10/27/17

Ability to Choose … Within Limits

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It’s not too difficult to discover where Sam Harris stands on whether or not humans have free will. We unequivocally don’t. “Free will is an illusion.” In a lecture Harris gave for Skeptic Magazine that was based on his book, Free Will, he added that if the scientific community were to publically declare free will to be an illusion, “it would precipitate a culture war.” Science has revealed that we are “biochemical puppets” and “The universe is pulling your strings.”

Free will is an illusion. Our wills are simple not of our own making. Thoughts and intentions emerge from background causes of which we are unaware and over which we exert no conscious control. We do not have the freedom we think we have.

This illusion of free will is based on two false assumptions, according to Harris. The first is that we can behave differently than we did in the past. But since we live in a world of cause and effect, our wills are determined by a long chain of prior causes, “and we’re not responsible for them.” Alternately, what we perceive as free will is the product of chance; and again, we’re not responsible. Or there could be some combination of chance and cause and effect, but still no personal agency. Whichever way we conceive it, free will is an illusion in a world ruled by chance and cause and effect.

The second false assumption is that we are the conscious source of our thoughts and actions. “We presume an authorship over our own thoughts and actions that is illusory.” There is no self, no ego, no soul to generate thoughts and actions, according to Harris. They just emerge in our consciousness. And if we cannot control our thoughts, if we don’t know what our next thought will be until it consciously emerges, where is our free will?

How can we be free as conscious agents, if everything we consciously intend was caused by events in our brain, which we did not intend, and over which we had no control?

Sam Harris is an author, philosopher and neuroscientist who has written several popular books in addition to Free Will. Along with Richard Dawkins, Daniel Dennett and Christopher Hitchens, he has been referred to as one of the “Four Horsemen of New Atheism.” The reference draws on the title of a 2-hour unmoderated discussion between the four that is available here on the website for the Richard Dawkins Foundation for Reason and Science. They discussed the public reaction to some of their books critical of religion, and some common misrepresentations of them and their beliefs.

Harris’s position on free will assumes the universe is a closed system of cause and effect. Since there are no creator gods, everything that now exists is the result of what has come from “a long chain of prior causes.” The theologian Francis Schaeffer referred to the understanding of science that comes from this view of the universe as modern, modern science—science rooted in naturalistic philosophy. The uniformity of natural causes, which is an essential starting point for scientific investigation, must be understood as occurring entirely within the natural order of the universe. Nature is closed to any causal intervention from outside.

There is no Creator; no First Cause. There is only chance or cause and effect. Not only physics, but psychology, social science and human nature must be explained within the confines of this closed system. The biologist and neuroscientist Robert Sapolsky believes that every bit of human behavior has multiple layers of causality. He said what we call “free will” is simply biology that hasn’t been discovered yet. “It’s just another way of stating that we’re biological organisms determined by the physical laws of the universe.” See “Ruling Over Our Genes” for more on Sapolsky.

In Escape From Reason, Schaeffer concluded this materialist unity of all things leaves us afloat on a deterministic sea with no shore. The only way this unity can be achieved is by ruling out freedom. “The result of seeking for a unity on the basis of the uniformity of natural causes in a closed system is that freedom does not exist.” Free will is therefore an illusory cognitive construct.  The nonmaterial mind or soul is also an illusion.

However, Harris and Sapolsky aren’t the only neuroscientists to ever consider the possibility of free will. Harvey McMahon is a staff scientist and group leader at the Medical Research Council Laboratory of Molecular Biology in Cambridge. He is also a member of The Royal Society, the world’s oldest independent scientific academy. Past members of the Society have included Isaac Newton, Albert Einstein and Charles Darwin. Current members include Richard Dawkins and Stephen Hawking.

McMahon discussed free will in: “How Free Is Our Free-Will?” He opened his essay by noting science has provided evidence that free-will may be an illusion. Yet free-will was fundamental to our sense of wellbeing, and underwrote our sense of morality, our judicial system, and our Judeo-Christian faith. “We may not be as free as we would like to think, but within boundaries shaped by our individual histories, our genetics, and our environment we can make decisions that determine our character, relationships and future.”

He noted the paradoxical nature of freedom. For example, if we marry we limit the relationships we will have with others, while at the same time opening up new avenues of freedom from being settled in our choice of partner. This principle, McMahon said, applies to all our choices. We change our future possibilities by the choices we make today. “Thus freedom is not unconstrained choice, for with each choice we limit our freedom, and in so doing shape our environment and ourselves.”

These constraints are from our culture, our relationships, our jobs and our families, and other influences. Added to these is the subconscious working of our brain, processing cues of which we are not aware. “Thus the brain may even be making decisions for us.” Do we really have a choice? Here McMahon acknowledged Harris’ above noted argument (and book), that free-will was an illusion. But rather than an illusion, he thought it better to say it was constrained by many factors.

Free-will, McMahon thought, “is a cognitive concept, involving the mind.” It is the ability to choose deliberately between options. “It cannot be regarded as the opposite of determinism, where events have cause and effect outside human control.” He illustrated what he meant with the following diagram. Free-will only applied to cognitive processes where we use our minds to make choices—in between the two extremes. Although not stated by McMahon, I’d say completely free choice is only possible within the mind of God.

Human free-will is then not completely determined, nor is it completely free. McMahon suggested free-will occurred within the boundaries of predetermined factors, where there was little or no freedom to choose. These factors could be biological or genetic. They could also be family, culture, or environmental factors. See the diagram below.

Within an outer sphere of predetermined boundaries, lies a continuum of interaction between prior free-will and proximal free-will. Prior free-will is where an immediate decision is constrained by past decisions and history. Going to work on a given day is more the result of a past decision than one made when you woke up that day. You can re-assess the decision and not go to work for some reason, “yet the choice does not have to be constantly re-evaluated.” In-the-moment or proximal decisions can be inconsequential, like choosing between tea or coffee, or involve active cognition, as when we weigh our options. “Both of these give a strong sense of free-will in the moment.”

Plasticity refers to the fact that our brains are moldable. “We are constantly learning new information, meeting new people and acquiring new skills, which all require that our brains are ‘plastic’.” New synapses can be formed or existing synapses can be modified or lost. “At a molecular level there can be changes in the expression of various proteins which in turn influence the excitability of a given synapse or circuit.”

The choices we make influence the behavior patterns we develop, which are laid down as neuronal pathways. In turn, these pathways influence other choices. “So in this sense we are masters of our own destiny… all because we have a ‘plastic’ brain (i.e. not completely preprogrammed).” Although there is difficulty in the process, we can change. If we make certain choices repetitively, they lay down neuronal pathways and turn into learned behaviors.

Plasticity is thus key to the possibility of free-will [see the above diagram]. While memories of past experiences may not be completely eradicated, they can be scaled back by the new experiences that occupy our minds as we choose to dwell on other things.

Jeffery Schwartz and Rebecca Gladding coauthored You Are Not Your Brain, a self-help book that applies the principles of neuroplasticity discussed above. Like McMahon, Schwartz and Gladding affirm the reality of the human mind and the existence of free-will. Dr. Schwartz is one of the world’s leading experts in neuroplasticity. You can read more about him and his books on his web page here.

McMahon said the relationship between this conception of free-will and intentionality is complex. To the extent we willfully choose and can foresee certain outcomes, ”we can be held responsible for the outcome.” However, if we could not foresee the potential consequences of decisions, to what extent can we say their outcome was intentional? Furthermore, what about when reason has been suppressed for some reason, or if it has been erroneously applied (if we haven’t reasonably weighed our potential thoughts or actions), and non-intended consequences result.

Despite the caveats, in general each of us is responsible today for what we did yesterday because these were acts of free-will, or actions resulting from an absence of self-control. The responsibility for evil can be lessened by considering our circumstances but it never excuses us because at some point in the past we have actively participated in shaping who we are today.

McMahon goes on to describe how he believes our brains and free-will interact with each other. He suggested that while individual neurons do not have free-will, “it is an emergent property of neuronal networks.” He suggested free-will sits upon a tripod of past memories, present inputs (combined with the ability to compute and learn) and future predictions and aspirations within the plasticity of the brain.

There is more to read and think about in his article. McMahon also shares his thoughts on how God constrains us and yet frees us. He wrestles with the question of whether free-will is compatible with divine sovereignty. Read more on how he applies the above discussion to this theological dilemma. His conclusions are worth repeating here.

With the above in mind the following definition of free-will can be offered: Free-will is the ability to choose intentionally within limits placed by a sovereign God, with resulting human responsibility. Free-will is not the opposite of determinism: one can have free-will within the limits set by determinism. Indeed our relationships and our decisions are not absolutely predetermined, and this is a reflection of the freedom given to us by being made in the image of God. So, we have the best of both worlds, where we have freedom to make decisions and yet our personal future and that of the world are secure.

The above understanding of free-will indicates we are less free than we may like to think we are at any given moment, because of prior decisions and predetermined factors. And while neuroscience hasn’t extinguished free-will, it does help us see why we do the things we do. So we are not biochemical puppets, but biology constrains us. “We are not determined by our past, but certainly influenced by it.”

10/3/17

Feuding Ideologies, Part 1

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In August of 2017, the now former Health and Human Services Secretary, Tom Price, said he didn’t think it was necessary to declare the opioid epidemic to be a national emergency. This was despite the president’s own opioid commission recommending it as the “first and most urgent recommendation.” Two days later, the President reversed Price’s statement, saying: “The opioid crisis is an emergency, and I’m saying officially right now it is an emergency.” The response was mixed. While President Trump’s announcement could be used to help free up federal resources and help to prioritize responses to the disaster, it could also permit the administration to push for new sentencing legislation in order to get “tough on crime” related to drug use.

What isn’t disputed is that the U.S. does have a serious opioid problem and something needs to be done about it. Drug overdose is the leading cause of death in Americans under the age of fifty. Forecasts by STAT News are the annual death rate will increase by at least 35 percent by 2027. The CDC reported that from 2002 to 2015 there was a 5.9-fold increase in the overdose deaths from heroin and non-methadone synthetic opioids.

The latest statistics for the U.S. opioid epidemic is now available in the 2016 National Survey on Drug Use and Health (NSDUH). Among the myriad of statistics reported there was news that heroin users increased 230% from 2002 to 2016, while heroin deaths increased 630%. An estimated 948,000 people aged 12 or over reported they used heroin in the past year. That translates to .4% of the country’s population. There were also an estimated 11.5 million people who misused pain relievers in the past year, 4.3% of the population aged 12 or over. Combined, there are 11.8 million people who misused opioids, 4.4% of the population, in 2016.

The 2016 NSDUH Report can be accessed here. A shorter, graphic-based report of key findings, including those noted above, is here.

One of the treatment approaches often touted to address the opioid crisis is medication-assisted treatment (MAT) with Suboxone. In January of 2015, Jason Cherkis wrote “Dying To Be Free.” His subtitle asked why we weren’t using a treatment for heroin addiction—Suboxone—that actually worked. The opioid problem in Kentucky was the focus of his article, which I found to be rhetorically persuasive and well written. You are introduced to individual after individual who wouldn’t or couldn’t use Suboxone and ended up dead from an eventual overdose.

“Dying To Be Free” was a finalist for a Pulitzer in 2016 for its “deeply researched reporting on opioid addiction” that showed how many drug overdoes deaths could have been prevented. The cover letter submitted for its entry for the Pulitzer by The Huffington Post said it triggered a series of state and federal policy changes that rejected abstinence for opioid misuse and embraced medication-assisted treatment. “‘Dying To Be Free’ offered readers an immersive experience that included audio and video documentaries and photo and data displays.”

This was not fake news. “Dying to Be Free” captured the agony of individuals and families who struggle with opioid misuse. But it also made abstinence-based approaches to treatment and recovery a bogeyman responsible for many of the unnecessary deaths from opioid overdoses. The rhetoric of the article was a straw man attack on abstinent-based treatment while it extolled MAT. Its biomedical treatment bias seemed to dismiss or ignore many of the problems with Suboxone as a MAT for opioid addiction. Nor did it tell the whole story behind Suboxone. It also misrepresented the recovery philosophy of self-help groups like Alcoholics Anonymous. Here’s what I mean.

In the last paragraph of his second chapter, Cherkis said: “There’s no single explanation for why addiction treatment is mired in a kind of scientific dark age, why addicts are denied the help that modern medicine can offer.” This succinctly captures the problem as he sees it with existing treatment approaches to the opioid crisis. Heroin addiction is a medical disease and should be treated as a medical disease. Modern medicine has a scientific treatment for heroin addiction that is resisted because of stigma, a deep-rooted adherence to self-help, and the criminalization of heroin addiction. If you question or oppose MAT, you are apparently mired in a kind of scientific dark age.

To enter the drug treatment system, such as it is, requires a leap of faith. The system operates largely unmoved by the findings of medical science. Peer-reviewed data and evidence-based practices do not govern how rehabilitation facilities work. There are very few reassuring medical degrees adorning their walls.

Dr. Mary Kreeft, one of the pioneers of methadone maintenance, was liberally quoted to support the medical model of addiction. She noted how opioid addiction alters multiple regions in the brain, including those that regulate reward, memory, learning, stress, hormonal response and stress sensitivity. According to Dr. Kreeft, after a long cycle of opiate addiction, a person needs specific medical treatment. Some people may be OK in time. But “the brain changes, and it doesn’t recover when you just stop the drug because the brain has been actually changed.”

An abstinence-only treatment that may have a higher success rate for alcoholics simply fails opiate addicts. “It’s time for everyone to wake up and accept that abstinence-based treatment only works in under 10 percent of opiate addicts,” Kreek said. “All proper prospective studies have shown that more than 90 percent of opiate addicts in abstinence-based treatment return to opiate abuse within one year.” In her ideal world, doctors would consult with patients and monitor progress to determine whether Suboxone, methadone or some other medical approach stood the best chance of success.

This is a rigid, strict medical model of opioid addiction. And it gives a mixed message regarding whether or not the individual will ever be able to stop taking Suboxone or methadone. Neither drug, said Cherkis, is a miracle cure. But they buy addicts time to fix their lives, seek counseling and allow their brains to heal. So far, so good. But here comes the caution: Doctors recommend tapering off the medication cautiously. The process could take years, as addiction is a chronic disease and effective therapy takes time. Then comes the typical analogy of the pure medical model of addiction:

Doctors and researchers often compare addiction from a medical perspective to diabetes. The medication that addicts are prescribed is comparable to the insulin a diabetic needs to live.

There is no mention of neuroplasticity—the brain’s ability to reorganize itself by forming new neural connections. “Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment.”

Jeffrey Schwartz and Rebecca Gladding use an almost identical description of neurological action to that given above by Dr. Kreeft to describe how to change the brain; to modify bad habits (including addiction) and unhealthy thinking. In You Are Not Your Brain, they describe how we teach our brains to act in unhealthy ways. The brain does not distinguish between beneficial and destructive habits, “it just responds to how you behave and then generates strong impulses, thoughts, desires, cravings, and urges that compel you to perpetuate your habit, whatever it may be.”

Clearly, the brain can exert a powerful grip on one’s life—but only if you let it. The good news is that you can overcome the brain’s control and rewire your brain to work for you by learning to debunk the myths it has been so successfully selling you and by choosing to act in healthy, adaptive ways.

Neuroplasticity, as described by Schwartz and Gladding, does not reject Kreeft’s neurological description of addiction.  But it does say it isn’t the whole story. An ideology of addiction as a purely biomedical condition seems to permeate “Dying To Be Free.” Addiction, when conceived strictly as a brain disease, rejects or ignores the non-scientific construct of mind. If we are conceived as only biological beings, then addiction is explained and treated within a biomedical worldview. Any treatment approach to addiction not based on this premise is therefore faulty.

Drug treatment facilities were said in “Dying To Be Free” to “generally” fail to distinguish between addictions. They have a one-size-fits-all approach.  Addicts in residential treatment experience a “hodgepodge” of drill-instructor tough love and self-help lectures. Programs appear simultaneously excessively rigid and wildly disorganized. “And with roughly 90 percent of facilities grounded in the principle of abstinence, that means heroin addicts are systematically denied access to Suboxone and other synthetic opioids.”

After describing two older, drug treatment programs with a therapeutic community model of care that used coercive techniques—Synanon and Daytop (Drug Addicts Yield TO Persuasion)— he said:

The number of drug treatment facilities boomed with federal funding and the steady expansion of private insurance coverage for addiction, going from a mere handful in the 1950s to thousands a few decades later. The new facilities modeled themselves after the ones that had long been treating alcoholics, which were generally based on the 12-step methodology. Recovering addicts provided the cheap labor to staff them and the evangelism to shape curricula. Residential drug treatment co-opted the language of Alcoholics Anonymous, using the Big Book not as a spiritual guide but as a mandatory text — contradicting AA’s voluntary essence. AA’s meetings, with their folding chairs and donated coffee, were intended as a judgment-free space for addicts to talk about their problems. Treatment facilities were designed for discipline.

In support of this claim, Cherkis referred to a 2012 study conducted by the National Center on Addiction and Substance Abuse at Columbia University. It apparently was a reference to “Addiction Medicine: Closing the Gap between Science and Practice.” He said the study concluded the U.S. treatment system was in need of a “significant overhaul” and questioned whether the low levels of care received by addiction patients constituted a from of medical malpractice.

While medical schools in the U.S. mostly ignore addictive diseases, the majority of front-line treatment workers, the study found, are low-skilled and poorly trained, incapable of providing the bare minimum of medical care. These same workers also tend to be opposed to overhauling the system. As the study pointed out, they remain loyal to “intervention techniques that employ confrontation and coercion — techniques that contradict evidence-based practice.” Those with “a strong 12-step orientation” tended to hold research-supported approaches in low regard.

The Columbia University study did state a significant overhaul was needed in current treatment approaches; and it raised the question if the insufficient care received by addiction patients constituted “a form of medical malpractice.” It also pointed to the need for medical schools to “educate and train physicians to address risky substance use and addiction.” Unsurprisingly, it went on to say that all aspects of stabilization and treatment with addictions should be managed by a physician “as is the case with other medical diseases.” Remember that the Columbia study and Cherkis were both advocating for a physician-centered, medical model approach to addiction treatment.

However, I couldn’t find where it was supposed to have said the majority of front-line treatment workers were low-skilled and poorly trained. There was a section stating that physicians and other health professionals should be on the front line addressing addiction. Then it said: “Paraprofessionals and non-clinically trained and credentialed counselors can provide auxiliary services as part of a comprehensive treatment and disease management plan.”

It did not say the majority of front-line treatment workers were low-skilled and poorly trained “incapable of providing the bare minimum of medical care.” Yet in the case study examples found in “Dying To Be Free,” that is what Cherkis presented. The Columbia study did cite another study, which found that recovering support staff had little enthusiasm for evidence-based practices. “They also were more likely to support intervention techniques that employ confrontation and coercion–techniques that contradict evidence-based practices.” But these paraprofessionals only made up “24 percent of the treatment provider workforce.”

Cherkis seems to have mis-remembered what the Columbia study actually claimed in this matter. I wonder if, because of his commitment to a strictly medical model ideology for opiate treatment, he was reading into the study. His quote above supported the description of the treatment facilities he highlighted in his article, but wasn’t found by me in the article he cited on the Columbia study.

Another example of how his treatment ideology distorted his portrayal of Suboxone treatment was with how he described Hazelden’s Suboxone treatment program. “Dying To Be Free” mentioned that Hazelden, now the Hazelden Betty Ford Foundation, developed its own Suboxone treatment program for opioid addicts. But it failed to note this wasn’t accompanied by a rejection of “Twelve Step practices.” Within “The History of Hazelden,” on the Hazelden Betty Ford Foundation website, was the statement of how it “integrates the cornerstone Twelve Step practices of mutual support along with multidisciplinary clinical care, evidence-based therapies and the latest research in brain science.” Why weren’t there some case study examples from Hazelden in “Dying To Be Free”?

The facilities Cherkis highlighted in Kentucky were not representative of abstinent-based addiction treatment centers in the U.S.; ones that use the 12 Steps to structure their treatment program. In reading “Dying To Be Free” I see an underlying ideology of conceiving and treating addiction, specifically opiate addiction, through a strict biomedical lens. That is not the whole story of addiction. As a result, the rhetoric of the article constituted a straw man attack on abstinent-based treatment while it extolled MAT. This bias presents readers with an implied choice, a dichotomy, between Suboxone as an MAT for addiction and 12 Step, abstinent-based treatment. Ironically, Hazelden, an historically important treatment center that pioneered 12 Step, abstinence-based treatment, did not choose MAT over the 12 Step-based treatment, but combined the two. But you don’t get that information in “Dying To Be Free.”

Parts 2 and 3 of this article will look at how “Dying To Be Free” misrepresented the recovery philosophy of self-help groups like Alcoholics Anonymous; and skimmed over the problems with MAT, specifically Suboxone.