Mark Twain (Samuel Clemens) spent his youth deciphering the Mississippi River, a system far more complex than any artificial intelligence (AI) algorithm. He learned that real understanding demands nuance, context, and skepticism. Were he alive today, he’d likely see NarxCare, the controversial opioid-risk AI algorithm, as a cautionary tale about the dangers of replacing human judgment with lies, damn lies, and statistics.
NarxCare scores patients based on morphine milligram equivalents and pharmacy shopping patterns, ignoring critical factors like tolerance, genetics, and socioeconomic context, factors Twain, the great observer of human complexity, never overlooked. Like river pilots who mistook calm waters for safety, NarxCare’s designers believe prescription data can predict overdose risk with mathematical certainty. But Twain knew better because beneath calm surfaces often lurked deadly currents.
Samuel Clemens’ romantic view of the river faded as he learned its hidden mechanics. In river slang, “Mark Twain” meant “two fathoms deep,” a safe depth for steamboats to navigate, measured by the leadsman’s line and called out to the pilot as a signal of safe passage through uncertain waters. Similarly, AI strips medicine of nuance, reducing pain care to a combined risk score. Patients stable for years on medication are flagged “high-risk” for crossing arbitrary AI algorithm thresholds. Like a pilot misreading a river chart, AI can’t distinguish danger from routine, a failure of judgment Twain would have derided.
“There are three kinds of lies: lies, damned lies, and statistics,” Twain once quipped. NarxCare inherits its data’s biases, much like AI predictive policing that conflates over-policing with high crime. In some communities, higher prescription rates reflect access or need, but NarxCare interprets this as risk. Twain, who distrusted blind consensus, would have seen this as statistical tyranny.
And then there’s the human cost. Twain’s characters—Huck, Jim, the Duke and King—were messy, flawed, and human. Artificial intelligence reduces people to categories. A chronic pain patient becomes a red flag. A veteran is labeled “likely to misuse.” A trauma survivor is deemed ineligible for relief. Real people are harmed. Doctors retreat into defensive medicine. Patients lose care. Despair follows.
Twain understood that mechanical systems, no matter how sophisticated, cannot replace human experience and wisdom. Artificial intelligence, like the shifting sandbars of the Mississippi, offers the illusion of control while concealing danger. Twain would warn us, not only because prediction is useless, but because blind faith in flawed AI models is perilous. As Twain said, “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.”
For all its data, NarxCare AI knows far less than it claims. Twain once read the river like a book, each ripple a word, each eddy a phrase. That living water shaped his vision of America. Today, our rivers are streams and waves of anonymized data, cold and unfeeling, feeding systems like NarxCare and AI predictive policing. These promise clarity but often deliver distortion. If Twain read rivers to understand America, we must learn to read these digital currents and waves with equal care.
Twain’s life depended on tiny observations, a flicker in the current, a shadow on the water. AI mimics this vigilance but without understanding. AI watches everything and knows nothing. Its judgments are indifferent and often erroneous. It lacks the reflexes and humanity of a pilot who knew life and death depended on subtle clues.
As Twain mastered the river, he mourned the magic lost to mechanistic understanding. In Life on the Mississippi, he lamented how poetry gave way to measurement. Today, we too have traded reality for red flag metrics. NarxCare AI reduces human pain relief to a number. It replaces doctor-patient relationships with AI black-box decisions. Patterns become pathology. Nuance is overridden by numbers. We’re left with Garbage In, Garbage Out, disguised as AI and run by technocrats who’ve never left the river dock. We’ve traded poetry for computer code, and in the process, lost compassion, creativity, and the courage to see patients as people.
Twain’s river teemed with unpredictable, complex lives. That chaos gave his writing soul. Today’s AI algorithms offer no such complexity. A mother in pain becomes a liability. A veteran becomes a statistic. A survivor becomes suspect. This isn’t help—it’s harm. And who benefits? Not the patients.
Twain knew freedom involved risk. The rich human tapestry he celebrated is now flattened into spreadsheets. These systems erase complexity rather than reflect it. Huck and Jim found freedom on the river, but only by respecting its dangers and learning its rhythms. Our digital systems should do the same. NarxCare claims to protect but often punishes. People lose care not because of wrongdoing, but because an AI algorithm labels them a threat. There is no appeal. No raft. No Huck Finn to escape with.
Freedom in the digital age demands more than computer code. It demands transparency, humility, and safeguards against AI algorithmic violence. Twain warned: “Whenever you find yourself on the side of the majority, it is time to pause and reflect.” AI algorithms speak in a language few understand, but many obey. They’re maps handed to children expected to pilot ships. Designed by the powerful, enforced on the powerless, NarxCare, like AI predictive policing, wears the mask of objectivity while reproducing old injustices. It doesn’t see people. It sees probabilities. It acts not on what someone has done, but what a machine predicts they might. It replaces care with control.
In Twain’s era, the steamboat symbolized progress. But Twain wasn’t seduced. He was no Connecticut Yankee. He knew technology without judgment was dangerous. The river was alive. It required respect. Misreading it was fatal. AI is our generation’s new steamboat—praised for efficiency, yet blind to nuance. Twain would have seen through it. He would have recognized the hubris in believing machines can replace wisdom. Heraclitus said, “You cannot step into the same river twice.” AI disagrees. It treats people as static patterns, denying change and redemption.
We must resist this flattening. Real rivers and real people don’t move in straight lines. Twain’s river carried rogues and saints, all sharing the same current. He knew freedom came with risk, and compassion required understanding. Twain’s river taught him to read America, its beauty, blindness, and contradictions. Our modern data streams could do the same, but only if we approach them with Twain’s skeptical eye. We must ask ourselves. Who built these AI systems? Whose stories are excluded? What truths are erased? What myths are sold as science?
Twain wrote, “The face of the water, in time, became a wonderful book.” Today, the face of AI has become a dangerous fiction. Each metric is a mask. Each score a sentence. If we don’t learn to read it wisely, we risk losing not just justice but the practice of medicine itself.
Neil Baum is a urologist. Mark Ibsen is a family physician.
