I Didn't Choose This

There has been quite a lot of news about the recall of Takata airbags--which have a nasty tendency of exploding. My airbag had been replaced, so I couldn't understand why I was still getting dire notices in the mail. The picture at left is the latest. It turns out that they had only replaced my driver-side airbag (the initial recall). This explains why Friday evening, when I went to Hall Honda to make the annoying orange light on my dashboard turn off--a process that requires me to have my oil changed--I wound up spending three hours in the waiting room while they replaced the passenger-side airbag.
I had brought a book which I needed to read, on the statistical analysis of ordinal categorical data. I haven't bothered providing you, gentle reader, a link to this book on Amazon because it is entirely as boring as it sounds. I found myself alternately falling asleep and being distracted by the blaring television. I listened intermittently to the Steve Harvey Show and to Dr. Phil. These are both shows that I generally try scrupulously to avoid. Much of the Steve Harvey show was about a case of spousal abuse. The episode of Dr. Phil concerned a mother who made the difficult choice to relinquish her teenage son into foster care because she was being repeatedly battered by him. At one point the son, who was also on the show, said with tears in his eyes: "I didn't ask to be born your son."
I am writing this week about choice; in particular, about instances where we assume people have a choice when they really don't--or sometimes, they don't yet--and instances where we don't want to let people choose. In the Dr. Phil episode, we saw two instances of choice: the mother chose to turn her son over to foster care, and the son had no choice in his birth.

Disease

Let's start easy. I have a friend who has pancreatic cancer. Did he choose to have pancreatic cancer? Of course not! But there are many areas where he still has choice. Obviously, he can choose, to some extent, whether or not to treat the cancer and what kinds of treatment to pursue. These are important questions, because they involve other choices he will need to make: what kind of life does he wish to have in the future? How important is it to extend his life as long as possible? How much does he desire to avoid pain? These considerations are often not discussed with doctors, but they should be, as Atul Gawande explains in his book Being Mortal.
He can also choose, again to some extent, how he reacts to his cancer: does he despair? or cling desperately to every hope of beating it? or rage at the unfairness of it? Of course, in this circumstance, it's normal to go through the stages of grief, but there's still much room for choosing. For example, it is well worth taking an hour and watching Randy Pausch's Last Lecture, It's in a very similar format to a TED talk (other than lasting an hour), and is about childhood dreams--an interesting topic for someone who starts the lecture by addressing the elephant in the room: he has about one month left to live.
While we don't choose to contract a disease like cancer (we'll come to life-style choices raising the odds shortly), we have a surprising degree of choice in whether or not we recover. For example, one study found that fatalism and feelings of helplessness were associated with lower survival rates after stroke. It's too early to be sure that the attitude caused the reduced survival, rather than the attitude being the result of an unconscious knowledge of the seriousness of the condition. In other research, it was found that people close to dying are less likely to die in the days immediately prior to a major celebration (e.g. Christmas or a birthday) than in the days immediately after. It appears that the will to live to see my last birthday can actually keep me alive, at least for a little bit. Yet another study found that depression weakened subjects' immune response to flu vaccine: while a healthy body can help stave off depression, depression can make the body vulnerable to illness.

David Ropeik introduces his book How Risky Is It, Really? with a scene he witnessed in a school auditorium, where officials were addressing concerns of parents that trace amounts of trichloroethylene (TCE) had been found in some areas of the school. "That school could give our children cancer! We demand that you close it and clean it up before our children have to go back there!... You will not decide whether they live or die" screamed one mother. That the level of TCE was so low that it was extremely unlikely that anyone would get cancer as a result of exposure was not what mattered to her, even if she was aware of the fact. Rather than let her child be exposed to that (negligible) risk, she demanded that the children be bussed across town (this was in Boston) to another school. The risk to the children of the extended time on (sometimes icy) roads was higher than the risk from TCE, but that was a risk we take every day and have come to accept, even ignore. As the mother later talked to reporters outside, "she anxiously puffed away on her tenth cigarette of the night. And the mother and daughter were also taking another big risk: both were significantly overweight." (Ropeik, How Risky is it Really?, p. xii.)

We do not choose to become ill, but we do make many choices in out life that can significantly increase the probability that we, or others around us, will become ill or be injured. Our dietary choices, our choice to drive or fly, our choice to smoke or not, all have an impact on our longevity. The impact can seem less, because it increases risk of something that may not happen for many years. And it's only changing probabilities: many people smoke their whole lives and do not get lung cancer or heart disease; many non-smokers do get lung cancer or heart disease. We can't see the increase in risk until we look at large numbers of people, so it's easy to convince ourselves that we'll be OK. There is also a question of the feeling of control: most people feel safer driving a car (where they are, in theory, in control) than riding in an airplane where their lives are in the hands of an unknown person. But the statistics say that the airplane is the much safer choice.
Smoking is an interesting case. Starting to smoke is a choice. I started smoking a pipe at university mostly to project an academic image. Two years ago, when I got tired of paying extra on my health insurance because I was a smoker, I stopped smoking. For me it was easy: I made a choice, and I stopped. But it is not so easy for everybody. A good friend knew that her smoking, which had been going on for many years, could kill her. A single mother with children still in school, she knew that she had to stop, that continuing to smoke was completely irresponsible. But she could not stop smoking. This is a case where choice has been taken away. This is addiction.

Addiction

(For the record, my friend was diagnosed with lung cancer, and had to have one lobe of one lung removed. During her stay in hospital, she was finally able to quit smoking, and not only has not smoked since, but has now been cancer free for three years.)
Heroin addiction is a growing threat in this country, leading to a rapidly burgeoning risk of death from overdose. It's worth taking six minutes to listen to this NPR story on opioid addiction. And while opioids are particularly potent at hijacking the brain and causing addiction, even tobacco and alcohol can have strong impacts on some people. Addiction takes away choice. And it takes great effort to restore the ability to choose to addicts. We like to think that they always have the choice; that they simply have to stop using. But until we have experienced having one's choice taken away, we really can't understand. An addict has to be helped, with compassion, to recover the choice. If you want to understand more, two excellent resources are Gabor Maté's book In the Realm of the Hungry Ghosts, and the recent Fresh Air story on Hope After Heroin.
Meanwhile, there is a debate in the medical community on how to conceptualize addiction. After years of considering addiction to be a form of moral weakness, the medical community came to understand addiction as a disease of the brain. Slowly, the general public is also coming to this understanding. But in his book The Biology of Desire, Marc Lewis suggests that this is not a good model. Instead, he thinks of addiction as a natural brain response--to seek pleasure--in a world that has changed from that for which the brain evolved. (Remember when we talked about the different paces of social evolution and genetic evolution?) Rather than a disease, "he argues, addiction is a behavioural problem that requires willpower and motivation to change." (The Guardian, 30 August 2015.) I suspect that we will find that, just as light fits both the wave model and the particle model, addiction fits both the disease model and Lewis' model, and which model applies depends on whether one is trying to study the condition or overcome it. Meanwhile, if you want to study willpower, the best source of information I have found is Roy Baumeister's book Willpower: Rediscovering the Greatest Human Strength.

Mental Illness

Addiction is just one example of a mental illness. What about more extreme cases of mental illness? I recently found a new grocery for Indian ingredients (the old one closed), but before going in I had to stay in my car to finish hearing an episode of This American Life. In this episode, a sufferer of schizophrenia talks us through what it was like to have his thoughts taken over by the disease. It is similar to the case portrayed in that wonderful movie A Beautiful Mind.  In these cases, it should be clear that the person with mental illness did not choose to be ill, and cannot choose to stop being ill. And the consequences of mental illness can be dire: Kyle Odom posted a manifesto which makes it very clear that mental illness was the reason he shot a pastor at the end of a service. But for less extreme cases, like depression, it is not so clear.

I have to disagree with Randy Pausch in his Last Lecture on one issue. He says that we must decide if we're going to be Tigger or Eeyore. But this requires that we have that choice. For someone who has never experienced clinical depression, it is difficult to imagine not being able to make that choice. But the condition of depression in itself deprives one of choice; it saps the will. Having a desire to get better does help in the recovery, just as it does for somatic disease, but it is not always sufficient. Eating disorders are in the same class of conditions: to the healthy mind it appears that the sufferer just needs to buck up and eat. Even those of us with compassion feel the need to rescue the sufferer by taking control of their eating. This is classic co-addictive behavior. Eating disorders (both anorexia and bulimia) are often about control--about wanting to have control over something in our lives.
There are times, however, when society must remove what little choice a mentally ill person still has for the protection of themselves and others. The person with anorexia may have to be admitted to hospital in order to keep them alive. Sufferers of mental illness may have to be admitted to a facility to protect themselves and others, and to start to provide therapy. Unfortunately, all too often, there is not space available. Not long ago, this lack of space resulted in a Virginia state senator being attacked by his own son, who subsequently died. The Washington Post ran a touching article on the case (TRIGGER ALERT: get tissues before reading).
Unfortunately, when the mentally ill person is a person of colour, he is more likely to end up in jail than in a treatment facility. Just this week a local young man with mental illness was in jail, having been arrested for the theft of $5. He died in custody. Since then there has been an editorial on the case, an NAACP response, and recently a full report released. What we learn from this case is that when we remove a person's choices, such as through incarceration, we acquire great responsibility for making correct choices on the person's behalf. In the case of Jaymicheal Mitchell, we failed in these responsibilities.

Elephants and Puppies

We have covered a lot of ground, and some of it has been difficult ground. But there remain a pair of elephants in the room, and we will need to address those elephants shortly. In the meantime, since this is the Internet, we should probably take a break and enjoy a video of puppies:

Beliefs

I have another friend (that's three so far, for those who are counting) who teaches music. Recently she witnessed some, as Winnie the Pooh would say, Bad Behaviour in the corridor at school, and for the first time had to send a note home to a parent. One third grader who tends to hyperactivity--let us call him Brian--was swinging a pendant as he walked down the corridor. He was also calling people "small-brains." Another student--we will call him Alan--asked to go to the nurse because Brian had hit him with the pendant. The teacher talked to Brian about the incident, and explained that it was quite possible he hadn't meant to hit Alan, but that he still needed to apologize. Brian refused. The teacher said that if he didn't apologize, she would have to send a note home to his parents. Brian crossed his arms and assumed a defiant posture.
The note went home. Unfortunately, I don't know the end of the story. But the lesson I want to draw here is that Brian was given a choice to do the right thing. We need to give our children choices, even when we think they really need to make a certain choice. There will, of course, be consequences for making the wrong choice, as Brian hopefully discovered. But it is important that they have that choice.

[Spoiler alert: the next paragraphs contains spoilers about the Harry Potter series.]

In a similar vein, there is a pivotal point in the Harry Potter series in The Half-Blood Prince, where Harry argues that the prophecy means that he has to kill Lord Voldemort. Dumbledore points out the importance of realizing that one has a choice:

"Got to?" said Dumbledore. "Of course you've got to! But not because of the prophecy! [...] You see, the prophecy does not mean you have to do anything! But the prophecy caused Lord Voldemort to mark you as his equal. ... In other words, you are free to choose your way, quite free to turn your back on the prophecy! But Voldemort continues to set store by the prophecy. He will continue to hunt you ... which makes it certain, really, that—"

"That one of us is going to end up killing the other," said Harry. "Yes."

 But he understood at last what Dumbledore had been trying to tell him. It was, he thought, the difference between being dragged into the arena to face a battle to the death and walking into the the arena with your head held high. Some people, perhaps, would say that there was little to choose between the two ways, but Dumbledore knew—and so do I, thought Harry, with a rush of fierce pride; and so did my parents—that there was all the difference in the world.

(Rowling, J. K., 2005. Harry Potter and the Half-Blood Prince. New York: Arthur A. Levine. pp. 511-512.) 

[End spoiler.]

In a similar way, I think we need to allow our children to make the choice to adopt our religious beliefs. For some denominations (notably Baptists--see Religions of America, and more generally for evangelicals) this is a central tenet of their beliefs--that the choice to follow Jesus must be made consciously and deliberately. An extreme case is seen in the Amish community, where at 16, teens are encouraged to experiment and explore, in the hope that they will eventually choose baptism in the Amish community. This period is called Rumspringa.
For others, such as Roman Catholics and Jews, there is a requirement to raise one's children within the faith. Indeed Judaism has always been something one was born into; there is no expectation or established ceremony (other than circumcision) to convert to Judaism. (A Jewish friend (that's four!) when asked how a Christian would convert to Judaism replied "it's done with a towel.")
But increasingly such "cradle-Catholics" are finding, when they leave home, the wide world of beliefs, and the option of making a choice. This has led to a growing group who identify with no religion, even if they retain their spiritual beliefs.
The thought that one could choose not to believe, or to believe something other than the received orthodoxy, can be very disturbing, especially for parents. There is even worry that elements of modern society provide pathways for the devil to corrupt believers, as in the recent concern over adult coloring books. And yet we find (for example, in Mark 10:17-22) that even Jesus recognized the option not to choose him.
Choosing to believe, on the other hand, may not be so easy. Marcus Borg, in his book Meeting Jesus Again for the First Time, provides a candid account of the development of his faith from early childhood. In adolescence, he began to have doubts about the existence of God, as his childish concepts of God collided with an increasing understanding of the physical world of matter and energy. He writes that "it was an experience filled with anxiety, guilt, and fear." He wanted to believe, and every night prayed for help to believe. "The inability to overcome my doubt confirmed for me that I had become more of an unbeliever than a believer. In retrospect, I can also see that, for me at least, belief is not a matter of the will. I desperately wanted to believe and to be delivered from the anguish I was experiencing. If I could have made myself believe, I would have." (Emphasis added.)
It would be tempting at this point to start a discussion about the difference between choosing a belief, as in religion, and forming a conclusion based on evidence, as in science. But we'll leave that for another day.

And now... Kittens

That wasn't so bad, was it? How about another break (kittens this time) before we tackle sex.

Sexuality etc.

My wife and I were talking with a (fifth) friend, when for some reason the topic of homosexuality came up. The friend commented "of course you know it's a choice." And there we have it: the importance of being able to ascribe choice to behaviours that we find objectionable, because then we can hold the person accountable for having made the wrong choice. We want to believe that people on welfare have chosen not to work and to be on welfare. We want to believe that people who have been arrested chose to commit a crime. And we want to believe that people who are different from us, such as being homosexual, chose to be different. Sometimes, especially today as we talk about the "Gay Agenda", it seems that "they" have chosen to be different just to rub our noses in their difference.
We want to believe it, but the evidence does not support that belief.
I read a memoir several years ago--I think in the literary magazine Granta--written by a man who grew up gay in the 60s. He didn't want to be gay, because that was "wrong", so he found a therapist in the yellow pages (a 20th century form of Google) who specialized in curing men of homosexuality. In those days, homosexuality was classified as a mental disorder. The cure didn't work. He tried living with the "illness" for a while, but it was no good, so he again tried to get himself cured. He was desperate to be normal. It was only considerably later that he came to realize that there was nothing he could do to change his homosexuality, and that he had better accept that he was who and what he was.
He thought he had a choice: he wanted to choose to be "normal". But eventually he found out that the only choice he had was whether or not to accept himself the way he was. If we think that being gay is a choice, then we should be prepared to ask ourselves when we opted to be straight rather than gay. In the interest of being Fair and Balanced, I should mention that there have been people who report being successfully cured of their homosexuality (and I'm sure the 700 Club has no agenda here). The support for reparative (or "gay conversion") therapy looked to be waning, until a study by R. L Spitzer in 2003 provided what appeared to be substantial evidence for its effectiveness. Subsequent studies have continued to show that reparative therapy is not only ineffective and inappropriate, but often unethical. The National Association of Social Workers has repeatedly issued position statements critical of the practice. The American Psychological Association has been clear about its opposition to such "therapies". And Spitzer himself has formally retracted his study and apologized.
There is something of a generational issue here. Those of us "of a certain age" have known people who appeared, for many years, to be perfectly "normal" but have recently "come out of the closet." I know two women who have been happily married to and had children with men who, one day, announced that they were actually homosexual and sought a divorce. Under these circumstances, it can certainly appear that the man has made a choice to be homosexual. What we miss is that the choice is to stop living a lie--the lie that he is heterosexual.

So far we have been discussing homosexuality vs. heterosexuality, but the topic is more complicated than that--much more complicated. To start with, this distinction describes only one axis--specifically Sexual Orientation, of a multidimensional problem. Another axis which has been in the news recently is Gender Identity: whether one thinks of oneself as a man or a woman. This should not be confused with Gender Expression: whether one behaves in a stereotypically masculine or feminine way. And then, of course, there's that rock of certainty: one's Biological Sex, which is the basis by which North Carolina now requires one to select a public restroom.
If only it were that simple. Much though we would like to think of these axes as dichotomies, i.e. binary states, they aren't. Each represents a continuum, and any individual may be located at pretty much any point along the continuum. In the case of sexual orientation,  Alfred Kinsey first proposed this continuum in his extensive research on sexuality in both men and women in the middle of the last century. And this has been borne out by further research, including the finding that orientation can shift over time. Some researchers have proposed that even this axis is actually seven different axes; or that heterosexuality and homosexuality should be measured on independent axes, so that a person might be (or consider themselves) Very Heterosexual and Slightly Homosexual.
It can be difficult to understand, as a predominantly "straight" person, what it means to be homosexual or bisexual. Part of the problem, as I have discussed previously, is that the very terminology seems to be about sexual activity. But it is not. It is about sexual attraction (although many researchers include sexual activity in determining a category). It is about the people whom we find attractive, in both a romantic and a sexual way. One easy, and non-sexual, way to assess this is by looking at pupil dilation, which is associated with sexual attraction.

"Yet ... researchers sometimes ignore both dimensional and dynamic aspects of sexual orientation, perhaps because society so strongly urges people to adopt one of two or at most three labels to describe their sexual orientation. This could be a situation in which scientific research and theory have been hampered by lay concepts and societal traditions." (Epstein et al., 2012, p. 1357)

As an example of these "lay concepts and societal traditions," let's put two axes together: sexual orientation and gender expression. Remember that the latter is most easily understood as masculinity ("macho-ness") vs. femininity. I have represented these two axes on the figure to the right. Please note that I have purposely used some very pejorative terms here, in order to highlight societal biases. The two axes are not orthogonal (i.e. perpendicular), because movement along one axis generally implies some movement along the other. Blue circles represent individuals who are genetically male and pink circles represent individuals who are genetically female.

In general, we think of homosexual men as effeminate, like Carson Kressley from Queer Eye for the Straight Guy (left). But this isn't necessarily the case. It can surprise people, even gay people, to find that there are homosexual men who are outwardly very masculine (e.g. Rock Hudson, right). An individual like this is represented by the A in the diagram above.

Similarly, while we expect a woman who is lesbian to be rather masculine in appearance (e.g. Lisa Lusero, left), there are others who are very feminine, such as Ellen Page on the right, who starred in the wonderful film Juno. Such women are represented by the B in the diagram above.
And then, there are the many people who fall between the extremes. The C in the diagram above represents a person who is almost completely bisexual (surprisingly rare), not distinctively masculine or feminine, and genetically and/or physically intermediate.
The Gender Identity axis is another interesting study. This deals with how we think of ourselves: do we think of ourselves as masculine, or feminine? This is where the issue of transgender enters the picture, an issue so poorly understood by the legislature in North Carolina, but (fortunately) understood well by at least one christian grandmother.
My point throughout this discussion is that none of these aspects of ourselves are things that we choose for ourselves. The development of gender identity, of sexual orientation, of sexual expression, are all complex events, which are often determined before birth, and at different times during foetal development. There has even been a case of a set of identical biologically male twins, one of whom self-identified from an early age as female. This case is explored in the book Becoming Nicole, which was well-reviewed in a Washington Post article.

Choice and the Criminal

We have traveled a long way on this discussion of choice. There are many aspects of ourselves that we did not choose. It is my hope that we can come to accept those aspects of others with increased compassion and understanding. There are also many instances where we have all made poor choices. For many of us, especially those of us who are white, heterosexual, and come from middle-class families, we were able to learn from these bad choices and move on. But not all of us are so lucky.
So I leave you with an incredible discussion about how prosecutors can use their choices to help others who have chosen poorly: