treat, in some way, even if the treatment may just be palliative. Unfortunately, not all disease will have a cure.
Where is a disease?
This leads us to another question that this piece of analogical reasoning needs and that is to establish a locus of the disease. Let’s say that we consider the techlash a disease - then who actually has that disease? Is it the companies or our societies overall?
The question of who really is sick is fraught with controversy, not least since the concept of disease sometimes is taken to establish some kind of fault or error (which is, of course, nonsense).
The question of where a disease is, is not easy even when it comes to disease proper. Where is ”burnout” located? The effects certainly hit the individual, but the disease is produced by organizational structures, personal networks, expectations and sometimes even by diet and exercise (or lack thereof).
One solution to this problem is to declare that diseases are systemwide. When we seek to cure a disease we need to accept that is embedded in our social systems, and that there is no single node in the network that is sick - even if symptoms might be distributed in specific ways.
This, again, leads us back to the problem we were discussing last week about wholes and parts. What is the whole that is sick and the parts that can be treated? In the human body the parts are the organs - and perhaps this metaphor is something we can extend? We do speak about the body politic - and as far back as at least Plato our Western philosophy has likened the state to a body in different ways.
Maybe, then, we should be interested in diseases of the political body of society? And then think about how to diagnose them?
A caveat here — historically such thinking has sometimes identified groups of individuals as the cause of a social calamity, and this is not what we are interested in at all. There is a danger inherent in medical thinking: it invites extreme measures. Cutting out a cancer, eliminating germs…As we explore this tool model we should remind ourselves that it has been used to legitimate inhumane and atrocious behavior in the past (one reason we might have shied away from it, in spite of its effectiveness).
A provocation
So, let’s put our analogy to use. We will now assume that the body politic exhibits a specific ”disorder of structure and function” related to technology in some way and that this disorder of structure and function needs to be explored more closely. As we do this we will run into controversy quickly, and for an interesting reason.
Let’s look into the symptoms that someone might list:
There is growing inequality in our societies, with a small set in society owning more and more.
There is a runaway consumption of energy, resources and a warming of the planet, and resultant climate change.
Our democratic systems have been decoupled from the capitalist market mechanisms - allowing for authoritarian capitalism that erodes liberty and autonomy.
Innovation is stagnant and productivity growth is weakening.
Demographic load is shifting massively towards the south where the resources are fewer.
Societies are increasingly polarized along almost tribal fault lines.
Now, assume that we agree with these symptoms for the sake of argument. What then is the differential diagnosis that we should propose? This is where it gets interesting. We could imagine a set of different diagnoses here:
This is an infection of technology run rampant. Technological progress has colonized the body politic as a core imperative that has taken over everything else and we need to address that. (This is the Ellul - Postman diagnosis.
This is a cancer of a few technology companies, generating massive disorders of structure and function across the whole system and needs to be addressed by targeted therapies addressing these companies. (This is essentially the tech lash).
This is secularization working its way through the body politic, rendering it incapable of carrying purpose, motivating individual agency and responsibility - essentially blocking the production of social meaning. (The religio-conservative diagnosis - or a conservative hypothesis)
This is a series of opportunistic infections that are taking over society as it ages and matures into complacency, weakening and opening up for widespread collective irrationality. (The Cowen diagnosis)
This is normal aging - and dying - of a civilization. (The Spengler diagnosis)
…add your own!
All of these diagnoses are possible differentials that we can discuss, but as we do so we should also note that they are all identifying different causes. As long as we play within the rules of the medical analysis we should recognize that more than one cause is possible, but unlikely. For a patient to have more than one disease at any time we would have to assume that they are in a very small minority — so for the purposes of our game here we need to choose one of these (or the one you come up with). Just saying ”all of the above” is lazy doctoring and worse: makes it almost impossible to choose medical treatment, since different treatments might then worse the co-causal disease!
So, how do we pick?
We need to figure out tests. Modern medical diagnosis has a number of interesting tests - x-rays, MRI, chemical panels etc - but modern political science has no decisive tests yet. An interesting task then would be to figure out if there are some symptoms that cannot be explained by one or more diagnoses?
How would, for example, the diagnosis of tech lash explain the shifting demographics or the wealth concentration? It seems that if we want to identify technology as the culprit we need to choose the Ellul-Postman diagnosis, and not focus on companies as much as technology itself, if we want to explain all the symptoms.
And the therapies for that diagnosis are things like stop developing new technologies and resist innovation - something that would directly worsen our chances to survive any complex climate change, one could argue - suggesting that those who bet on the Ellul-Postman diagnosis have to either think that climate change would recede if we eliminated technological progress or come up with a process whereby which we can continue technological progress but with a reduction in absolute energy consumption or a way that we can shift energy production to renewables fast enough to enable continued energy consumption, which seems to require new technological progress…
If your pick is the Spengler-diagnosis, well, then there may be palliative therapies, but you do not need to worry much about trying to cure anything. Sure, there is a disorder of structure and function, but that is what aging leads to - the release being collapse and death. That seems, well, grim.
The Cowen and religio-conservative diagnoses are complex - because they identify systemwide challenges where we have no known therapies. There is no known way to address the lack of a capability our society has to create the same structures of meaning that a non-secularized society had (except perhaps turning back to a more religious society) and complacency might naturally evaporate if the symptoms worsen into a more acute disease.
In a way that makes the Cowen diagnosis the most interesting - and self-correcting. Here we could apply the equivalent of ”take two aspirins and call me in the morning if it is not better”, knowing full well that it will be worse, and when it is the complacency will fade away.
This does presuppose that we survive the catastrophic worsening of the patient’s condition. It almost reminds us of the person who works too hard, smokes, eats unhealth and then - bam - has a heart attack and reinvents themselves with yoga, veganism and a new focus in life. Maybe the body politic needs a massive heart infarction to change its ways - at least that seems to be what the Cowen diagnosis could imply.
Here is the thing, though: more and more of the doctors at our bedside today seem to be leaning towards the techlash diagnosis, and on the basis of a very weak anamnesis. Most of the symptoms we described above pre-date the Internet and cannot be explained by the tech companies, and so we need to think hard about if the diagnosis we are being offered really makes sense.
And we have to take a much better patient history. As suggested in an earlier note we would benefit from thinking through how we got here, and how that story unfolds. That more thorough anamnesis would allow us to study the symptoms in greater detail as well - really understanding what it is that is happening, something we are not doing today to the best of our abilities.
So what
This analogy is just a tool. It suggests a few general take-aways however, aside from the provocation.
First, it suggests that applying the medical model of reasoning - conducting thorough anamnesis, establishing patterns of fact, weighting them and then matching them across differential diagnosis to different disorders of structure and function - is a model of reasoning, a tool, that we should use more as we try to understand public policy problems and government affairs. It might feel contrived to begin with, but it is certainly a way to look at things from a new perspective.
Second, we should be more careful in writing the anamnesis of our society. Today we suffer from amnesiac anamnesis in collecting only symptoms and not asking for when they started appearing or how long we have seen them. This is especially true for theories trying to tie technology to inequality or populism — phenomena that predate at least Internet technology by decades. Such chrono-blindness is dangerous.
Third, we need to agree that not all is well with society, and then debate if that is indeed something that rises to the level or dignity of a ”disorder of structure or function” that should qualify as a disease. Or is this what society looks like? There is this weird sense that we are living in a golden age or our last decade that might actually be a be a necessary framing for a healthy society and not a reason to panic; maybe the firmest sign of a healthy society is that it thinks it lives in the end times? If this is the mentality that makes it able to continue to adapt to rising levels of complexity? Only the paranoid survive, as Andy Grove notes.
Fourth, we should ensure that the patient asks for a second opinion, especially as the techlash comes up. The theory that we are where we are because of a few tech companies simply does not stand up to any more robust scrutiny - and if technology is to blame we need to discuss the Ellul-Postman diagnosis and what therapies if any it affords us.
Fifth, we should write more case histories. A good doctor has a crystalline intelligence honed over years of living and reading case histories - just as a good detective. Government affairs professionals need to start treating bills, discussions, hearings, debates, investigations to forensic examination and documenting them. We are losing so much learning by not writing more case histories. If we fear discovery - and we do - we should ensure that they are written in a way that reflects the more neutral language in medical case histories. Not learning from the past does not so much force us to repeat it as not recognize it at all or learn from it.
As always, thank you for reading and let me know if you have any questions or ideas for other notes!
Nicklas