ODR 007 – Liberterian Free Will, Blame and Shame

This Article is a Must Read if you Found this Episode on Free Will Interesting

The Lucretian Swerve


While 1% of this episode may be independent thinking, the rest was surely based on influences too countless to cite. Some that clearly remain foremost as inspiration are the article above, Dan Dennett’s work, Sam Harris’ book, the book, Four Views on Free Will, and all by poor undergrad professors that had to put up with the utter annoyance of my stubbornness.

One of the Most Critical Articles to Read on the Topic

  • Chun SS et al. Unconscious determinants of free decisions in the human brain. Nat Neurosci. 2008 May;11(5):543-5. PMID: 18408715
Image by Narcournus

Now on to the ‘cast


56 thoughts on “ODR 007 – Liberterian Free Will, Blame and Shame”

  1. George DOUROS

    Same concept, different discipline (human factors ergonomics)

    The natural response to an adverse incident is for the reviewer to use hindsight bias, outcome bias, attribution bias and counterfactual realities to retrospectively label a decision an error and then dole out retributive justice (what rule was broken? how badly was it broken? how much do we punish?). The trouble is, making an error is not actually a prospective choice so retribution isn’t an effective preventative tool.

    A cognitive de-biasing tool to avoid this is to apply the local rationality principle: assume people come to work to do the right thing. The decisions they make are a consequence of their 1) focus of attention 2) their knowledge and 3) their goals and seemed like the right decision at the time otherwise they wouldn’t have done it.

    When analysing an incident, the goal should be to understand local rationality of those involved. If you achieve this, two things occur
    1) you have no room to judge people actions
    2) you can see the systems contributory factors. (error may be human but the context of that error is institutional)

    Your approach to an incident (good or bad) should be that of simulation debriefer rather than a cop or detective; blame-free, understanding mind-frames, cues and knowledge. Ask what do we do differently when it goes right? (safety 2 which is like Klein’s shadow boxing).

    And move from retributive justice to restorative justice (who is hurt? what do they need? whose responsibility is it to fulfil that need?). Its what New Zealand’s medical system uses – keep the lawyers out.

    “You can either learn or blame, you can’t do both.” – Sidney Dekker

    1. George– I think you need to come on the show to talk about how you would run the ideal M&M. I’ve loved your LitFL posts on this and would love to talk. Let me know if you are game.

  2. Márcio (Eu)

    I really enjoyed this philosophical episode, Scott! Thoughtful and helpful. Looking forward a next show on the subject!
    Kind regards.

  3. Maarten Van Hemelen

    I liked this episode and feel I’d enjoy the two other topics as well. (That said, ultimately I listen to emcrit for tips on how to get things done in patient care.)

    I don’t feel like this focus on libertarian free will helps a lot though – the concept seems almost meaningless to me. Libertarian free will seems just to be enslavement to a different set of dice (that being your free will, now acting independent of everything that makes you who you are). To me, free will would represent the freedom to act on your preferences – for example, a person with a drug addiction who wants to quit but can’t, is acting out of an unfree will, even is they’re being forced only by themselves. Does that make me a compatibilist?

    Re: medical malpractice, I generally agree with your conclusions there should be more room for nonpunitive interpretation of errors. I don’t feel that the free will argument helps us there though. Certainly, having a culture where, say, speed of disposition is emphasised over diagnostic accuracy could lead to more errors, and therefore you’d have to make the case that this culture is not affected by punitive action (I would maintain that this is far less likely to be effective than internal culture change).

      1. Maarten Van Hemelen

        Sure. I wasn’t disagreeing so much as saying that I have no problem with being predetermined, as long as I still get to like what I’m doing.

  4. Daniel McCollum

    I really enjoyed this episode. This reminds me a great deal of the arguments put forth by Sam Harris in his book Free Will. Philosophical libertarianism is very challenging to defend in a rational way. I personally alternate between compatabilism and determinism. I strongly suspect the logical arguments for determinism are much stronger than the innate “feeling” that we must have free will. I struggle to poke holes in the logic of the arguments for determinism, and it is likely the concern of drifting into fatalism that prevents a wholehearted acceptance of determinism.

    The fundamental attribution error is of obvious importance to the practice of medicine and I’d welcome further discussion on this. Your response to my piece in EM:RAP touched on this and I think misunderstandings of this key concept are a common source of misunderstanding in medicine.

    Further topics that might merit philosophical discussion include the application of stoicism to medicine, why meditation makes you a better clinician, insights from Taoism on resuscitation, and almost anything from the field of ethics.

  5. Jennifer Bolster

    Scott! This was an incredible listen, and perfectly relevant. Keep the grade A content coming!

  6. Definitely some good thought-provoking stuff here, and I am fortunate to work in two systems, both air and ground based, that adopted some form of the “just culture” framework. One wrinkle I see, though, is that we can’t treat something such as a medical error completely independent of the circumstances leading up to it. And when we consider those things, we need to find a line somewhere between “negligence” and “human error”. Put another way, you or I may consider ourselves experienced, up-to-date clinicians, and when we have an error in judgement, we can look back and say we were doing our best, and sleep well at night. But what about those in our fields that are just “phoning it in”? They don’t follow Emcrit, haven’t read a new study in 15 years, and while they may have all the qualifications on paper, we would prefer not to have them treating our family. Maybe they have been out partying lately instead of getting enough sleep, What if they make those “human errors” 3x as often as you or I?

    To use the driving analogy, maybe the driver that struck the pedestrian was sober, but going 3 mph too fast? What about 20 mph too fast? Maybe he knew that he had bad brakes and bald tires but hasn’t gotten around to fixing them? I guess the point is, there is a line, somewhere.

    I see both ends of this spectrum because I work for a fire department where we are all well (over?) protected by a union. It is hard to lose the job short of actively commiting a felony on duty. The result is that in addition to a huge majority of excellent providers, we have some bad apples that we can’t get rid of, because they “meet the standards.” On the other end, I work HEMS for a private company. We are all well aware that we could lose our job at any time for almost any reason. Fortunately the nature of critical care and flight medicine is such that we are almost all independently motivated to stay sharp anyways, so it rarely comes to that. But is certainly one extra incentive to stay on our game.

    To boil it all down – How do we decide if a practitioner has earned the mulligan or not?

    1. Think it is still a systems problem. If a system tolerates people that are just phoning it in, then it is the fault of the system when that level of knowledge causes a problem. If we tolerate unions protecting ineptitude than the unions are to blame, not the individuals.

  7. Ryan Sullivan

    I found this discussion refreshing and needed. Would probably enjoy it with bourbon…

  8. Interesting podcast, as always. I agree with the conclusion regarding moving away from a blame based approach to error. However I disagree with some of the process of getting there, specifically the complete rejection of free will.

    It is interesting that the two named references of Dan Dennett and Sam Harris make up half of the “four horsemen of new atheism” and so represent a narrow perspective. The article by Cashmore certainly seems to follow in the same vein.

    It seems that the argument for philosophical determinism is somewhat predicated on scientific determinism which is largely out the window with chaos on the quantum level. Cashmore’s re-labelling of chaos as stochasticism makes me suspicious. Modern people love to pretend they can order the universe in an understandable fashion. I suspect that his use of a big word (stochasticism) instead of a better, smaller one (chaos) reflects that.

    Stephen Hawking has a great public lecture about the how previous scientists incl Einstein were wrong about their “deep emotional attachment to determinism”: http://www.hawking.org.uk/does-god-play-dice.html.

    To be honest I haven’t read enough philosophy to have heard of libertarian free will but will take your word that that it has been rejected, presumably by the philosophical community (or at least have the illusion that I am taking your word for it!!). My general problem is that philosophers can’t know much when physicists don’t know much e.g. no one knows what energy or gravity is on a fundamental level, so a stab at consciousness or free will seems out of reach at this point. Humans seem vastly better at human level observations (e.g. most things in medicine) than these fundamental questions that seem to deteriorate quickly into indecipherable hoodoo.

    Of course free will (if it does exist) is very much limited by biology (re Phineas Gage etc). But to say it does not exist at all seems a mighty step!

    If scientific determinism does not exist on the micro level, then why would it exist on the macro level? I haven’t read all the referenced authors but I’m not aware of any good evidence to support the assertion that the universally experienced sensation of free will is an illusion. Doesn’t that mean that we should revert to the null hypothesis until better data comes to hand?

    The movement away from a blame culture does not require a philosophical rejection of free will. My two cents is that the really yuck moral-outrage-y kind of blame that we all hate is equally pointless to inflict on a willful creature as it would be on a creature without free will.

    1. Luke, thanks so much for commenting and offering a differing opinion. It very well may come to pass that chaos at a quantum level is what eliminates fatalism. But that doesn’t give us the ability to alter our choices via our consciousness. Our consciousness doesn’t have access to effects of randomness at the quantum level–we can’t make choices or find our ability to choose there. Those effects are included at the level of randomness in the argument I have laid out.

      When you say, “If scientific determinism does not exist on the micro level, then why would it exist on the macro level?”, it seems you are conflating fatalism, i.e. that everything in the universe is already scripted and inviolable with determinism–that given the same exact factors going into a choice (including at the quantum level) our decision would always be identical. Sure, if you replayed time things may be different due to the cat being alive when you hit play again–but free will doesn’t exist in that difference–you did not choose differently.

      I believe the atheistic bent of the folks espousing a lack of liberterian free will is a confounder, not a direct connection. Aside from the Calvinists, most modern religions would have a tough time abandoning the concept of liberterian free will, so any devout practitioner is going to have a large amount of cognitive dissonance if she wanted to keep both beliefs intact.

      1. Hi Scott – thanks very much for your reply. I’m sure we are all too busy to get sucked into a vortex of the details of such things but I’ve reflected on it some more and thought it worth a reply.

        Perhaps I am not familiar enough with the incredibly precise semantics of the many “-isms” needed to engage with established philosophy. However, on first principles I think I probably agree with your argument about libertarian free will, as you defined it. Though I think the definition is the problem. My conception of free will would be better defined as “capable of action where the primary mover is willpower.” Clearly most action is due to instinct / habit etc (hence the focus on systems when assessing error) but the question is, are we capable of free will at all?

        I concede this would require phenomena outside the standard scientific model which at first glance may seem to be an unjustifiably large conclusion (and especially uncomfortable for Harris & co). However with a non deterministic universe (as per Stephen Hawking) this is not impossible. The real selling point is that we have a precedent for such phenomena in the concept of consciousness, which I really really hope the philosophers do not deny. I’d say human experience is different to everything else as we can look at it from the inside so will require completely methods to study it.

        I’d probably avoid the use of the word ‘soul’ in polite conversation to avoid upsetting the hard line new atheists. However a complete denial of anything vaguely metaphysical / extraphysical seems to assume we have a good understanding of the universe. My personal opinion is that humanity is probably still in its infancy of discovery. Again, the illusion of free will (if it is an illusion) is a damn good one (subjectively I’d say its 90% as compelling as my own physical existence) so it’d require reasonably weighty evidence to undermine it.

        Lastly, I’d argue that there could be negative consequences to an intellectual rejection of free will. Atul Gawande writes in ‘Being Mortal’ that cancer survivors with a will to live have some statistically demonstrable improvement in survival (sorry for the crappy referencing). The idea that I am in partial control of my future sure makes studying at the library on a blue sky day much easier to endure!

        Not sure if my semantics regarding free will are way off track here but that’s my two cents anyway. Thanks again for your excellent work.

  9. Wow. Listening to Scott Weingart talk about free will and philosophy of mind was a surreal experience I never knew I wanted. I’m on board, good times.

    I think the reason we hold clinicians accountable for errors we consider below the standard of care isn’t because they should have done something differently in the moment, but because they should have prepared differently before that moment. They should have chosen to study harder, attend more classes, read more attentively, and basically hold themselves to a higher standard of competence. We all probably looked sideways at certain students in school and wondered how they were going to hack it in the field, or we watch colleagues practice very differently than ourselves (outdated, incautious, cognitively slowing with age, etc) and wonder how long it’ll be until they run out of rope and face the consequences. Whatever the reason for it, they’re practicing in a way that’s inadequately safe, current, and skilled, and eventually that comes to light via a bad outcome. You don’t “punish” them for the decision they made on that night, not really — you punish them for becoming the person who would make such a decision.

    Similarly, we recognize that drunk people often have poor judgment, and we’re not going to change that. But pre-drunk people CAN choose not to drink. So the error isn’t that they drove into a tree, vomited on the mayor, swore at their mother; the problem is that they decided to get drunk enough that they couldn’t control themselves.

    (Obviously, from a perspective of strict philosophical determinism, much of this is moot, or at least academic. But like the logical conclusions of many vexing arguments in philosophy, the main way to resolve that is to ignore it. There’s no reconciling a lived existence with a fully-operationalized belief in a lack of free will.)

    1. the ? becomes what is the standard. Most docs out there, do their society recommended yearly CME, recert tests, and maybe a national conference a year. This is therefore the de-facto standard. Expecting more and blaming folks for error would only be fair if we make those expectations explicit and required.

      1. Surely we can agree that the standard of care is actually higher than this? I don’t think anybody believes that the mechanisms of licensing/certification/credentialing are comprehensive (i.e. fully specific tests) for assessing competence. There would be nothing particularly incongruent about hearing a provider passed his board exams one day and then went out and committed malpractice the next. (And how about the one who took his exams 8 years ago?) Above a certain baseline, we essentially trust clinicians to uphold the standard of care on their own, and use peer review/institutional oversight/lawsuits as a second line defense to “help” them to do so.

        I agree that this can go too far, and easily enter the realm of retrospectoscopic “something could have been done differently/better, so you did it wrong.” But I don’t think we can be so extreme as to claim that clinicians who check their boxes on paper are by definition meeting the standard of care.

        1. I understand why you wouldn’t–the viewpoint I espoused above is counter-intuitive and just feels wrong. Nevertheless it is the core of the human factors approach to error. You’ll hear more about this with George Douros when we do a podcast. Reading Dekker’s book, A Field Guide to Human Error Investigations, was entirely view changing. I highly recommend grabbing a copy from the Med Library.

          1. I’ll try to pick it up. But I take your point to mean that our system of licensing and compliance for clinical practice implies that adherence to those requirements is both necessary and sufficient to meet the standard of care. Outside of gross negligence or malfeasance, providers who meet the requirements and yet still make errors are making errors we have endorsed.

            I don’t think this is how we see it currently — there is an implied standard of care above and beyond the basic requirements to practice. But I think I see your point, that it’s hard to fault anyone for falling into this invisible donut hole between standards. In some ways, implicit standards are the worst kind (see: “We don’t have a dress code, but [we have an unspoken cultural rule about what you should wear]”), prone to misunderstanding, variable application, and abuse.

            At the same time, I’m not sure how we could make our explicit metrics exactly match our implicit standard of care. No standard can ever have 100% fidelity with the referent. Imagine if we required doctors to take a test every year that evaluated 99.999% of every single fact, concept, and skill required for their practice! Even then, the one key fact that didn’t get tested — are we suggesting it’s okay if they don’t know it? No, of course not; we’re testing a sample and extrapolating to the whole, without suggesting that the sample is comprehensive.

            We can push our stated and evaluated standards closer and closer to our true expectations, with more and more burden of assessment, but I think there will always be a degree of extrapolation — a degree of weighing a provider by their training, experience, and personality, and saying: “I trust that you’ll do the right thing and give adequate care, in all the moments when it’s out of our hands and solely determined by your own character.”

            1. Well sort of…
              Everything you say is true, but that’s not really it.

              Here it is in markedly reduced form.
              If you are a leader or a peer, and you know someone is just coming to their shifts, taking the 10 year reup test, and maybe going to a conference every 2 years or so as there only post-training con. ed; and you tolerate this situation when no error is occurring (i.e. every moment up until the error). Then you can’t change your tolerance when an error occurs.

              If you eliminate the error and say to yourself, if there was no error is a situation acceptable, or even further–the norm; then you don’t get to be upset with the identical situation when an error occurs.

              1. What’s the alternative, though?

                Of course one option is to simply say that it’s “okay” when bad things happen (that is, those errors in the gray area where we feel they might have been preventable with different care), but I’m not sure we want to do that.

                I think it was Nagel who used the phrase “intuition pump” to describe the goal of a lot of philosophical arguments, particularly in ethics. We want to develop rules that fit our intuitive sense for what’s “right” when we feel like we know what’s right, so that we can apply those rules in other situations when it’s not clear. Coming up with arguments why something that seems wrong is actually right doesn’t usually accomplish much; it might make sense on paper but usually bounces off our reality without making any dents in behavior.

                So: assuming we want people to give excellent care, what’s the most logical, consistent, reliable way to create a system where it’s expected from them (to the extent that deviations will only occur in actual clear negligence)? How do we enforce that higher level across the board?

              2. Intuition pumps are the work of Dan Dennett.

                Other than pointing that out, in answer to the rest, I would simply say that we gain v. little by blaming individuals and gain a ton by blaming the system–so even if every fiber of your body screams the reason this happened is that the person in front of you is an idiot, you will quickly see that mindset doesn’t make anything better if you really think through the consequences of going down that path.

                I will again recommend Dekker’s, “Field Guide to Understanding ‘Human Error'”

                I am going to make it an EMCrit book club.

    1. Absolutely love the non-medicine podcasts, Every time. Would love to see Stoicism, Taoism, any of the ideas mentioned above. What about fasting, nutrition, exercise, hormesis.
    2. I admit I have not yet listened to the podcast! Just looking at comments and the Swerve article. I had not read it before today. Please forgive me, I will listen to the podcast and repost a comment asap.
    3. I am a Harris fan, have enjoyed his debates with Peterson and others. I have read End of Faith and Waking Up, but not Free Will. The free will problem seems like a bit of a case where philosophy gets carried away with semantics and definitions. It seems like I make decisions, like I am the mover. Of course this biologic argument against free will is compelling. But I keep feeling like there is some sort of contradiction, some internal inconsistency in a purposeful argument against the ability to purposely / intentionally argue. Cashmore is writing this excellent paper, and making “A Proposal” for changes in the criminal justice system, and then we are considering modifying error management in medicine. But if we have no free will, who is making the proposal? I don’t see Cashmore using any metacognition to see this irony, he doesn’t refer to his own ideas / free will in writing or arguing for changes in this determined world. Perhaps he would admit that he was destined to write this article, and we were destined to read it, and changes in justice or medical errors are predetermined to happen or not happen whether we are persuaded or have our minds changed by the discussion. That would be coherent with his apparent views. But is seems circular to me. What does it mean to write a persuasive piece when you have no ability to do otherwise? I also would have liked to see him talk more about emergent phenomena, what consciousness is, etc.
    4. I would throw in ideas from somewhat fringe thinkers on quantum mechanics on the possibility to “change your destiny.” Joe Dispenza is one. Fully admit some of these folks are out there, not exactly scientists. Many can articulate the argument for how Cashmore’s “new law” (QM) could allow for free will beyond random stochasticism. I confess that my gut tells me something extraphysical or maybe even “supernatural” exists in the world, that Scientism may be overreaching, Science might not possess a monopoly on Truth. Is it possible that something exists even if scientists cannot measure it? If that means I am a believer in “causal magic,” I guess I can live with that.
    5. Thank you again for all of your material, and especially these paradigm busting podcasts. Excellent for strengthening the mind, whether I am choosing to do it or not.
    1. Listened to the podcast. Love the concepts. I would have to read more about the underlying philosophical arguments. Especially the concept of “entity based free will” and “compatibilist” ideas.

      I do not see the logical leap of treating the anecdotal offenders differently based on the above. If libertarian free will is not real, how is the drunk driver different than the sober one, the good hearted doctor different from the one who doesn’t care?
      I do fully agree that physicians are generally trying to do a good job, we say this all of the time. And I do not think they should be blamed and especially not shamed for mistakes. Saying the driver or doctor had “good intentions” is somewhat nonsensical when they have no choice of what their intentions are, no little person in the brain.

      On an unrelated note, this lack of free will also dismantles the Stoic dichotomy of control (or the trichotomy according to William Irvine). The stoics seemed to have a fatalistic streak, but they also strongly encouraged us to focus on the aspects of life over which we have control. It appears that at least in this “focus on what you can control” realm, Stoicism allows for free will.

      Again, thanks for the thought-provoking podcast. Looking forward to more.

      1. Martin, my distillation to entity-based free will is you are punishing the machine regardless of choice. Bad robot if the robot’s programming led to the action. Not bad robot if chance led to the action. The reason you punish the first case is it will change the programming of the robot and all other robots that see the punishment. That is why we punish the entities that drive drunk. They had no choice, but by punishing we make it less likely for future drunk drivers to drive drunk b/c it becomes part of the GESS that alters all future decisions.

        Same thing for the Stoic dichotomy of control. You are conflating determinism with fatalism. Your consciousness still affects decisions, it is the consciousness that is determined. If you give up and say fuck it all, your entity is to blame. You are a defective entity.

        Both of these are the same thread.

    2. the word destiny is another bid to fatalism. We are not fated.

      We still affect the outside word, Cashmore’s article changed my life and thinking. If he had not written it, my determined course would be different. This is true even though he was determined to write it.

  10. Christine Jefferies, MSN, RN, CNL

    I listened to it twice in quick succession. This was great, thanks Scott! Looking forward to the next two episodes.

  11. Hal Canham

    Excellent podcast. I’m a big fan of Sam Harris and have read his book “Free Will” a few times. I am a full believer in our lack of free will and you summarized it well in a relatively short period of time. Aligning this with the practice of medicine as you did in the conclusion of this podcast was very helpful to me as I recently had a complex case with a poor outcome. It helped me not “beat myself up”. Thanks again and I look forward to more podcasts in this similar vein.

  12. Loved this section! I had begun to come to these conclusions from my own experiences and general pondering so its great to hear them backed up by actual sound philosophical reasoning. So important to surviving and thriving in medicine. Please do a part 2! Thanks so much.

  13. gregory norris

    I enjoy these types of discussions and as a neurointensivist i spend an enormous amount of time thinking about consciousness. There is no good reason to believe consciousness is some variation of matter or that you can reduce consciousness to something on the periodic table of elements. It’s the ultimate mystery.
    The hard problem as David Chalmers described. My two cents…Consciousness exists within the electromagnetic nature of the brain. Consciousness comes and goes as the brain generates or does not generate direct current and specific rhythms that we can see on the eeg. Remember…eeg is measure of electric field’s which interact with the brain. Consciousness reduces to the EM nature of our brains…not brain matter. Brain matter doesnt come and go at night. Brain matter creates the EM pulse which creates consciousness. How? I have no idea…

  14. I loved this episode! A little heavy, albeit, even ion your attempt to laymen-ize, but super good stuff!
    It’s a nurse, I’ve made a couple med errors., one worse than the other! The shame storm to follow certainly made an indelible mark on me….. and the guilt (never helps being a Jew) is still haunting.
    My med error did not have any untoward consequences to the patient, thank all the gods! However, the experiences were profound. It not only effects the patient but also the provider.

    Though it’s hard for me to wrap my head around the philosophical concepts you discussed, the real life applications you used as examples were palpable and resonant.

    Bring on the second half, please!!!

  15. Derik Frieda

    Great topic of discussion. It’s great to slightly deviate from the typical medicine talk and nice to engage my mind in a whole different way. A way that is is still relevant in my clinical application.

  16. I thoroughly enjoyed this episode, and would love to hear more like this- Regards, Austin

  17. Scott, I enjoyed your latest podcast and look forward to more in the same vein. After practicing 35 years and seeing over 200,000 patients in the emergency setting, I find it much more fascinating to study our decision-making and our interactions with our patients rather than focusing on the disease processes we confront. In the most recent episode of my podcast (Podcastofexbem.libsyn.com) I discussed what I called the boogie man that accompanies me to work. This is the embodiment of my instinctual fear that ceaselessly argues that I protect myself while making decisions often to the detriment of my patients. Your discussion of the little man or little woman in our head therefore struck a harmonious cord with me, That incessant internal voice shouting ” what if this happens or what if that happens” remains inescapable but must be held and check if I’m to be of maximum service as a physician. The perfect strategy for doing this is what remains elusive.. Whether we call it free will, or determinism or fatalism or whatever, we are in the decision-making business and shining light on this process to better understand it is a prerequisite for improving this skill. Unfortunately .I believe that in my three decades of practice, I have witnessed a growing reluctance among my peers to trust their judgement in favor of a quixotic quest for certainty driven by fear. This has led to frustration and an errosive anxiety that, I believe contributes mightily to burn out in our specialty. Discussions such as yours encourage us to consider new ideas and grow in our ability to be comfortable with the decisions we make.

  18. Scott, thanks for bringing this up. Very important ideas to consider. I would love to hear more like this.

  19. Ross Bryan

    Super appropriate and fascinating discussion. I agree entirely and have a lot of interest in understanding why we do what we do, and how uncertainty affects our practice (we cannot know the future due to randomness). These are ideas that should be more explored and understood in medicine.

  20. Bryan Miller

    Great episode! I look forward to hearing the next two installments! I love that the podcasts occasionally address the issues around emergency & critical care, not just the direct medical practice. Please keep up this fantastic resource!

    -Bryan Miller

  21. Scott, you lost me when, in the course of this “heady” discussion you continued – as you, and almost everyone else, seems to always do – to reference your’s/one’s “feelings” about a subject in lieu of the accurate term….”thoughts”; as in “my feelings about push dose pressers are…”. How can you conduct a meaningful philosophical/psychological discussion if you conflate “feeling” with “thinking”?

  22. I think the topic of medical errors needs much more thought than just the concepts of “blame” associated with “free will” as analogized by a preventable death by drunk driving vs an “unavoidable accident”. We are in a culture of medical paternalism where while physician cognitive biases (e.g. based on overconfidence, low tolerance to risk, high tolerance to ambiguity, cognitive anchoring, racial bias, etc.) are now recognized as “reasons” for errors and poor patient outcomes, these errors continue and avoidable deaths occur despite advances in medicine, education and supportive technology. I think due to fear of blame and attribution, we fail to openly recognize avoidable errors and perform real “root cause” analysis that can inform systematic change towards virtually error free medicine. What lessons are being learned in grand rounds/M&M meetings? How are these lessons disseminated? How does fear of liability affect the learning process? How is progress being measured? Our incredibly safe air traffic system is a great example. of what is possible.

  23. Dennis Hughes

    I enjoyed this swerve on the edge of the curve and look forward to more of the same. Dumbing it down to my mantra for the last 30 years: “always better to be lucky than smart” (clearly luck favors the prepared in most instances).

  24. This podcast was excellent.
    I would love to hear more psychology, philosophy, and medicine intertwined.
    Keep on crushing it.

  25. Wm. R. Gailmard
    1. Yes, please, more episodes in this vein. 2. Would that I read as well as you and your listeners who’ve commented here. 3. To wander a bit after reading many but not all 51 comments, I continue to see patients in the ED who have a current Rx for a fluoroquinolone, prescribed inappropriately in every example (wrong indication, drug interactions, no diagnosis) and with no apparent awareness on the part of the prescriber of the near-monthly medical and general news releases regarding the need to curtail prescribing. Is fault to be assigned to a system when a warfarin-treated patient suffers a fatal hemorrhage while taking ciprofloxacin prescribed for acute bronchitis?

    I would never call myself an adequate consumer of CME, but just Physicians’ First Watch and EM:RAP have brought me actual life saving knowledge. (Bougie for chest tube insertion with bilateral flail chest) I am not casting the first stone, but as I am currently applying for hospital privileges for the first time in 8 years, laboring under the startling increase in documentation now required, that we have no effective mechanism in the US to ensure that providers – physicians, PA/NP – are well educated and following sound practice principles comes into sharp focus since the vast majority no longer have hospital privileges.

    Underlying philosophical principles of behavior with respect to techniques and prescribing patterns have potentially profound implications for the patient. We owe it to ourselves and to those we care for, to constantly question ourselves: how did I come to this decision? are there hidden errors or missing steps I fail to account for? have I failed to correctly assign a setting for the diagnosis (is the patient’s new hypotension part of their presenting chest pain complaint or despite the absence of skin or airway changes a direct result of anaphylaxis to the IV contrast given for the CT angiogram?) Have I allowed myself to be led down a path by a consultant?

    I suppose I would offer, then, that as long as we operate under what is perhaps merely an illusory free will, we should make every effort to be aware of as many of the factors (not facts) as possible that lead us to choices / decisions, especially those effecting patients. On the other hand, if all behavior is determined I can stop wasting my time counseling smokers to quit. But then I wouldn’t get to celebrate the 4 out of 100 that stop.

    1. Will,
      a few points:
      if the physicians don’t know about the fluroquin. stuff whose fault is that. If the group thinks it is important for the group docs to know, they should have sent this info and disseminated in every possible way. If they are reliant on the individual docs to come across it, then that is bound to fail.

      As to counseling smokers, perhaps I was not clear not enough in the ‘cast. Doing so will absolutely change behavior. We are all subject to external persuasion. You can change the behavior of others and that is fully compatible with the absence of libertarian free will.

  26. Good to hear a different podcast outside the medical field. Let me share my two cents on this.
    As a starting comment I would say that you should never be afraid of discussing any topic in philosophy just because you don’t have a doctorate degree in that area. Most professors of phylosophy are not philosophers, and the majority of the most important philosophers in history did not have any formal university education.
    That being said, let’s exam the actual problem: is there such thing as free will or not?
    The answer for that is yes, there is, and the reason resides in the fact that it is simply impossible to build an argument against free will for the sole reason that the person arguing against free will is, him or herself, exercising his free will to do so. I came to this website to comment because I wanted to do so. You created a podcast about that topic because you wanted to do so. An author may choose to write a book against free will (while paradoxically exercising his free will to write the book) because he decided to do so. The existence of free will is, therefore, empirically clear, given the impossibility of building an argument against it that is not self contradictory in its very root.
    Nonetheless, the question that you are trying to answer seems to be less about the existence of free will itself, and more about the degree to which free will determines one’s actions. In other words, is free will the sole determinant of one’s actions? In that regard, the answer is probably not. There are a lot of other internal and external components that dictate the final action or reaction of an individual. Free will seems to be only one of the components of the equation (although some could argue that’s probably the most important of them). The extent of this influence is, in itself, a very long and heated debate about a problem for which I’m not sure we have an answer to date (and probably we may never have).
    Looking forward to continue this discussion in a cocktail party. Cheers.

    1. I must be a poor philosopher indeed as seemingly I did not explain things well enough to be understood.

      Your argument is that since you made the choice to come here and comment, then there is free will… QED.

      Things get more interesting when we parse that statement. First of all what is YOU?

      I think you mean that your consciousness made the decision to come here and comment. I am willing to grant you that as I did in the podcast. Your consciousness, for the purposes of this comment, is free to think things, to decide things, and to make good on these decisions. This, if I infer correctly, is what you are arguing proves free will.

      The level where that libertarian free will disappears is that your consciousness is determined. It emerges from a brain and that brain is built of stuff and generates stuff and you have absolutely no control over that stuff. Every decision your consciousness makes is determined by that stuff. Your free will is illusory as while you did indeed decide to come here and comment, there was zero possibility of you deciding any other way unless some random effects, which you have no control over, altered your stuff.

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