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hyporational comments on Open Thread, October 20 - 26, 2013 - Less Wrong
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I think your perception of this problem has more to do with stigma associated with medical conditions. If you taboo the associated words, what you're left with is improving people and what's wrong with that? Do you oppose transhumanism on the same grounds?
And big pharma, we meet again. What is this singular, evil, money grabbing entity? I'd try to google it but I know I'd meet a violent mess of blogosphere mythology.
In the most narrow definition big pharma means AstraZeneca, Bristol-Myers Squibb Eli Lilly, GlaxoSmithKline, Merck, Novartis, Pfizer and Sanofi-Aventis.
If you define it a bit more widely it also includes the other members of PhRMA.
Those companies make money through being gatekeeprs. In the words of Sanofi-Aventis CEO Viehbacher that idea gets expressed:
In addition to validation big pharma also invests a lot of money in capturing the political process and pushing their drugs through various forms of marketing on as many people as possible.
As they make money by being a gatekeeper they make it harder for other people to enter the health care market.
The goal of transhumaism isn't to make people more normal. Various forms of transhumanism increase human diversity.
Upvoted for defining big pharma. Ok, let's say big pharma makes money as a gate keeper and controls policy. Does this argument lead us to some definitive point where's it's clear which drugs and treatments are good and which aren't, which drugs and treatments should be opposed and which shouldn't?
Making people normal isn't my goal either.
What makes you think it's improving people?
Look at my post again -- which words would you like to taboo? I am pretty sure I can rewrite it without them.
It's neither singular nor evil. However it is a collection of entities which have certain goals (which mostly involve profits) and incentives to pursue these goals.
I'm not saying medicalization = improving people. What I'm saying is most solutions that are pejoratively called medicalization probably improve people in their opinion. From your post I would taboo "medical", "medicalization", "normal" and "big pharma". Keep in mind that medicine is optional and patients have different perceptions of what they would call improvement. I think they should have as many options as possible and safe.
I was unfair and I agree with this. They also compete with each other and with regulating mechanisms. Therefore I think "big pharma" is a lazy and misleading expression.
Sure.
The trend to consider certain conditions and psychological states "diseases" or "illnesses" (which implies biological causality) is bad because:
It narrows the range of what's considered acceptable human variation. Consider e.g. a grumpy guy. Would it be good if he were to be diagnosed with the illness of grumpiness (with associated social costs) and prescribed a pill for that?
It assumes biological causality for what are not necessarily problems of human biology (or biochemistry).
There are considerable forces in the business world which would stand to gain huge amounts of money were this to happen. This is not an outright argument against per se, but it does make one suspicious.
Well, among other things, it depends on what the pill does. If it doesn't make him less grumpy, for example, then I can't see any benefit at all. If it makes him less grumpy but also does a bunch of other stuff that leaves him worse off, then there's no net benefit. Etc.
All that aside, if being prescribed a pill that makes me less grumpy inevitably subjects me to social attack, I would say that being able to be less grumpy is a good thing, and the social attacks are bad things, and the net value of being prescribed the pill depends on the ratio of costs to benefits.
And in both cases, I would strongly endorse a social shift that stops attacking me for being prescribed such a pill, rather than blame the pill for the social attacks. There's all kinds of things I can do that subject me to social attacks; blaming me for doing them on that basis is suboptimal.
Here again, it depends on what the pill does. If I start with a false theory of the causes of the problem, I'm unlikely to come up with a pill that actually solves the problem in an acceptably targetted way; by the same token, if the pill actually does make me less grumpy without too many side-effects, that's a pretty good sign that there's a biological (or biochemical) cause for grumpiness.
Incidentally, I would say all the same things about being prescribed a pill that makes me less cancerous.
Actually, I would argue that it's not good regardless of what the pill does.
That's 'cause you're looking at it too narrowly. Is there a benefit for the doctor who sees the guy and who gets paid for it? Sure is. Is there benefit for the company which makes the pill and sells it for a nice profit? Sure is.
What subjects you to social attack is having been diagnosed with a mental illness.
It's not what you can do -- it's what can be done to you.
Not necessarily. A common description of the effects of SSRI anti-depressants on some people is that they make you feel completely indifferent inside. Sure, you don't want to kill yourself any more, but you don't want ANYTHING. I am pretty sure that if you react to anti-depressants this way, they will also make you less grumpy. That doesn't mean grumpiness has a biochemical cause.
Would you deny treatment from a patient who has different values from yours?
This is a separate issue and applies to all treatments.
"Mental illness" is old and stigmatizing terminology. People who need help shouldn't be left undiagnosed just because of cultural connotations. Luckily there are confidentiality laws that prevent people having "psycho" tattooed on their forehead.
I take SSRIs regularly. I also happen to be a doctor. The kinds of social costs you're talking about aren't there because judgmental people don't know about my condition. I can tell you yes they make me feel different inside and yes they make me feel less motivated and less emotional. I'm still motivated to do things I would normally do, just a bit less. Depression doesn't make people motivated to do anything positive either. If those people think that SSRI induced state is not preferable to depression, they can quit medication. It's their choice.
How bad would you have to feel to consider killing yourself? Just think about it, try to imagine it vividly. I will take my current condition any day compared to the black, hopeless void that's waiting for me if I don't. That's my choice to make, not yours or big pharma's.
Given that the SSRI messes with their ability to make motivated self determined choices, they don't have full freedom.
There are also a lot of cases where a person might be forcefully hospitalised.
Part of the idea of having a doctor as an expert is also that the doctor will make choices.
I don't think that anybody here advocates that you shouldn't have the choice.
That's a strong claim to make without a shred of evidence.
Are you saying this shouldn't be done? Do you understand how or why it is done?
I think there's this concept of "informed consent". Doctors are expected to make choices, yes, but at no time is the patient rendered powerless in these decisions.
It was a rhetorical device. Don't twist it to make it something else. Replace "me" with anyone else.
Given that I don't know where the people I'm talking with live I know that I don't have full knowledge of how it's done. If I tell someone to go to a local doctor, I'm not sure what the doctor will do with them.
A doctor in a small town in Utah, in Washington, in Berlin, in Moscow, in some small Russian down, in Mumbai or in some small Indian town.
As to why people get hospitalized I think there are three whys: 1) Why did doctors get that power historically? 2) Why did nobody politically move to take that power away from them? 3) Which reasons do doctors have to make that decision?
As far as 1) goes, it has today with a general believe in the usefulness of authorities and removing people who might disturb society out of sight.
As far as 2) goes, Big Pharma wouldn't want that power to be taken away and lobbies accordingly. There political risk involved when you take the power away and then someone commites a suicide. Politcally it's much safer to just allow the status quo to perpetuate.
As far as 3) goes, experts want to do everything that's in their power to deal with a problem and have as much control over it as possible. It's human nature to seek power and use it.
As to how it's done, I have a bunch of anecdotal reports from people who reported that it is done pretty badly.
Theoretically the It's a bit like the standford prison experiment expect in the standford prison experiment the guards didn't have the choice to admister sedating substances.
There are plenty of issues involved and I haven't dealt enough with the issue to propose a specific reform. I guess an increase in accountability through auditing would help against power abuse, but getting something like that right is complicated.
It's no strong claim as you already conceeded that they reduce your motivation. If they do so it's easy to deduct that your choice to move away from the drug will also be effected.
I think choice engineering with a goal of 100% compliance rates has effects even if you allow for "informed consent". Power isn't all or nothing.
I didn't intend to focus on the "you" part. I think access to drugs is a different topic then the usefulness of doctors and the behavior of doctors.
I would like to legally access Modafinil in my country to experiment with whether it helps me. That doesn't mean that I want to interact with doctors about that topic. I would guess that Lumifer would also be in favor of complete drug legalisation.
That position is also the opposite of the one for which big pharma lobbies.
Do you believe that about cancer as well? Or merely about grumpiness?
I would similarly strongly endorse a social shift that stops attacking me for being diagnosed, rather than blame the diagnosis for the social attacks.
If I were subject to social attacks for being diagnosed with cancer, would you recommend we stop issuing cancer diagnoses, or recommend we stop attacking people diagnosed with cancer? I would recommend the latter. I feel the same way about mental illnesses.
I can't tell whether you consider that an example of "without too many side-effects," (in which case I simply disagree with you; flattened affect is an unacceptable side-effect here) or whether you somehow missed that phrase when you quoted it (which seems unlikely barring seriously motivated cognition).
Regardless, I agree that if the pill makes me less grumpy with lots of side-effects (for example, completely flattening affect as you describe), that's far less clear evidence than in the case I actually described which you quote.
I would similarly
You seem to think that having cancer and being grumpy are very similar conditions (in the context of discussing medicalization). To me that doesn't look like a serious assertion to engage with.
And evidently you don't consider anything else I said worth engaging with even to the extent of dismissing it as not worth engaging with, either. So, shall we drop this here?
This is why I thought that tabooing "associated words" would be a good thing. Many treatable conditions in medicine are not considered "diseases" or "illnesses" anymore, and they shouldn't be. This especially applies to psychiatry. Many diagnoses cannot be made unless the condition "causes significant harm to the patient" is met.
I would go even further than most doctors, and say that it's a failure of medicine to only try to normalize harmful conditions instead of trying to improve upon what's considered normal. This means that the language of medicine has to change even further. A diagnosis certainly shouldn't automatically be a "disease" and not even a "disorder".
"Acceptable human variation" and "illness of grumpiness" is a again a way to say there should be stigma attached to a diagnosis. I don't think there should and this is a separate problem from whether certain conditions should be considered treatable. If the guy thinks his grumpiness is a problem and causes significant harm, and it can be treated without side effects that are unacceptable to him, and he would knowingly accept the social costs, then I think he should have the option of treatment available. A diagnosis isn't an illness, it's a label that doctors use to communicate with each other.
Also keep in mind that therapy is a medical intervention too, and is usually better for specific behavioral problems.
Like TheOtherDave said, the pill is unlikely to work, unless there is a biological mechanism involved.
In this case one should be suspicious of all treatments and not just psychiatric ones, and perhaps one should. I think this is a separate problem from whether certain conditions should be considered treatable. There's certainly a need for a system that has less perverse incentives.
Well, I think you and I are approaching this thing from opposite directions. You're an optimist and I'm a cynic. Here's what I think you are imagining:
Grumpy Guy: Doctor, I'm grumpy. I don't want to be grumpy, it seriously screws up my life. Can anything be done to make me less grumpy?
Doctor: Hmm... Well, there that pill. Try it, see if it helps you.
And here's what I'm imagining:
Grumpy Guy: I'm here for my annual check-up.
Doctor: Hmm, you look grumpy. That's not good. <goes looks into his DSM manual> Tell me, does grumpiness lead to impairment of your social life?
Grumpy Guy: Um, I don't know. I guess..
Doctor: Aha! I hereby diagnose you with grumpiness. Here are two pills, come visit me in a month, we'll adjust the dosage and the interaction of the two pills. You will have to take them for the rest of your life. See you in a month!
I suppose my situation demands optimism. However, I think both scenarios you're describing do happen, and I have no idea in what proportions. There's also a whole spectrum of behaviour between them.
I don't know how to prevent the scenario you're seeing, some patients are really passive. Any ideas?
Some of my optimism must stem from the fact that I'm finnish. Mostly public health care, minimal advertising and bans on most kinds of bribery help. Unfortunately the situation is quickly eroding due to privatization. (I'm not against privatization per se, just the way it's usually done.)
The passivity of a patient is not a good reason for the doctor to decide that he now has to run the patient's life.
More things help like cultural and religious uniformity (yes, I know about the Swedish minority, no, they're not different enough to matter) which leads to the high level of trust in the society, specifics of culture (protestant work ethic, strong cultural disapproval of cheating), etc.
In the best of all possible worlds I agree. What if the patient has a physical condition that lowers his quality of life or shortens it? How does a passive patient get help? Should all persuasion be banned? What's your solution to the situation?
All good points. Are you finnish? :)
By the way, I'm not downvoting you.
In theory, you offer help (which is different from force it) which the patient might accept or reject.
In practice, it depends, as usual.
No, but I have some familiarity with the Baltic Sea region.