 Very pleased to welcome you all today to this discussion on on the deaths of despair in the future of capitalism and and to welcome our honored guests And case and Angus Deaton. I'm going to say just a very few words about them and about the the the the discussions The discussions that we have who are going to I guess their interlocutors I guess is the way you put it through or somewhere else Okay, so and professor and case is the Alexandra Stewart 1886 professor of economics and public affairs I had to look at that twice when it's over down 1886 She is the arrow award winner for work linking the on on the the origins of the gradient in in Health status and economics status in early childhood. In fact, I teach her her work in my health economics class and I It's influenced a lot of my thinking She she won the Cozelli Prize from from the proceedings of National County Sciences for research in midlife mobility and mortality She has a long list of honors. I'm just gonna list a few of them She's a fellow of the National Academy of Medicine American Philosophical Society the fellow of the American Academy of Arts and Sciences She serves on the President's Committee on National Medal of Science and on the committee on the now on national statistics She is it led an incredibly distinguished career and I personally learned a lot about health inequality from her work Sir Angus Deaton is the is this is this is fantastic because it Stanford doesn't name its professors in this in exactly this way He was the Dwight D Eisenhower professor of economics and international fairs and emeritus, I guess He is at the Woodrow Wilson School in the Times Department Princeton His he won the 2015 Nobel Prize in economics on the analysis and consumption of poverty and welfare I first encountered his work on a book that he wrote with with with I'll call the economics consumer behavior And that that also in grad school transform the way I think about a lot of a lot of things The the the book of previous to this one that he that he published is called the great escape health wealth And the origins of inequality Where he extols many of the virtues of capitalism, but also but and I guess this is that we get to we get to hear the downsides Discussing this this work with them today will be a Professor Dan Winkler from from Harvard. He Dan Dan is the Mary B. Salt install professor of population of ethics He at the Harvard T. H. Chan School of Public Health. He is Also, it's impossible to summarize the the the the worth that he's done in Very very succinctly, but he's he's the for instance. He's the author of a book called chance to choice genetics and justice he he's he's worked extensively on on issues of ethics in in medicine and he he's the It's it well, maybe you'll get a chance to hear from him last night at dinner We heard about his father Abraham Winkler who was a who's a pioneer in the research on addiction addiction disorders in a particular on Conditioning and relapse and he has some very very colorful stories to tell if you if you guys can get him to get him to tell them, okay? And then finally we have professor Anna Lemke. She was the associate professor of Psychiatry and Behavioral Sciences here at Stanford. She is the medical director of addiction addiction medicine She is the program director of Stanford addiction medicine fellowship. She's the chief of staff of addiction Addiction met and medical dual diagnosis clinic And she is the author of drug dealer MD how doctors were duped patients got hooked and why it's so hard to stop So it's like the perfect person for the for this discussion. I think See and she's a fellow MD. It's from Stanford as well. So So let's join in welcoming all four of us and what I'm looking forward to good discussion Well, I'm delighted to be here today. I wanted to thank and an angus for inviting me I want to thank the Tanner lecture series For inviting me. I want to thank the McCoy family center on ethics In asking me to speak today. You really honor me and my work unless of course it was a height requirement. I I Want to say also just kind of echoing some of the things that president testier Levine and Deborah sat said in the two previous nights that it's so important and wonderful that we have a Space dedicated to discussing human values because it's so important I also want to say that I am really personally inspired by and case and her work And I think it's marvelous that especially in this very controversial era of women economists and The discussion about their work being recognized. I'm I'm very happy that I can be inspired by her work being recognized in this forum Okay, so today I'm going to make comments on The this astounding piece of work that I was lucky enough to have an advanced reading of And my comments will be in response to what I have read and also the many times I've heard and an angus speak in person and also in other forums. I Should say that I do have a disclosure I've been retained as an expert witness in the federal MDL litigation against opioid manufacturers Distributors and other defendants Based on my book and my prior work on the origins of the opioid epidemic Briefly the overview of what I'd like to talk about today is first. I want to talk very briefly about the power of language vis-a-vis the deaths of despair Then I want to ask the question is this a problem unique to the less educated underclass Which is the point that an angus seemed to be making or is this a more universal phenomenon differentially affecting the undereducated underclass and The short answer in my opinion is that this is actually a universal phenomenon to which we are all vulnerable That differentially affects This subset of individuals that present with a certain phenotype that they try to capture And I think it's important that they capture it But I would say that it is my my opinion that we're dealing with something much more universal That this the undereducated underclass is the harbinger of what is more broadly affecting Not just American society but developed nations and that America is just or the United States is just a first to manifest The signs and symptoms of a systemic disease If so then what might be that universal phenomenon and what to do about it? First the power of language so I want to just speak to this wonderful title deaths of despair Every once in a while a title or a catchphrase comes along that captures the popular imagination ways that are really profound And I think deaths of despair does that it's something that immediately resonates it resonated for me I know it resonates for others. It seems to speak to something deeply true about what's happening in American society So I wanted to reflect on why is it that this title deaths of despair? Is so perfect for this time and I believe that it's because of the use of the term Despair a non-clinical Non-reductionistic non biological term. I am a psychiatrist. I was trained in medical school and through my residency In the age of the brain. I learned a reductionistic approach to mental illness as a rising from Aberrations in the chemical soup. I've been practicing psychiatry for almost 25 years And I am now convinced that the chemical soup has very little to do with it that really what we're dealing with is ecological problems To which people are variably vulnerable a stress vulnerability Diathesis, so I really love deaths of despair But I want to talk about another way that they've used a kind of a lumping or a term that I don't think works as well Which is calling drug overdoses and alcoholic liver disease suicides. Let me explain why I don't think that that is qualitatively accurate I Have practiced psychiatry for a long time and although it's certainly true that people with The disease of addiction that leads to overdose and alcoholic liver disease Can become suicidal after many years of hopeless attempts to get into recovery and fail failing to do so And it is true also that while intoxicated People can experience suicidal ideation that they don't experience when they come out of it I don't think fundamentally that people with addiction Want to die in the way that people who are depressed and suicidal want to die I think these are different things So just an example and anecdotally I had a patient call me and say to me I'm surrounded by empty bottles I can't stop drinking, but I don't want to die. Will you help me? So I think I think again these phenomena are related, but it's somehow not accurate to To state that they're all suicides. I think what Because if you were to do that I Think there's a sense of we attribute a sense of volitional behavior to Addiction to drugs and alcohol that may not be entirely accurate once people are truly deep in their addiction I also think that deaths of despair should include all problems of pathological overconsumption Including obesity which leads to type 2 diabetes malatis And I don't think anybody would say that people who are obese are suicidal So in that same sense, I would not say that people who are addicted to drugs and alcohol are suicidal Okay, so let me try to capture then what I believe is the unifying problem affecting all of us that Disproportionately and differentially affects people who are without a BA and people who are living in poverty. I Think the fundamental problem is a problem of pathological overconsumption We are in essence Human beings are cacti in the rainforest. Let me explain human beings are evolutionarily designed to seek out pleasure and Avoid pain and we are remarkably Adept at doing that so much so that we have in fact transformed the world into one for which we are not Evolutionarily adapted. I love the concept of the Anthropocene this idea That's often used up for climate change to explain the way in which human behavior has changed the face of the planet I think that we can apply that same concept to this problem that we're that's manifesting as deaths of despair We have changed our ecosystem through the remarkable success of capitalism To the point where we are killing ourselves We are in essence awash in dopamine dopamine being that pleasure neurotransmitter In many different forms we have increased access increased potency and increased consumption So in essence in essence I believe that deaths of despair are the result of pathological overconsumption Due to increased access to high potency pleasure goods, which I think could also include things like screens More disposable income to buy those goods, which I think somewhat challenges this notion of Income inequality as the core problem Which is not actually what case indeed and say they talk in a much more nuanced way about rent-seeking, but this idea that somehow class and poverty explain this More leisure time to consume of these pleasure goods. I think time is a really Fundamental variable in this discussion of deaths of despair and I'll talk about that and then importantly Which is really what case indeed and are getting at more broadly the lack of alternative sources of dopamine or what Freud Referred to as love work and play the question that I would ask is this our deaths of despair really indeed the dark side of capitalism You've all seen this graph Showing that as opioid prescribing has quadrupled over the last several decades So have opioid related deaths. I Believe that the opioid epidemic is fundamentally and Primarily a supply problem People who have increased access to opioids are at higher risk to use them become addicted to them and die from them access to addictive substances are Fundamental risk related Is probably the primary risk for becoming addicted at least in the modern society We're now of course in the second wave of that epidemic where deaths attributable to heroin and fentanyl Now supersede deaths related to prescription opioids. But again, that's a natural transition from prescription opioids to these illicit substances and potency plays a big role in this in this Problem again as as as an angus have pointed out and this is part of the innovation of Technology the fact that we have Substances like fentanyl that we can make them cheaply in illicit laboratories that they're actively being made Across China and imported into the United States and a kind of reverse opium wars is really a testament to technology mechanization globalization and the vastly increased access to addictive substances I'm going to go through it very briefly a series of papers that I think Are in support of this idea that although economic factors and individual factors play a role in deaths of despair The primary role is exposure and consumption of these drugs This is an article by Edlund at all look at the looking at the odds ratio of developing an opioid use disorder On prescription opioid medication. These are chronic pain patients finding that the number one Most important risk for developing an opioid use disorder while receiving prescription opioids for chronic pain is not Individual factors like co-occurring mental health disorders or even prior history of addiction It's dose and duration of that substance What drives prescription opioid abuse evidence from migration a very cleverly done study including? people here at Stanford looking at if you take a medicare patient on SSDI and Well, and watch them move from a region of higher or lower opiate prescription opioid misuse How does that geographic change affect their risk of opioid misuse and addiction and finding that? Whether or not there was prescription Over-prescribing in that region and prescription opioid misuse was a stronger predictor than individual factors of whether or not that Individual would then engage in opioid misuse Likewise Christopher room has done work in this area, and I can't really comment on his math because that's not my area, but ultimately he also concludes that That really this is a drug exposure problem more than it is a problem of class or race or economics And you and Lisa were discussing the the racial differences in terms of Opioid misuse and addiction, and I think supply can explain those racial differences Namely that you know in the 1990s and early odds If you were white you were more likely to have good health insurance And if you were more likely to have good health insurance then good medical care meant that you were more likely to Be prescribed opioids at higher and higher doses So I think it's the endemic racism in our medical system that explains why a white people Were were more likely to be prescribed opioids than brown or black people of a similar economic class We also know that there's incredible implicit bias in medicine that doctors are less likely to prescribe opioids to black and brown people Because they believe those individuals are more likely to misuse them I also think that supply can explain class differences when it comes to the opioid epidemic to some extent There are data showing that people receiving Medicaid are prescribed opioid painkillers at twice the rate of non-medicaid patients and Dye from prescription overdoses at six times the rate, and I have argued that we have essentially Medicalized poverty we do not have a social safety net medicine has become our social safety net and when doctors encounter Complex problems like unemployment homelessness multi-generational trauma in their patients They are not given the tools to actually address those problems So instead they Biologize problems weren't which are not in fact biological and then use a pill to solve that problem The same thing that we are seeing with opioids can be seen with cigarette consumption, which vastly increased Between 18. Well, this is the graph showing in the 1800s when the cigarette Manufacture machine was invented. There was a sudden uptick in cigarette consumption Why because of increased access a wonderful book by? Cross and proctor showed called packaged pleasures have technology and marketing revolutionized desire Show how these sudden uptick in cigarette consumption correlates with the a cigarette rolling machine that used to be that We could roll about four cigarettes permit per minute and now we roll about 20,000 cigarettes per minute And although smoking cigarettes has gone down in North America. It's on the rise in the rest of the world And in fact we now have our new version of that again fueled by capitalism and technology the jewel One jewel cartridge is an equivalent of approximately one to two packs of cigarettes a very popular among teenagers similar story with cannabis with the legalization of recreational cannabis on The heels of medical marijuana what we have now is easy access to very high potency cannabis This was not true before average THC content and CBD levels is going up drastically in terms of cannabis What was a weak drug is now a strong drug once you legalize drugs It means that everybody will use more but in particular a vulnerable subset of the population will use much much more What we're seeing now is daily very heavy smokers in a subset of this population And again, I think much of this is attributable to and being fueled by this capitalist idea of just sort of rent seeking through substances and then of course there's smartphones which I Think are the equivalent of a modern-day hypodermic needle Basically delivering digital dopamine for our wired generation These devices are not just addictive in and of themselves, but they create access To these other substances and they also create Addictions that didn't exist before I Want to talk a little bit more about? Disposable income I learned about this from what I think is a really remarkable book the fourth grade awakening by another Nobel Prize-winning economist. I'm looking forward to putting your book on my shelf next to this book But this was really a revelation for me when I read this book Robert Fogel talks about how by the mid 1970s not only the rich but virtually everyone in the middle and many at The lower end of the income distribution owned a washing machine or had access to one our society is so well saturated with Consumer durables in fact that even the poorest fifth of households are well endowed with them to me This is really really important income inequality is important But really what we're talking about is a class of individuals with tremendously access to drugs in part because of disposable income I Also think that time is a really important variable not only are we living longer? But we're working less and if you look at the difference by education In terms of leisure time what is striking is that overall we work fewer hours than we did a hundred two hundred years ago But if you have less than a BA you have more leisure time than if you have a BA or greater So again, I think this really plays into vulnerability. I think we're all struggling with the growing problem of boredom But I think that the undereducated underclass is more burdened with this problem and then people who have Meaningful work or let's say very lucrative work because in many ways what we have now is addiction incentives Built into lucrative work That has contributed to the growing problem of workaholism among people. I think who are more highly educated Also, I want to speak briefly about how the nature of work has changed Through mechanization and technology. We are also more sedentary than we ever have been before we are not moving our bodies There's a kind of a mind by duality people are incredibly disconnected to their bodies. This comes out again clinically In my work seeing patients how detached people are from their physical experience I think that plays into increased consumption of these highly sensory substances like drugs and alcohol And also in other ways in which we interface with screens It's not also just blue collar jobs or Jobs that are lower paying that are divorced from meaning I would also argue that many jobs that we would traditionally think of as deeply meaningful Have now become divorced from meaning I will use medicine as the example. There's been a mass migration in medicine over the last 30 years Out of physician-owned practice into large integrated health care centers Physicians and other health care providers today are essentially hospital factory workers as a result we are Obligated to practice in certain ways and according to certain protocols And some of the mandates include paliating pain prescribing pills and performing procedures because that's what pays Protecting privacy and pleasing patients Essentially doctors have become waiters and patients have become our customers As I said before addictive incentives have been woven into this corporate structure This just happens to be a plot of my revenue earning Graph that I receive monthly from my administration, which tells me whether or not I am meeting my targets You can imagine that when that line is above the purple line And I happen to choose one that's above to show you all I get a little jolt of dopamine and when it's below I'm quite unhappy a Couple of years ago my then 11 year old son decided to Google my name on the internet and he found This and called me over and seemed alarmed. He said mom Is this you and I looked at it it appears to be a doctor rating site and you'll note at the bottom that This patient gave me one out of four stars and had this to say about me. She'll make you wish Oh, I can't even read it from here. Let's see This can be terrible seek help from someone else I Was naturally mortified I immediately began to click through in my brain who possibly else might have seen this I mean I had to admit to my son that yes that that was me This is really Fundamental to this problem. I've gone all around the country in the past several years Speaking to healthcare providers and urging them to prescribe more judiciously and they'll say to me dr. Lemke I'll prescribe fewer opioids when you can promise me I'll still get good scores on my patient rating satisfaction surveys How we do on these surveys in medicine is directly tied to our professional advancement and directly tied to our salaries And you can imagine how that impacts our prescribing habits now the good They're also by the way is no evidence to show that patients who rate their doctors more highly have better health outcomes There is evidence to show that they're more likely to go back to that doctor But not that they're necessarily going to get better And there are some data showing that individuals who rate their doctors more highly are more likely to use prescription drugs and to die Earlier even when controlling for comorbidity now the good news is for me is that my son did come back in a few minutes later And he said don't worry mom. I just gave you four out of four stars twice I also think and and And an angus you talk about this in myriad ways But I think it's worth pointing out that cultural narratives have also played a role here We had an interesting question on the first night. What is it about the 1970s? Why this transition and of course you talked about stagnating wages and other reasons why that was a pivotal Turning point, but I think there's something also going on culturally that we have now developed over many decades Starting about in the 1960s and 70s Narratives that promote consumption as the highest good I will just share with you a patient who I'm currently treating brought in by distressed parents a 21 year old male Who explained to me his? Life philosophy as follows. I do whatever I want whenever I want if I want to stay in my bed I stay in my bed if I want to play video games I play video games if I want to snort a line of coke I snort a line of coke if I want to have sex I go online and find someone and meet them and have sex Very distressing life philosophy. It's not working particularly well for him But he's not really inclined to change it and I'm struck by the normalization of this hedonistic approach As I've written about before we're also culturally in a time when we have no tolerance for pain when pain has become Anathema we believe that in fact the experience of pain in ever in any form whether physical or emotional Can leave a kind of psychic scar which sets people up for vulnerability for future pain For example in the form of a post-traumatic stress disorder Whatever you may think of the diagnosis of post-traumatic stress disorder What's interesting to notice that it's a very modern concept 150 years ago people including physicians believed that pain was salutary that it boosted the immune response that what doesn't kill you Makes you stronger now It has become the obligation of health care providers of all ilk to eliminate all pain Immediately lest they make that individual vulnerable to suffer future pain furthermore patients expect that we will eliminate their pain Along with this is the cultural narrative if I am sad I am sick the kind of pathology Logization of everyday life, which I think has contributed to this problem And I really do wonder if it's a legacy of the 1960s and you talked about how this is not the baby boomers It's the children of the baby boomers, which I think is fascinating So in short, I do believe that deaths of despair is the phenomenon of us titillating ourselves to death Yesterday Debra Satt said I had this wonderful quote from Dante's Inferno, which I had never heard before She said Quoting Dante without hope we live in desire I think a way to rework this quote for the modern age when we live in desire. We are without hope How to move forward? I Would think that some of the important things that we need to do as a culture and a society to move forward are actually to decrease Access to high potency pleasure goods That we need to have less and not more disposable income to buy these goods That we need less leisure time to consume them. I'm very skeptical of the idea of the universal income I think a universal income might be the very worst thing that happens to people Especially people who have less than a BA which has been the focus of our talks and of course we need alternative sources of dopamine Much harder to achieve. I just want to remind everybody In case you didn't know that public policy initiatives like prohibition which banned the sale and possession and consumption of alcohol Worked so there was a remarkable decrease in alcohol consumption in alcoholic a liver Related cirrhosis decreased by 50 percent. Yes, there were unintended consequences of prohibition, but in terms of this outcome It did work Will we be able to do something like prohibition today? Not likely So more likely than not although public policy efforts will be important including restricting opioid prescribing We are going to have to come up with self-binding strategies in a world. That's really overloaded with dopamine meaningful work That's going to be very important. I just found this cartoon and I love it. I'm laying bricks versus. I'm building a cathedral I am really excited about the green movement and the reason I'm excited about this movement is not just because It may save our planet but because it has the possibility To give young people a sense of meaning and purpose in a new age of restraint and denial That will allow them to feel that their suffering is worth something Thank you That was just wonderful Editorialized really enjoyed it so so very much. So Let me just get something out of the way first I'm delighted to be here and I'm Probably don't need to repeat the thank yous and the Hosanna's it's an enormous honor to be commenting on papers by two eminent economists whose work Admires so much and I too am very grateful to the McCoy family Center and to Stanford and I'm very pleased to be here and look forward to Discussing these issues with you Now let me first mention my very very weird origins On occasion when I'm asked to introduce myself I say the following I Was raised by Chinese opium addicts on a Kentucky prison farm On whom my father performed experiments for the CIA's mind control program That's all true now, how could that be well Maybe after the after noon we can go into that. But anyway, that is that is so it all began at this place This the federal government built a a large Penitentiary in the bluegrass region of Kentucky The first as people in there were the Southerners who were abusing opiates like louden them But after a while they were replaced by hipsters and other Relative outsiders from the fringes of urban society mostly in the big cities Supplemented by others My dad was the deputy director of the addiction research center, which is one of the precursors to nighta and a lot of the early work on the mechanisms of addiction And in general on the encyclopedia ecology was actually done in the labs at this place And I grew we lived on the grounds and I grew up there Why was I raised by Chinese opium smokers? because Some of the Chinese are ever great to the United States brought with them the Tradition of opium smoking and it was illegal in the United States when when the feds arrested them they the offenders were sent here And why do they raise me? Well every prisoner had to have a job and the jobs that were most desirable were to work in the households of the medical staff and The the doctors got their got their choice of which prisoners Would work there and of all the people who were in the Lexington prison the one they liked the most Were the Chinese because the Chinese were ordinary people with jobs and families and children Whereas the blacks and the whites tended to be hipsters or other people in the fringes of society And so the doctors felt fine about having the Chinese opium addicts to raise their children They had some concerns about the others. So that's that's a short end It's a story. So I did come from there. Okay, and I just thought I'd share this wonderfully optimistic poster with you This is created about the time that's a Lexington Narcotic farm was created and as you can see Relief is nigh We're still waiting We always think we're just about there There's a documentary on called the narcotic farm as we end and actually this This is the cover of a book as you can see And if you're curious about all this the documentary is on YouTube now it was it was on PBS a few years ago there's a brief picture of me as a three-year-old In it. Okay. So enough of that But it meant was that when as I read the the book this wonderful book that we're commenting on There were parts that had enormous resonance for me just because of this crazy background But that didn't give me any peculiar expertise. It just meant that I was gonna be absolutely riveted So I Will say though just to try to tie that into a commentary a little bit that the order that my strange origins did augment the the impact of this powerfully deeply sympathetic book that Directs our attention to the plight of a huge swath of the American population that's often perceived only through stereotypes and Who stresses entire streets have noticed that all are often blamed on their own personal failings and I'll say more about this in just a moment I'm the only Ethicist or philosopher on this panel and this is sponsored by the McCoy family Center for Ethics and Society So I gather that my job as a commentator is to raise some questions about values Which is fine because values Most emphatically according to the authors to lie at the heart of this book And like Vic last night The remarks that come are not meant as opposition because I mostly share these values But there's an attempt to suggest some points on which further elaboration could strengthen the the value of this book So I'm going to raise three relatively minor points, and they're not minor. They're being major but They're Relatively speaking points of detail Just to point them out and say that maybe a few words on each of them might be opposite In the next draft and then I'll raise a more substantive question as the fourth and last point So the first one is this question of responsibility personal responsibility Think about the deaths of despair is that they are self-inflicted in some sense. I guess the obvious sense People die at their own hand Now in the American context this prompts us to ask Where responsibility for these deaths should be assigned and where there's a suffering rather than death Similarly the question about who's responsible for the suffering And an Angus mentioned American individualism in partial explanation of why the safety net in the United States is so meager Compared to what goes on in pure countries They explained this American Individualism as quote the belief that people should not depend on others even when they're in trouble on quote It seems that's pretty good But it's a it's a more complicated doctrine Their book is not the occasion for a long analysis of it But it has other clauses and implications in particular It seems to mean that if someone comes to grief as a result of foolish choices They're not entitled to make a claim on others for help Although they may receive it as an act of charity and this is all the more true when the choices that they've made and Have caused them such grief of reflect badly on their moral character and Deaths of despair or cases in point drunkenness and drug abuse are highly stigmatized and suicide Although no longer viewed solely or even mainly as a sin is still disguised as a cause of death when family and others say what something about the deceased The notion of personal responsibility for health has a long and varied history in US health policy John Knowles the Rockefeller Foundation wrote a much-noted article in 1977 called the responsibility of the individual and He proposed replacing the idea of a right to health with that of a duty to avoid overburdening the health system, so It's sort of the converse I guess And we see this idea Bubbling up again in some of the requirements being placed on Medicaid recipients in some states a lot of this began with the state of West Virginia, which had a personal responsibility contract that called on various acts on the part of the recipients before in order to To be eligible I one time at one point convened a small meeting on this and was trying to figure out where this came from I think it actually began with consulting from the new gingrich had put together when he was out of office one time And the expert use of the responsibility card is how the tobacco industry avoided destruction financially through litigation for decades up until the documentation of the effects of second-hand smoke where the Responsibility card no longer worked Um My own view is that the question of how we assign responsibility for bad health outcomes has been under analyzed And that's why I teach a course every year at this Harvard school public health on that exact topic It's a course about a health promotion and Priority setting and related topics The logic of this notion of responsibility for health. I think is about the clotty People have some very strange ideas about it. Just let me share one anecdote many years ago There was a bioethics commission the presidential level and to date myself. This was president Carter. We're talking about and one of the reports that this commission was supposed to put out was a What turned out to be a three-volume study of patterns of access to health care in America and to my Surprise I was invited one day to come to Washington and serve as staff philosopher So I had I was the only person in Washington with a business card That had the presidential seal one corner and then the name and then some little staff philosopher on it people thought it was a joke So when they when I told no this is real and I told them what I was working on they said oh good I'm glad we have you doing what you do because you're gonna explain How American individualism Explained accounts for why Americans don't like collective solutions or collectivist solutions to problems to health care delivery. I Heard that from a lot of people now what struck me is strange about it was that Americans love Medicare and That's one of those collectivist solutions. So I thought you know, it's a funny country where Americans have so built into their moral fiber from birth This antipathy toward collectivist solutions and then on the night of their 65th birthday Everything changes and they all become socialists So that may be rather Suspicious that there was a any simple minded notion of individualism out there that Provided a philosophy that could be consistently applied. I wonder what else might be involved Now this book doesn't have to Go into any of that stuff But at the same time The question of responsibility does figure somewhere in there now it's it's not it's not talked about in the book except in passing You would hope perhaps that the responsibility card wouldn't be Played in the case of deaths of despair I mean people dying for Christ's sake so Why talk about what whose fault it is or especially if we intend to do is to pin the fault on them our response should be Should come from pity or or solidarity or sympathy, but I'm afraid this is taking too much for granted Many of you I'm sure have read this book hillbilly elegy by JD Vance Which paints this picture of devastation in a family of Appalachian origin that he grew up in and north of the of the Mason Dixon line And that book as his heart-rending as his story are it's a victim blaming book and Vance is talking about his own family here And it's gotten a huge readership and an appreciative one He escaped all this but Although he sympathizes with the people who didn't escape and the fallen victim to mayhem That's taking everybody down It's pretty clear that they are There to be blamed for it and What's saddest about all this I think is that so many of the victims accept this verdict and How that could be it's a long story, which probably others are better Equipped to answer or to tell but when the victims accept the story and accept the responsibility for themselves Perhaps this robs them of their capacity to protest and to resist So You may think I'm speaking and Angersen and here you may think that This question of who's responsible for these self-inflicted wounds is the answer so obvious It's not worth the dwelling on but for I'm afraid that in the minds of a good number of readers If they think if they agree that the answer is obvious, it's not going to be the right the same answer that you come up with Now here's the second one, which is rather different. I want to point out one Question that comes up in the context of their discussion of globalization And Nangus acknowledged the role that globalization in particular the Chinese Inexpensive imports have had in undermining the economic base of the American working class and They they rightly point out that the same phenomenon has not led to the deaths of despair in our peer countries So and they are of course are they're also flooded with Chinese imports So we can't invoke globalization as in the single unanswerable explanation of the patterns that and and Angus have shown us prevailed in in the American working class Okay, fine. I had no argument there But but I wonder if they might want to address even a briefly a different aspect of this issue Which is how to take the gains to the Chinese into account and reaching an overall judgment about these exchange of these exchanges of benefits and risks I've been traveling in China for decades and Watching the development of China even as an occasional visitor over this time has put me in awe It's it's been said that the augmentation of human well-being That's taken place just recently in China as hundreds of millions of people have risen from poverty to the middle class has been the greatest movement the greatest Collective benefit in the history of the human race at least within such a short period and Indeed for that reason but also because of the implications for economic and even military dominance The rise in China of China may be the single moments momentous development of our lifetime now to the extent that our loss is their gain and You know, we can have a much argument about how much that extent is real Can we automatically say that? The losses are what matter Because after all there may be a multiplier effect here Maybe that the loss of somebody's job in America provides employment for three or four people in China Who then lift their their families out of poverty and then with them? Perhaps the families of the people who sell them things in the village because they have the money to spend So When jobs are lost to factories here possible that more people are helped over there than are hurt here Now in a in an era of America first The idea that we should try to factor in the benefits of the to the Chinese before reaching overall judgments about the direction of affairs Might seem unthinkable. It's certainly unsayable outside of this room But what is the job of the economist or for that matter of a philosopher? Do we have a national bias? We're not supposed to I think Now, of course the the point that being made by and an Angus Which is that globalization need not entail deaths of despair as shown by the fact that they haven't done so elsewhere Is the most important? But the moral calculus that I'm talking about here might be worth engaging if only briefly as As they proceed Now third one, which I think was gonna come as a bit of a surprise. I just want to mention the word tobacco It happens to be my current preoccupation these days, so I think about tobacco whenever I think but There's not much about tobacco in this book I don't want to propose how it should figure in but I want to raise the question of why it's not there and That leads to some themes. I think that Anna also raised. I'll try to explain that Now the the deaths the number of deaths per year from tobacco Which is even now about four hundred and sixty or more 460,000 per year in the United States That's not so different from the six hundred thousand deaths of despair that and and Angus have Uncovered And it's larger than their components So that's pretty big and The track of deaths have some commonalities with these deaths of despair deaths of despair Fatalities for one thing it's self-inflicted as they are and smoking furnishes a pipeline from household budgets of the working class into corporate treasuries Where a lot of it is recirculated to Republican politicians and to amaze of organizations that present themselves as think tanks but are in fact public relations exercises and disinformation and This is a circuit of funds that kills and impoverishes the working class Whose victims in turn act as allies in defending it and this story? I think again mirrors the some of the stories That are told in other connections in this book So maybe all that's needed is just a short explanation of why you're not talking about tobacco But it also might be an opportunity to address a question that I think hovers over this discussion This is one that Anna alluded to which is exactly what this notion of despair amounts to and and and how it figures in these causal explanations of the excess mortality that That we've been introduced to in such a For soul way So what makes a choice an example of despair? So we this question comes up when we think as Anna pointed out when we think of these accidental drug overdoses where the deceased Probably thought he or she was just trying to get high rather than committing suicide Some people get high by shooting up drugs and other people go to the Metropolitan Opera Which fortunately is dangerous only to your budget So how do we know when to invoke despair? Is a smoker despairing Is someone who overeats myself included despairing and Why isn't smoking or overeating for the matter classed alongside alcohol and drug use? In the case of smoking is certainly more lethal In terms of half the people who do it die from it if they keep it up And it's hard to find that kind of Lethality and almost any other product that Americans die from in large numbers So I come finally to my last point which is the one that where I think there is a possibility of substantive Disagreement although I don't have a position. So that's kind of hard to To prove but if I had one it might be different from yours So this is the notion of unfairness as a cause As a philosopher ethicist and I read this wonderful book I saw at several points a quite insistent emphasis on A thesis that What's causing all this mayhem? It's not globalization. It's not inequality It's not poverty. It's unfairness unfairness is what the cause is Okay, now I thought look, I'm in the philosophy business. This is great We're colonizing economics, you know, here's here's a You know philosophical idea and it's being used as a It's a key element and a causal explanation by two of the world's greatest economists. This is you know We've made it But of course it raises some questions We want to know exactly how this works out, you know What's the causal sequence exactly and how does the unfairness get in there and right? So that's one question, you know, just can what is the model of cause out of chain of causes here in which the unfairness Is what causes it? causes this Now that but the second question to which is what is the theory or standard of fairness and unfairness that's being used here So something's unfair and the unfairness of it is what's causing these 600,000 excess deaths per year in the American working class So I've been puzzling over these questions since I read the book and maybe I should have devoted my whole commentary to them But I think as a commentator it's just better for me to flag the questions rather than to try to work out an answer Now and an angus might respond by saying there's no real mystery here just seems to be just a philosopher making trouble American workers are suffering and they're dying as their counterparts in pure countries are not even though the latter are facing many of the same dangers because the US Hasn't protected them indeed both corporations and now the government which is increasingly their ally if not their agent or joining in the looting That's self-evidently unfair and it's what we should point to is causes of despair. So what's the problem? Well, maybe there isn't maybe that's maybe that's enough of an answer, but maybe not so one problem is that rent-seeking and also reverse Robin Hood plundering and so on didn't begin in 1970 as I reminded us last night. It's been going on for quite a long time and it's not restricted to the United States The big difference is that in times of slower growth These practices inflict pain winners are taking well-being from losers in a zero-sum game And that's this is a great tragedy when this kind of plundering and Rent-seeking is is a possibility for the haves when The fight over a pie that's not getting any bigger Okay, but we can still ask the question back before growth slowed when it was two and a half percent The workings of the economy were sorting out benefits Profits and they were being allocated in some process of some way or another Was the division of these benefits fair all this time? Because it's a really important question. I mean the unfairness of All this reverse Robin Hood stuff is what's the causal explanation of the excess deaths So how about before 1970 was that fair? Even if people were doing a bit better and there were many fewer deaths of despair we can still raise this question now What is the standard of fairness? Well Marxist saw exploitation as the absolutely normal Process that occurs in capitalism. It's part of one of the anchors of their theory although Marxist tended to Refuse to talk about this in moral terms Presumably and an angus don't think that in the ordinary workings of capitalism Let's say us pre 1970, you know during the boom years when all that money was coming out of the system They don't think that people were being exploited I don't know but maybe they can answer. Okay. If if so What when does it become exploitative and what is an exploitative? division of the sport of the of the benefits of of commerce and and manufacturing and so on and If they think it's Non-exploitative, okay, but you know what would be exploitative then and when does unequal sharing of benefits become unfair? And I wondered do and and our and angus have an implicit theory of justice Recipe for what would constitute? fairness on a grand scale I don't think it's consequentialist or utilitarian and the reason I think that is that In their analysis the fact that people are dying means it's wrong So that the sharing pattern Can be condemned because of all those deaths now if you're a consistent Utilitarian you wouldn't say that you there aren't any trumps for utilitarians you just ask. Well, what are you getting in exchange? and there's certainly not Rawlsians because Rawls was very very uncomfortable with With Prosperity on the part of people who were well-placed Unless their prosperity was essential for increasing the share of the smallest Holdings of the people in that society and I think it's pretty plain in the book Please correct me if I'm wrong that and an angus are not bothered by Great wealth as long as it's obtained Without hurting other people So inequality is not what really is bad. What's bad is hurting people on the short end of the stick So maybe maybe the best way to describe the implicit theory as far as I could Figure out what it was is the kind of any in the allitarian contractualism Where we as a society must agree we like that we like the growth engine that capitalism is But we don't like it if it starts killing people and So the the principle is something like do no harm But if that's what it is, I wonder is there a whiff of circularity here? because We have the thesis that what causes the deaths these excess deaths is unfairness Okay, well, what's unfairness all the division of Benefits because unfair if it causes deaths should we be worried? I'm not sure Well, I think I've used up my time if I had another moment, which I don't I would then throw all caution aside and Pretend to be a political scientist. I Think there's there's a big story that is not in the last part of the book but I think Be bolstered if it were there and that's a The basically it's the an account of the rise of the of the far right in American politics which we can date back to the reaction to the new deal and It's one that has been chronicled now in a series of of rather alarming and fascinating books by historians That Mostly a question of infiltrating the Republican Party, which used to have a lot of quite moderate people and some of us may remember And it started back in the 30s under Roosevelt It was regarded as fringy up to Goldwater and then got ahead of steam even though he was disastrously defeated and culminated in the takeover of the 2016 trifecta Which wasn't just a victory by the Republican Party, but by the far right wing of the Republican Party In my own view the key figure is not Trump who's just an aberration, but McConnell and I don't think it's a Accident that he comes from a tobacco state namely same one that I do. I know that type and The part of the story is their mastery Just amazing mastery of the message the informational part where they they managed to create a virtual monopoly of the source of information in Fox News and to dismantle systematically dismantled one by one every protective agency every process that had been erected to Stay the ravages of Overbearing American capitalism and they they do it in a way that I mean going from all the way from civil rights commission to the consumer finance protection managed protection Bureau and Above all to do but pay to smiley face on it at all times so that no one's alerted to what's going on So I'll just conclude on a happy note The only silver lining to the current dominance of the far right Movement within the Republican Party is that the 2016 vote refocused our attention on the sufferings of the working class those to whom the Democratic Party once pledged its Troth it's a it's a mission And I'll just conclude by saying of this deeply compassionate book Offers help in rededicating ourselves to this mission and explains why we must thank you We don't have this we just have the two lectures followed by discussions And so this is a rather strange beast As far as I'm concerned and I didn't know what to expect and this has just been wonderful I mean it's great to have the two discussants have a real amount of time and develop arguments and boy did they develop some arguments so I Think there's several things Obviously, Anne and I have not had the time to consult yet, but it's clear that several things Are going to get changed in the book and for that we're just a internally grateful and I think on on both sets of comments that You know not everything I would a hundred percent agree with but there are things that really I And and I've thought about pretty hard, but I think This is probably really changed your mind to some extent so just Going through one or two of the notes here. I think that you're perhaps worth talking about on Anna's comments, I think This power of language I really go along with And I think though the one thing we really will talk about much more carefully is this You know, I think in the book we say in some sense. These are all suicides And that's a very weasley Statement so I think we have to be much clearer about to what extent they're self-inflicted and to what extent they're not Self-inflicted and they clearly are very different While there's still a coming out to there that we want to talk about We thought about including obesity type 2 diabetes deaths and so on The problem with that is that once you you know, we've got a fairly sharp thing where we are And if we extend it too far, we're worried that we would lose the sharpness So we really thought about that hard, but and maybe we should have done it, but We really have not Gone that way But I hope we can use this quote about I'm surrounded by bottles I can't stop drinking and I don't want to die because that strikes me as Exactly the right thing to say and it's a quote that Captures something that's really very very important and that's not in our book right now, so I think we would really Really move on that It relates also to And I spent a lot of time not as much as we used to at the Metropolitan Opera We don't think of ourselves as on the verge of verge of deaths of despair Listening to the opera it might be deaths of something else But it's true that you're sort of feeding the beast in some sense And we're just feeding the beast and I think that is actually a very important distinction between rich people and less rich people you know one of the things that education brings you is Ways of being able to soothe the beast there are less destructive than you know, I'll call tobacco or drugs It's something that economists have to there was a Set of papers about 25 30 years ago about that which is that one of the distinctions between People who wealthy and people are not wealthy is that poor people by and large only have their bodies They have very little else. They did what economists call Human capital meaning education and so on they have relatively little of that and so People who have to rely on their physical Capital their bodies essentially they have to use that for both work So they do heavy manual work, which can be destructive As opposed to sitting behind a desk, which is destructive to but not in the same way And also if to get pleasures You know, they very little interesting going to the opera or maybe reading books or something like that But there are other ways and that could be quite destructive of the body too I do want to say though that I Agree with almost everything that Dan said he may have left you with the impression that we endorse American Individualism, I mean we talk about it in the book as a possible cause of this thing But it's not something that we actually endorse nor did we say that people are entirely I mean the responsibility issue is a very interesting one. I've talked with Dan about this before And I'm not quite sure where he's sit on this, but it's not we're not endorsing American individualism I think one of the things that explains the lack of a safety net in the US that we talked about a little bit And which hasn't really come up here is race you know the the people who came witherspoon and the other people who came to Princeton and who Trained up Madison and where the sort of fathers of the revolution came from the same place. I came from I mean they came from Scotland If you look at what's in Scotland now, they're going to elaborate welfare state We don't have an elaborate well-stated state in America and the answer and why not and one of the answers that repeatedly comes up from the Historians is race that people don't want to construct insurance schemes with people that they see is very different from themselves And so this issue of race just keeps coming back in the social policy Issues, and I think you're quite important. Let me I'm going to hand over to Anne But I just wanted to say something in defense of capitalism and this is where Anna and I really I think do disagree You know, I don't know what's wrong with washing machines, right? You know my mother Used to get up every Monday at five o'clock in the morning to put coal under the boiler To start off her Monday washing cycle which took from 6 a.m. Until 5 p.m. When she took these frigid clothes off the Scottish washing line that weren't particularly dry at the end of an absolutely exhausting day When my mother got a washing machine, and I think about 1960 it completely changed her life And it made her life hugely better And that comes to what Dan said too about the Chinese I think about this in a different way one of the reasons I'm so pro-capitalism is You know the billion people that have been taken out of poverty In the last 30 years and that would not have happened without the power of markets without globalization So don't fool yourself that there's some other way that that could have been engineered by the World Bank or the UN or something of the sort You know directing the world to make it better Those people got there because of you know the power of the market in some sense You know Chinese market is not like an American market, but nevertheless without that none of that really would have happened And as Dan said that is perhaps the greatest achievement in human history That something like two billion people were taken out of poverty over that period and out of a poverty Which was just grinding and awful and sort of impossible not like we think of Poverty here, so that's a huge achievement So I don't but I don't think that we're trading off Chinese lives for American lives or something first of all the China shock work has got huge publicity But it's local. So, you know just as the world trade organization to open things up It made jobs in Seattle for people building Boeing airplanes or at least it did for a while Just as it lost jobs in places that were competing with China and there are many estimates Which suggests that the net job loss to opening up in China was not really very large and May not have been may even would be in the other way around you know there might have been jobs gained But the issue here is to me at least we want these benefits of capitalism You know, but we've got to control it because if it's not controlled You know, we'll get the sort of crap that we're getting now and we'll get them a colonels You know, I very much agree with that Where the excesses are defended and the right of people to treat us as sort of It's almost like they're forming us as well, not us But that a lot of people are being treated purely as fodder for this machine as opposed having human dignity and Responsibility of their own. Let me just say one last thing. I'll stop Okay This really is the last thing About my mother again Always comes back to my mother. That's one of the things I learned in America That my mother used to say I hope you never get rich. Maybe I'll do a Scottish accent here She said, I hope you'll never get rich and I'd say mom. Why do you hope I never get rich? She says because if you get rich, you'll become an alcoholic Everybody I know who has money is an alcoholic. Well, that's the analemka theory And I'm not okay Thank you both so much. This is enormously helpful and for us with the book It comes at exactly the right time Because we're going to spend from now until the end of August revising I'm really on it and This is just really important changes To be made to the book that I think will make it much stronger. I just want to pick on I think on one point Each just so that we have time to open it up with Anna I you know I Think it would be great for us to have a longer conversation on the extent to which this is a supply problem I mean before there was oxycontin there was Vicodin Right and and at least in my reading of it Vicodin was the second most prescribed Drug in America for many years running and yet this explosion of deaths caused by Opioid addiction didn't take place So it seems like there there were Drugs there prior to the arrival of oxycontin but oxycontin seemed to and indeed it is a supply problem in the sense that there was Sackler there was this 800 person marketing force that Targeted poor areas unless well educated areas so that they they could pick up sales more rapidly So certainly that was there, but I think if if people had Been well it would not have Taken hold quite as as much as it did so Chris room wanted to set up some weird dichotomy where we were all about the demand side and he was going to come in and explain the supply side and we think that's really a false dichotomy that This is something that happened to people who are already showing signs of increased deaths from cirrhosis of the liver Suicides were already on the rise and then boom Let's drop a match on a dry patch here and get oxycontin going so We certainly think that one of the taps that needs to be turned off is the over prescription of These heavy-duty opioids, but we think that we'd be fooling ourselves to think that everything was going to be fine once we did that on the the really important and I think this is where a lot of time between us will be spent and reading and talking to people is Unfairness and what our theory of unfairness is I Think in my head what I have is that it's a fuzzy Area and that if you stay within the bounds it seems to be fair But that we have come outside of Any bounds that anyone might think of as being fair, but I that that does not come from a deep Reflection on that at this point, but hopefully by the time we get the book back to Princeton University Press We will have dug into that in a in a bigger way. I don't know if you want to talk about unfairness I knew you would leave that me Well, I I mean I said a lot. I thought bounds. No, no, no, I agree with that And I just I need time to think about what Dan said, which is just really really Which is partly I think this came from Let me say negative thing and then say that I don't think I have the answer I mean, I agree with what you said about what we don't say Partly there's a view out there and it actually said that on a version of this poster Which it doesn't say anymore. It says come and see how inequality kills and that inequality killing argument Which is very widespread. We think is really wrong And you know, I wrote another book called the great escape this part of the subtitle of which is You know the origins of inequality and my argument there is that you can't get this enormously beneficial capitalist development without generating a lot of inequality along the way and that Inequality is actually a sign of good things happening much of the time but somehow it gets out of hand and it's the getting out of hand that we're bothered by and I think most people when you pick them apart and when you look at a lot of the lab Experiments that being done about inequality what really upsets them is not so much the inequality It's the unfairness and a lot of the experiments that you see in which people are upset We saw a picture of the who's the primatologist front is the wall front's the wall has has this experiment with two monkeys in a cage and There's little holes in the cage and there's an experimenter outside and the monkeys have heaps of rocks In their cage about hand-sized rocks monkey hand-sized rocks and the monkeys have to hand a rock out and in exchange The experimenter gives them a piece of fruit For the rock and they've been feeding them cucumber cucumbers approved It's just not a very nice fruit This thing has been running along for a while the monkeys are taking rocks out happy as clams and getting pieces of cucumber back And munching on them and all's happy and then the experimenter gives the monkey on the right a grape instead of the cucumber It's the other one money. Oh, this is really nice right and the other one goes on eating cucumber and looking over shoulder They're in perspex cages so they can see each other and The next time around another grape another piece cucumber and eats it sort of very slowly And then the next time he gets a cucumber and the other one gets a great the monkey Hurl starts hurling rocks cucumber right back at Beating on the cage and trying to tear the whole world apart right now That's not inequality and fronts that well immediately after the word said that's the effect of inequality All right, I don't think it's the effect of equality at all. It's just grossly unfair Why the hell is he getting a grape while I'm getting this rotten cucumber and I'm gonna hit it in your face and I think what's going on in our society a lot of the time is just organized theft and And you know, I think rather than me say Dan said it, you know organized that organized by mr. But again, but organized theft is as Dan said was happening before 1970 right But the pie was bigger and everybody was getting something actually I disagree with you there I think this the lobby the rent seeking really did start in 1970 you know when Ralph nader went after General Motors in 1970 there was not a single General Motor lobbyists in Washington. There were no lobbyists in Washington There were trade associations that basically reported back So the whole modern lobbying industry, which is sort of slowly strangling and corrupting our government really started in 1970 and I think it's a response to the slowing growth or that's one of the causes of it I mean, I think the Nixon, you know all the stuff that went on around that time Geared it up, but I think it's a modern phenomenon and that's what most people don't understand that lobbying The modern lobbying industry that we really see is a post 1970s creature. Yeah, but that doesn't make the Treaty of Detroit fair