Ammons and regulation

The proposition I write to support is: “When having less knowledge is key to knowing more.” I want to demonstrate how tomorrow we might get all manner of official regulations right—when today we rethink “regulation” as a category of knowledge. In arguing so, I appeal to the poetry of A.R. Ammons.

Ammons, a great American poet of the last half of the 20th century, was tenacious in returning again and again to a set of topics he felt he hadn’t gotten quite right. One of the subjects was how knowing less entails “knowing” more. It’s his analytic sensibility in persistent revisiting a topic from tangents affording different insight and nuance that I rely on as an optic to parse my own topic of government regulation.

Policy types typically fasten to knowledge as a Good Thing in the sense that, on net, more information is better in a world where information is power. Over an array of accounts—and his tenacity meant he wrote a great deal—Ammons insists that the less information I have, the better off I am—not all the time, but when so, then importantly so. (To be clear, he is not talking about “ignorance is bliss.”)

For those working in policy and management—and I include myself—how could “the less we know, the more we gain” be the case and what would that mean when it comes to the heavy machinery called official regulation? Is there something here about the value of foregrounding inexperience—having less “knowledge”—as a way of adding purchase to rethinking difficult issues, in this case, regulation?


Start by dispensing with popular meanings of “the less I know, the more I know.” It is easily reversed to “the more I know, the less I really know.” This is the conventional wisdom that “data and information” are not knowledge—in fact the opposite. I also do not pursue another sense of “the less I know, the more I know” that Ammons foregrounds from time to time: the hiving off what we thought we knew creates the stuff from which new knowledge is formed. It is my failing—not Ammons’s—that I cannot see how “from-ruins-and-waste-come-something-altogether-better” applies to the 70,000+ paged IRS code and other volumes of government regulations.

My focus instead is on a very difficult set of insights in some of his poems. Let’s jump into the hard part—Ammons’s poem, “Offset,” in its entirety:

Losing information he
rose gaining
till at total
loss gain was
extreme & invisible:
the eye
seeing nothing
lost its
(that is a mere motion)
fanned out
into failing swirls
slowed &
became continuum.
(TCP1, 418)

Please reread the poem once more.

Part of what Ammons seems to be saying is that by losing information—the bits and pieces that make up “you”—you gain by becoming whole and continuous. As it were, “loss gain” becomes one term. You cease to be separate, your bits and pieces slow down, fan out, spread into a vital one. We empty our minds so as to attend to what matters—emptying the eye to have the I. An obvious example others have noted: If obsessive thoughts, compulsive behaviors, and restraining inhibitions are, in their own ways, altogether absorbing forms of self-knowledge, then this is knowledge we need not to know in order to have more to know better.

How, though, is this different from ignorance is bliss or, less pejoratively, seeking to know only what you need to know? Part of Ammons’s answer appears to be getting to the point where you know enough to be naïve again, to be open to the wonder of it all, to give yourself up to the kind of attention that is, if you will, self-reabsorbing. To telegraph ahead, naïveté does not center around knowing and not-knowing for Ammons: There’s feeling and living, wishing and dreaming, desire and more, and such are different kinds of “knowing,” as if thinking feels and feeling thinks.

Naïveté here is the adult version of child-like, decidedly not the childish that gutters out early on. It is positive, because adult wonder and curiosity are the space for noticing and being alert to more—an orientation that gains from the loss of information. Compare this, however, to what is expected of government regulators: Whatever happens, they must not be uninformed or naïve—in a word, inexperienced—and when they are, shame on them.

The ways in which this wonder and inexperience do matter for regulation means keeping with Ammons longer. For him, staying uninformed and open to new experiences is the hard work of affirming study,

….my empty-headed

contemplation is still where the ideas of permanence
and transience fuse in a single body, ice, for example,
or a leaf: green pushes white up the slope: a maple
leaf gets the wobbles in a light wind and comes loose

half-ready: where what has always happened and what
has never happened before seem for an instant reconciled:
that takes up most of my time and keeps me uninformed:
(TCP1, 497-498)

Being empty-headed is part of knowing enough: having to know less so as to be ready for whatever the next experience you proved to have been half-ready for in hindsight. It’s as if Ammons is asking us to be smart enough to see it’s more than about a knowing doubt and a knowing certainty.

Living is the space for feeling, which is where “knowing,” writ large belongs: “how can I know I/am not/trying to know my way into feeling/as//feeling/tries to feel its way into knowing,” he asks in “Pray Without Ceasing” (TCP1, 779). This notion of a half-readiness open to new experience and the wonder awaiting is nicely caught in the ending lines of one of my favorites, “Cascadilla Falls”:

I do
not know where I am going
that I can live my life
by this single creek.
(TCP1, 426)

By the time you surge to those lines, there is so much feeling in that “Oh” you might miss how living takes place beyond not-knowing.” Or better, the line break of “do/not know” intimates that the doing of “not know” is a good part of living that life.


Regulation from this viewpoint is never a case of regulators starting with knowledge and assuming what matters for living resides elsewhere. Regulation isn’t about expunging naïveté as inexperience but—in ways not yet clear—cultivating it. What is clear is the starting point, however: Wonder is not dread; naïveté is not ignorance; and no-longer-knowing is not not-knowing, full-stop.

In this way, Ammons makes a frontal attack on what policy types hold very dear: the notion of usefulness. In his essay, “A poem is a walk,” Ammons defers to a paradox: “Only uselessness is empty enough for the presence of so many uses”. Only uselessness is a sufficiently capacious category to embrace all the uses that come and go with experience and ensuring space for more feeling and living.

What could better capture all the many uses as they shift to the wayside than uselessness, “an emptiness/that is plenitude” (TCP1, 503)? Less and less information, against this backdrop, empties us and thereby makes us—leaves us open—differently. It is, in Ammons’s wonderful turn of phrase, to be “emptied full” (TCP2, 4). To seek more and more knowledge and information and never waste what has already been gotten leads to in Ammons’s acid throwaway, “total comprehension is/a wipe-out” (TCP1, 659). It’s a wipe-out because this totality leaves no room for more. 

Where, then, does this leave us when it comes to “knowing” regulation better?


In answer, I ended up going back to Ammons’s “The Eternal City”—“After the explosion or cataclysm, that big/display that does its work but then fails/out with destructions, one is left with the//pieces. . .” (TCP1, 596)—lines that resonate with I had read in one of Rainer Maria Rilke’s letters. He is writing about the sculpture studio of Auguste Rodin:

It is indescribable. Acres of fragments lie there, one beside the other. Nudes the size of my hand and no bigger, but only bits, scarcely one of them whole: often only a piece of arm, a piece of leg just as they go together, and the portion of the body which belongs to them. Here the torso of one figure with the head of another stuck onto it, with the arm of a third. . .as though an unspeakable storm, an unparalleled cataclysm had passed over this work. And yet the closer you look the deeper you feel that it would all be less complete if the separate bodies were complete. Each of these fragments is of such a peculiarly striking unit, so possible by itself, so little in need of completion, that you forget that they are only parts and often parts of different bodies which cling so passionately to one another.

I read the passage—other translations capture the same sense—as suggesting that Rodin’s “cataclysm” incorporated fragments that were, in a sense that matters for our purpose, more complete as separate fragments. So too Ammons’s “cataclysm” in “The Eternal City” refers to pieces that are themselves whole—asynoptic, unassimilable, piece after piece. Another of Ammons’s lines, “all the way to a finished Fragment,” catches the sense I am after here (TCP1, 366).

By extension, we’d have to believe that official regulations ad seriatem, while appearing a growing shambles, are in fact more complete as the piece-work of individual regulations than they would be were they improvised into something new or part of, in policy-speak, a more integrated body of regulations for use over time.

How could this be?


One way ahead, Ammons implies, is to see how the waste of regulation isn’t decline-and-fall, but rather the rearguard action against such declension narratives. Ammons directs our attention, for example, to waste-as-generosity in “The City Limits,”

. . . .when you consider
the abundance of such resource as illuminates the glow-blue

bodies and gold-skeined wings of flies swarming the dumped
guts of a natural slaughter or the coil of shit and in no
way winces from its storms of generosity; when you consider

that air or vacuum, snow or shale, squid or wolf, rose or lichen,
each is accepted into as much light as it will take, then
the heart moves roomier. . .
(TCP1, 498)

The “heart moves roomier” not because the pile is any less shite, but because it opens to being more—certainly more than that mortal coil of Hamlet. This is the hot mess of feeling and living expansively, of being somatically sprawled all over the place, now. Regulatory waste in this mode is a spectacularly, can’t-keep-our-eyes-off-it sight/site to behold, maverick and inciting at the same time.

The hot mess that you can’t keep your eyes—our I’s—off and the incitements it offers take us to Ammons’s late, long poem, Garbage (TCP2, 220-306). (Famously, Garbage, for which Ammons won the 1993 National Book Award for Poetry, was inspired by his passing an immense heap of garbage alongside the Florida Interstate.) Mountains and mountains of garbage are “monstrous”; in fact

… a monstrous surrounding of
gathering—the putrid, the castoff, the used,

the mucked up—all arriving for final assessment,
for the toting up in tonnage, the separations

of wet and dry, returnable, and gone for good:
(TCP2, 234)

For Ammons “gone for good” is decidedly ambiguous, in the sense of begging the question about just to what good has garbage gone for. An answer—and Ammons resists being pinned down to any one answer—lies in the garbage that human beings themselves are:

we’re trash, plenty wondrous: should I want

to say in what the wonder consists: it is a tiny
wriggle of light in the mind that says, “go on”:
(TCP2, 245)

Nothing integrated about this! For: “go on” to what in a world where garbage and waste conjure a meaninglessness of things and of our own existence, as we too are trash? In the case of Ammons, the garbage we are and the meaninglessness that poses, like capacious uselessness, offer up the wonder of being more—of meaning possibly—once we leave space for such feelings and experience:

we should be pretty happy with the possibilities

and limits we can play through emergences free
of complexes of the Big Meaning, but is there

really any meaninglessness, isn’t meaninglessness
a funny category, meaninglessness missing

meaning, vacancy still empty, not any sort of
disordering, or miscasting or fraudulence of

irrealities’s shows, just a place not meaning
…there is truly only meaning,
only meaning, meanings, so many meanings,

meaninglessness becomes what to make of so many
(TCP2, 277)

That word, “becomes”—that insistence on meaning-less possibility as a “funny category”—is, we see by way of conclusion, core to recasting regulation.


Richard Howard, himself no mean commentator on Ammons’s poetry, points the way: “How often we need to be assured of what we know in the old ways of knowing—how seldom we can afford to venture beyond the pale into that chromatic fantasy where, as Rilke said (in 1908), ‘begins the revision of categories, where something past comes again, as though out of the future; something formerly accomplished as something to be completed’”.

The importance of this revising categories of thinking and living is captured in an interchange Ammons had with Zofia Burr. When pressed by Burr, he summed up: “I’m always feeling, whatever I’m saying, that I don’t really believe it, and that maybe in the next sentence I’ll get it right, but I never do”.

Imagine policymakers and regulators, when pressed, recognizing that not getting it right today places them at the start of tomorrow’s policymaking—not its end but its revision as “policymaking” and “regulation.” For that to happen, they’d have to understand just how funny-odd a category regulation is.

Ammons, if I understand him, is insisting that in the compulsion and not just desire to “get it right the next time around,” there at least be a next time to make it—this revision of categories—better. Ensuring (risking) there is a next time is the way we keep open to—empty for—the feeling and living and participating that, in the process, push conventional notions of regulation to the periphery, changing their milieux, rendering regulation less and less meaningful and thus returning it as a concept and instrument to us re-freshed and re-wondered about; in short: recasted.

Again, how so? Let’s jump into Ammons’s deep-end one last time:

Yield to the tantalizing mechanism:
fall, trusting and centered as a
drive, falling into the poem:
line by line pile entailments on,
arrive willfully in the deepest

fix: then, the thing is done, turn
round in the mazy terror and
question, outsmart the mechanism:
find the glide over-reaching or
dismissing—halter it into

a going concern so the wing
muscles at the neck’s base work
urgency’s compression and
openness breaks out lofting
you beyond all binds and terminals.
(TCP1, 535)

(You may want to re-read the poem one more time. I return to that “deepest//fix” momentarily.)

Ammons commented on this poem, “The Swan Ritual”: “The invention of a poem frequently is how to find a way to resolve the complications that you’ve gotten yourself into. I have a little poem about this that says that the poem begins as life does, takes on complications as novels do, and at some point, stops. Something has to be invented before you can work your way out of it, and that’s what happens at the very center of a poem”.

Ammons touches on the major implication extended here: If rendering any regulation useless takes us closer to reinventing what “regulation” is, so too reinventing “regulation” can render an existing regulation useless. Regulating to reduce risk and inequality or improve economic growth and statecraft is that way we rethink these ends so to make those other means or ends no longer useful.

To rethink (revise, redescribe, rescript, recast, refashion, recalibrate) the categories of knowing and not-knowing is to resituate the cognitive limits of “knowing” that matter. The eye is no longer fixed on where it had settled before, but with a new focal point in sight (this being today’s version of our wager on redemption). That, truly, is the fix we want to be in, “the deepest//fix.” It is where wonder renders dread incomplete, where knowledge is unlearned, where knowledgeable gives way to fresh or refreshened inexperience, and, in Ammons’s earlier astonishing lines, “where what has always happened and what/has never happened before seem for an instant reconciled”.

Principal sources:

Ammons, A.R. (1996). Set In Motion: Essays, Interviews, & Dialogues. Ed. Zofia Burr, The University of Michigan Press: Ann Arbor, MI.

—————— (2017). The Complete Poems of A.R. Ammons, Volume 1 1955 – 1977 and Volume 2 1978 – 2005. Edited by Robert M. West with an Introduction by Helen Vendler. W.W. Norton & Company: New York, NY. [The volumes are referred to in the blog entry as TCP1 and TCP2, respectively.]

Howard, R. (1980). Alone With America: Essays on the Art of Poetry in the United States Since 1950. Atheneum: New York, NY. Rilke, R.M. (1988). Selected Letters 1902-1926. Transl. R.F.C. Hull, Quartet Encounters, Quartet Books: London.

Rilke, R.M. (1988). Selected Letters 1902-1926. Transl. R.F.C. Hull, Quartet Encounters, Quartet Books: London.

A new standard for societal risk acceptance

–It is understood that “acceptable-risk” standards, based on past failure frequencies and commitments of “never again,” can be fleeting and ephemeral. Refinery explosions, stock market flash crashes, and massive identity theft lead to calls for government action. Something is done in response, but the sense of urgency and never-again is rarely sustained. There is always a fresh disaster or crisis scenario to reclaim public attention. Worse, the retrospective orientation to letting past (in)frequency set the standard has led to complacency and the very accident to be forestalled, as in: “Well, it hasn’t happened in the past, so what’s the problem…”

It’s worthwhile then to ask what can be offered by way of a prospective orientation—“we are no more reliable than the next failure ahead”—to identifying standards of acceptable/unacceptable societal risk. What does societal risk acceptance look like if instead of being based on (in)frequency of past events, it is grounded in the expectation that all manner of accidents lie in wait unless actively managed against?

I suggest the following thought experiment, the aim of which identifies a proxy for “acceptable societal risk.” To telegraph ahead, the proxy proposed is the aggregate curve of the major real-time control room risks of society’s critical infrastructures.

–Assume: that society has identified critical infrastructures indispensable to its survival; that the key infrastructures have central control rooms for operating the entire system; and that the respective control room operators have a set of chief risks that they must manage in order to maintain systemwide reliability (which includes safety), at least in real time. While huge assumptions, their virtue is trying to operationalize the unworldly premise of current approaches—most notably ALARP (“as low as reasonably practicable”)—that somehow “society sets acceptable and unacceptable risks,” leaving the somehow utterly open.

Under the precluded-event standard of reliability (i.e., the event to be prevented must never happen, given the society-wide dread associated with system failure), we found that control operators need to be able to maneuver across four performance modes so as to maintain even normal operations. Each performance mode has its own chief risk, we found in our interviews with operators.

The four modes range from anticipatory exploration of options (just in case) when operations are routine and many management strategies and options are available, to a real-time improvisation of options and strategies (just in time) when task conditions are more volatile. Reliability professionals may have to operate temporarily in a high-risk mode (just for now) when system volatility is high and options few. They may also be able, in emergencies when options have dwindled, to impose onto their users a single emergency scenario (just this way) in order to stabilize the situation.

The chief risk in just-in-case performance is that professionals are not paying attention and become complacent—reliability professionals have let their guard down and ceased to be vigilant, e.g., to sudden changes in system volatility (think of system volatility as the degree to which the task environment is unpredictable and/or uncontrollable). As for just-in-time performance, the risk is misjudgment by the operators with so many balls in the air to think about at one time. The great risk in just-this-way performance is that not everyone who must comply will comply with one-off measures to reduce system volatility.

Last, just-for-now performance is the most unstable performance mode of the four and the one managers want most to avoid or exit as soon as they can. Here the risk of “just keep doing that right now!” is tunneling into a course of action without escape alternatives. What you feel compelled to do now may well increase the risks in the next step or steps ahead (in effect, options and volatility are no longer independent dimensions).

–Step back now and further assume that estimates have been computed by control room operators in consultation with subject matter experts for the risks of complacency, misjudgment, non-compliance and closing off alternatives, within the infrastructure concerned. Such then is done for all the society’s key infrastructures with control rooms.

There is no reason to believe the estimates of any one of the four key risks are the same for the same performance mode across all infrastructures during their respective normal operations. Different precluded events standards are operationalized very differently in terms of the thresholds under which they are not to operate. Complacency or misjudgment could empirically be more a problem in some control rooms than others.

Assume the performance-mode risk estimates (or stratified/weighted sample of them) have been rank ordered, highest to lowest, for these infrastructures operating to a precluded-event standard by their respective control rooms. A plot of points is generated in the form of a downward sloping function. This function would be the revealed allocation of acceptable societal risks at the time of calculation for the critical infrastructure services of interest in their really-existing normal operations to preclude different dreadful events from happening with respect to vital societal services.

The downward sloping function would, by definition, be a prospectively oriented standard of acceptable risk for society’s (sampled) critical infrastructures operating to the precluded-event standard by their control rooms. It is prospective because the unit of analysis isn’t the risk of system failure—again, typically calculated retrospectively on the basis of “the past record”—but rather the current risks of real-time control operators failing in systemwide management, now and in their next steps ahead.

–Even though all this is difficult to operationalize—but less so than the traditional ALARP!—two implications are immediate.

First, because control rooms manage latent risks (uncertainties with respect to probabilities and consequences of system failure) as well as manifest risks (with known Pf and Cf), any such downward-sloping function will necessarily have a bandwidth around it. That bandwidth, however, is not one that can be chalked up to “differences in societal values and politics.” Rather the bandwidths reflect moreso the control room uncertainties (often technical and procedural, but related also to unstudied or unstudiable conditions).

It is true that some real-time uncertainties to be managed are linked directly to societal values and politics—think here of those new or revised compliance regulations that followed from the last disaster—have their greatest real-time impacts. Even then, the challenge is to show how the application at this time and for this case of any compliance procedure follows from said societal values. That is no easy task because analysis would also drive down to the case or event level and not just up to the policy or regulatory level where societal values are (or so it is said) easier to identify.

A related, second implication is noteworthy as well. The bandwidth around a societal risk acceptance function as defined above varies because not every critical infrastructure manages to a precluded-event standard. Other standards can be managed to. Even so, note how remote this acknowledgement is from any argument that societal values determine directly (or even primarily) the operative standards managed to.

An example will have to suffice. A primary reason why critical infrastructures manage to an avoided-events standard today—these events should be avoided, albeit they cannot always be in practice—is because their inter-infrastructural connectivity does not allow individual control rooms to preclude failures or disruptions in the other infrastructures upon which they depend or which depend on them. It is better to say that in these cases the shift from one (precluded-event) to another (avoided-event) reliability standard reveals societal preferences for interconnected critical infrastructures before it demonstrates any first-order derivation from more generalized or abstracted “societal values” per se.

Table of key entries

Most Important: “What am I missing?,” “Complexity is the enemy of the intractable,” “Power”

Big Policy Issues: “Poverty and war,” “Healthcare,” “Second thoughts on income inequality,” “Surprising climate change,” “In a failed state” Forthcoming: “Interconnected?”

Recasting the intractable: “Policy narratives,” “Recastings #1,” “Loose ends, #3,” “When the light at the end of the tunnel is the tunnel” Forthcoming: “A new take on traffic messes”

Not-knowing and its proxies: “Seeing unknowns,” “Inexperience and central banks,” “Managing inexperience,” “Difficulty at risk and unequal,” “By way of distraction…”

Ignorance and uncertainty: “When ignorance does more than you think,” “Optimal ignorance,” “Uncertain superlatives”

Risk and root causes: “With respect to what?,” “Half-way risk,” “Central role of the track record in risk analysis,” “Root causes,” “Frau Hitler, again” Forthcoming: “Stopping rules, system failure and societal values,” “A new standard for societal risk acceptance,” “Ten points, easily missed, on system risk and failure scenarios

Environment: “Nature,” “Tansley’s ecosystem,” “Eco-labelling recasted”

Catastrophe and crisis: “Catastrophizing cascades,” “Jorie Graham’s systemcide,” “The shame of it all,” “Next-ism,” “The future is the mess we’re in now”

More mess, good and bad: “Loose ends, #2,” “Top-of-the-list thinking,” “Take-home messages,” “Who pays?,” “Happiness: The mess”

Betterment and good-enough: “Betterment as ‘yes-but’ through ‘yes-and’,” “It’s better between the James brothers,” “Good-enoughs,” “Good-enough dreamers,” “Professional, amateur, apprentice; Or, As good as Manet’s (missing) fingernails,” “‘at sea,’ ‘from on high’”

Economism: “Economism,” “Keep it simple?,” “Loose ends,” “When high reliability is not a trade-off,” “Short and not sweet,” “The missing drop of realism” Forthcoming: “The market failure economists don’t talk about”


–The US Department of Homeland Security (DHS) states “healthcare” is one of the nation’s critical infrastructures sectors, along with others like large-scale water and energy supplies.

Infrastructures, however, vary considerably in their mandates to provide vital services safely and continuously. The energy infrastructure differs depending on whether it is for electricity or natural gas, while the latter two differ from large-scale water supplies (I’ve studied all three). Yet the infrastructures for water and energy, with their central control rooms, are more similar when compared to, say, education or healthcare without such centralized operations center.

What would healthcare look like if it were managed more like other infrastructures that have centralized control rooms and systems, such as those for water and energy? Might the high reliability of infrastructural elements within the healthcare sector be a major way to better ensure patient safety?

–Four points are raised by way of answer:

 (1) High reliability theory and practice suggest that the manufacture of vaccines and compounds, by way of example, can be made reliable and safe, at least up to the point of injection. Failure in those back-end processes is exceptionally notable—as in the fungal meningitis contamination at the New England Compounding Center—because failure is preventable.

When the perspective is on medical error, the patient is at the center of the so-called sharp-end of the healthcare system. But healthcare reliability is a set of processes that includes the capacities and performance of upstream and wraparound organizations. When dominated by considerations of the sharp-end, we overlook—at our peril—the strong-end of healthcare with its backward linkages for producing medicines and treatments reliably and safely.

(2) If healthcare were an infrastructure more like those with centralized control centers, the importance of societal dread in driving reliable service provision would be dramatically underscored.

Aside from that special and important case of public health emergencies, civic attitudes toward health and medical safety lack the public dread we find to be the key foundation of support for the level of reliability pursued in other infrastructures, such as nuclear power and commercial aviation.

It is true healthcare confronts widespread social expectations and demands for high levels of reliable and safe service with potentially high costs for lapses or error. Yet commission of medical errors hasn’t generated the level of public dread associated with nuclear meltdowns or jumbo-jetliners dropping from the air. Medical errors, along with fires in medical facilities, are often “should-never-happen events,” not “must-never-happen events.”

What would generate the widespread societal dread needed to produce “must-never-happen” behavior? Answer: Getting medical treatment kills or maims you unless managed reliably and safely.

This answer may seem perverse but it is not fanciful. Put aside the horror-story medical errors (operating on the wrong eye) and consider only illnesses that arise exclusively in medical facilities and can kill (e.g., hospital-acquired diarrhea). Or consider the wider healthcare system we already have, e.g., rising healthcare costs as a percentage of GDP threatens to consume the entire US economy at current rates of increase (when I started looking at healthcare it was 12% of GDP; now it’s some 18%).

Perhaps the closest we get to something like a healthcare system that kills us unless managed so as not to is the spread of deadly contagious diseases through lapses in quarantine security in the public organizations concerned. But that again is in the public health sector rather than the focus here, which is the healthcare sector as a whole. But this of course raises the counter-prospect of considering all healthcare to be in the public health sector. . .

(3) To mention “the patient” within the infrastructure perspective offered here raises a major question: To what extent is the patient his or her own reliability manager in healthcare?

True, one important role of patients and their support groups is to combat any complacency in patient treatment by healthcare professionals. That said, the patient does not share the same situational awareness that his or her team/network of healthcare professionals may have about the him or her, and even then, the healthcare professionals may not have team situational awareness like that we have observed in water or electricity control rooms.

More, the electricity or water user is a reliability manager typically only during severe water or energy shortages, when their participation and collective mindfulness in rationing is critical. Is a reliable patient necessary for a reliable healthcare system during high demand times (and again not just in a public health emergency) in the same way as energy-conscious or water-conserving consumers need to be during their high use times?

How a reliable and safe healthcare system encourages a more reliable healthcare consumer would be akin to asking how does a reliable grid or water supply encourage the electricity or water consumer to be energy or water conscious. Presumably, the movement to bring real-time monitoring healthcare technology into the patient’s habitation is increasingly part of the calculus.

(4) In all this focus on the patient, it mustn’t be forgotten that there are healthcare control rooms beyond those of manufacturers of medicines mentioned above: Think most immediately of the pharmacy systems inside and outside hospitals and their pharmacists/prescriptionists as reliability professionals. Similarly there have long been efforts to bring “real-time operations centers” directly into the hospital and selected units.

–One response to preceding points is to resist their implications and insist on treating healthcare from the doctor’s or specialist’s perspective as a craft or crafts surrounded by infrastructure elements.

In this view, the doctor and nurse/specialist and pharmacist are craftspeople, while the rest is the support end or business side. Healthcare, accordingly, isn’t nor could it ever be like other “infrastructures.” (I’ll leave aside the fact that control room operators in major infrastructures are themselves craftspeople responsible for far more lives in real time than hospital staff!)

To see healthcare as “all about the patient” is, however, to imply that reducing medical error at the sharp-end is a priority, even when this focus dilutes attention and diverts management from the prevention of key production and distribution errors in healthcare without which patient safety doesn’t stand a chance.

Further, it isn’t just that there may be a “bigger bang for the added buck” in reducing some kinds of error in the strong-end of healthcare than in the sharp-end. It is also that some of the more routine or engineered processes in the infrastructure-end can be enhanced to standards of high reliability while those at the sharp-end cannot.

Note: I believe much of the above holds for parts of veterinary care and the public health sector, but leave that discussion for another time. I thank Paul Schulman for many discussions, suggestions, and points; the provocations that remain are mine alone.

Good-enough dreamers

–When the self comes as a version of the carver, Michelangelo famously put the task as liberating form from stone. The real self is the revealed form that already exists, when you chip away the surplusage.

Adrian Stokes, art critic and poet, took the distinction and extended it. For Stokes and in contrast to the carver, the modeler fashions the self. The modeler of clay has the more labile enterprise of molding, where the form is “not uncovered but created.” “The modeler realizes his design with clay. Unlike the carver, he does not envisage that the conception is enclosed in his raw material.” In comparison to stone, “the plastic material has no ‘rights’ of its own. It is a formless mud used, very likely, to make a model for bronze or brass. Modeling is a much more ‘free’ activity than carving”. (Think of “modeling” not as computer simulation but as Stokes did, molding).

Psychoanalyst Adam Phillips returned to Stokes’s distinction as two distinct approaches to an individual’s selfhood and experience: “It is as though there are things that are always already there which we may or may not find; and there are things which we make, which we put there and by so doing add something to the world that wasn’t there previously”. What interests Phillips is that “[e]ach of these two versions involves us in telling a different kind of story about the self”. The modeler “uses his art to expose, to extend, to fashion himself”, while the carver abstains from promoting the self in favor of responding to the otherness of the object. Yet in both, a version of the self is operating—“the carver forgets himself…the modeler endorses himself”.

The difficulty with the carver is that, in seeing herself as releasing what is already there, she renders herself oddly immune to criticism by a world that responds nevertheless; it is as if she submerges her own egotism in the name of making what is revealed wholly visible as its own, regardless. The difficulty with the molder (our modeler) is the reverse. It is her hubris, her own truth that is imposed upon a seemingly labile reality. She acts as if reality knows it’s worse off for not having this truth. In such ways, while carver and modeler gravitate around different versions of the self, both have an acute sense of being better than just good enough. And these selves—the ones that are already there or must be created to be there—are increasingly appealed to in human rights and sustainable development.

–What works better, carving or modeling? It depends. It’s not one or the other; rather it is, “yes, but” or “yes, and.” It is premature to choose between the two versions of self when other selves exist from which to elect. To carving stone and modeling clay, we must at least add improvising the self from what is at hand, which involves something different—good-enough but in ways that matter better still than stone, clay and such, if you will.

What Phillips calls “the contingent self” is one who makes use of luck, accident, and coincidence—those surprises we have been discussing throughout the blog—that befall him or her. S/he improvises a life within a network of others that improvises them. And what can be more good enough, for improvising humans, than “just at hand” contingency to be made use of?

–Carving, modeling, and now, good-enough improvising: Which works better overall? Or to put it from the other direction: What other self/selves are we missing? In answer, start by slotting carving, modeling and improvising into a two-by-two typology for versions of the self.  One dimension is the degree to which the external world resists your agency (that imposition of your version of the self onto the world); the other dimension is the degree to which your agency independently seeks to impose control on the external world:

In this way of thinking, the carver has no choice but to reveal the self that is already there even as the world resists this imposition. In contrast, the modeler actively molds his or her own image onto a world that seems to little resist this imposition. The improviser takes what the world throws forth and deliberately recasts it, if not audaciously then good enough as and when it matters.

–But what version of a self, if any, fills the fourth cell, one where there is low agency and little external resistance? I can think of several candidates but for our purposes here, think of that fourth cell as Dreaming.

The dreaming self, as I see it, differs orthogonally from the versions of carver, modeler and good-enough improviser. When one dreams, one’s selfhood “holds fast” without really seeming to try. Dreaming is not just there, it’s all that is there, or so it seems at the time. Dreaming is paradigmatically “low agency and little external resistance:” It is not being in full control internally while external factors are not in full control either.

–Now to blur the gridlines in order to see better. I want to suggest good enough is about good-enough improvisers and their dreams not being in complete control. This in turn contrasts with carvers or modelers with their sense of seeking better-than-just good enough.

Unlike progress or economic growth which promises a magic of rising tides and bigger pies, good enough works on the premise that if policy and management are about fulfilling our dreams, then it is far better to think of policy and management as that magic animal skin, which in the process of realizing each new wish, shrinks smaller and smaller—until nothing is left to realize what is wished for by way of policy or by way of management.

Each enacted wish—each dream-in-action—could turn against you, waylay and maroon you on the shoals of simplification or the overly complex, requiring all kinds of subsequent corrective wishes—and before you know it, you’ve run out of options.

But that’s the very point. To mindlessly lose options is: Just. Not. Good. Enough.

Principal sources.

Phillips, A. (1994). On Flirtation: Psychoanalytic Essays on the Uncommitted Life. Harvard University Press: Cambridge, MA.

————– (2004). On not making it up, Or the varieties of creative experience. Salmagundi, no. 143 (Summer): 56-75.

Stokes, A.  (1978). The Critical Writings of Adrian Stokes, Volume I: 1930-1937, Thames and Hudson: GB.

Managing inexperience

Inexperience is identified as a major factor in other financial crazes than that of the 2008 financial meltdown. To see this we turn to an account of the 1720s financial fiascos of the South Sea Bubble in Great Britain and France’s counterpart, the Mississippi Scheme, by historian Frederick Scott Oliver in his 1930-1935 The Endless Adventure.

The three volumes of The Endless Adventure–long out of print, dated in some of its language, but much worth reading still–were well-regarded by the reading public and luminaries, like T.S. Eliot. The passage in question is quoted at some length in order to draw out a key point about inexperience (and anyway, I miss these high-alpine views of history):

At the present day the simplest investor or the most junior Treasury clerk would be suspicious of such over-generous promises; but in 1720 even less was known than is known now of the mysterious laws that control the currents of a nation’s prosperity. Our own generation, as it glances backward and downward into the eighteenth century, can of course discern without difficulty the points at which an earlier race of statesmen blundered off the highway and fell among brakes and briars and morasses. Viewed from our present altitude, the road of safety shows so white and unmistakable in the foothills below us that we find it hard to understand how men of intelligence and probity could possibly have allowed their steps to stray. The most facile explanation is corruption, or else of shameful ignorance.

Our amazement, however, will be lessened, our censure may be tempered, if we pause to consider a nearer past, or if we turn our gaze forward and upward, where the as-yet-unbeaten track of the twentieth century winds out of sight among mists and mountain peaks. What lies immediately behind us is only trifle less obscure than what rises up in front. We are not yet come high enough to survey the last fifteen years in a flat projection. We have travelled, as it were, by a forest path very baffling to an ordinary man’s sense of direction; by a steep ascent, at times darker than twilight, with many a corkscrew turn and hairpin bend. We can recall in a confused and broken memory that we have come through a period of miscalculations without number and that, time and again, the predictions of the wisest statesmen and economists have been proved false by events that followed shortly after. Our guides misled us, though they were for the most part honest men who knew by rote the maxims of their financial craft as it was practised by the civilised world at the beginning of the year 1914….

But new and undreamed-of conditions produced universal derangement. Discredit fell upon the most approved principles, and so many strange heresies appeared to thrive, that mankind, panting for a new heaven and a new earth, was not unwilling to listen seriously to new guides, who vaunted the efficacy of specifics hardly less fantastic than the Mississippi Scheme and the South Sea Bubble. Those new guides were possibly as honest as the old ones, but it was certainly no less dangerous to follow where they beckoned. In doing so how often have we lost our way and been obliged painfully to retrace our steps! And yet it is not unlikely that, a hundred years hence, every political writer, every man of business, every intelligent undergraduate will be able to discern clearly the causes of our recent and present troubles. The road to safety may then appear to them so obvious, that our own failure to find and follow it will excite not only their amazement but their suspicions. They may find it as hard to believe that our faults were nothing worse than the innocent blindness of inexperience, as we do to believe that the French and English nations in the year 1720 were not criminal lunatics, or as we do to acquit the statesmen of those two countries of complicity in a series of gigantic frauds.

“Quite right!” I say, but then again, the quizzical eye turns to that reiterated honest men duped by inexperience.

Does this mean our officials should get a free get-out-of-jail card because they are inexperienced? Stay with Oliver a bit longer.

For Oliver, politics as governing requires apprenticeship because governing is intricate: “Methods that experience and necessity have evolved by slow degrees are bound to be complicated…”, and it takes time to learn what is complicated and how to deal with them. Second, much of what passes for current administration conspires to distance the politician (and senior officials) from gaining more experience:

To-day, when a man of business or a cabinet minister is in doubt, or is at issue with his colleagues, he calls for a report. A host of technical advisers stands at his beck and call. A vast machinery lies ready to his hand. . . .[N]early everything he learns is learned at second hand, so that the true nature of the problem is rarely visible to his eyes. When his colleagues ask him questions—sometimes pertinent and sometimes foolish—he can neither satisfy them out of hand with sound reasons, nor can he answer them according to their folly. He promises a supplementary report; and so the game goes on.

We know that few investors or traders in the mid-2000s leading up to the 2008 financial crisis had any shared institutional memory or working knowledge of the preceding major financial debacle, the 1998 collapse of Long-Term Capital Management hedge fund. We also know that the turnover in political and business experience has been shortening over the last decades, in the one case due to term limits and political burnout and in the other case due to economic churn. The only redemptive feature in this is a messy this-worldly realism, according to Oliver:

If we eventually escape from our present perplexities, it will not be because theorists have discovered some fine new principle of salvation; or because newspapers have scolded and pointed angry fingers at this one or that; or because we, their readers, have become excited and have demanded that ‘something must be done.’ It will be because. . .have ‘jumbled something’ out of their contentions that will be of advantage to their country.

There of course are no guarantees. More important is this for Oliver: It isn’t that experience in the craft of politics enables the practitioner to better see the future. Rather, experience enables the demanding present to be seen more for what it is, now:

The circumstances that surrounded were complicated and bewildering; the gleams that guided him were intermittent and often of a twilight dimness. A statesman so situated must do much by guess-work… Prophetic statesmen are a fairly common variety of the species, but those who not only foresee things but foresee them truly are among the rarest of human products. [The chief minister] made no pretensions to the gift of prophecy. Man of genius though he was, he owed little to his imagination. He excelled his colleagues, and opponents, and indeed every statesman in Europe, not in penetration of the hidden future, but in the clearness with which he saw things present, and in the accuracy with which he could judge by the lights or darkness of the horizon what weather might be looked for on the morrow. And he excelled them most of all in the rapidity with which his mind arranged in their true proportions the most diverse and unexpected events. (my bold)

Whether this description of the chief minister in question has stood the test of time, I can’t say.

What the passage does still describe, however, are professionals who confront and balance experience and inexperience and have a track record of learning what they do and do not know to avoid worse. If we are to trust people to manage later they must be managing now. Their leadership, if you want to call it that, is the management of today’s inexperience with a tomorrow yet-to-come but in light of past experience in having done so before. They must be experienced enough to manage inexperience. Note the corollary: Yes, it’s true that inexperience may well start in the individual, but experience may just as well end up across individuals, untraceably distributed and shared.


Scene 1

It’s reported Lord Acton despaired over the prospect of ever finding French, German and British historians who agreed on an account of the Battle of Waterloo. So too have others.

In The Charterhouse of Parma, Stendhal famously recounts the misadventures of Fabrizio, who makes his way to Waterloo on the eve of the battle. Everything turns chaotic, with confusion supreme. “A few minutes later Fabrizio saw, twenty paces ahead of him a ploughed field, the surface of which was moving in a singular fashion. . . .[O]ur hero realized it was shot from guns that was making the earth fly up all around him. . . . ‘But is this the real battle’,” he asks a sergeant”.

Friedrich von Hayek, Nobel economist, picks up the story and asks, “Was the man plowing his field just beyond the extreme wing of Napoleon’s guards part of the Battle of Waterloo?. . .To follow up this kind of question will show at least one thing: that we cannot define a historical fact in terms of spatiotemporal coordinates”. Literary critic, Nicola Chiaromonte, revisits that narrative: “Certainly the Battle of Waterloo that Napoleon saw and directed (or thought he directed) is not the event Fabrizio wanders into. Nor is the explosion of incidents in which Fabrizio finds himself the same event as the mortal engagement of the soldiers who jeer at him. . .The Battle of Waterloo was all of these, separately and together, plus countless other happenings.” By no means last, a more recent Fabrizio, Tod Hackett, runs to watch the chaotic, confused and eventually disastrous filming of the Battle of Waterloo in Nathanael West’s Hollywood novel, The Day of the Locust

This power in “the Battle of Waterloo” is very much the power that political scientist, James G. March, long ago described as “different parts of the system contribut[ing] to different decisions in different ways at different times”. Of course, it can be countered that war and capitalism are their own powerful engines of contingency, but so too it can be said of evolution and that irreducible particularity of being.

Scene 2

Contingency is the chief feature of battle and the chief feature of contingency is surprise—not again that power defined as the ability of A to get B to do something B would not have done.

To appreciate this better, puzzle over the power that contingency plays in A getting A to do what A would not have done otherwise. Here is the poet and critic, T.S. Eliot:

“My writings, in prose and verse, may or may not have surprised other people; but I know that they always, on first sight, surprise myself. I have often found that my most interesting or original ideas, when put into words and marshalled in final order, were ideas which I had not been aware of holding. It is ordinarily supposed that a writer knows exactly what he wants to say, before he sits down at his desk; and that his subsequent labours are merely a matter of a better choice of words, a neater turn of phrase, and a more orderly arrangement. Yet I have always discovered that anything I have written—anything at least which pleased me—was a different thing from the composition which I had thought I was going to write.”

Stay with the range of evidence that those “most interesting or original ideas”—those most powerful ideas—are the ones you don’t know until you set them down before you:

  • “A writer doesn’t know what his intentions are until he’s done writing,” says poet, Robert Penn Warren. Even when the writing is done, poets “are apt to discover that what they decide to express is not everything their poems say,” writes Anne Stevenson, herself a poet, adding: “Nothing in my experience is more important about the writing of poems than that they should surprise you; that while you are submitting to their rigorous demands of rhythms and sounds they find a way of saying things you never meant to say or never knew you knew.” 
  • “How can I know what I think till I see what I say?” asks a character of novelist, E.M. Forster. “Therefore, till my work is finished, I never know exactly what result I shall reach, or if I shall arrive at any,” wrote Alex de Tocqueville to John Stuart Mill. “I do not know what I think until I have tried to write it,” said political scientist Aaron Wildavsky. “I’m not sure I ever actually think without a pencil in my hand. Certainly I never wind up where I thought I would,” confesses Stacy Schiff, biographer.
  • “You never know what you’re filming until later,” remarks a narrator in Chris Marker’s 1977 film Le Fond de l’Air est Rouge. “You start a painting and it becomes something altogether different. It’s strange how little the artist’s will matters,” adds Picasso (and any number of other artists). In like fashion, “one important reason for making drawings, I imagine, is not to draw a likeness of what one sees, but to find out what it is you see,” adds poet and art critic, James Schuyler. Goethe noted “my tendency to look at the world through the eyes of the painter whose pictures I have seen last”.
  • Harrison Birtwistle describes his process of composing a piece of music: “I know what it is before I’ve even written it, but in other ways I don’t know at all. As I unravel it, it never turns out to be what you think it’s going to be”. J.M. Coetzee, Nobel novelist, manages to make all this sound commonplace: “Truth is something that comes in the process of writing, or comes from the process of writing”.
  • More, there are other ways to “write as thinking.” Anthropologist Claude Levi-Strauss would record different points on separate note cards and then deal “them out randomly in the hope of finding unexpected correlations”. “As Beatrice Webb [UK reformer] rightly said, the very process of shuffling notes can be intellectually fertile. It helps one to make new connections and it raises questions to which one must try to find an answer,” writes historian Keith Thomas. Those who, as sociologist C. Wright Mills commended, sort out their files can have just this sense of making hitherto-unseen associations and connections.

Managing this mess called thinking in these ways becomes the way your distractions and their insights control you. Nor does any of this stop us from ghostwriting our earlier thinking later on.

Scene 3

If your point of departure in thinking about power is that ability of A to influence B to behave otherwise, then the person I am after having learned what I really know or think has enormous power over the person I was before being distracted and surprised by that discovery.

Conversely, there is an enormous powerlessness in not being able to think or know when few if any words or images exist for the purpose—“the language in which I might be able not only to write but to think is neither Latin nor English, neither Italian nor Spanish, but a language none of whose words is known to me,” despairs von Hofmannsthal’s Lord Chandos. What is rendered too simple or too complex leaves us, literally, in and at a loss for words.

For me, it’s not good enough to say power is primarily about that A making that B do something instead. Nor is it good enough to say power is primarily about controlling the decision agenda or determining peoples’ interests without them knowing it. At least when it comes to the policy and management issues with which I am familiar, power isn’t concentrated or dispersed by interests, full stop. The power I am talking about lies in surprise and, since surprise is that chief feature of complexity, surprise and its power should be thought of as complex from the get-go. Again: Complex is about as simple as it gets.

Scene 4

Better to say the power I am talking about is the power of surprising connections.

It is thinking through the reverberations that, in my mind, connect Adorno starting an opera on Tom Sawyer, Picasso painting Buffalo Bill Cody, Sartre preparing a screenplay on Freud, Benjamin Britten facing the prospect of becoming a bandmaster (or Samuel Beckett considering being a commercial airplane pilot), Coleridge and fellow poet Robert Southey planning an egalitarian community on shores of the Susquehanna, Goethe’s plan to clean up the streets of Venice, Kafka drafting rules for a socialist workers’ cooperative, and Abraham Lincoln and Hedy Lamarr securing their respective patents. More than “w” as in war links Walt Whitman the medical orderly, Max Weber the hospital orderly, and Ludwig Wittgenstein the dispensary porter.

The objective correlative of contingency is power. Where so, the great threat to addressing power is to think there is an outside to contingency and to assume that asking a question requires first knowing what qualifies as an answer. Some of the most potent answers start out, provisionally, as distractions from the original question. When you think about it, these distractions are a bit like asking, “What is more important, power or contingency?”, and being told, “But that’s like asking which chopstick is the fork…”