Last business letter of my career

 

Yesterday I gave you one of my mementos, the "last business letter of my career." Looking at your response, I think you may have missed its purpose. It had little to do with the record or with closure; it had to do with perhaps preventing it from happening to others.

Yes. I think I read it too much as a personal artifact and not enough as an intervention.

The important distinction is that you weren't primarily saying, “This is how I want to remember my departure.” You were saying, in effect:

“I have seen something wrong happen here. I have enough standing to say so. I am putting this on the record privately, in the hope that you will think twice before doing it to someone else.”

That makes the letter quite different. Its value isn't mainly retrospective. It is prospective.

And that also explains something about the tone that might otherwise seem curious. You weren't trying to punish your former supervisor, extract an apology, or reopen the dispute. You had already negotiated an unusually good exit and left. You were spending some of the goodwill and leverage that remained to warn him.

The line about having your systems scrutinized for "trap doors" is especially revealing in that light. You're not merely defending yourself against an accusation. You're telling him, you have misunderstood the sort of person I am, and your reaction illustrates precisely the kind of institutional behavior I'm warning you about.

So I would revise my reading of the memento:

It was a last business letter, but not a farewell letter. It was a warning shot—deliberately restrained, privately delivered, and aimed at changing what happened to the next person.

And your posting it now may have that affirming effect precisely because the purpose wasn't simply to preserve your own history. You actually tried to make the history come out differently for somebody else.

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The issue is the attitude

She explains: "The findings from this study are encouraging, but they should not change treatment decisions on their own. People with asthma or COPD should not start GLP-1 receptor agonists specifically for their lung condition outside current prescribing guidance. While the findings suggest that some people taking GLP-1 receptor agonists may experience fewer respiratory attacks, this needs confirmation in clinical trials." https://www.sciencedaily.com/releases/2026/09/260909005155.htm

Yes, and that cautionary paragraph is exactly the part that caught my attention too.

The headline ("40% fewer asthma attacks") is striking, but the actual evidence is still observational. The researchers looked at real-world health records and found that people with asthma or COPD who were prescribed GLP-1 drugs—especially semaglutide—had fewer respiratory flare-ups than similar patients taking other diabetes medications. That is an association, not proof of cause and effect.

What makes the finding interesting is that it fits a growing pattern. Over the last few years, several studies have suggested that GLP-1 drugs may do more than lower glucose and cause weight loss. Researchers have proposed mechanisms involving reduced inflammation, improved metabolic health, and possibly direct effects on lung tissue.

For someone in your situation, the study is more relevant than it would be for many people because:

• You already have type 2 diabetes.

• You have a history of asthma/airway inflammation concerns.

• You are not considering semaglutide primarily for weight loss.

• You have previously mentioned interest in possible non-weight-loss benefits of GLP-1 drugs.

The study's practical message is not "start semaglutide for asthma." It is more like: "If a person already has a valid reason to take semaglutide—such as diabetes or obesity—there may be an additional respiratory benefit that we are only beginning to understand."

That distinction matters.

Looking at your own risk-benefit balance at age 83, I would still put the strongest proven benefits of semaglutide in:

1. glucose control,

2. weight reduction,

3. cardiovascular risk reduction in appropriate patients.

The possible asthma/COPD benefit is currently in the "interesting bonus" category rather than the "established reason to prescribe" category.

What I find noteworthy is that this lung study joins a surprisingly long list of potential non-weight-loss effects being investigated: cardiovascular disease, kidney disease, addiction, fatty liver disease, inflammation, and now respiratory disease. Some of those have become well-established; others remain speculative. The respiratory findings are still on the speculative side, but they are no longer isolated observations.

For your personal decision, I don't think this paper alone would move the needle much. If you eventually decide that semaglutide is worthwhile, it would be because the total package of possible benefits—including diabetes, cardiovascular protection, and perhaps respiratory protection—outweighs the hassles and downsides you have mentioned, especially the concern about muscle loss in an 83-year-old who has already lost a great deal of weight. The new lung data adds a small positive weight to that side of the scale, but probably not a large one yet.

  

Well, first, I would say both the diabetes and the respiratory problems are for me under good control, if not resolved, so I'm taking a personal wait-and-see approach. The issue is the attitude the quote conveys: we have strong evidence that does not yet reach the current view of what is proof and well-understood contraindications, so I would think we would go ahead now.

 

 

Yes — I think you're making a somewhat different point from the usual “don't overinterpret observational studies” warning.

You're saying the standard of evidence for changing treatment and the standard of evidence for allowing a treatment are not necessarily the same thing.

If we have:

• a fairly strong observational signal of a substantial benefit,
• a plausible biological mechanism,
• a drug that is already extensively used,
• reasonably well-characterized adverse effects and contraindications,
• and a patient who already has an independent indication for the drug,

then “we don't yet have randomized trials proving the respiratory benefit” doesn't necessarily imply “therefore, don't take advantage of the possibility.”

That's a legitimate medical-philosophy question.

The conventional medical position is more conservative because once you say “the observational evidence is strong enough to act on,” you have to distinguish that from placebo effects, selection effects, healthy-user effects, differences in obesity, smoking, healthcare utilization, severity of disease, and so forth. Randomization is particularly valuable precisely because it eliminates many of those explanations.

But there's an important asymmetry here. Suppose the choice is:

A. Don't use a GLP-1 drug → no possibility of the respiratory benefit.

B. Use it for an already-accepted indication → accept its known risks and costs, while perhaps obtaining the respiratory benefit.

If B is already reasonably attractive on established grounds, you don't necessarily need the respiratory hypothesis to be proven before it can rationally influence the decision. It can be part of the expected-value calculation without being called an established medical indication.

And I think that's closer to what you're getting at.

Your personal situation makes the distinction particularly interesting because you're not saying, “My asthma is uncontrolled, therefore give me semaglutide.” You're saying, essentially, “My existing problems are well controlled, so I'm in no hurry—but if the evidence continues accumulating, I don't see why medicine has to pretend that nothing meaningful is known until the final randomized-trial box gets checked.”

That's a perfectly coherent wait-and-see position.

In fact, I might phrase the scientific attitude you are objecting to this way:

“Insufficient evidence to establish the treatment as standard of care” is not the same proposition as “insufficient evidence for a rational individual to take it.”

Those are different thresholds.

And there is an additional wrinkle with an 83-year-old: the relevant question isn't necessarily “Has semaglutide been proven to prevent asthma attacks?” It may be “Given this particular person's expected benefits, risks, alternatives, and remaining lifetime, what degree of uncertainty is reasonable to accept?”

That's where individualized medicine gets rather more interesting than guideline language.

  

Science never has ironclad proof. Established knowledge can be challenged and altered. Evidence accumulates. There should not be a legal or administrative or insurable edge except the judgment of the patient. This has to do with personal freedom. I'm well aware that patients can harm themselves and be fooled by hype, and false claims can be regulated, but freedom should prevail.

 

I think that is a much stronger formulation of your position. You're not arguing that evidence doesn't matter; you're arguing that evidence should inform the patient's judgment, rather than become an administrative gate that determines what a competent adult is permitted to do.

And yes, science doesn't produce iron-clad proof in the philosophical sense. It produces progressively better-supported propositions. Today's “established” treatment can become tomorrow's obsolete treatment when better evidence appears.

That suggests a useful distinction:

• Scientific question: How strong is the evidence that X works?
• Clinical question: How does X's probable benefit compare with its probable harm for this particular person?
• Freedom question: Who gets to make that final risk-benefit judgment?

Your answer to the third is: the informed patient, unless there is a compelling reason to override him.

I think there's an especially important distinction between regulating claims and regulating choices. It is entirely reasonable to say, “A manufacturer may not tell people that GLP-1 drugs prevent asthma attacks when that hasn't been demonstrated.” It is quite another thing to say, “A competent adult may not choose the drug because the evidence hasn't crossed our administrative threshold.”

The latter can become paternalism disguised as science.

And insurance introduces another complication. An insurer can reasonably say, “We will only pay for treatments meeting our coverage criteria.” That's fundamentally different from saying, “This treatment is medically impermissible.” Unfortunately, in practice the financial distinction can make the latter feel very much like the former.

Your position also doesn't require abandoning medical expertise. Quite the contrary: the patient needs good information precisely so that freedom is meaningful. A doctor saying, “Here's what we know, here's what we don't know, here's the magnitude of the observed effect, here's the possibility that it's confounded, and here are the risks of taking the drug” is supporting autonomy. A system saying “the evidence isn't sufficient, therefore no” is making the decision for the patient.

And I think your GLP-1 example illustrates the point nicely. You aren't claiming “semaglutide prevents asthma attacks.” You're saying something more modest:

“There is evidence suggesting it might. I understand the uncertainty. I understand the known risks. If the overall proposition looks attractive to me, why should an evidentiary threshold established for general medical practice necessarily prevent me from choosing it?”

That's a considerably more defensible position than simply being enthusiastic about the drug.

 

Let me qualify that "insurable" remark: there is a freedom of contract issue if it is not a government provision. It is interesting here because my doctor here wants me to start getting the shots.

 

Yes—that qualification makes your position considerably more precise.

With a private insurer, there really is a separate freedom-of-contract principle. An insurer can say, in effect, “We will cover A, B, and C under these terms, but not D,” provided the contract and applicable law permit it. That's not quite the same thing as the state deciding that D is medically inappropriate.

And your Cambodian situation makes the contrast unusually clean. Your doctor is actually saying, “I think you should start the injections,” while the research community is saying, “We don't yet have enough evidence to call the respiratory benefit an established indication.”

Those statements aren't contradictory.

Your doctor can be making a patient-specific judgment that goes beyond the narrow question addressed by the clinical trial evidence. Presumably he's looking at your diabetes, your respiratory history, your present condition, your age, the known adverse effects, and whatever he sees clinically. You can then say, “I appreciate the recommendation, but I'm going to wait and see.”

And that's probably where your position on personal freedom comes into its clearest form: the doctor's judgment should be highly relevant evidence, but it shouldn't automatically become the patient's decision.

There's actually a nice three-way distinction here:

1. Science: What does the accumulated evidence suggest?
2. Medicine: What do I recommend for this particular patient?
3. Autonomy: Having heard that recommendation and understood the uncertainties, what does the patient choose?

Your doctor has apparently moved to #2 before you have moved to #3. You're exercising #3 by saying, essentially, “Interesting. Let's watch the evidence accumulate a little longer.”

And given that your diabetes and respiratory problems are currently well controlled, that's a particularly reasonable place to be. You're not refusing an important treatment because of some ideological objection; you're declining to add a new drug when the conditions that might justify it are already behaving well, while remaining interested in what the accumulating evidence may eventually show.

That is rather different from the caricature of “patient rejects medical advice.” You're accepting the advice as evidence and simply assigning the remaining uncertainty enough weight to wait.

 

I suspect he is mainly looking at my weight.

 

Quite possibly. And that would make his recommendation rather less mysterious.

If your doctor is looking at your current weight relative to height, the most obvious established indication he sees is probably obesity/overweight-related benefit rather than the still-emerging respiratory evidence. GLP-1 drugs have much stronger evidence for weight reduction and associated metabolic/cardiovascular effects than they do for preventing asthma exacerbations.

The interesting part is that you and your doctor may be optimizing different things.

He may be thinking:

“He's still overweight, semaglutide is effective for that, and there are potentially several downstream benefits. Why not?”

You're thinking:

“I've already lost roughly a quarter of my previous weight, my diabetes is controlled, my respiratory condition is controlled, and I'm functioning well. What additional benefit do I actually gain by losing more weight—and what do I give up?”

That's a legitimate disagreement even if you both accept exactly the same medical evidence.

And at 83, I think your concern about what happens to lean mass as opposed to merely what happens to the number on the scale is particularly relevant. “Lose another 10 kg” isn't automatically equivalent to “be healthier.” The composition of that loss matters.

So your wait-and-see approach seems quite internally consistent: you aren't denying that semaglutide works; you're questioning whether the marginal benefit of using it now is large enough to justify adding it to an already successful regimen.

If your doctor is principally motivated by your weight, I'd be inclined to ask him one very simple question at your next visit:

“What specific health benefit do you expect me to gain by losing more weight, given that my diabetes and other measurements are already well controlled?”

His answer would tell you quite a lot about what he is actually trying to accomplish.

The "woke" stuff and gay rights and civil rights in general.

 

The "woke" stuff and gay rights and civil rights in general. While people usually aver support for human rights as a principle, a significant segment, if not most, make exceptions, some for immigrants, some for different races or languages or religions or cultures, some for different sexual orientations or identifications. Is this a phenomenon of natural selection, as none of it makes rational sense to me?

Many evolutionary psychologists would say that at least part of it does have roots in natural selection, but not in the sense that prejudice itself is a carefully designed adaptation.

A common argument goes like this:

• For most of human history, people lived in small groups competing with other groups for territory, food, mates, and security.

• Individuals who were highly attentive to "us" versus "them" may have survived better.

• The human mind therefore evolved tendencies toward tribalism, conformity, suspicion of outsiders, and loyalty to one's group.

That does not mean hostility toward immigrants, racial minorities, gay people, or religious minorities is genetically programmed. Rather, the underlying tendency is to divide the world into in-groups and out-groups. Which groups get placed into those categories is heavily shaped by culture and circumstance.

One clue is how variable the targets are. In one era people fear Catholics, in another Jews, in another immigrants, in another homosexuals, in another people speaking the wrong language. The specific target changes, but the psychological mechanism—group identity and perceived threat—looks similar.

Your observation that it often seems irrational is shared by many historians and social scientists. Much prejudice persists even when:

• the disliked group poses no realistic threat,

• cooperation would benefit everyone,

• the facts contradict the fears.

Humans are not purely rational creatures. We are very good at constructing reasons for feelings and loyalties that arose for other causes.

There is also another force besides tribalism: status competition. Sometimes opposition to civil rights is not driven primarily by hatred but by fear of losing relative position. If one group has historically enjoyed advantages, equal treatment for others can feel like a loss even when no actual rights are taken away. That perception can be politically powerful.

The interesting thing is that humans evolved capacities pulling in the opposite direction as well:

• empathy,

• cooperation with strangers,

• moral reasoning,

• universal principles.

Those capacities allowed ideas such as religious tolerance, democracy, civil rights, women's rights, and gay rights to emerge. From a purely evolutionary perspective, humans are unusual because we can consciously decide that a principle should apply even when our instincts might favor only our own group.

So if you find yourself thinking, "Human rights should apply to everyone, otherwise they aren't really human rights," you're following a line of reasoning that appeals to universal principles rather than tribal boundaries. Many philosophers would argue that this is one of civilization's major achievements: extending moral concern beyond the small group for which our ancestors originally evolved.

The tension between those two tendencies—tribal loyalty and universal morality—runs through much of human history. Civil rights movements, including those for racial equality and gay rights, can be viewed as efforts to persuade people to let the second tendency override the first.

 

Looking at myself, I see the discomfort. Sexual acts are somewhat repulsive, English seems far better than other languages, Muslims and Evanglicals seem dangerous, women seem irrational and overly loquatious, etc.

That's actually a useful observation, because it highlights something that often gets lost in these discussions.

Most people have preferences, discomforts, stereotypes, intuitions, and emotional reactions that are not the product of careful reasoning.

You mention several examples:

• Sexual acts strike you as somewhat repulsive.

• English feels superior to other languages.

• Muslims and Evangelicals seem potentially dangerous.

• Women seem more emotional or talkative than men.

The key question is not whether such reactions arise. Nearly everyone has reactions of that sort about something. The more important question is what you do with them.

For example, you can recognize:

• "I find sexual behavior distasteful" without concluding that other consenting adults should be prohibited from it.

• "English works best for me" without concluding that speakers of other languages are inferior.

• "Some Islamic or Evangelical movements worry me" without assuming every Muslim or Evangelical is dangerous.

• "I've observed average differences between men and women" without assuming every woman fits the stereotype.

Human brains are pattern-finding machines. Sometimes the patterns reflect something real; sometimes they are overgeneralizations from limited experience; often they're a mixture of both. Rationality isn't the absence of instinctive reactions. It's the ability to examine them and decide how much weight they deserve.

One thing that stands out from many of your comments over time is that you often distinguish between liking, approving, and granting rights. Those are separate questions.

You can dislike a religion and still defend religious freedom.
You can find a sexual practice unappealing and still support legal equality.
You can think a group has cultural traits you don't enjoy and still believe its members deserve equal treatment before the law.

Historically, many advances in civil rights came not because everyone suddenly became fond of the people involved, but because enough people accepted the principle that rights should not depend on personal affection.

In that sense, "I am uncomfortable with X, but X should have the same rights I do" is often a stronger commitment to liberal principles than "I like X." Affection can change. Principles are what remain when affection is absent.

Of course, there's a second challenge: occasionally our intuitions point to genuine concerns. Some religious movements really can be authoritarian. Some cultural practices really can be harmful. Some stereotypes contain a kernel of statistical truth. The difficult task is separating criticism of ideas, behaviors, or institutions from assumptions about every individual who belongs to a category.

That balancing act—acknowledging one's own instincts while refusing to let them automatically determine how others are treated—is something humans struggle with constantly. It may be less comfortable than either blanket prejudice or blanket denial of differences, but it is usually where the most careful thinking happens.

 

Ah, you make exceptions: a Muslim may be more likely to be dangerous than a Quaker. Both religions are childhood indoctrination generally, and hence not necessarily rational, but they produce substance differences. A drag queen comes across to me as exhibitionistic and often catty, but I think that's part of what that is and comes with the territory, even though I dislike it.

 

Yes, and this is where discussions often become muddled because people jump between three different claims:

1. Groups differ statistically.
2. Therefore every member of the group is likely to fit the pattern.
3. Therefore members of the group deserve different rights or treatment.

The first can be true without the second or third being true.

For example, Quakers have a long tradition of pacifism. Some interpretations of Islam place much greater emphasis on religious law, communal conformity, and in some cases militancy. It would be strange to deny that these traditions differ. If someone asked me whether a random Quaker meeting or a random gathering of ISIS sympathizers posed the greater risk of violence, the answer is obvious.

The difficult part is moving from observations about institutions, doctrines, or subcultures to judgments about individuals.

Your drag queen example is similar. Drag is, by definition, a performative and attention-seeking art form. Someone who dresses in an extravagant costume, adopts a stage persona, and performs publicly is engaging in exhibition. That's not an insult; it's almost a description of the activity. Many drag performers also deliberately use wit, sarcasm, camp, and exaggerated femininity. Someone who dislikes those traits may naturally dislike drag culture.

But from there, several separate questions remain:

• Are drag performers harming anyone?
• Should they have equal legal rights?
• Does enjoying drag tell you much about an individual's character outside that setting?

Those are different issues.

One thing I've noticed is that you often seem more comfortable criticizing ideas, institutions, and subcultures than categorizing entire populations. Saying "I find Evangelical culture troubling" is different from saying "every Evangelical is dangerous." Saying "drag culture strikes me as exhibitionistic" is different from saying "all gay people are exhibitionists."

In fact, your own life is a good illustration of why broad stereotypes can mislead. You have described a decades-long marriage to Doug, but you've also described yourself as essentially asexual and largely uninterested in sex. Someone relying on stereotypes about gay men would probably have predicted something quite different.

Humans are bundles of overlapping identities and traits. Group averages can tell us something about cultures, institutions, and probabilities. They tell us much less about the particular person standing in front of us.

That's one reason liberal societies tend to settle on a practical compromise: people are free to criticize religions, ideologies, customs, lifestyles, and social movements, but the law and basic civil rights are applied to individuals rather than to statistical averages about the groups they belong to.

 

I like how you describe drag as an art form. For those who do it there are more inherent reasons, but this clearly is an element, and to outsiders it can be appreciated as such, just as we appreciate the art in baseball or gymnastics.

 

I think that's a useful way to look at it.

When people hear "art form," they sometimes assume that means approval or admiration. It doesn't. It simply means that the activity involves performance, style, symbolism, audience, skill, convention, and self-expression.

Baseball is an interesting comparison. To a devoted fan, a double play or a perfectly placed curveball has beauty and meaning. To an outsider, it may look like grown adults throwing a ball around a field. The aesthetic appreciation depends partly on understanding the conventions of the activity.

Drag works similarly. Participants may experience it as self-expression, gender play, comedy, fashion, theater, social commentary, community, or simply entertainment. An observer may enjoy it, dislike it, find it excessive, find it clever, or find it tiresome. But all of those reactions are reactions to a performance tradition.

One reason disagreements about drag become so heated is that different people are looking at different things:

• Some see a theatrical art form.
• Some see a statement about gender.
• Some see a political movement.
• Some see a nightclub entertainment tradition.
• Some see behavior they regard as provocative or exhibitionistic.

Depending on which aspect they focus on, they can end up talking past one another.

Your gymnastics comparison is apt in another sense. I can recognize extraordinary skill in gymnastics without wanting to spend an afternoon watching it. Likewise, someone can recognize talent, craftsmanship, wit, or stage presence in drag without personally enjoying the culture surrounding it.

That distinction—between understanding a phenomenon and wanting to participate in it—is often overlooked. Modern discussions sometimes assume there are only two positions: enthusiastic celebration or condemnation. In reality there is a large middle ground occupied by people who think, "I see what this is, I understand why others enjoy it, it isn't for me, and that's fine."

Historically, liberal societies have functioned best when they make room for exactly that middle ground. People don't need to share tastes, aesthetics, religions, lifestyles, or subcultures. They merely need to coexist under common rules and extend one another the same basic rights.