- - Wednesday, September 11, 2013

Critical decisions require preoperative clarity.

As the saga in Syria demonstrates, life is full of dilemmas for all of us. As I was approaching the end of my residency training for neurosurgery, I was faced with the significant dilemma of deciding whether to pursue private practice opportunities, which were offering a great deal of money, or remain in an academic practice with little in the way of financial rewards, but with great opportunities to contribute to the field. After much soul-searching and prayer, I decided on an academic career.

In retrospect, I think that was the correct choice. It gave me not only an opportunity to make neurosurgical contributions, but because of the storybook nature of my career, I was afforded a platform from which many lives outside of the medical arena would be positively affected.

Now our nation is faced with the very difficult dilemma of whether or not to involve ourselves militarily in the Syrian conflict. The Middle East has been the site of almost continuous conflict for hundreds of years despite our efforts and the good intentions of many other nations around the world. The relationships between the various factions that are fighting are extremely complex and plunging oneself into the middle of them without a deep understanding of all the players is unlikely to yield peace. Fortunately, a breakthrough may be at hand if Syria places its chemical weapons under international control.

The current Syrian conflict is about two years old and has produced about 100,000 deaths — 1,400 of which have been attributed to chemical warfare. This has evoked an angry response from much of the world, but at the same time, most world leaders are reluctant to advocate or endorse an external military solution. Perhaps they are asking the question: “Why is it worse to kill 1,400 people with chemicals than it is to kill 100,000 people with conventional weapons?” Certainly, some thought should be devoted to the answer that question. We should also be asking who are the good guys and who are the bad guys in the Syrian conflict, and how do we make that determination? It certainly seems that the constituency of the rebels is undergoing metamorphosis and now includes avowed enemies of the United States and Israel. What will these people do if they, rather than an international force, are able to gain control of a chemical-weapons stockpile, and what role will they play in a new government? Are we certain that the chemical attack was ordered by the current government and not by members of the rebel group who would benefit greatly by staging such an attack in a way that would implicate the government of Syrian President Bashar Assad? If we didn’t help the Iranian people four years ago when they were rising up against a totalitarian government, why are we now involving ourselves in a conflict that is not nearly as clear cut as that one was? Is it only because we suspect that the government used chemical weapons against its own people? If the answer to that last question is yes, then the only thing that rebels have to do in the future to secure our help is to feign a government-sponsored chemical attack on the people. This is not to say that the rebels were responsible for the current attack, but it is to emphasize the fact that we need to establish clear, well-thought-out policies that are understandable by the average citizen.

When I faced difficult surgical decisions, I used to perform something called a best-worst analysis. This is explained in some detail in my book “Take the Risk,” but basically involves asking four questions:

1. What’s the best thing that happens if I do it?

2. What’s the worst thing that happens if I do it

3. What’s the best thing that happens if I don’t do it?

4. What’s the worst thing that happens if I don’t do it?

If one thoughtfully answers these questions, it is pretty easy to see that the worst things could be catastrophic not only in the Middle East, but could trigger World War III. In light of that possibility, the argument that America must act to avoid the appearance of a paper tiger seems trite. I certainly am not advocating ignoring what has happened in Syria, but I think it would be wise to support the move to place Syria’s chemical-weapons stockpile under international control and explore other non-military options, such as a financial boycott. These are things that could and should fall under the purview of the United Nations, which at some point needs to justify its existence.

When this crisis is over and before the next one starts, we need to clarify our goals not only in the Middle East, but around the world. These should not be partisan issues; we cannot afford to change our goals with each administration. We must also not waste this opportunity to learn important lessons. We do not need to draw red lines in the sand that telegraph our intentions. Rather, we need leaders whose foreign policy is guided by America’s best interests, rather than their own political motives.

Ben S. Carson is professor emeritus of neurosurgery at Johns Hopkins University.

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