Harm mitigation vs. cure

Scott Alexander has a very good post up about semantics and gender, which you should read in its entirety even though it is very long.  I have nothing to add to his main thesis, but there is a cute little anecdote about a woman with OCD whose life was nearly ruined by her fear she’d left the hair dryer plugged in, no matter how many times she checked it or how far she was from her house.  She was on the verge of living on SSDI for life despite trying every therapy and medication in the book.

Finally, a psychiatrist suggested she keep the hair dryer with her.  This transformed “checking if the hair dryer is unplugged” from a 40 minute task (to drive home and back) to a 2 second one.   The psychiatrists at the hospital were divided on this.  Scott doesn’t specify, but I assume the argument against was that you have to rip the problem out by its roots.  OCD is anxiety in search of a cause and if you assuage this one she’ll just find something new to worry about, and if you keep treating the symptoms she’ll end up loading her car with every appliance she owns every day.

This strain of thought is not baseless, and I think it’s important to keep in mind when developing population-level guidelines for treatment.  I also think that any doctor that argues that hairdryer therapy for this particular woman should be sent to a reeducation camp, because

  1. it worked, so shut up
  2. root-cause psychiatry and psychology had their shot.  They had in fact emptied an entire clip into the problem and had no more bullets.  At that point, unless something is actively and immediately harmful, they need to gracefully exit the field.

There’s also the matter that the problem was not just “she felt bad”, but also “she’s about to lose her job.”  Jobs are important.  They provide the money and health insurance that let you go to fancy psychiatrists that don’t believe in hair dryers.  Even if you’re independently wealthy, jobs are important psychologically and socially.  SSDI is oriented around the problems of factory workers who lost limbs, and really does not work well with people with high-variance mental disabilities, who can do some work some of the time but cannot function at the level society demands.   If hair dryer therapy does nothing more than buy you six more months before she experiences a negative shock from which it is very difficult to recover, that’s actually pretty good.

Even more than that, I think the psychiatrists are underestimating palliative care.  I absolutely do not think overcoming mental disorders is a matter of will power or wanting it enough, but I do believe that human brain and body are very good at repairing themselves, and that this implies that any non-traumatic disorder that persists must be in a self-reinforcing loop.  Chronic pain lowers your pain tolerance, worry that something will trigger a panic attack makes you anxious.  Pain and depression are mutually reinforcing.  Mental Illness saps your energy and cope and time, which makes it difficult to seek and follow through on treatment.  “Palliative” care like pain killers and anti-depressants give people energy they can use to heal, which is why oncologists sometimes prescribe them. For big scary things we don’t know how to cure, freeing up the patient’s own resources may be the most helpful thing we can do.

Meanwhile, my EA group is debating this article on charitable giving, which articulates something I’ve been trying to say for a long time, and not just about charities.  American capitalism is set up to encourage shooting the moon.  We’ve carried that over to charity, trying to find The One Simple Trick To End Poverty.  That is toxic on many levels: it doesn’t exist, we can’t measure finely enough to detect it, the most effective thing now is not going to be most effective thing after we’ve done it to death, finding things that work is a massive expense in its own right, and oh, poverty is a system of many millions of moving parts.  Waiting for the silver bullet is doomed and immoral, and perhaps a bit like refusing to let this patient adopt a hair dryer as her constant companion.  Yes, treating the root cause would be better, but it’s not on the table.

But that doesn’t mean we can stop doing RCTs and start firehosing money again.  It is tragically easy for aid to make things worse.  This is what the anti-hair dryerists were afraid of: that putting a salve on the symptoms will make the root problem, and thus eventually the symptoms, worse.  Possibly much worse.  Most people who gave food aid did it with the best of intentions: even the American agricorp executives who benefited probably convinced themselves this was a way of giving back .

So: you can’t tell people it’s cure or nothing, but you also have to be really careful with palliative care.  It’s even harder for charity, because you have to consider the externalities, not just the affect on the recipients.  This is one good argument for donating local, even if distant recipients are dramatically worse off: you will naturally get and give more feedback on a local charity’s effectiveness.  It’s also a very good argument for restricting yourself to charities that measure their effectiveness, almost independent of what the measurement says.  When we don’t know what to do, gathering new data is a good in and of itself.  And small pareto improvements may eventually free up the resources for societies to heal themselves.