May 30, 2010
Today's therapeutic ethos, which celebrates curing and disparages judging, expresses the liberal disposition to assume that crime and other problematic behaviors reflect social or biological causation. While this absolves the individual of responsibility, it also strips the individual of personhood, and moral dignity
-- George Will, townhall.com
Sandy is a morbidly obese woman looking for advice.
Her husband has no sympathy for her, and tells her she obviously needs to stop eating like a pig, and would it kill her to go to the gym once in a while?
Her doctor tells her that obesity is primarily genetic, and recommends the diet pill orlistat and a consultation with a surgeon about gastric bypass.
Her sister tells her that obesity is a perfectly valid lifestyle choice, and that fat-ism, equivalent to racism, is society's way of keeping her down.
When she tells each of her friends about the opinions of the others, things really start to heat up.
Her husband accuses her doctor and sister of absolving her of personal responsibility with feel-good platitudes that in the end will only prevent her from getting the willpower she needs to start a real diet.
Her doctor accuses her husband of ignorance of the real causes of obesity and of the most effective treatments, and accuses her sister of legitimizing a dangerous health risk that could end with Sandy in hospital or even dead.
Her sister accuses her husband of being a jerk, and her doctor of trying to medicalize her behavior in order to turn it into a "condition" that will keep her on pills for life and make lots of money for Big Pharma.
Sandy is fictional, but similar conversations happen every day, not only about obesity but about a host of other marginal conditions that some consider character flaws, others diseases, and still others normal variation in the human condition. Attention deficit disorder, internet addiction, social anxiety disorder (as one skeptic said, didn't we used to call this "shyness"?), alcoholism, chronic fatigue, oppositional defiant disorder ("didn't we used to call this being a teenager?"), compulsive gambling, homosexuality, Aspergers' syndrome, antisocial personality, even depression have all been placed in two or more of these categories by different people.
Sandy's sister may have a point, but this post will concentrate on the debate between her husband and her doctor, with the understanding that the same techniques will apply to evaluating her sister's opinion. The disagreement between Sandy's husband and doctor centers around the idea of "disease". If obesity, depression, alcoholism, and the like are diseases, most people default to the doctor's point of view; if they are not diseases, they tend to agree with the husband.
The debate over such marginal conditions is in many ways a debate over whether or not they are "real" diseases. The usual surface level arguments trotted out in favor of or against the proposition are generally inconclusive, but this post will apply a host of techniques previously discussed on Less Wrong to illuminate the issue.
What is Disease?
In Disguised Queries , Eliezer demonstrates how a word refers to a cluster of objects related upon multiple axes. For example, in a company that sorts red smooth translucent cubes full of vanadium from blue furry opaque eggs full of palladium, you might invent the word "rube" to designate the red cubes, and another "blegg", to designate the blue eggs. Both words are useful because they "carve reality at the joints" - they refer to two completely separate classes of things which it's practically useful to keep in separate categories. Calling something a "blegg" is a quick and easy way to describe its color, shape, opacity, texture, and chemical composition. It may be that the odd blegg might be purple rather than blue, but in general the characteristics of a blegg remain sufficiently correlated that "blegg" is a useful word. If they weren't so correlated - if blue objects were equally likely to be palladium-containing-cubes as vanadium-containing-eggs, then the word "blegg" would be a waste of breath; the characteristics of the object would remain just as mysterious to your partner after you said "blegg" as they were before.
"Disease", like "blegg", suggests that certain characteristics always come together. A rough sketch of some of the characteristics we expect in a disease might include:
1. Something caused by the sorts of thing you study in biology: proteins, bacteria, ions, viruses, genes.
2. Something involuntary and completely immune to the operations of free will
3. Something rare; the vast majority of people don't have it
4. Something unpleasant; when you have it, you want to get rid of it
5. Something discrete; a graph would show two widely separate populations, one with the disease and one without, and not a normal distribution.
6. Something commonly treated with science-y interventions like chemicals and radiation.
Cancer satisfies every one of these criteria, and so we have no qualms whatsoever about classifying it as a disease. It's a type specimen, the sparrow as opposed to the ostrich. The same is true of heart attack, the flu, diabetes, and many more.
Some conditions satisfy a few of the criteria, but not others. Dwarfism seems to fail (5), and it might get its status as a disease only after studies show that the supposed dwarf falls way out of normal human height variation. Despite the best efforts of transhumanists, it's hard to convince people that aging is a disease, partly because it fails (3). Calling homosexuality a disease is a poor choice for many reasons, but one of them is certainly (4): it's not necessarily unpleasant.
The marginal conditions mentioned above are also in this category. Obesity arguably sort-of-satisfies criteria (1), (4), and (6), but it would be pretty hard to make a case for (2), (3), and (5).
So, is obesity really a disease? Well, is Pluto really a planet? Once we state that obesity satisfies some of the criteria but not others, it is meaningless to talk about an additional fact of whether it "really deserves to be a disease" or not.
If it weren't for those pesky hidden inferences...
Hidden Inferences From Disease Concept
The state of the disease node, meaningless in itself, is used to predict several other nodes with non-empirical content. In English: we make value decisions based on whether we call something a "disease" or not.
If something is a real disease, the patient deserves our sympathy and support; for example, cancer sufferers must universally be described as "brave". If it is not a real disease, people are more likely to get our condemnation; for example Sandy's husband who calls her a "pig" for her inability to control her eating habits. The difference between "shyness" and "social anxiety disorder" is that people with the first get called "weird" and told to man up, and people with the second get special privileges and the sympathy of those around them.
And if something is a real disease, it is socially acceptable (maybe even mandated) to seek medical treatment for it. If it's not a disease, medical treatment gets derided as a "quick fix" or an "abdication of personal responsibility". I have talked to several doctors who are uncomfortable suggesting gastric bypass surgery, even in people for whom it is medically indicated, because they believe it is morally wrong to turn to medicine to solve a character issue.
While a condition's status as a "real disease" ought to be meaningless as a "hanging node" after the status of all other nodes have been determined, it has acquired political and philosophical implications because of its role in determining whether patients receive sympathy and whether they are permitted to seek medical treatment.
If we can determine whether a person should get sympathy, and whether they should be allowed to seek medical treatment, independently of the central node "disease" or of the criteria that feed into it, we will have successfully unasked the question "are these marginal conditions real diseases" and cleared up the confusion.
Sympathy or Condemnation?
Our attitudes toward people with marginal conditions mainly reflect a deontologist libertarian (libertarian as in "free will", not as in "against government") model of blame. In this concept, people make decisions using their free will, a spiritual entity operating free from biology or circumstance. People who make good decisions are intrinsically good people and deserve good treatment; people who make bad decisions are intrinsically bad people and deserve bad treatment. But people who make bad decisions for reasons that are outside of their free will may not be intrinsically bad people, and may therefore be absolved from deserving bad treatment. For example, if a normally peaceful person has a brain tumor that affects areas involved in fear and aggression, they go on a crazy killing spree, and then they have their brain tumor removed and become a peaceful person again, many people would be willing to accept that the killing spree does not reflect negatively on them or open them up to deserving bad treatment, since it had biological and not spiritual causes.
Under this model, deciding whether a condition is biological or spiritual becomes very important, and the rationale for worrying over whether something "is a real disease" or not is plain to see. Without figuring out this extremely difficult question, we are at risk of either blaming people for things they don't deserve, or else letting them off the hook when they commit a sin, both of which, to libertarian deontologists, would be terrible things. But determining whether marginal conditions like depression have a spiritual or biological cause is difficult, and no one knows how to do it reliably.
Determinist consequentialists can do better. We believe it's biology all the way down. Separating spiritual from biological illnesses is impossible and unnecessary. Every condition, from brain tumors to poor taste in music, is "biological" insofar as it is encoded in things like cells and proteins and follows laws based on their structure.
But determinists don't just ignore the very important differences between brain tumors and poor taste in music. Some biological phenomena, like poor taste in music, are encoded in such a way that they are extremely vulnerable to what we can call social influences: praise, condemnation, introspection, and the like. Other biological phenomena, like brain tumors, are completely immune to such influences. This allows us to develop a more useful model of blame.
The consequentialist model of blame is very different from the deontological model. Because all actions are biologically determined, none are more or less metaphysically blameworthy than others, and none can mark anyone with the metaphysical status of "bad person" and make them "deserve" bad treatment. Consequentialists don't on a primary level want anyone to be treated badly, full stop; thus is it written: "Saddam Hussein doesn't deserve so much as a stubbed toe." But if consequentialists don't believe in punishment for its own sake, they do believe in punishment for the sake of, well, consequences. Hurting bank robbers may not be a good in and of itself, but it will prevent banks from being robbed in the future. And, one might infer, although alcoholics may not deserve condemnation, societal condemnation of alcoholics makes alcoholism a less attractive option.
So here, at last, is a rule for which diseases we offer sympathy, and which we offer condemnation: if giving condemnation instead of sympathy decreases the incidence of the disease enough to be worth the hurt feelings, condemn; otherwise, sympathize. Though the rule is based on philosophy that the majority of the human race would disavow, it leads to intuitively correct consequences. Yelling at a cancer patient, shouting "How dare you allow your cells to divide in an uncontrolled manner like this; is that the way your mother raised you??!" will probably make the patient feel pretty awful, but it's not going to cure the cancer. Telling a lazy person "Get up and do some work, you worthless bum," very well might cure the laziness. The cancer is a biological condition immune to social influences; the laziness is a biological condition susceptible to social influences, so we try to socially influence the laziness and not the cancer.
The question "Do the obese deserve our sympathy or our condemnation," then, is asking whether condemnation is such a useful treatment for obesity that its utility outweights the disutility of hurting obese people's feelings. This question may have different answers depending on the particular obese person involved, the particular person doing the condemning, and the availability of other methods for treating the obesity, which brings us to...
The Ethics of Treating Marginal Conditions
If a condition is susceptible to social intervention, but an effective biological therapy for it also exists, is it okay for people to use the biological therapy instead of figuring out a social solution? My gut answer is "Of course, why wouldn't it be?", but apparently lots of people find this controversial for some reason.
In a libertarian deontological system, throwing biological solutions at spiritual problems might be disrespectful or dehumanizing, or a band-aid that doesn't affect the deeper problem. To someone who believes it's biology all the way down, this is much less of a concern.
Others complain that the existence of an easy medical solution prevents people from learning personal responsibility. But here we see the status-quo bias at work, and so can apply a preference reversal test. If people really believe learning personal responsibility is more important than being not addicted to heroin, we would expect these people to support deliberately addicting schoolchildren to heroin so they can develop personal responsibility by coming off of it. Anyone who disagrees with this somewhat shocking proposal must believe, on some level, that having people who are not addicted to heroin is more important than having people develop whatever measure of personal responsibility comes from kicking their heroin habit the old-fashioned way.
But the most convincing explanation I have read for why so many people are opposed to medical solutions for social conditions is a signaling explanation by Robin Hans...wait! no!...by Katja Grace. On her blog, she says:
...the situation reminds me of a pattern in similar cases I have noticed before. It goes like this. Some people make personal sacrifices, supposedly toward solving problems that don’t threaten them personally. They sort recycling, buy free range eggs, buy fair trade, campaign for wealth redistribution etc. Their actions are seen as virtuous. They see those who don’t join them as uncaring and immoral. A more efficient solution to the problem is suggested. It does not require personal sacrifice. People who have not previously sacrificed support it. Those who have previously sacrificed object on grounds that it is an excuse for people to get out of making the sacrifice. The supposed instrumental action, as the visible sign of caring, has become virtuous in its own right. Solving the problem effectively is an attack on the moral people.
A case in which some people eat less enjoyable foods and exercise hard to avoid becoming obese, and then campaign against a pill that makes avoiding obesity easy demonstrates some of the same principles.
There are several very reasonable objections to treating any condition with drugs, whether it be a classical disease like cancer or a marginal condition like alcoholism. The drugs can have side effects. They can be expensive. They can build dependence. They may later be found to be placebos whose efficacy was overhyped by dishonest pharmaceutical advertising.. They may raise ethical issues with children, the mentally incapacitated, and other people who cannot decide for themselves whether or not to take them. But these issues do not magically become more dangerous in conditions typically regarded as "character flaws" rather than "diseases", and the same good-enough solutions that work for cancer or heart disease will work for alcoholism and other such conditions (but see here).
I see no reason why people who want effective treatment for a condition should be denied it or stigmatized for seeking it, whether it is traditionally considered "medical" or not.
People commonly debate whether social and mental conditions are real diseases. This masquerades as a medical question, but its implications are mainly social and ethical. We use the concept of disease to decide who gets sympathy, who gets blame, and who gets treatment.
Instead of continuing the fruitless "disease" argument, we should address these questions directly. Taking a determinist consequentialist position allows us to do so more effectively. We should blame and stigmatize people for conditions where blame and stigma are the most useful methods for curing or preventing the condition, and we should allow patients to seek treatment whenever it is available and effective.