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Progress in Medicine: Balancing Between Hope and Hype.
Progress isn’t as straightforward as we like to think.
Reviewed by Lybi Ma

KEY POINTS-
We think of medical progress in terms of our personal hopes and fears.
What if it focused on improving the health of the community instead?
Medicine that promises too much has potentially serious side-effects.
Are arguments for ‘limits to medicine’ taken seriously enough?
We’re all in favor of progress, aren’t we? If we think of progress in medicine, we imagine new possibilities for curing diseases. New ways of slowing down physical and mental decline. Better protection against genetic and environmental risks. As we age, we do what we can to keep our bodies and our minds in good shape. The advice of experts is welcome, as is some help from medical science. We tend to see the future of medicine in terms of our personal hopes and desires. Daniel Callahan, a pioneer of bioethics in the U.S., argued repeatedly that that’s not right. We should be aiming at improving the health of the population as a whole.

Sometimes the two coincide. Most vaccines protect each of us individually against what could be a life-threatening disease. They also protect the community against the potentially devastating effects of an epidemic. Pretty good value for what’s often no more than a few cents per person.

On the other hand, there are medicines being used to treat very rare conditions that cost $700,000 or more per year per patient. Would a radical shift in healthcare priorities mean drugs like these wouldn’t be developed? Perhaps. It’s not likely to occur though. One thing that stands in the way is empathy. The story of a single desperate patient can move mountains.

But without going as far as Callahan suggested, we really do need to look critically at how medicine progresses.

Hype and Hope
There is a common tendency to exaggerate the likely benefits of ‘promising new treatments.’ This starts long before they actually reach the market. One thing that plays a role is physicians’ desire to give patients hope. Reluctance to accept the current limits of what they can offer. There’s no doubt that economic interests also play a role. Med-tech start-ups try to attract venture capital or prepare for a stock-market launch. And we certainly mustn’t forget media enthusiasm for gee-whiz technology.

We heard recently that in a few years, there’d be vaccines against cancer and heart disease. Who could fail to be excited by that? Your or my life could be among the millions they’d save, of course, we’re delighted. Perhaps we’re less keen to hear about for whom they probably wouldn’t work, or about potential side effects. We don’t stop to wonder what exactly they’d do. Preventing us from dying isn’t the same as preventing us from getting sick in the first place.

The fabrication of hope, that is what it really is, can actually have serious side effects. It can lead to patients (and their carers) expecting too much, resulting in disappointment.

For example, for years a great deal has been claimed for gene therapy. One of the conditions for which it’s being tried out is hemophilia.

Gene therapy for hemophilia
A recent literature review explains that though gene therapies may soon become available, they’re unlikely to do all that’s claimed for them. Instead of offering a permanent cure, they’re likely simply to alleviate symptoms “possibly with burdensome side effects. The treatment may also create psychosocial challenges that require support.”

Medical professionals want to do the best they can for the patient they are treating. They’re committed to offering what professional opinion regards as the best available treatment. Of course, they’ll warn of the risks of possible side effects. But they’ll be less focused on non-clinical issues, like those psychosocial challenges. Or perhaps still more problematic, the possibility that a treatment (such as gene therapy) could affect someone’s personality or sense of identity?

Opposition to treatment
This is most problematic in relation to conditions that aren’t universally accepted as pathological at all. Two such conditions come immediately to mind. There are certainly others.

Autism
One is autism. Having a child diagnosed as having a (severe) autism disorder represents a major challenge for any parent. What to do? In this situation, most parents see autism as a pathology, for which treatment is crucial for alleviating the child’s suffering. I doubt many parents are sympathetic to the claims of the neurodiversity movement, or the professionals who back it. The fact is that numerous high-functioning adults with autism argue that children shouldn’t be treated at all. That autism is best regarded as a different way of being in the world. Children with this condition should be taught to embrace their neurodiverse identity. Parents likely feel advice like that simply ignores their daily struggles.

Deafness
In 1990 the FDA approved cochlear implants for deaf children. Newspaper headlines such as ‘An end to deafness’ were not uncommon. Little wonder that many parents of deaf (born) children expected a miracle. Their small child would soon hear and speak ‘just like everyone else.’ Ironically, the development of the implant coincided with the emergence of a new spirit of emancipation among deaf people. Inspired by the new field of sign language research, the idea of a deaf community was gaining ground. With it came commitment to deafness as an identity, and resistance to the idea of treating it.

Shortly afterwards, I began what I naively thought would be a quick study of the dispute. Implanting children was in its infancy then. Surgeons setting up implant programs were focused on the individual child. On its parents’ hopes for their child’s future. They rarely had much contact with the local deaf community.

Soon after I began, one ENT surgeon said to me, with total conviction, that eventually all deaf children would be implanted. That no one could stop it. We know now he wasn't far off the mark. But it wasn’t clear at that time how effective the implant would be, or for whom exactly. It wasn’t clear who would actually want it, or what effect the arguments of the deaf community would have.

I’ve often wondered whether his certainty, at so early a stage, doesn’t point to something quite problematic in the dynamics of medical progress.

ANXIETY-
How Uncertainty Causes Anxiety.
Insights from the neuropsychology of anxiety.
Reviewed by Gary Drevitch

KEY POINTS-
Your brain is a prediction machine, and uncertainty can be quantified in terms of prediction error.
We evolved anxiety as a response to uncertainty.
Mindfulness, gratitude, and routine can help minimize uncertainty and maximize well-being.
Whole or skim milk? Take your normal route home, or an unfamiliar potential shortcut? Flip a hypothetical trolley switch that would kill one person, saving five others?

All of these decisions have two things in common: uncertainty and anxiety.

Whether you consciously feel anxious or not in deciding between two similar options at the grocery store, I mean anxious in the technical sense. Anxiety is your brain’s response to uncertainty, big or small.

The Fantastic Organ
Neuroscientist Karl Friston has called the brain a “fantastic organ.” The brain is not only an organ which is fantastically complex, but one which is constantly generating fantasies. Your brain is a prediction machine—this is the basis for predictive processing theories of consciousness.

Most of what your brain and body does is unconscious: There is high predictability, little uncertainty, and attending to these details would be exhausting. We can choose to take conscious control of our breathing, but can you imagine if we had to do this all the time? How tiring, and perhaps even deadly, would it be to exist in a world where our brain couldn’t take over and regulate our breathing unconsciously?

But when there is uncertainty, prediction becomes much harder. There is no unconscious smooth sailing. The whole reason we have conscious thought is to deliberate between actions when multiple decisions are possible. Our fantastic organ must generate the right fantasy map to navigate us safely to our goals.

Entropy Equals Uncertainty
From a computational perspective, uncertainty increases entropy. You may recognize this term from physics. It is a law of nature that entropy always increases. Entropy is chaos, and disorder. Heat dissipates, the universe expands, and order does not stay ordered. Sandcastles collapse every day, but there is no universe in which sand spontaneously arranges itself into castles.

The caveat, of course, is that it is possible to build sandcastles and to create order in a disordered universe. We cannot create order from nothing; it comes at the cost of energy. Expending energy into work still increases entropy, globally, but we can trade energy from the outside world to maintain order in a narrow context.

This anti-entropic process of consuming energy to maintain order is the whole basis of life. Homeostasis is an organism’s process of expending energy to maintain itself, whether that energy is gathered from photosynthesis, or from eating other organisms.

And at a much higher level, your brain, the prediction machine, is fundamentally in pursuit of minimizing entropy. What does a prediction machine want more than anything else? To be right. What does it need to be right? Certainty. Why does it want certainty? There are two answers to this. From a low-level computational perspective, the less uncertainty there is in a problem, the more straightforward the answer. Your brain saves energy. From a high-level evolutionary perspective, the more uncertain your environment is, the less likely you are to survive. We need certainty.

Of course, if all we wanted was certainty and to minimize brain power, we would be in a constant state of hibernation. This is not a long-term adaptive solution. The best types of prediction machines are those which can handle high amounts of uncertainty, and still come out on top.

Three Types of Brain:
The struggle to navigate uncertainty is the best way to understand the evolution of our large brains, and to understand the neuropsychology of anxiety.

The brain can broadly be divided into three layers:
First there is the brainstem, which governs basic survival processes. This includes largely unconscious processes like breathing, heartbeat, digestion, and reflexive movement. This most ancient brain system is common to all vertebrates and is sometimes referred to as the “reptilian” or “lizard” brain.

Next there is the limbic system. The limbic system controls our emotions, ranging from pain and pleasure, love and fear, and hunger and sex drives. Compared to the basic reptilian brain systems shared across all vertebrates, the limbic system is more developed in social species. Whether predator or prey, parent or child, if your survival depends on receiving care from or avoiding harm from others, it pays to have emotions.
Finally, there is the cortex, or the “rational brain.” (Cortex has the same Latin root as corona, meaning crown; it sits on top of the rest of the brain.) The more intelligent an animal is, the larger its brain (relative to its body), and the more cortex it has. We see the largest cortical brain areas (again, relative to body size) in highly social birds and primates, with humans at the forefront.

Predictive Processing
Looking at this in the context of brains as prediction machines, this makes perfect sense. Think about the primitive lizard brain, or better yet, even more primitive fish vertebrates. Yes, they need to survive and reproduce like the rest of us, but these simple organisms may lay dozens, hundreds, or even thousands of eggs at a time. Their prediction machines are straight and narrow; they live largely by reflex. When prediction fails, they die. But what they lack in cognitive flexibility, they make up for in numbers.

More complex social mammals, like rats, have limbic brain systems (and some cortex) much more similar to us humans. They truly experience anxiety in the face of threat and uncertainty. Their tiny but fantastic organs do have a vested interest in generating fantasies of safety, security, nourishment, and social bonding. We know from decades of animal research that rodents experience anxiety in uncertain environments, and that their anxiety response is very similar to ours. We release the same stress hormone, cortisol, and the same anti-anxiety medications that humans are treated with work on rats. (That is, after all, where they are first tested to make sure they are safe and effective on mammals.)

Anxiety Is Prediction Error
The fact that all ties it together, posed by Friston’s model of predictive processing in the brain, is that anxiety is the felt experience of entropy. Your brain is constantly making predictions about the world, and judging those predictions against what actually happens. The greater the prediction error, the greater the entropy. Prediction error can be as simple as a single neuron firing or misfiring at the wrong time, or as dramatic as an entire belief system falling apart.

This is where humans’ uniquely large prefrontal cortex comes into play for our unique relationship with anxiety. Even for an animal with a sophisticated limbic system, such as a rat, uncertainty is marked by the direct presence or absence of threat. Even for animals with highly developed frontal lobes, such as chimpanzees, uncertainty is marked by uncertainty about the attitudes of others. Where am I in the dominance hierarchy? Is this chimp friend or foe? If I share my food, will the favor be repaid? All of the uncertainty an animal has to keep track of is magnified when living in a social environment. There is uncertainty not only about its own thoughts, feelings, and security, but about everyone else’s as well.

The most socially complex species have had to evolve the most advanced prediction machines in order to keep up with uncertainty. This is the case for humans as well as primates. But where humans excel—and this is arguably our greatest strength and greatest weakness, when thinking about anxiety—is metacognition, or the ability to think about our own thoughts, and to think in terms of abstract symbols.

What other species can have an anxiety attack brought on by existential dread—just thinking about the meaning of life, or what happens after death? Our ancient brain regions respond physiologically to uncertainty with anxiety, just as they evolved to. But we are no longer only dealing with uncertainty about an immediate threat. Uncertainty can mean losing your job, or hearing bad news about stock market futures, or flunking a test. It doesn’t matter; our fantastic brain, the prediction machine, still produces the physiological response of anxiety that is meant to protect us from immediate physical threat: Cortisol levels rise. Your heart rate increases. Your pupils dilate. You begin to sweat. All of these are genuinely adaptive responses when faced with uncertainty, in an evolutionary landscape in which uncertainty means fight or flight.

The problem is that this system is too good at its job. The theory of psychological entropy states that uncertainty is always felt as anxiety, no matter the cause. It does not matter if you are anxious because of prediction error caused by an immediate threat, when you were expecting safety, or because you have begun questioning a worldview that used to give you a sense of security in the world. It does not matter if you are uncertain about something trivial, like whether to buy whole or skim milk. Your brain evolved to deal with uncertainty as a threat, and anxiety is the natural response to that.

Where does this leave us? Are we doomed to become anxious over everything we can’t predict with absolute certainty—which is, literally, everything—like the neurotic philosopher Chidi in The Good Place? Not quite.

Living Out the Fantasy
The optimistic part about the theory of psychological entropy is that it tells us where all emotions are rooted, positive or negative. Fundamentally, it all has to do with prediction error. We inherently experience greater prediction error, greater uncertainty, and greater entropy, as negative. But on the flip side, we inherently experience reduced prediction error as positive. This is why (as mediated by dopamine) it feels so good when you achieve a goal.

This is also why practicing mindfulness and routine improves well-being: It minimizes prediction error, directly or indirectly. Gratitude and humility help rein in your fantasies, leaving less room for disappointment. And journaling and self-reflection help you more clearly map out your thoughts and worldview, leaving less room for error. And healthy habits leave less room for uncertainty. For the fantastic organ, reducing psychological entropy is the key to well-being.

ANXIETY-
Dealing with Extreme Uncertainty.
How irrational thinking can serve you.
Reviewed by Abigail Fagan

KEY POINTS-
Under extreme uncertainty, rational decisions or shortcuts in thinking do not work since information is scarce and people get stuck.
When rational thinking fails, people can turn to eristic (self-serving, wishful or superstitious) reasoning.
Eristic reasoning is self-serving, and it motivates people to keep going.

When uncertain, we typically react initially by seeking the information we need to reduce that uncertainty. We try to find mental shortcuts that help problem-solving and increase the probability of success. This is called heuristic reasoning, and it makes sense when there is enough information to draw conclusions. However, heuristics fail when there is extreme uncertainty because the information is so scarce that any heuristic would be inaccurate.

So, what can you do under these circumstances? In February 2023, a group of researchers suggested that the solution is a type of reasoning called eristic reasoning1.

What is eristic reasoning?
Whereas in heuristic decision-making, decisions are made to satisfy desires by intelligently processing the cues in the external environment (e.g., when stuck in traffic, you may decide to take an exit to find a shorter cut even if you don’t know the way), in eristic decision-making, decisions are made by blindly following desires through self-serving illusory beliefs. Eristic reasoning gives you pleasure and may involve superstitious or wishful thinking.

How can illusory beliefs help?
As a temporizing measure under conditions of extreme uncertainty, eristic reasoning can help. It gives you a sense of purpose. For example, you develop a winning mindset regardless of the circumstances under which you are competing. In some cases, this may work since such beliefs can artificially decrease the anxiety caused by uncertainty, which can boost your performance. The pleasure offsets the discomfort of the uncertainty.

What are the types of pleasure derived from eristic reasoning?
Different types of people will concoct different scenarios for themselves based on their basic needs. For example, a neurotic person may derive pleasure from relieving their anxiety. In contrast, a pleasure-seeking person might seek to bond with others or be sensation-seeking just to keep going. That’s why, when facts are questionable, people turn to their own personalities to satisfy their needs.

How does eristic reasoning show up in our daily lives?
Eristic reasoning is initiated by myths, passions, prejudices and vested interests2. You’ll often see this in political debates, where rather than a weighed argument, the goal is to win the debate at all costs. Sometimes, you see this in legal arguments, where lawyers represent their clients to win a case. One also sees this in the multitude of health-related recommendations that come from experts, where, due to the ample contradictions in the medical literature, people will take one side or another on eating meat, drinking alcohol, exercising a certain way, or following a certain diet. These recommendations are rarely heuristic, even when they are framed that way. They are often self-serving, and the person offering the advice is vested in your following it. You may even follow them to get the pleasure of that bonding and relieve yourself from the anxiety that comes with this.

What are the biases of eristic reasoning?
The biases of eristic reasoning include the overconfidence bias, the endowment effect, status quo bias, loss aversion, and wishful thinking. With overconfidence, the person’s passion is so great that they lose sight of arguments that contradict their own views. With the endowment effect, people often value what they have more highly than if they did not have them. You might, for example, value having a pet after you get one more than prior. Status quo bias keeps people stuck in their own points of view without any propensity to change. Loss aversion makes people attached to their own possessions (even if they don’t particularly want or need them.) And wishful thinking is simply about hoping that something unlikely will happen. One key shift underlying these biases is switching attention away from outside cues to only what will please us.

Why not just rely on reason?
If information sources are not available or reliable, there is no way to reason. This could paralyze you under conditions of extreme uncertainty. Turning to what pleases you is a way to escape that rut. It helps you keep an open mind, though looking for environmental cues is important. The stock market, capital raising, socio-economic shifts, and market dynamics are all situations that can create this kind of extreme uncertainty. Entrepreneurs deal with this all the time. To deal with this stress, eristic reasoning can be very helpful, but it will be dangerous if it consumes you.

Conclusion
Under conditions of extreme uncertainty, you may feel empty, lost, or paralyzed. But eristic reasoning is a way of temporarily escaping these mental states, helping you get to a place where facts will reveal themselves if you are open to them. Satisfying a basic need safely is a good way to get started.