Omadacycline (Nuzyra, Paratek) may help prevent Clostridioides difficile infections, which are responsible for nearly 500,000 infections annually in the United States
Omadacycline had demonstrated a low likelihood of causing C. difficile in clinical trials, but no one understood why. In a small phase 1 human clinical trial, Kevin Garey, PharmD, MS, the Robert L. Boblitt Endowed Professor of Drug Discovery at the University of Houston College of Pharmacy, assessed the pharmacokinetics and gut microbiome effects of oral omadacycline compared with vancomycin.
Although vancomycin is used to treat C. difficile, it is not good at eliminating it over the long term.
Dr. Garey’s team investigated whether omadacycline, given orally, achieves high concentrations in the gut and its effects on the gut microbiome. Sixteen healthy volunteers tolerated omadacycline with no safety differences compared with vancomycin.
A rapid initial increase in fecal concentration of omadacycline was observed compared with vancomycin, with maximum concentrations achieved within 48 hours. Rapid increase is a good thing—it means the active drug is getting to the site of the infection faster, according to Dr. Garey.
“Both the omadacycline and vancomycin groups showed significant changes in their microbiomes when we looked at how diverse they were internally (alpha diversity). However, when we compared the changes between the two groups (beta diversity), they were noticeably different from each other,” Dr. Garey explained.
“Omadacycline caused a distinctly different effect on the microbiome than vancomycin. This could explain why omadacycline is a safe drug to give to patients at high risk for C. difficile infection. This could become a new method in drug development to see if antibiotics are not only killing the bacteria causing infections (the bad bugs) but not causing harm to the beneficial microbes that live in our body (the good bugs),” Dr. Garey said.
Omadacycline is indicated for the treatment of adults with community-acquired bacterial pneumonia and acute bacterial skin and skin structure infections caused by selected susceptible microorganisms.
Though quantum mechanics is an incredibly successful theory, nobody knows what it means. Scientists now must confront its philosophical implications.
KEY TAKEAWAYS
Despite the tremendous success of quantum physics, scientists and philosophers still disagree on what it’s telling us about the nature of reality.
Central to the dispute is whether the theory is describing the world as it is or is merely a mathematical model.
Attempts to reconcile the theory with reality have led physicists to some strange places, forcing scientists to grapple with matters of philosophy.
The world of the very small is like nothing we see in our everyday lives. We do not think of people or rocks being in more than one place at the same time until we look at them. They are where they are, in one place only, whether or not we know where that place is. Nor do we think of a cat locked in a box as being both dead and alive before we open the box to check. But such dualities are the norm for quantum objects like atoms or subatomic particles, or even larger ones like a cat. Before we look at them, these objects exist in what we call a superposition of states, each state with an assigned probability. When we measure many times their position or some other physical property, we will find it in one of such states with certain probabilities.
The crucial question that still haunts or inspires physicists is this: Are such possible states real — is the particle really in a superposition of states — or is this way of thinking just a mathematical trick we invented to describe what we measure with our detectors? To take a stance on this question is to choose a certain way of interpreting quantum mechanics and our take on the world. It is important to stress that quantum mechanics works beautifully as a mathematical theory. Itdescribes the experiments incredibly well. So we are not debating whether quantum mechanics works or not, because we are well past that point. The issue is whether it describes physical reality as it is or whether it does not, and we need something more if we are to arrive at a deeper understanding of how nature operates in the world of the very small.
States of thinking about the quantum world
Even though quantum mechanics works, the debate about its nature is fierce. The subject is vast, and I could not possibly do it justice here. My goal is to give a flavor of what is at stake. (For more details, see The Island of Knowledge.) There are many schools of thought and many nuanced arguments. But in its most general form, the schools line up along two ways of thinking about reality, and they both depend on the protagonist of the quantum world: the famous wavefunction.
In one corner stands those who think that the wavefunction is an element of reality, that it describes reality as it is. This way of thinking is sometimes called the ontic interpretation, from the term ontology, which in philosophy means the stuff that makes up reality. People who follow the ontic school would say that even though the wavefunction does not describe something palpable, like the particle’s position or its momentum, its absolute square represents the probability of measuring this or that physical property — the superpositions that it does describe are a part of reality.
In the other corner stand those who think that the wavefunction is not an element of reality. Instead, they see a mathematical construct that allows us to make sense of what we find in experiments. This way of thinking is sometimes called the epistemic interpretation, from the term epistemology in philosophy. In this view, measurements taken as objects and detectors interact and people read the results are the only way we can figure out what goes on at the quantum level, and the rules of quantum physics are fantastic at describing the results of these measurements. There is no need to attribute any kind of reality to the wavefunction. It simply represents potentialities — the possible outcomes of a measurement. (The great physicist Freeman Dyson once told me that he considered the whole debate a huge waste of time. To him, the wavefunction was never intended to be a real thing.)
Note the importance in all this of measurements. Historically, the epistemic view goes back to the Copenhagen interpretation, the hodgepodge of ideas spearheaded by Niels Bohr and carried forward by his younger, powerhouse colleagues such as Werner Heisenberg, Wolfgang Pauli, Pascual Jordan, and many others.
This school of thought is sometimes unjustly called the “shut up and calculate approach” due to its insistence that we do not know what the wavefunction is, only what it does. It tells us we accept the superpositions of possible states, coexisting before a measurement is made, as a pragmatic description of what we cannot know. Upon measurement, the system collapses into just one of the possible states: the one that is measured. Yes, it is weird to state that a wavy thing, spread across space, instantaneously goes into a single position (a position that lies within what is allowed by the Uncertainty Principle). Yes, it is weird to contemplate the possibility that the act of measurement somehow defines the state in which the particle is found. It introduces the possibility that the measurer has something to do with determining reality. But the theory works, and for all practical purposes, that is what really matters.
Forks in the quantum road
At its essence, the ontic vs. epistemic debate hides the ghost of objectivity in science. Onticists deeply dislike the notion that observers could have anything to do with determining the nature of reality. Is an experimenter really determining whether an electron is here or there? One ontic school known as the Many Worlds interpretation would say instead that all possible outcomes are realized when a measurement is performed. It’s just that they are realized in parallel worlds, and we only have direct access to one of them — namely, the one we exist in. In Borgean style, the idea here is that the act of measurement forks reality into a multiplicity of worlds, each realizing a possible experimental outcome. We do not need to speak of the collapse of the wavefunction since all outcomes are realized at once.
Unfortunately, these many worlds are not accessible to observers in different worlds. There have been proposals to test the Many Worlds experimentally, but the obstacles are huge, for example requiring the quantum superposition of macroscopic objects in the laboratory. It is also not clear how to assign different probabilities to the different worlds related to the outcomes of the experiment. For example, if the observer is playing a game of Russian roulette with options triggered by a quantum device, he will only survive in one world. Who would be willing to be the subject of this experiment? I certainly would not. Still, Many Worlds has many adherents.
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Other ontic approaches require, for example, adding elements of reality to the quantum mechanical description. For example, David Bohm proposed expanding the quantum mechanical prescription by adding a pilot wave with the explicit role of guiding the particles into their experimental outcomes. The price for experimental certainty, here, is that this pilot wave acts everywhere at once, which in physics means that it has nonlocality. Many people, including Einstein, have found this impossible to accept.
The agent and the nature of reality
On the epistemic side, interpretations are just as varied. The Copenhagen interpretation leads the pack. It states that the wavefunction is not a thing in this world, but rather a mere tool to describe what is essential, the outcomes of experimental measurements. Views tend to diverge on the meaning of the observer, about the role the mind exerts on the act of measuring and thus on defining the physical properties of the object being observed, and on the dividing line between classical and quantum.
Due to space, I will only mention one more epistemic interpretation, Quantum Bayesianism, or as it is now called, QBism. As the original name implies, QBism takes the role of an agent as central. It assumes that probabilities in quantum mechanics reflect the current state of the agent’s knowledge or beliefs about the world, as he or she makes bets about what will happen in the future. Superpositions and entanglements are not states of the world, in this view, but expressions of how an agent experiences the world. As such, they are not as mysterious as they may sound. The onus of quantum weirdness is transferred to an agent’s interactions with the world.
A common criticism levied against QBism is its reliance on a specific agent’s relation to the experiment. This seems to inject a dose of subjectivism, placing it athwart the usual scientific goal of observer-independent universality. But as Adam Frank, Evan Thompson, and myself argue in The Blind Spot, a book to be published by MIT Press in 2024, this criticism relies on a view of science that is unrealistic. It is a view rooted in an account of reality outside of us, the agents that experience this reality. Perhaps that is what quantum mechanics’ weirdness has been trying to tell us all along.
What really matters
The beautiful discoveries of quantum physics reveal a world that continues to defy and inspire our imaginations. It continues to surprise us, just as it has done for the past century. As said by Democritus, the Greek philosopher who brought atomism to the forefront over 24 centuries ago, “In reality we know nothing, for truth is in the depths.” That may very well be the case, but we can keep trying, and that is what really matters.
A study suggesting papers and patents that change the course of science are becoming less dominant is prompting soul-searching — and lively debate about why, and what to do about it.
The discovery by Michel Mayor (right) and Didier Queloz of a planet orbiting a Sun-like star launched the search for exoplanets
The influential twentieth-century physicist and philosopher Thomas Kuhn was instrumental in formulating the term ‘paradigm shift’ to characterize how unexpected evidence can set research fields off in new directions. A paper published in Nature earlier this month by the social scientists Michael Park, Erin Leahey and Russell Funk has prompted lively debate by suggesting that the proportion of disruptive papers and patents has been decreasing over time1.
By analysing more than 60 years of data from bibliometric and patent databases, the authors conclude that it is less likely now than in the mid-twentieth century that any one paper or patent will be ‘highly disruptive’ — that is, that it will change the course of an entire scientific field. Although the number of new papers and patents the researchers classified as disruptive stayed broadly the same over the period they studied — from 1945 to 2010 — the explosion in research articles, patents and funding in that time means that disruptive science’s share of publishing and patenting has been dropping.
Much of the reaction has involved soul-searching about the implications for science if innovation is slowing down, as well as questions about the nature of the modern scientific enterprise itself. This, in turn, is prompting more questions that could become the subject of further analysis.‘Disruptive’ science has declined — and no one knows why
The study uses a number of measures of disruptiveness. The one that has attracted perhaps the most attention is called the CD index, which is based on citations. As the authors write, “if a paper or patent is disruptive, the subsequent work that cites it is less likely to also cite its predecessors”, whereas “if a paper or patent is consolidating, subsequent work that cites it is also more likely to cite its predecessors”. In other words, with more consolidation, the same previously disruptive papers continue to be cited.
Single papers do have the potential to disrupt or create fields. One of the best-known examples is James Watson and Francis Crick’s model of DNA from 1953, created with the help of Rosalind Franklin’s ground-breaking X-ray crystallography work2,3. Another is the 1995 discovery by Michel Mayor and Didier Queloz of a planet orbiting a Sun-like star4 that launched the field of searching for exoplanets.
But new directions also arise from many studies reporting long-running research efforts. Gravitational waves are one example. Much as the paper from the LIGO collaboration reporting the first direct detection of a gravitational wave5 is itself highly cited, subsequent work has continued to cite work that led up to it. Researchers cite studies for different reasons, and not only to acknowledge previously important work that is being built on. Park and his colleagues do control for some of these things to better compare disruptiveness today with that several decades ago.The science that’s never been cited
For this Editorial, Nature spoke to a number of scholars who study science and innovation. The paper by Park and his colleagues1, they say, builds on a pattern identified elsewhere in the specialist literature6,7, and some are worried by the findings’ implications. Science and innovation are drivers of both growth and productivity, and declining disruptiveness could be linked to the sluggish productivity and economic growth being seen in many parts of the world.
Others argue that a decline in the fraction of disruptive science shouldn’t cause concern if the absolute number of disruptive studies has remained relatively constant over time. If a greater proportion of publications are consolidating, that could just reflect the current scientific situation: in many disciplines, the fundamentals are agreed on, so most further advances will be incremental, rather than disruptive.
It is also possible that researchers are recording more incremental steps in formal research papers than before, rather than waiting to report something of greater significance. No doubt scholars will further analyse the importance of these findings using qualitative empirical approaches, such as detailed interviews and observations that capture researchers’ own experiences in individual fields, as the sociologist Harry Collins has done from within the LIGO team.
Growing division
Another reason why the study by Park and his colleagues has created such resonance is that it plays into wider concerns about how science is organized. One of these is whether the division of science into ever-narrower units of knowledge is detrimental to the discovery of new paths. Critics also point to publication incentives and metrics-driven research evaluations, which steer scientific study away from risk-taking as funders, researchers and institutions take the safe option to keep the grant–publication–citation wheel turning.Bibliometrics: Is your most cited work, your best?
This periodically leads to calls to either incentivize or directly fund more high-risk, high-reward research, and initiatives such as the United Kingdom’s Advanced Research and Invention Agency. This is modelled on the US Defense Advanced Research Projects Agency, which was founded in 1958, so the search for disruptive innovation is not new.
But it is also possible that science’s knowledge and publication overload is not specifically a research problem. The lack of space to think in the face of an information deluge is increasingly apparent across many sectors of society. Some in innovation studies think that artificial intelligence could help, by sifting and sorting information in meaningful and beneficial ways: aiding researchers in summarizing cutting-edge knowledge in a discipline8, for example, or identifying which research projects have the potential for breakthroughs9. If used appropriately, such technological disruption has the potential to free up more time for scientists to progress their fields — disruptively or otherwise.
Asking questions about the nature of science and reflecting on the answers can only be a good thing. The work by Park and his colleagues must continue to be built on, using both quantitative and qualitative methods, down to the level of individual fields. This will help us to understand in more detail how and why science is changing, and where we want it to lead. The end result could be disruption or consolidation — or even a paradigm shift.
The humanities, from music and painting to literature and poetry, offer limitless opportunities to grow as a professional and as an individual.
For physicians in particular, although medicine is doubtless an endeavor into the sciences, their knowledge and expertise can only be improved with a dollop of the arts — and the empathy it can inspire.
“I do think that the humanities, as a broader field, is very important, and that we should not be allowing ourselves to become one-sided in terms of the science,” Ronald F. van Vollenhoven, MD, PhD, told Healio Rheumatology. Source: Ronald F. van Vollenhoven, MD, PhD
“I think that we are in a time where we need more humanities in medicine to balance the science that we are blessed with,” Leonard H. Calabrese, DO, director of the RJ Fasenmyer Center for Clinical Immunology at the Cleveland Clinic, told Healio Rheumatology.
That science, and the advancements it has made possible, from the revolution in biologic therapies to the emergence of precision medicine and improved diagnoses, has been a boon for rheumatology — both for patients and providers. However, there is another side to patient care, one that is strengthened not by trials and data but through exercising empathy and connecting with patients.
Leonard H. Calabrese
According to Calabrese, physicians who take part in various artistic pursuits, be it classical piano, reflecting deeply with a piece of writing or examining the life of artists long passed, can bring those qualities — empathy and human connection — from the studio into the clinic.
Yet, this requires an understanding that the humanities and the arts can be just as important as the hard sciences.
“It’s almost like the art of medicine is not given any credence, it’s all hard data and science, and there’s a lot more to medicine than that, I think,” Ronan Kavanagh, MD, a rheumatologist at the Galway Clinic, in Ireland, told Healio Rheumatology.
Kavanagh, who had a previous life as a musician before pursuing medicine, is also the founder of dotMD, an annual 2-day “festival of curiosity” for physicians and other health care professionals that seeks to “awaken a sense of wonder and curiosity about medicine that some may have lost along the way,” according to its website. The festival accomplishes this by, among other means, “viewing medicine with fresh eyes through the lenses of culture, the arts, philosophy and technology.”
According to both Kavanagh and Calabrese, and others, rheumatology requires a balance between the seemingly — but not necessarily — opposing disciplines of science and art, a balance that becomes easier to achieve when providers are steeped in the humanities.
Maintaining the Engine of Empathy
For medical doctors, the humanities formed the cornerstone of the profession until the 19th century, when the scientific setting of the laboratory seemed to remove medicine from the arts, according to Calabrese. The result of this divergence, he explained, was rising skepticism regarding the value of indulging in the humanities. One prevailing opinion was that the feeling and passion involved with music, literature and the like made the humanities all but incompatible with the data-based path medicine seemed to be following.
However, according to Calabrese, by engaging in the arts, either through active participation or passive observation, the humanities can provide physicians with the opportunity to develop their humanity and empathy — attributes that are key in medicine.
“Empathy is an incredibly important attribute of the healing relationship,” Calabrese said. “It’s transmitting feelings.
“This is not just to make someone ‘feel good,’ but it has the capacity to both heal in terms of empowering patients and strengthen the healer-patient relationship, as well as imprint the messages from the visit,” he added. “Our patients may forget the details of what we instruct them, but they never forget how we made them feel during a visit.”
As such, Calabrese said he considers engagement with the humanities to be an amplifier of personal empathy, which can then be drawn upon “to both help our patients and enrich ourselves at the same time.”
Ronan Kavanagh
Specially, engaging with the arts on a passive level, be it reading an enthralling novel or attending a gripping concert, can “soften up the edges,” for physicians, making them able to better connect with patients, said Kavanagh.
“If reading a book helps me empathize or connect with a patient a bit better, I think that has to be a good thing,” he added.
Meanwhile, active engagement with the arts can exercise myriad qualities that can be invaluable in practice, including not only empathy but also curiosity and self-awareness.
Iris Y. Navarro-Millan, MD, of the Hospital for Special Surgery and Weill Cornell Medicine, in New York, describes herself online as a musician who happens to be a doctor. A lifetime of playing music with family members and singing her way through college as an undergrad before joining a band has resulted in a sharpened sense of empathy, she said.
Iris Y. Navarro-Millan
“I think empathy, kindness and curiosity definitely lend toward understanding patients’ reality, and eliciting their specific goals,” Navarro-Millan said, adding that involvement in the arts has also helped to sharpen her self-awareness.
According to Navarro-Millan, empathy gained from her involvement with music lends itself toward reflecting more on the world around her, allowing her to connect with her patients much more easily.
“I think it makes me more sensitive, more self-aware,” she added.
As an example, Navarro-Millan recalled one patient from Colombia who spoke only Spanish. When the patient asked Navarro-Millan if she knew a specific song, the two sang together, forging a connection between patient and doctor that Navarro-Millan still recalls fondly.
“I do think that the humanities, as a broader field, is very important, and that we should not be allowing ourselves to become one-sided in terms of the science,” Ronald F. van Vollenhoven, MD, PhD, professor of rheumatology at Amsterdam University Medical Center, and a classical pianist, told Healio Rheumatology.
Although the humanities have the power to foster empathy and deeper understanding between patients and their caregivers, for many involved in both the arts and medicine, their connection to the former long predates their career in the latter.
A Lifetime Pursuit
For many who play and have a connection to music, it is not uncommon for that connection to have been forged at a young age. Vollenhoven originally picked up piano as a child at the urging of his parents, and kept up with the habit throughout his life. Additionally, both Kavanagh and Navarro-Millan played music in various capacities before ultimately finding medicine.
According to Navarro-Millan, music is not necessarily something to be performed for other people, although she has done a fair bit of that as well. When she was growing up and family got together, music was guaranteed to fill the air.
“Nobody wanted to be famous — it was about having a good time and a connection while enjoying music,” Navarro-Millan said.
In a family filled with musicians and singers, there was always the chance to join in the song or pick up a guitar. Navarro-Millan was trained as a bel canto singer in high school and sang mezzo soprano opera throughout college, before joining a band with some peers in medical school.
“It was something that I felt like I needed to do because it gave me purpose,” she said. “It is something that is so mine and only mine. It doesn’t depend on a peer review process or the outcome of a patient.”
Navarro-Millan’s relationship with music, from informal song performances with family to playing bars in Mexico through medical school, has rarely remained static for long.
Similarly, others with a strong relationship to music have had to put the passions of their youth aside to continue professional development.
Kavanagh, who practices rheumatology in his hometown of Galway, Ireland, said that the musical and artistic culture of the city seeped into his personality. In the late 1980s, he was part of the original line-up of The Stunning, playing keyboard. Their 1988 single “Got to Get Away” reached No. 17 on the Irish charts, and the group would eventually become one of the most well-known rock bands to come out of Ireland.However, just before The Stunning exploded in popularity, Kavanagh made the call to step away and study medicine.
“I played keyboards with them for about 2 years, but really, like Pete Best and the Beatles, just as they were about to really take off, I had to make a call, and I decided I was going to continue with my medical studies,” Kavanagh said. “I live in a town that is deeply immersed in the arts and culture. So, everything that’s done, is done surrounded by a culture of music and theater, and it somehow seeps into your pores.”
Meanwhile, Vollenhoven’s own musical journal started with piano lessons as a young child before finding a deeper passion for music as a teenager.
“It’s something I have done all my life. I mean, I was a kid when I started taking piano lessons, and I guess I was in my teenage years when I really found the enjoyment in paying and also listening to piano music,” he said. “I also had times in my life where I did not have that much time to play piano, so there were periods of time where I had hardly any time to spend on it.”
Still, no matter the duration of those stretches of time when other duties denied him the opportunity to regularly play, Vollenhoven said he always — eventually — has been able to return to music.
Lives filled with art and music also give physicians the ability to view rheumatic care not only as a sterile science, but also as a performance.
Improvisation ‘At the Heart’ of Patient Care
According to Kavanagh, there is bound to be something missing when physicians practice medicine, be it rheumatology or any other specialty, strictly as a science.
“The more you know, and the more patients you see, the more automatic your decision making becomes, and the more possible it becomes to stop thinking of yourself and your own performance,” Kavanagh said.
For that reason, it is important and useful to approach rheumatology, at least in part, as a performance, including everything from improvisation to communication between doctor and patient, he added.
Influenced by the work of Penn State medical educator Paul Haidet, MD, MPH, who has written about the connections between jazz and the art of medicine, Kavanagh has looked to legendary trumpeter Miles Davis as an inspiration in the school of thinking of patient care as a performance. The way Davis used improvisation, from paying attention to the music made by those performing with him to responding with the perfect notes and rhythms, can teach rheumatologists a lot about interacting with patients, he said.
“I believe that improvisation is at the heart of really good patient care,” Kavanagh said, noting the importance of listening and taking each individual patient factor into account before recommending a course of action.
Although many aspects of patient care can be completed simply by following algorithms and ordering the appropriate tests, this may not always be appropriate in every situation. Just as performing a composition exactly as written may leave a piece sounding a bit lifeless and without expression, so too should physicians, including rheumatologists, emphasize communication and think beyond the algorithm in patient care, according to Vollenhoven.
“Even if you do exactly as it says on the sheet in music, it will sound boring and not very inspiring. There is so much more to be done,” he said. “If you do that in medicine, you’re also missing something, because you need the art of medicine on top of that.”
By incorporating your own communication and treatment styles, it not only brings life to the practice of rheumatology, but makes that practice more humane and creative, Vollenhoven said.
Additionally, although music offers a great pathway to achieve this, it is by no means the only route.
Long before Navarro-Millan met and sang with the patient from Colombia, she was regularly attending plays and theater productions while in college. She credits those experiences, combined with the near-constant presence of music, with helping to develop her ability to connect with patients.
“I think it is something that makes me also reflect on the world around me,” she added. “I do think that it makes me more empathetic and more compassionate to the reality and challenges of my patients.”
Although a history of deep involvement in the humanities can have the impact of improving communication and increasing empathy with patients, there are also conferences and events that can help to reframe and reorient the goal of patient care for art-minded physicians.
Reframing the Focus
Kavanagh’s dotMD, the arts-meets-science conference he founded to help expand the horizons of health care professionals around the world, has been attracting rheumatologists, primary care physicians, psychiatrists, hospitalists and emergency physicians to Galway since 2013.
“The aim of the festival is to reawaken a sense of wonder and curiosity about medicine that some of us may have lost along the way,” Kavanagh said, adding that many who attend are able to find deeper meaning in medicine.
The joke, he says, is that dotMD is a meeting for doctors who “used to play the piano.”
The meeting is billed as “anti-reductionist,” and serves as a way for a wide variety of speakers to help attendees gain a different perspective, Kavanagh said. What the meeting lacks in traditional rheumatological lectures, it makes up for in talks focusing on the parallels in developing expertise in non-medical and medical professions.
Although Vollenhoven and Calabrese have not attended dotMD, the idea and goal of reawakening a passion and unlocking perspectives is one that both agree is a worthy cause. Calabrese regards attending the meeting as an item on his wish list, while Vollenhoven would appreciate a wider adoption of similar events.
“I very much applaud that kind of initiative,” Vollenhoven said.
In terms of success, Kavanagh measures dotMD not by the number of attendees, but through the impact it has on those who attend.
“We do a simple questionnaire for feedback afterwards, and 98% grade their experience as ‘excellent’ or ‘very good,’ but the best possible outcome is not the information they learned, but the feedback we get about how the meeting makes them feel,” Kavanagh said.
Recalling feedback, terms like “transformative,” “sublime,” and “breathtaking,” come to mind, he added.
Although it is important to engage with medicine in non-traditional ways, such as at meetings and talks that allow for some artistic reflection, rheumatologists can also learn from the artists themselves who have dealt with life-changing diseases such as RA and scleroderma in their own time.
Determination and Passion
Throughout history, many artists, including several iconic painters, have dealt with rheumatic and musculoskeletal diseases. James Louie, MD, professor emeritus of medicine at the University of California, Los Angeles, has spoken about several of them and how they attended to the challenges of their rheumatic diseases, as well as how their determination enabled them to display the beauty of their art in personal, technical and philosophical terms.
“To enable patients in their decisions for best care of their rheumatic diseases, it is often helpful to describe how other famous persons throughout history had met their challenges and continued the creativity and grace of their lives,” Louie said.
For example, Pierre-Auguste Renoir (1841-1919), the renowned French painter who contributed to the impressionist style, developed rheumatoid arthritis at the age of 47 years. According to Louie, he sought out the best available physician, took the non-steroidal therapy of that time, designed his own physical and spa therapies, and continued to mature his style of painting.
By age 71, Renoir could no longer ambulate and was restricted to a wheelchair and bed, yet he continued to paint with enthusiasm until his death at age 78 years, saying, “The pain passes but the beauty endures.”
“That was his goal in life, to share his sense of beauty as he saw life, regardless of what he went through,” Louie said.
In the next generation, Raoul Dufy (1877-1953), French painter and designer of artistic tapestries, fabrics and ceramic pieces, developed rheumatoid arthritis at age 58 years. When he no longer responded to gold injections, at age 73 years, he traveled from Paris to Boston to participate in a therapeutic study of corticosteroids.
“He then returned to his painting,” said Louie. “His friend wrote, ‘Viva le difference.’ While continuing his cortisone, he died of a gastrointestinal bleed two years later.”
In the last generation, John Outterbridge (1933-2019), an assemblage artist and sculptor in Los Angeles, developed rheumatoid arthritis at age 60 years. When he sought out best care, he enrolled in a study of a TNF inhibitor and returned to his constructs, directing the Watts Towers Art center for 27 years.
“Using refuse from the Watts riots, he built a ship with three masts for children to walk through,” said Louie, who provided care for Outterbridge. “He explained to me, ‘I want the children to know that after a riot and life is a mess, if you reach down, pick up the pieces and build something that raises your eyes up to God, you will be okay.’”
According to Louie, the determination and dedication of these three artists encourages patients and physicians to pursue the best care together, particularly as science has provided more effective therapies.
“Ben Franklin suggested, ‘Teach me and I remember, involve me and I learn,’” he said. “And Franz Kafka predicted, ‘Anyone who keeps the ability to see beauty never grows old.’”
For Calabrese, engagement with the arts began early in his career when the Cleveland Clinic assumed the care of the newly formed Cleveland Ballet.
“That was at a time when the field of dance medicine was in its infancy,” he said.
Calabrese described how exciting it was to combine medical care for injured dancers with research into the epidemiology, risks and attendant medical problems they were first noted to be experiencing. Soon after, he began to perform similar work with instrumentalists as part of a newly formed collaborative multidisciplinary group dedicated to care and research across the arts.
According to Calabrese, this early exposure and experience enriched him both professionally and personally in ways that have remained with him for his entire career.
“To me, it was an opportunity to grow,” he said. “My involvement with dance and dancers over these many decades has been very fulfilling for me. I think it has helped me grow as a person.”
After caring for dancers throughout his career, Calabrese said that he grew to appreciate the art form.
“You don’t have to be a performer to reap the benefits of arts in medicine,” Calabrese said.
In Galway, Kavanagh has similarly cared for musicians throughout his career.
“I kind of found myself, full circle, learning from them,” Kavanagh said.
Enriching the Profession
According to Calabrese, engaging with humanity-enriching art is an essential part of the profession of caring for patients.
“This is important because humanism is vital for a successful and fulfilling career as a healer,” he said. “I think that through the arts, we can fuel this humanistic need that we all have.”
Calabrese, who describes himself as a “guerilla writer,” offers reflections in Healio and other outlets, but he is also involved with the reflective writing course for medical students at the Cleveland Clinic.
“We de-emphasize the grammar and the style, and we instead emphasize sharing what is on your mind,” he said.
Meanwhile, Vollenhoven and Navarro-Millan satisfy their artistic impulses by finding time to attend concerts and visit museums when the opportunity arises.
Losing the art and becoming engulfed in the science side of things presents a “real risk,” Vollenhoven said.
“Music can be just a very superficial enjoyment, but if you take a little bit more serious interest and try to discern the reasons behind the composition, there is much to be learned from that,” he added.
Similarly, Kavanagh argued that the more perspectives an individual has access to, and an understanding of, the better life can be.
“If reading a book helps me empathize or connect with a patient a bit better, I think that has to be a good thing,” Kavanagh said. “It expands the human dimension of who we are, to be immersed in arts and literature. I think it would make them better human beings.”
According to Navarro-Millan, music in general can ignite joy and provide a sense of purpose. That joy transcends every facet of her life, she said, including rheumatology, and allows her to connect with patients more naturally.
“I think that authenticity is what probably makes me take better care of patients,” Navarro-Millan said.
Apart from engaging in the humanities through active or passive involvement, it is imperative that no matter the inclination, diversity of style in the rheumatology field remains strong.
Although art and the humanities offer ways for physicians to connect to patients, and see and be seen as “real people,” there is still a significant place in medicine for professionals who do not, or cannot, engage as vehemently, Kavanagh said.
“There is no question in my mind that there are people at the very top of their game in rheumatology, who dedicate their entire lives to the mastery of our specialty through the lens of science, who are wonderful rheumatologists,” he said. “You need people who have those supreme analytical skills to deep-dive and get to work in the lab. We wouldn’t be where we are in medicine without those people.
“However, I guess what I’m advocating for is a broader perspective of how we look at our specialty — one of course firmly grounded in science, but also one where multiple perspectives from the world of the arts and performance science are valued,” he added. “I think it has made me a better rheumatologist.”
“To feel afraid is natural. To rise above your fears and realize that you are far greater than what frightens you, that is supernatural. Strive to become supernatural and your fears will melt away.” ~ Luminita D. Saviuc
WHEN YOU FEEL AFRAID
When you feel lost, frightened and all alone, know that you can do something about it. You can take charge of your own thoughts and feelings, and shift yourself and your life in a totally different direction.
And it is my hope that the reminders I will share with you below will inspire and empower you to make use of this great power that lies dormant within you so that you can start making the shift from fear to courage, love and greatness.
3. Courage is not the absence of fear, but the triumph over it.
“I learned that courage was not the absence of fear, but the triumph over it. The brave man is not he who does not feel afraid, but he who conquers that fear.” ~ Nelson Mandela
4. True courage is being afraid, and going ahead anyhow.
“True courage is being afraid, and going ahead and doing your job anyhow, that’s what courage is.” ~ Norman Schwarzkopf
5. Fear is the cheapest room in the house. You deserve to live in better condition
“Fear is the cheapest room in the house. I would like to see you living in better conditions.” ~ Hafiz
6. Do not be afraid. Nothing in life is to be feared, it is only to be understood.
”Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less.” ~ Marie Curie
7. Fear doesn’t exist anywhere except in the mind.
”Fear doesn’t exist anywhere except in the mind.” ~ Dale Carnegie
8. Expose yourself to your deepest fear and fear vanishes.
”Expose yourself to your deepest fear; after that, fear has no power, and the fear of freedom shrinks and vanishes. You are free.” ~ Jim Morrison
9. Look fear in the face.
”You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. You are able to say to yourself, ‘I lived through this horror. I can take the next thing that comes along.” ~ Eleanor Roosevelt
10. Fear is nothing but False Evidence Appearing Real.
“.. Fear is often described as False Evidence Appearing Real.” ~ Nick Vujicic
11. Make up your mind and fear will disappear.
“Where there is fear, it is because you have not made up your mind.” ~ A Course In Miracles
“What is a fear of living? It’s being preeminently afraid of dying. It is not doing what you came here to do, out of timidity and spinelessness. The antidote is to take full responsibility for yourself – for the time you take up and the space you occupy. If you don’t know what you’re here to do, then just do some good.” ~ Maya Angelou
14. Prove yourself strong when they expect you to be afraid
“Always do what you’re afraid to do. … I will prove myself strong when they think I am sick. I will prove myself brave when they think I am weak.” ~ E. Lockhart
“Fear is really nothing and love is everything. Whenever light enters darkness, the darkness is abolished. What you believe is true for you.” ~ A Course in Miracles
16. Nothing real can be threatened. Nothing unreal exists.
“Nothing real can be threatened. Nothing unreal exists. Herein lies the peace of God.” ~ A Course in Miracles
“If you are fearful, it is certain that you will endow the world with attributes that it does not possess, and crowd it with images that do not exist.” ~ A Course In Miracles
17. There is no fear in love, but perfect love casts out fear.
“There is no fear in love, but perfect love casts out fear. For fear has to do with punishment, and whoever fears has not been perfected in love.” ~ 1 John 4:18
18. You can’t serve two masters. You have to choose one—fear or love.
“If you want to be happy, if you want to experience the many wonders of life… you have to let go of fear. .. You can’t serve two masters. You have to choose one—fear or love—and based on the one you choose your life will either be happy or unhappy.” ~ Luminita D. Saviuc
19. The one who is always afraid is the ego.
“If you identify with the ego, you must perceive yourself as guilty. Whenever you respond to your ego you will experience guilt, and you will fear punishment. The ego is quite literally a fearful thought.” ~ A Course in Miracles
20. Everyone who loves has been born of God and knows God.
“Everyone who loves has been born of God and knows God. Whoever does not love does not know God, because God is love.” ~ 1 John 4:7-8
“The memory of God comes to the quiet mind. It cannot come where there is conflict; for a mind at war against itself remembers not eternal gentleness. . . . What you remember is a part of you. For you must be as God created you… Let all this madness be undone for you, and turn in peace of the remembrance of God, still shining in your quiet mind.” ~ Wayne W. Dyer
22. If God is for you, who can be against you?
“What then shall we say to these things? If God is for us, who can be against us?” ~ Romans 8:31
“The Lord is on my side; I will not fear. What can man do to me?” ~ Psalm 118:6
23. Fear no evil.
“Even though I walk through the darkest valley,I will fear no evil, for you are with me; your rod and your staff, they comfort me.” ~ Psalm 23:4
“When a man’s ways please the Lord, he makes even his enemies to be at peace with him.” ~ Proverbs 16:7
24. Cast all your anxiety on the Divine.
“Humble yourselves, therefore, under God’s mighty hand, that he may lift you up in due time. Cast all your anxiety on him because he cares for you.” ~ 1 Peter 5:6-7
25. You are far more powerful than you believe.
“Because of your belief in external things you think power into them by transferring the power that you are to the external thing. Realize you yourself are the power you have mistakenly given to outer conditions.” ~ Neville Goddard
26. Fear is such an unlucrative business. Why not find a better job?
“Now that all your worry has proved such an unlucrative business, why not find a better job.” ~ Hafiz
27. Life opens up opportunities to you.
“Life opens up opportunities to you, and you either take them or you stay afraid of taking them.” ~ Jim Carrey
“Fear not, for I Am with you; be not dismayed, for I am your God; I will strengthen you, I will help you, I will uphold you with my righteous right hand.” ~ Isaiah 41:10
“Have I not commanded you? Be strong and courageous. Do not be frightened, and do not be dismayed, for the Lord your God is with you wherever you go.” ~ Joshua 1:9
30. If you look for nothing but God, nothing or no one can disturb you
“If you look for nothing but God, nothing or no one can disturb you. God is not distracted by a multitude of things. Nor can we be.” ~ Meister Eckhart
31. Be not so afraid of dying that you forget to live.
“Some people are so afraid to die that they never begin to live.” ~ Henry Van Dyke
If you lack forgiveness, you are giving your Light away and absorbing the dense emotions of those you cannot seem to forgive… Give not your Light to those who have proven not to be a friend to you.
32. Do not be afraid. God is with you wherever you go.
“When you go out to war against your enemies, and see horses and chariots and an army larger than your own, you shall not be afraid of them, for the Lord your God is with you, who brought you up out of the land of Egypt.” ~ Deuteronomy 20:1
33. If there is no enemy within, the enemy outside can do you no harm.
“if there is no enemy within, the enemy outside can do us no harm.” ~ African proverb
And these are the 33 powerful things you should always remember when you feel afraid. May they inspire and empower you to rise above fear and become powerful and courageous being you have always been.
**What about you? What is the one thing that helps you when you feel afraid? You can share your comment below 🙂
Philosopher Peter Carruthers insists that conscious thought, judgment and volition are illusions. They arise from processes of which we are forever unaware
Peter Carruthers, Distinguished University Professor of Philosophy at the University of Maryland, College Park, is an expert on the philosophy of mind who draws heavily on empirical psychology and cognitive neuroscience. He outlined many of his ideas on conscious thinking in his 2015 book The Centered Mind: What the Science of Working Memory Shows Us about the Nature of Human Thought. More recently, in 2017, he published a paper with the astonishing title of “The Illusion of Conscious Thought.” In the following excerpted conversation, Carruthers explains to editor Steve Ayan the reasons for his provocative proposal.
What makes you think conscious thought is an illusion?
I believe that the whole idea of conscious thought is an error. I came to this conclusion by following out the implications of the two of the main theories of consciousness. The first is what is called the Global Workspace Theory, which is associated with neuroscientists Stanislas Dehaene and Bernard Baars. Their theory states that to be considered conscious a mental state must be among the contents of working memory (the “user interface” of our minds) and thereby be available to other mental functions, such as decision-making and verbalization. Accordingly, conscious states are those that are “globally broadcast,” so to speak. The alternative view, proposed by Michael Graziano, David Rosenthal and others, holds that conscious mental states are simply those that you know of, that you are directly aware of in a way that doesn’t require you to interpret yourself. You do not have to read you own mind to know of them. Now, whichever view you adopt, it turns out that thoughts such as decisions and judgments should not be considered to be conscious. They are not accessible in working memory, nor are we directly aware of them. We merely have what I call “the illusion of immediacy”—the false impression that we know our thoughts directly.
One might easily agree that the sources of one’s thoughts are hidden from view—we just don’t know where our ideas come from. But once we have them and we know it, that’s where consciousness begins. Don’t we have conscious thoughts at least in this sense?
In ordinary life we are quite content to say things like “Oh, I just had a thought” or “I was thinking to myself.” By this we usually mean instances of inner speech or visual imagery, which are at the center of our stream of consciousness—the train of words and visual contents represented in our minds. I think that these trains are indeed conscious. In neurophilosophy, however, we refer to “thought” in a much more specific sense. In this view, thoughts include only nonsensory mental attitudes, such as judgments, decisions, intentions and goals. These are amodal, abstract events, meaning that they are not sensory experiences and are not tied to sensory experiences. Such thoughts never figure in working memory. They never become conscious. And we only ever know of them by interpreting what does become conscious, such as visual imagery and the words we hear ourselves say in our heads.
So consciousness always has a sensory basis?
I claim that consciousness is always bound to a sensory modality, that there is inevitably some auditory, visual or tactile aspect to it. All kinds of mental imagery, such as inner speech or visual memory, can of course be conscious. We see things in our mind’s eye; we hear our inner voice. What we are conscious of are the sensory-based contents present in working memory.
In your view, is consciousness different from awareness?
That’s a difficult question. Some philosophers believe that consciousness can be richer than what we can actually report. For example, our visual field seems to be full of detail—everything is just there, already consciously seen. Yet experiments in visual perception, especially the phenomenon of inattentional blindness, show that in fact we consciously register only a very limited slice of the world. [Editors’ note: A person experiencing inattentional blindness may not notice that a gorilla walked across a basketball court while the individual was focusing on the movement of the ball.] So, what we think we see, our subjective impression, is different from what we are actually aware of. Probably our conscious mind grasps only the gist of much of what is out there in the world, a sort of statistical summary. Of course, for most people consciousness and awareness coincide most of the time. Still, I think, we are not directly aware of our thoughts. Just as we are not directly aware of the thoughts of other people. We interpret our own mental states in much the same way as we interpret the minds of others, except that we can use as data in our own case our own visual imagery and inner speech.
You call the process of how people learn their own thoughts interpretive sensory access, or ISA. Where does the interpretation come into play?
Let’s take our conversation as an example—you are surely aware of what I am saying to you at this very moment. But the interpretative work and inferences on which you base your understanding are not accessible to you. All the highly automatic, quick inferences that form the basis of your understanding of my words remain hidden. You seem to just hear the meaning of what I say. What rises to the surface of your mind are the results of these mental processes. That is what I mean: The inferences themselves, the actual workings of our mind, remain unconscious. All that we are aware of are their products. And my access to your mind, when I listen to you speak, is not different in any fundamental way from my access to my own mind when I am aware of my own inner speech. The same sorts of interpretive processes still have to take place.
Why, then, do we have the impression of direct access to our mind?
The idea that minds are transparent to themselves (that everyone has direct awareness of their own thoughts) is built into the structure of our “mind reading” or “theory of mind” faculty, I suggest. The assumption is a useful heuristic when interpreting the statements of others. If someone says to me, “I want to help you,” I have to interpret whether the person is sincere, whether he is speaking literally or ironically, and so on; that is hard enough. If I also had to interpret whether he is interpreting his own mental state correctly, then that would make my task impossible. It is far simpler to assume that he knows his own mind (as, generally, he does). The illusion of immediacy has the advantage of enabling us to understand others with much greater speed and probably with little or no loss of reliability. If I had to figure out to what extent others are reliable interpreters of themselves, then that would make things much more complicated and slow. It would take a great deal more energy and interpretive work to understand the intentions and mental states of others. And then it is the same heuristic transparency-of-mind assumption that makes my own thoughts seem transparently available to me.
What is the empirical basis of your hypothesis?
There is a great deal of experimental evidence from normal subjects, especially of their readiness to falsely, but unknowingly, fabricate facts or memories to fill in for lost ones. Moreover, if introspection were fundamentally different from reading the minds of others, one would expect there to be disorders in which only one capacity was damaged but not the other. But that’s not what we find. Autism spectrum disorders, for example, are not only associated with limited access to the thoughts of others but also with a restricted understanding of oneself. In patients with schizophrenia, the insight both into one’s own mind and that of others is distorted. There seems to be only a single mind-reading mechanism on which we depend both internally and in our social relations.
What side effect does the illusion of immediacy have?
The price we pay is that we believe subjectively that we are possessed of far greater certainty about our attitudes than we actually have. We believe that if we are in mental state X, it is the same as being in that state. As soon as I believe I am hungry, I am. Once I believe I am happy, I am. But that is not really the case. It is a trick of the mind that makes us equate the act of thinking one has a thought with the thought itself.
What might be the alternative? What should we do about it, if only we could?
Well, in theory, we would have to distinguish between an experiential state itself on the one hand and our judgment or belief underlying this experience on the other hand. There are rare instances when we succeed in doing so: for example, when I feel nervous or irritated but suddenly realize that I am actually hungry and need to eat.
You mean that a more appropriate way of seeing it would be: “I think I’m angry, but maybe I’m not”?
That would be one way of saying it. It is astonishingly difficult to maintain this kind of distanced view of oneself. Even after many years of consciousness studies, I’m still not all that good at it (laughs).
Brain researchers put a lot of effort into figuring out the neural correlates of consciousness, the NCC. Will this endeavor ever be successful?
I think we already know a lot about how and where working memory is represented in the brain. Our philosophical concepts of what consciousness actually is are much more informed by empirical work than they were even a few decades ago. Whether we can ever close the gap between subjective experiences and neurophysiological processes that produce them is still a matter of dispute.
Would you agree that we are much more unconscious than we think we are?
I would rather say that consciousness is not what we generally think it is. It is not direct awareness of our inner world of thoughts and judgments but a highly inferential process that only gives us the impression of immediacy.
Where does that leave us with our concept of freedom and responsibility?
We can still have free will and be responsible for our actions. Conscious and unconscious are not separate spheres; they operate in tandem. We are not simply puppets manipulated by our unconscious thoughts, because obviously, conscious reflection does have effects on our behavior. It interacts with and is fueled by implicit processes. In the end, being free means acting in accordance with one’s own reasons—whether these are conscious or not.
Briefly Explained: Consciousness
Consciousness is generally understood to mean that an individual not only has an idea, recollection or perception but also knows that he or she has it. For perception, this knowledge encompasses both the experience of the outer world (“it’s raining”) and one’s internal state (“I’m angry”). Experts do not know how human consciousness arises. Nevertheless, they generally agree on how to define various aspects of it. Thus, they distinguish “phenomenal consciousness” (the distinctive feel when we perceive, for example, that an object is red) and “access consciousness” (when we can report on a mental state and use it in decision-making).
Important characteristics of consciousness include subjectivity (the sense that the mental event belongs to me), continuity (it appears unbroken) and intentionality (it is directed at an object). According to a popular scheme of consciousness known as Global Workspace Theory, a mental state or event is conscious if a person can bring it to mind to carry out such functions as decision-making or remembering, although how such accessing occurs is not precisely understood. Investigators assume that consciousness is not the product of a single region of the brain but of larger neural networks. Some theoreticians go so far as to posit that it is not even the product of an individual brain. For example, philosopher Alva Noë of the University of California, Berkeley, holds that consciousness is not the work of a single organ but is more like a dance: a pattern of meaning that emerges between brains.
Philosopher Peter Carruthers insists that conscious thought, judgment and volition are illusions. They arise from processes of which we are forever unaware
Peter Carruthers, Distinguished University Professor of Philosophy at the University of Maryland, College Park, is an expert on the philosophy of mind who draws heavily on empirical psychology and cognitive neuroscience. He outlined many of his ideas on conscious thinking in his 2015 book The Centered Mind: What the Science of Working Memory Shows Us about the Nature of Human Thought. More recently, in 2017, he published a paper with the astonishing title of “The Illusion of Conscious Thought.” In the following excerpted conversation, Carruthers explains to editor Steve Ayan the reasons for his provocative proposal.
What makes you think conscious thought is an illusion?
I believe that the whole idea of conscious thought is an error. I came to this conclusion by following out the implications of the two of the main theories of consciousness. The first is what is called the Global Workspace Theory, which is associated with neuroscientists Stanislas Dehaene and Bernard Baars. Their theory states that to be considered conscious a mental state must be among the contents of working memory (the “user interface” of our minds) and thereby be available to other mental functions, such as decision-making and verbalization. Accordingly, conscious states are those that are “globally broadcast,” so to speak. The alternative view, proposed by Michael Graziano, David Rosenthal and others, holds that conscious mental states are simply those that you know of, that you are directly aware of in a way that doesn’t require you to interpret yourself. You do not have to read you own mind to know of them. Now, whichever view you adopt, it turns out that thoughts such as decisions and judgments should not be considered to be conscious. They are not accessible in working memory, nor are we directly aware of them. We merely have what I call “the illusion of immediacy”—the false impression that we know our thoughts directly.
One might easily agree that the sources of one’s thoughts are hidden from view—we just don’t know where our ideas come from. But once we have them and we know it, that’s where consciousness begins. Don’t we have conscious thoughts at least in this sense?
In ordinary life we are quite content to say things like “Oh, I just had a thought” or “I was thinking to myself.” By this we usually mean instances of inner speech or visual imagery, which are at the center of our stream of consciousness—the train of words and visual contents represented in our minds. I think that these trains are indeed conscious. In neurophilosophy, however, we refer to “thought” in a much more specific sense. In this view, thoughts include only nonsensory mental attitudes, such as judgments, decisions, intentions and goals. These are amodal, abstract events, meaning that they are not sensory experiences and are not tied to sensory experiences. Such thoughts never figure in working memory. They never become conscious. And we only ever know of them by interpreting what does become conscious, such as visual imagery and the words we hear ourselves say in our heads.
So consciousness always has a sensory basis?
I claim that consciousness is always bound to a sensory modality, that there is inevitably some auditory, visual or tactile aspect to it. All kinds of mental imagery, such as inner speech or visual memory, can of course be conscious. We see things in our mind’s eye; we hear our inner voice. What we are conscious of are the sensory-based contents present in working memory.
In your view, is consciousness different from awareness?
That’s a difficult question. Some philosophers believe that consciousness can be richer than what we can actually report. For example, our visual field seems to be full of detail—everything is just there, already consciously seen. Yet experiments in visual perception, especially the phenomenon of inattentional blindness, show that in fact we consciously register only a very limited slice of the world. [Editors’ note: A person experiencing inattentional blindness may not notice that a gorilla walked across a basketball court while the individual was focusing on the movement of the ball.] So, what we think we see, our subjective impression, is different from what we are actually aware of. Probably our conscious mind grasps only the gist of much of what is out there in the world, a sort of statistical summary. Of course, for most people consciousness and awareness coincide most of the time. Still, I think, we are not directly aware of our thoughts. Just as we are not directly aware of the thoughts of other people. We interpret our own mental states in much the same way as we interpret the minds of others, except that we can use as data in our own case our own visual imagery and inner speech.
You call the process of how people learn their own thoughts interpretive sensory access, or ISA. Where does the interpretation come into play?
Let’s take our conversation as an example—you are surely aware of what I am saying to you at this very moment. But the interpretative work and inferences on which you base your understanding are not accessible to you. All the highly automatic, quick inferences that form the basis of your understanding of my words remain hidden. You seem to just hear the meaning of what I say. What rises to the surface of your mind are the results of these mental processes. That is what I mean: The inferences themselves, the actual workings of our mind, remain unconscious. All that we are aware of are their products. And my access to your mind, when I listen to you speak, is not different in any fundamental way from my access to my own mind when I am aware of my own inner speech. The same sorts of interpretive processes still have to take place.
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Why, then, do we have the impression of direct access to our mind?
The idea that minds are transparent to themselves (that everyone has direct awareness of their own thoughts) is built into the structure of our “mind reading” or “theory of mind” faculty, I suggest. The assumption is a useful heuristic when interpreting the statements of others. If someone says to me, “I want to help you,” I have to interpret whether the person is sincere, whether he is speaking literally or ironically, and so on; that is hard enough. If I also had to interpret whether he is interpreting his own mental state correctly, then that would make my task impossible. It is far simpler to assume that he knows his own mind (as, generally, he does). The illusion of immediacy has the advantage of enabling us to understand others with much greater speed and probably with little or no loss of reliability. If I had to figure out to what extent others are reliable interpreters of themselves, then that would make things much more complicated and slow. It would take a great deal more energy and interpretive work to understand the intentions and mental states of others. And then it is the same heuristic transparency-of-mind assumption that makes my own thoughts seem transparently available to me.
What is the empirical basis of your hypothesis?
There is a great deal of experimental evidence from normal subjects, especially of their readiness to falsely, but unknowingly, fabricate facts or memories to fill in for lost ones. Moreover, if introspection were fundamentally different from reading the minds of others, one would expect there to be disorders in which only one capacity was damaged but not the other. But that’s not what we find. Autism spectrum disorders, for example, are not only associated with limited access to the thoughts of others but also with a restricted understanding of oneself. In patients with schizophrenia, the insight both into one’s own mind and that of others is distorted. There seems to be only a single mind-reading mechanism on which we depend both internally and in our social relations.
What side effect does the illusion of immediacy have?
The price we pay is that we believe subjectively that we are possessed of far greater certainty about our attitudes than we actually have. We believe that if we are in mental state X, it is the same as being in that state. As soon as I believe I am hungry, I am. Once I believe I am happy, I am. But that is not really the case. It is a trick of the mind that makes us equate the act of thinking one has a thought with the thought itself.
What might be the alternative? What should we do about it, if only we could?
Well, in theory, we would have to distinguish between an experiential state itself on the one hand and our judgment or belief underlying this experience on the other hand. There are rare instances when we succeed in doing so: for example, when I feel nervous or irritated but suddenly realize that I am actually hungry and need to eat.
You mean that a more appropriate way of seeing it would be: “I think I’m angry, but maybe I’m not”?
That would be one way of saying it. It is astonishingly difficult to maintain this kind of distanced view of oneself. Even after many years of consciousness studies, I’m still not all that good at it (laughs).
Brain researchers put a lot of effort into figuring out the neural correlates of consciousness, the NCC. Will this endeavor ever be successful?
I think we already know a lot about how and where working memory is represented in the brain. Our philosophical concepts of what consciousness actually is are much more informed by empirical work than they were even a few decades ago. Whether we can ever close the gap between subjective experiences and neurophysiological processes that produce them is still a matter of dispute.
Would you agree that we are much more unconscious than we think we are?
I would rather say that consciousness is not what we generally think it is. It is not direct awareness of our inner world of thoughts and judgments but a highly inferential process that only gives us the impression of immediacy.
Where does that leave us with our concept of freedom and responsibility?
We can still have free will and be responsible for our actions. Conscious and unconscious are not separate spheres; they operate in tandem. We are not simply puppets manipulated by our unconscious thoughts, because obviously, conscious reflection does have effects on our behavior. It interacts with and is fueled by implicit processes. In the end, being free means acting in accordance with one’s own reasons—whether these are conscious or not.
Briefly Explained: Consciousness
Consciousness is generally understood to mean that an individual not only has an idea, recollection or perception but also knows that he or she has it. For perception, this knowledge encompasses both the experience of the outer world (“it’s raining”) and one’s internal state (“I’m angry”). Experts do not know how human consciousness arises. Nevertheless, they generally agree on how to define various aspects of it. Thus, they distinguish “phenomenal consciousness” (the distinctive feel when we perceive, for example, that an object is red) and “access consciousness” (when we can report on a mental state and use it in decision-making).
Important characteristics of consciousness include subjectivity (the sense that the mental event belongs to me), continuity (it appears unbroken) and intentionality (it is directed at an object). According to a popular scheme of consciousness known as Global Workspace Theory, a mental state or event is conscious if a person can bring it to mind to carry out such functions as decision-making or remembering, although how such accessing occurs is not precisely understood. Investigators assume that consciousness is not the product of a single region of the brain but of larger neural networks. Some theoreticians go so far as to posit that it is not even the product of an individual brain. For example, philosopher Alva Noë of the University of California, Berkeley, holds that consciousness is not the work of a single organ but is more like a dance: a pattern of meaning that emerges between brains.
“And it is so simple… You will instantly find how to live.”
One November night in the 1870s, legendary Russian writer Fyodor Dostoyevsky (November 11, 1821–February 9, 1881) discovered the meaning of life in a dream — or, at least, the protagonist in his final short story did. The piece, which first appeared in the altogether revelatory A Writer’s Diary (public library) under the title “The Dream of a Queer Fellow” and was later published separately as The Dream of a Ridiculous Man, explores themes similar to those in Dostoyevsky’s 1864 novel Notes from the Underground, considered the first true existential novel. True to Stephen King’s assertion that “good fiction is the truth inside the lie,” the story sheds light on Dostoyevsky’s personal spiritual and philosophical bents with extraordinary clarity — perhaps more so than any of his other published works. The contemplation at its heart falls somewhere between Tolstoy’s tussle with the meaning of life and Philip K. Dick’s hallucinatory exegesis.
Portrait of Fyodor Dostoyevsky by Vasily Perov, 1871
The story begins with the narrator wandering the streets of St. Petersburg on “a gloomy night, the gloomiest night you can conceive,” dwelling on how others have ridiculed him all his life and slipping into nihilism with the “terrible anguish” of believing that nothing matters. He peers into the glum sky, gazes at a lone little star, and contemplates suicide; two months earlier, despite his destitution, he had bought an “excellent revolver” with the same intention, but the gun had remained in his drawer since. Suddenly, as he is staring at the star, a little girl of about eight, wearing ragged clothes and clearly in distress, grabs him by the arm and inarticulately begs his help. But the protagonist, disenchanted with life, shoos her away and returns to the squalid room he shares with a drunken old captain, furnished with “a sofa covered in American cloth, a table with some books, two chairs and an easy-chair, old, incredibly old, but still an easy-chair.”
As he sinks into the easy-chair to think about ending his life, he finds himself haunted by the image of the little girl, leading him to question his nihilistic disposition. Dostoyevsky writes:
I knew for certain that I would shoot myself that night, but how long I would sit by the table — that I did not know. I should certainly have shot myself, but for that little girl.
You see: though it was all the same to me, I felt pain, for instance. If any one were to strike me, I should feel pain. Exactly the same in the moral sense: if anything very pitiful happened, I would feel pity, just as I did before everything in life became all the same to me. I had felt pity just before: surely, I would have helped a child without fail. Why did I not help the little girl, then? It was because of an idea that came into my mind then. When she was pulling at me and calling to me, suddenly a question arose before me, which I could not answer. The question was an idle one; but it made me angry. I was angry because of my conclusion, that if I had already made up my mind that I would put an end to myself to-night, then now more than ever before everything in the world should be all the same to me. Why was it that I felt it was not all the same to me, and pitied the little girl? I remember I pitied her very much: so much that I felt a pain that was even strange and incredible in my situation…
It seemed clear that if I was a man and not a cipher yet, and until I was changed into a cipher, then I was alive and therefore could suffer, be angry and feel shame for my actions. Very well. But if I were to kill myself, for instance, in two hours from now, what is the girl to me, and what have I to do with shame or with anything on earth? I am going to be a cipher, an absolute zero. Could my consciousness that I would soon absolutely cease to exist, and that therefore nothing would exist, have not the least influence on my feeling of pity for the girl or on my sense of shame for the vileness I had committed?
From the moral, he veers into the existential:
It became clear to me that life and the world, as it were, depended upon me. I might even say that the world had existed for me alone. I should shoot myself, and then there would be no world at all, for me at least. Not to mention that perhaps there will really be nothing for any one after me, and the whole world, as soon as my consciousness is extinguished, will also be extinguished like a phantom, as part of my consciousness only, and be utterly abolished, since perhaps all this world and all these men are myself alone.
Beholding “these new, thronging questions,” he plunges into a contemplation of what free will really means. In a passage that calls to mind John Cage’s famous aphorism on the meaning of life — “No why. Just here.” — and George Lucas’s assertion that “life is beyond reason,” Dostoyevsky suggests through his protagonist that what gives meaning to life is life itself:
One strange consideration suddenly presented itself to me. If I had previously lived on the moon or in Mars, and I had there been dishonored and disgraced so utterly that one can only imagine it sometimes in a dream or a nightmare, and if I afterwards found myself on earth and still preserved a consciousness of what I had done on the other planet, and if I knew besides that I would never by any chance return, then, if I were to look at the moon from the earth — would it be all the same to me or not? Would I feel any shame for my action or not? The questions were idle and useless, for the revolver was already lying before me, and I knew with all my being that this thing would happen for certain: but the questions excited me to rage. I could not die now, without having solved this first. In a word, that little girl saved me, for my questions made me postpone pulling the trigger.
Just as he ponders this, the protagonist slips into sleep in the easy-chair, but it’s a sleep that has the quality of wakeful dreaming. In one of many wonderful semi-asides, Dostoyevsky peers at the eternal question of why we have dreams:
Dreams are extraordinarily strange. One thing appears with terrifying clarity, with the details finely set like jewels, while you leap over another, as though you did not notice it at all — space and time, for instance. It seems that dreams are the work not of mind but of desire, not of the head but of the heart… In a dream things quite incomprehensible come to pass. For instance, my brother died five years ago. Sometimes I see him in a dream: he takes part in my affairs, and we are very excited, while I, all the time my dream goes on, know and remember perfectly that my brother is dead and buried. Why am I not surprised that he, though dead, is still near me and busied about me? Why does my mind allow all that?
In this strange state, the protagonist dreams that he takes his revolver and points it at his heart — not his head, where he had originally intended to shoot himself. After waiting a second or two, his dream-self pulls the trigger quickly. Then something remarkable happens:
I felt no pain, but it seemed to me that with the report, everything in me was convulsed, and everything suddenly extinguished. It was terribly black all about me. I became as though blind and numb, and I lay on my back on something hard. I could see nothing, neither could I make any sound. People were walking and making a noise about me: the captain’s bass voice, the landlady’s screams… Suddenly there was a break. I am being carried in a closed coffin. I feel the coffin swinging and I think about that, and suddenly for the first time the idea strikes me that I am dead, quite dead. I know it and do not doubt it; I cannot see nor move, yet at the same time I feel and think. But I am soon reconciled to that, and as usual in a dream I accept the reality without a question.
Now I am being buried in the earth. Every one leaves me and I am alone, quite alone. I do not stir… I lay there and — strange to say — I expected nothing, accepting without question that a dead man has nothing to expect. But it was damp. I do not know how long passed — an hour, a few days, or many days. Suddenly, on my left eye which was closed, a drop of water fell, which had leaked through the top of the grave. In a minute fell another, then a third, and so on, every minute. Suddenly, deep indignation kindled in my heart and suddenly in my heart I felt physical pain. ‘It’s my wound,’ I thought. ‘It’s where I shot myself. The bullet is there.’ And all the while the water dripped straight on to my closed eye. Suddenly, I cried out, not with a voice, for I was motionless, but with all my being, to the arbiter of all that was being done to me.
“Whosoever thou art, if thou art, and if there exists a purpose more intelligent than the things which are now taking place, let it be present here also. But if thou dost take vengeance upon me for my foolish suicide, then know, by the indecency and absurdity of further existence, that no torture whatever that may befall me, can ever be compared to the contempt which I will silently feel, even through millions of years of martyrdom.”
I cried out and was silent. Deep silence lasted a whole minute. One more drop even fell. But I knew and believed, infinitely and steadfastly, that in a moment everything would infallibly change. Suddenly, my grave opened. I do not know whether it had been uncovered and opened, but I was taken by some dark being unknown to me, and we found ourselves in space. Suddenly, I saw. It was deep night; never, never had such darkness been! We were borne through space and were already far from the earth. I asked nothing of him who led me. I was proud and waited. I assured myself that I was not afraid, and my heart melted with rapture at the thought that I was not afraid. I do not remember how long we rushed through space, and I cannot imagine it. It happened as always in a dream when you leap over space and time and the laws of life and mind, and you stop only there where your heart delights.
Through the thick darkness, he sees a star — the same little star he had seen before shooing the girl away. As the dream continues, the protagonist describes a sort of transcendence akin to what is experienced during psychedelic drug trips or in deep meditation states:
Suddenly a familiar yet most overwhelming emotion shook me through. I saw our sun. I knew that it could not be our sun, which had begotten our earth, and that we were an infinite distance away, but somehow all through me I recognized that it was exactly the same sun as ours, its copy and double. A sweet and moving delight echoed rapturously through my soul. The dear power of light, of that same light which had given me birth, touched my heart and revived it, and I felt life, the old life, for the first time since my death.
He finds himself in another world, Earthlike in every respect, except “everything seemed to be bright with holiday, with a great and sacred triumph, finally achieved” — a world populated by “children of the sun,” happy people whose eyes “shone with a bright radiance” and whose faces “gleamed with wisdom, and with a certain consciousness, consummated in tranquility.” The protagonist exclaims:
Oh, instantly, at the first glimpse of their faces I understood everything, everything!
Conceding that “it was only a dream,” he nonetheless asserts that “the sensation of the love of those beautiful and innocent people” was very much real and something he carried into wakeful life on Earth. Awaking in his easy-chair at dawn, he exclaims anew with rekindled gratitude for life:
Oh, now — life, life! I lifted my hands and called upon the eternal truth, not called, but wept. Rapture, ineffable rapture exalted all my being. Yes, to live…
Dostoyevsky concludes with his protagonist’s reflection on the shared essence of life, our common conquest of happiness and kindness:
All are tending to one and the same goal, at least all aspire to the same goal, from the wise man to the lowest murderer, but only by different ways. It is an old truth, but there is this new in it: I cannot go far astray. I saw the truth. I saw and know that men could be beautiful and happy, without losing the capacity to live upon the earth. I will not, I cannot believe that evil is the normal condition of men… I saw the truth, I did not invent it with my mind. I saw, saw, and her living image filled my soul for ever. I saw her in such consummate perfection that I cannot possibly believe that she was not among men. How can I then go astray? … The living image of what I saw will be with me always, and will correct and guide me always. Oh, I am strong and fresh, I can go on, go on, even for a thousand years.
[…]
And it is so simple… The one thing is — love thy neighbor as thyself — that is the one thing. That is all, nothing else is needed. You will instantly find how to live.
Zen Buddhism is a profound philosophy that counters much of what we’re taught in the west.
In western society, we tend to think that we’ll find happiness once we reach certain goals. However, Zen Buddhism says that happiness doesn’t come from any outside achievements. Instead, it believes that true inner peace comes from within.
The key, according to Zen, is to let go of attachments and embrace living fully in the present moment. It’s certainly an outlook on life that all could benefit from, no matter your religion or race.
Below we have found 25 pieces of concise Zen Buddhist wisdom that summarize the wisdom of life. I hope they shift your perspective as much as they have mine. Enjoy!
1) The temptation to give up is strongest just before victory.
2) The goal in life is to die young, but to do as late as possible.
3) Don’t speak if it doesn’t improve on silence.
4) A thousand-mile journey begins with just one step.
5) A strong man overcomes an obstacle, a wise man goes the whole way.
6) Don’t be afraid to go slowly. Be afraid of stopping.
7) Even the happiness of a fool is a stupid kind of happiness.
8) Even if you stumble and fall down, it doesn’t mean you’ve chosen the wrong path.
9) A hut full of laughter is richer than a palace full of sadness.
10) Always look on the bright side of things. If you can’t comprehend this, polish that which has become dull until it begins to shine.
11) Whatever happens always happens on time.
12) Someone who points out your flaws to you is not necessarily your enemy. Someone who speaks of your virtues is not necessarily your friend
13) Don’t be afraid that you do not know something. Be afraid of not learning about it.
14) A good teacher opens the door for you, but you must enter the room by yourself.
15) A mountain never yields to the wind no matter how strong it is.
16) Live calmly. The time will come when the flowers bloom by themselves.
17) There’s no such thing as a friend who doesn’t have any flaws. But if you try to look for all their flaws, you will remain with no friends.
18) Unhappiness enters through a door that has been left open.
19) No one returns from a long journey the same person they were before.
20) A person who is capable of blushing cannot have a bad heart.
21) It’s better be a person for a day than to be a shadow for a 1,000 days.
22) Your home is where your thoughts find peace.
23) The man who moved the mountain was the one who began carrying away the smallest stones.
24) If you’ve made a mistake, it’s better just to laugh at it.
25) The best time to plant a tree was 20 years ago. The second best time is now.
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