The Irrational American Voter – Arrogance, Ignorance, or Both?

 

 “Critics are men who watch a battle from a high place then come down and shoot the survivors."  -  Ernest Hemingway

Let me preface this essay by saying that I am an expert in assessing cognition and cognitive disorders  based on my 35 years as a psychiatrist doing that specific job in acute care settings, outpatient clinics, nursing homes and other healthcare centers, guardianship and conservatorship proceedings, and contested hearings about decisional capacity.  For 15 years I ran a Geriatric Psychiatry and Memory Disorders Clinic.  I have made positive diagnoses of the various forms of dementia, detected and treated reversible forms of cognitive impairment, and corrected misdiagnoses of dementia. So, I was more than slightly taken back by all the armchair diagnosing of President Biden during the debate last Thursday. The press got (at least) – 3 days of sensational and speculative headlines. I just saw a poll today that showed an increase in the number of Americans who think “President Biden has a cognitive problem” from 35% prior to the debate to 70% after the debate.  As an expert – with no special knowledge of the President’s health status I can tell you why there is no sufficient information to make that determination.  I also have doubts about what “cognitive problem” means to the average American based on the hundreds of family conferences I have had to explain that concept.  

Just based on the debate, the President’s responses and overall presentation were suboptimal - but there are many untouched explanations.  I would describe the resulting press as excessive and discriminatory against Biden. Here are a few possible explanations:

My first thought was he was over preprepared and probably angry about having to confront a liar and a propagandist.  Let’s face it – this is the first time any Presidential debater has been forced to do this.  Trump is the first convicted felon and repetitive liar in any presidential debate.  He is good at it.  Recall how Trump made his fellow Republican primary candidates look in those debates.  Many of them were speechless and ineffective.  Trump’s propaganda style clearly makes it difficult for the media to criticize him.  He effectively neutralized the moderators who were unable to get him to answer questions.  Some in the press described him as a “ball of energy” rather than a “ball of lies”. They know that no matter what they say – Trump is repetitive and successful in wearing them down.  The best example is “The Big Lie” about how the election was stolen but there are more. He maintains lies in the face of solid evidence and even the press does not know how to handle it. They eventually acquiesce and start to treat the propaganda as fact.  During the debate he was able to not provide responses to questions while repeating his own brand of propaganda.  

Second, the cognitive task was much more demanding for Biden.  In the news leading up to the debate there was clear messaging from both camps on how they were being prepared. Trumps preparation was clearly casual and not information intensive. That was reflected exactly in his ease with repeating his overlearned propaganda, dodging solid answers to questions, and ad hominem attacks on Biden.  The Biden camp reported an intensive schedule of fact-based mock debates and attempting to answer moderators’ questions based on much more factual content.  Clearly the Trump strategy presented a markedly lower cognitive load and practically no information content to memorize.

Third, a single debate is not a marker of much – recall Barack Obama’s problematic debate from 2012 when CNN stated that Mitt Romney “trounced” Barack Obama in a debate. That is one reason Obama came out two days ago with the statement that “bad debates happen”.

Fourth, choking in a presentation even substantially should be a common experience. Public speaking is an almost universal fear. It happened to me in a memorable incident where I found myself suddenly blank and thinking about driving across Montana – as I was presenting in a pharmacology seminar in medical school.  I was about 26 years old at the time. My professor snapped me out of it by reminding me where I was and what we were doing. I was intensely prepared and sleep deprived at the time. Since then, I have found that the ability to focus and pay attention to what is happening in a presentation is inversely related to preparation intensity.  In other words – if I overprepare, I am likely to get bored with the content and will find my mind wandering in the presentation even to the point that I do not want to be there. Now, once I have the content mastered – I stop studying it and my plan is to just free associate to the bullet points.  President Biden had no bullet points.

Fifth, the reaction of the pundits has bordered on mass hysteria. Their conclusions that Biden is acutely impaired and too “feeble” has very little basis in fact. Several people including some pundits have described talking to Biden and noticing that in his face-to-face conversations there is no doubt that he is capable and mentally competent.  The fact that he seemed like his old self immediately after the debate in a Waffle House and the next day in a rally also defies the common explanation of what happened in the debate – that he is somehow irreparably impaired. I also had some interesting reactions to this when I was contacted and asked about “what they gave Biden after the debate that brought him back to normal.”  To my knowledge there is nothing.  Memantine was suggested to me, but as a physician who has prescribed this medication for cognitive problems the results are far from impressive. The real question is whether he took anything for cold symptoms before the debate.  Typical medications used have clear cognitive side effects. 

Sixth, time of day – the debate started at 9 PM and went to 10:30 PM Eastern time.  Circadian rhythms are important.  Drawing on my own experience I would never schedule a presentation or a lecture in the morning.  I am not a morning person and that is probably the main reason I did not elect to go into a surgical specialty.  I could not imagine trying to concentrate intensely in the early morning hours. The later in the day the better. I don’t know Biden’s typical schedule but speculate it is loaded in the mornings rather than evenings.

Seventh, Biden’s longstanding articulation disorder.  He has never tried to cover it up. It is a life long problem with no cure, but he has discovered some management strategies. It is probably worsened by stress and changes in voice quality from a recent cold.

Eighth, the pervasive ageism bias has never been more real.  The next day Biden observed that he doesn’t walk, talk, or debate like he did when he was a young man but he is still competent to do the job. His record of accomplishments in the face of an obstructionist party and their Supreme Court - backs him up.

If anything, the debate has taken the focus off Trump’s severe deficiencies.  There were several attempts to fact check the candidates and it was clear Trump had 3 to 4 times as many inaccurate statements.  Some were obvious like the stolen election and infanticide propaganda.  Like all propagandists – repetition seems to work on an unknowing or willfully ignorant public. Apparently, Mussolini was such a skillful propagandist that some of what he said is still believed as accurate today.  In this case the focus on Biden has basically given Trump and the MAGA GOP a free pass and they have been emboldened to the point of suggesting the 25^th Amendment be invoked against Biden based on a 90-minute television broadcast.

Rather than provide another point-by-point contrast between the candidates like I have done in the past there is a simple thought experiment that involves common sense thinking that can be applied. It is not based on wishful thinking or speculation.  It involves looking at the Presidency like a job application. Anyone who has ever applied for a job knows that you need to get recommendations from previous employers, supervisors, and in some cases co-workers.  The Presidency is interesting from this perspective because – all the coworkers are hand selected by the President himself.   Of the 15 cabinet level positions in the Trump administration only 6 people endorse him for re-election.  Eleven do not.  That number does not add up to 15 because of the turnover in the Trump administration and there are probably more people that I missed.  In addition, the most recent same party President George W. Bush and 2 of his 3 Chiefs of Staff, and a National Security Advisor do not endorse Trump in some cases criticizing him with the harshest possible language.  I am not aware of a single Biden staffer who has not endorsed him and President Obama came out with a statement of his support after the debate.

Although a direct comparison of Trump versus Biden is not possible on Cabinet level endorsements because of the lack of a survey of the Biden cabinet – the Trump results are striking based on the level of vehement criticism and what they say about the former President’s intelligence, inquisitiveness, and character.  A direct comparison across multiple dimensions is possible in the survey that President Biden described during the debate.  Presidential scholars rank Presidents across a number of dimensions and in that process, Biden ranks number 14 and Trump is dead last at number 45. Refer to the link for the specifics and outside validation.  The survey has received no coverage post debate relative to President Biden’s performance – even though it is an acknowledgement of his administrations’ accomplishments and a stark contrast to Trump’s rhetoric about how Biden has “destroyed” the country (he used the word destroy 22 times) and he is the “worst” President – (he used the word worst 22 times).  That contrast alone reveals Trump’s strategy.

That is my analysis of the debate from the perspective of a physician who has done thousands of cognitive and decisional capacity examinations.  To be clear, I have no way of knowing whether my suggestions are accurate.  I have not examined either candidate or their medical records. But I know that it takes a lot more to determine a person’s cognitive capacity than what we saw in that debate. The most straightforward solution would be to have each candidate take a standard assessment of their cognitive status and release the results to the public – but politics rarely takes a rational approach.  In the meantime, it is best to avoid the assessments of partisan politicians and party members, comedians, and gossip show pundits.  

This is not a laughing or pitiable matter.

 

George Dawson, MD, DFAPA

 

References:

1:  Nicholas P, Liebowitz M.  Dozens served in Trump’s Cabinet. Four say he should be re-elected.  NBC News July 30, 2023 https://www.nbcnews.com/politics/donald-trump/trump-cabinet-endorsements-rcna96648

2:  Joint Statement from Elections Infrastructure Government Coordinating Council & the Election Infrastructure Sector Coordinating Executive Committees.  November 12, 2020.  Accessed July 1, 2024  https://www.cisa.gov/news-events/news/joint-statement-elections-infrastructure-government-coordinating-council-election

This was known within days of the 2020 election. It is still not accepted by former President Trump and MAGA Republicans:

“The November 3rd election was the most secure in American history. Right now, across the country, election officials are reviewing and double checking the entire election process prior to finalizing the result.

“When states have close elections, many will recount ballots. All of the states with close results in the 2020 presidential race have paper records of each vote, allowing the ability to go back and count each ballot if necessary. This is an added benefit for security and resilience. This process allows for the identification and correction of any mistakes or errors. There is no evidence that any voting system deleted or lost votes, changed votes, or was in any way compromised."

3:  Presidential Greatness Project - see rankings at this site.  Biden #14  Trump #45   

No mention of this comment by Biden or the survey by any of the press.

Graphics Credit:  

Wikimedia Commons - click on photo for full credits and Creative Commons License

Disclaimer: 

As previously noted I am not now and have never been a member of any political party in the United States.  At the same time, it is clear to me that the Republican party, their Presidential candidate Donald Trump, and their partisan Supreme Court are an unprecedented danger to the United States that I have known all of my life and that they should be defeated. It is also clear that they have a level of organization that resulted in political advantages over the opposition and that their rhetorical strategy is to blame the opposition for what they in fact are doing.   

Foreign Policy Implications Of The Business Takeover Of Medicine

Don't worry.

This post is not about the current Presidential election.  I have no horse in the race.  Nobody to vote for.  I have been a staunch 3rd party voter for a long time and there is not even a third party candidate that I would currently vote for.  I know that opens me up to criticism from major party partisans who commonly accuse independents of either losing them the election or being too arrogant to hold their nose and vote like everybody else.  I trust my nose more that I trust that kind of rhetoric.  The current campaign highlighted everything that is wrong with the political process including a lack of focus on real issues, a lack of inspiring candidates,  and plenty of dishonesty on both sides.  I want to focus on one real issue and that is national security.  And I want to get at it from a perspective that is described primarily on this blog.

Early in the 21st century, I involved myself in a lot of political debates.  As an example, I was very active in the debates about whether the United States should have invaded Iraq under President George W. Bush.  At the time there was the unfounded belief that Iraq had weapons of mass destruction and a push to invade even though UN weapons inspectors under Hans Blix had really not found any positive evidence.  Minnesotans is a state with active political dialogues.  Senator Paul Wellstone and his fellow Democrat and current Governor Mark Dayton were two of the few Senators who voted against authorizing the use of force in Iraq and the rest is history.  Unnecessary wars, massive military spending, and an ongoing drone war carried on by the Obama administration.  The longest continuous period of warfare in the history of the USA.  The end result is that we are in a continuous war against terrorists,  continuous cyberwarfare against China and Russia, and we are current seeing significant military build ups by those same countries.  All of this against the backdrop of President Eisenhower's remarkable farewell address to the nation televised January 17, 1961.  The relevant sections include (my emphasis added):

"..........A vital element in keeping the peace is our military establishment. Our arms must be mighty, ready for instant action, so that no potential aggressor may be tempted to risk his own destruction.

Our military organization today bears little relation to that known by any of my predecessors in peacetime, or indeed by the fighting men of World War II or Korea.

Until the latest of our world conflicts, the United States had no armaments industry. American makers of plowshares could, with time and as required, make swords as well. But now we can no longer risk emergency improvisation of national defense; we have been compelled to create a permanent armaments industry of vast proportions. Added to this, three and a half million men and women are directly engaged in the defense establishment. We annually spend on military security more than the net income of all United States corporations.

This conjunction of an immense military establishment and a large arms industry is new in the American experience. The total influence -- economic, political, even spiritual -- is felt in every city, every State house, every office of the Federal government. We recognize the imperative need for this development. Yet we must not fail to comprehend its grave implications. Our toil, resources and livelihood are all involved; so is the very structure of our society.

In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military industrial complex. The potential for the disastrous rise of misplaced power exists and will persist.

We must never let the weight of this combination endanger our liberties or democratic processes. We should take nothing for granted. Only an alert and knowledgeable citizenry can compel the proper meshing of the huge industrial and military machinery of defense with our peaceful methods and goals, so that security and liberty may prosper together........"      


Eisenhower was a genius -  decades ahead of the current thinking on conflict-of-interest and its problematic results.  Going beyond the famous reference to the military industrial complex, Eisenhower's speech was about balance, conservation, and mutual respect. Disarmament described as being necessary because another war could destroy civilization. It was a speech made by a military expert turned statesman - balanced and very reasonable.

But despite Eisenhower's best intention, the American military has marched on with three unnecessary wars in my lifetime and continued record amounts being spent on the machinery of war.  In 2105 the US spent $596 billion dollars - more than the next 7 nations combined.  The Department of Defense is the largest single employer in the world.  The defense budget has long been the subject of cost overruns and overspending.  The word corruption is rarely used appropriately in American politics, but what would Eisenhower call  a $640 toilet seat?  From that same timeline - cost overruns alone add an additional 25% to the cost of weapons systems.  It seems clear that top down management massive budgets in a political atmosphere dominated by funding concerns, lobbyists, and special rules that favor the major parties is a recipe for inefficiency at best and corruption at the worst.

Parallels between what happens to the military budget and healthcare funding are undeniable.  In health care - the politics is clearly on the side of large businesses that were put in place as proxies by the federal government for containing costs - despite the clear evidence that has not happened.  Professional organizations also lobby they are generally ignored relative to business interests.  Per capita health care spending in the US is roughly 40% more than the next highest nation with no incremental increase in quality and much worse access to health care.  All of this mismanagement flows from politicians and bureaucrats at federal and state levels who talk about the constant need to reform health care.  The only notable reforms have been the use of large health care companies as inefficient proxies for government control,  selective rationing of specific areas of health care like psychiatric and addiction services, ballooning administrative costs, and placing an intense, costly level of administrative control over the physicians who are delivering the service.  Instead of learning from the past 30 years, the managers at all levels are doubling down with more requirements and regulations.  We have an endless supply of $640 toilet seats in the health care system and at the same time entire states where a person cannot get adequate treatment for an addiction or a psychiatric problem.  The government and business side of the equation needs to cling to the myth that this type of management is necessary, despite the fact that it was unequivocally demonstrated in 1998 that it was not and the more important long term trend that these business managers add no value to the system as all - apart from what they can make up as advertisements.

Does that sound like a system that can manage foreign policy or military strategy?  Somewhere along the line Americans are led to believe that we have competent military leaders who are advising Congress and the Executive branch.  In order to accept that advice a lot of political demagoguery that occurred in the election campaigns must be set aside.  A lot of past mistakes must be acknowledged and corrected.  A lot of the accusations about immoral and criminal behavior do not inspire the confidence of Americans or other citizens around the world. The scare tactics about whose finger is a safer finger to put on the nuclear button needs to be stopped and a more sober discussion about stepping back from high alert nuclear status and disarmament needs to happen.  Warfare and aggression should never be the default position.

The major difference between the military and healthcare funding is that the financial drain on the averagae family for military funding is less transparent that healthcare.  With costs being transferred to the working class under high deductible plans, the average retired couple paying and average $250K in retirement for healthcare, and now exploding costs for Obamacare, working class families are tired of paying excessive amounts for healthcare.  Any head of household who has survived the tech bubble stock market crash, the housing bubble crash, and the associated Wall Street scandal where hardly anyone was prosecuted and all of the major players were essentially unfazed.  Everybody knows some working class person who ended up fined or sent to jail for cheating the IRS.  It is also common knowledge that these infractions are trivial compared with tax breaks and questionable financing by the affluent.

Although the major parties have certainly played a role in orchestrating this dramatic fiasco - they don't bear complete responsibility.  At many levels American culture is poorly equipped to deal with tough problems.  There is a love of technology but a focus on impoverished data sets.  There is a limited understanding of current problems and potential solutions.  The best solutions are rarely reached by political compromise and the end to those arguments typically results in wrapping oneself in the flag and declaring that there has never been a better system (or country) invented.

Rather than putting it all behind us and uniting behind the next President like we all traditionally do - I hope this ugly campaign gets Americans contemplating the larger issues instead of what is commonly referred to as "the narrative".  We need to get back to the real story itself rather than the narrative.  The issues are there and they are not going away just because some politician is trying to buy your vote with money, a job, an empty promise, or special interest politics.  The issues are there no matter how we get "handled" by the managerial classes.

That is what we all have to keep in focus.



George Dawson, MD, DFAPA  


Supplementary 1:

I filed the above piece on Election Day, at least 8 hours before the New York Times election site started to predict that Donald Trump had a "greater than 95% chance" of winning the Presidential Election.  Since then I have been shocked at the number or reasonable people who are outraged by the election result and suggesting that this election is an indictment of the American character.  I won't list the specifics but they are easily viewed elsewhere.  Maybe I am just a hardened Minnesotan who can still clearly remember when professional wrestler named Jesse Ventura shocked the major parties in the state by being elected Governor.  Looking at the debates he had with those candidates - the outcome should have been predicted.  Both the Democrat and the Republican in that race found themselves agreeing Ventura on most of the major topics.  As I drove into work the next day, I listened to a major party legislator predict a catastrophe due to a professional wrestler rather than a career politician.  And guess what?  No catastrophe - in fact - a seamless transition.  The Governor's Office ran well.  Ventura's  only error (and it was a big one) was not to make the most of this victory and prove once and for all that the major parties can be superfluous in the process.

The failure of the polls to predict the election result, is instructive for any students of sampling and statistics.  If the sample is inadequate, don't print the headlines based on the inadequate sample.  I don't think the second question about that has been answered yet.  That question would be whether enough people are "off the grid" or uncooperative with the sampling process enough to make these polls predictably unpredictable.  Is it safe to say it was a failure of Big Data?

From what I know about the political process I see this playing out a few ways:

1.  Trump makes a seamless transition to office in a manner very similar to Ventura.  It will actually be easier for a Trump transition because he is technically a Republican,  even though many Republicans clearly dislike him.  Ventura was a member of the Independence Party and both parties disliked him and yet he was able to form a reasonable cabinet and nobody noticed that there was not a Democrat or a Republican in office.  He maintained a populist position by provided tax rebates.  The real potential for damage from a Trump administration will be a ballooning federal deficit, but even then it is a matter of degree.  There is no way that any Democrat or Republican will establish a precedent of actually paying for the expenditures on their watch.

2.  I have been stunned by the naivete that some people have about how men talk.  Trump's 'locker room" talk is what I am referring to.  I had a discussion last week about this very issue.  One opinion was that this kind of talk was a "generational thing" - in other words done only by dinosaurs like me.  I have certainly talked with men of all ages who refer to women in a crude manner.  I certainly don't use those terms myself and never have.  I don't "approve" of these references, but I also realize that men who talk that way are certainly not waiting on my approval.  I know this type of discussion exists.  I also know the meta-language involved.  In other words, the language has different meanings in different contexts like most language does.  I will let the linguists come up with a detailed analysis, but at the common sense level it is clear that a lot of people could ignore it.

3.  Trump has been conciliatory in his early remarks since the win.  The key question at this point is whether he can maintain that demeanor.  If he does not become antagonistic and uncompromising he has a great opportunity to seen what he can accomplish. From the political debates, it was clear that the Trump campaign was more about process and rhetoric that it was about content and a mastery of the issues.  He needs to take a lesson from Governor Ventura about what not to do when you unexpectedly get into office.

4.  Most but not all of the pundits seem to have missed the point that a lot of the Trump emotionality was directed at the working class and the working class has not fared well in American politics for decades.  Wages are flat, unions have disappeared, health care costs have increased and were set to explode with Obamacare.  Against that backdrop, the major parties have really done nothing but shore up Wall Street.  The working class has been a traditional mainstay of the Democrats.  As my grandmother used to say" "They are for the little guy!"  That has not seemed to be the case to me for a long time.

5.  Most Trump supporters do not take him literally - this is my speculation and it is in direct opposition to opposition to other more radical theories of the motivations of Trump supporters.

Just a few early observations about why a Trump presidency is not necessarily a catastrophe and also - how it happened.....