[Content note: Suicide. May be guilt-inducing for people who feel like burdens. All patient characteristics have been heavily obfuscated to protect confidentiality.]

The DSM lists nine criteria for major depressive disorder, of which the seventh is “feelings of worthlessness or excessive or inappropriate guilt”.

There are a lot of dumb diagnostic debates over which criteria are “more important” or “more fundamental”, and for me there’s always been something special about criterion seven. People get depressed over all sorts of things. But when they’re actively suicidal, the people who aren’t just gesturing for help but totally set on it, they always say one thing:

“I feel like I’m a burden”.

Depression is in part a disease of distorted cognitions, a failure of rationality. I had one patient who worked for GM, very smart guy, invented a lot of safety features for cars. He was probably actively saving a bunch of people’s lives every time he checked in at the office, and he still felt like he was worthless, a burden, that he was just draining resources that could better be used for someone else.

In cases like these, you can do a little bit of good just by teaching people the fundamental lesson of rationality: that you can’t always trust your brain. If your System I is telling you that you’re a worthless burden, it could be because you’re a worthless burden, or it could be because System I is broken. If System I is broken, you need to call in System II to route around the distorted cognition so you can understand at least on an intellectual level that you’re wrong. Once you understand you’re wrong on an intellectual level, you can do what you need to do to make it sink in on a practical level as well – which starts with not killing yourself.

As sad as it was, Robin Williams’ suicide has actually been sort of helpful for me. For the past few days, I’ve tried telling these sorts of people that Robin Williams brightened the lives of millions of people, was a truly great man – and his brain still kept telling him he didn’t deserve to live. So maybe depressed brains are not the most trustworthy arbiters on these sorts of issues.

This sort of supportive psychotherapy (ie “psychotherapy you make up as you go along”) can sometimes take people some of the way, and then the medications do the rest.

But sometimes it’s harder than this. I don’t want to say anyone is ever right about being a burden, but a lot of the people I see aren’t Oscar-winning actors or even automobile safety engineers. Some people just have no easy outs.

Another patient. 25 year old kid. Had some brain damage a few years ago, now has cognitive problems and poor emotional control. Can’t do a job. Got denied for disability a few times, in accordance with the ancient bureaucratic tradition. Survives on a couple of lesser social programs he got approved for plus occasional charity handouts plus some help from his family. One can trace out an unlikely sequence of events by which his situation might one day improve, but I won’t insult his intelligence by claiming it’s very probable. Now he attempts suicide, says he feels like a burden on everyone around him. Well, what am I going to say?

It’s not always people with some obvious disability. Sometimes it’s just alcoholics, or elderly people, or people without the cognitive skills to get a job in today’s economy. They think that they’re taking more from the system than they’re putting in, and in monetary terms they’re probably right.

One common therapeutic strategy here is to talk about how much the patient’s parents/friends/girlfriend/pet hamster love them, how heartbroken they would be if they killed themselves. In the absence of better alternatives, I have used this strategy. I have used it very grudgingly, and I’ve always felt dirty afterwards. It always feels like the worst sort of emotional blackmail. Not helping them want to live, just making them feel really guilty about dying. “Sure, you’re a burden if you live, but if you kill yourself, that would make you an even bigger burden!” A++ best psychiatrist.

There is something else I’ve never said, because it’s too deeply tied in with my own politics, and not something I would expect anybody else to understand.

And that is: humans don’t owe society anything. We were here first.

If my patient, the one with the brain damage, were back in the Environment of Evolutionary Adaptedness, in a nice tribe with Dunbar’s number of people, there would be no problem.

Maybe his cognitive problems would make him a slightly less proficient hunter than someone else, but whatever, he could always gather.

Maybe his emotional control problems would give him a little bit of a handicap in tribal politics, but he wouldn’t get arrested for making a scene, he wouldn’t get fired for not sucking up to his boss enough, he wouldn’t be forced to live in a tiny apartment with people he didn’t necessarily like who were constantly getting on his nerves. He might get in a fight and end up with a spear through his gut, but in that case his problems would be over anyway.

Otherwise he could just hang out and live in a cave and gather roots and berries and maybe hunt buffalo and participate in the appropriate tribal bonding rituals like everyone else.

But society came and paved over the place where all the roots and berry plants grew and killed the buffalo and dynamited the caves and declared the tribal bonding rituals Problematic. This increased productivity by about a zillion times, so most people ended up better off. The only ones who didn’t were the ones who for some reason couldn’t participate in it.

(if you’re one of those people who sees red every time someone mentions evolution or cavemen, imagine him as a dockworker a hundred years ago, or a peasant farmer a thousand)

Society got where it is by systematically destroying everything that could have supported him and replacing it with things that required skills he didn’t have. Of course it owes him when he suddenly can’t support himself. Think of it as the ultimate use of eminent domain; a power beyond your control has seized everything in the world, it had some good economic reasons for doing so, but it at least owes you compensation!

This is also the basis of my support for a basic income guarantee. Imagine an employment waterline, gradually rising through higher and higher levels of competence. In the distant past, maybe you could be pretty dumb, have no emotional continence at all, and still live a pretty happy life. As the waterline rises, the skills necessary to support yourself comfortably become higher and higher. Right now most people in the US who can’t get college degrees – which are really hard to get! – are just barely hanging on, and that is absolutely a new development. Soon enough even some of the college-educated won’t be very useful to the system. And so on, until everyone is a burden.

(people talk as if the only possible use of information about the determinants of intelligence is to tell low-IQ people they are bad. Maybe they’ve never felt the desperate need to reassure someone “No, it is not your fault that everything is going wrong for you, everything was rigged against you from the beginning.”)

By the time I am a burden – it’s possible that I am already, just because I can convince the system to give me money doesn’t mean the system is right to do so, but I expect I certainly will be one before I die – I would like there to be in place a crystal-clear understanding that we were here first and society doesn’t get to make us obsolete without owing us something in return.

After that, we will have to predicate our self-worth on something other than being able to “contribute” in the classical sense of the term. Don’t get me wrong, I think contributing something is a valuable goal, and one it’s important to enforce to prevent free-loaders. But it’s a valuable goal at the margins, some people are already heading for the tails, and pretty soon we’ll all be stuck there.

I’m not sure what such a post-contribution value system would look like. It might be based around helping others in less tangible ways, like providing company and cheerfulness and love. It might be a virtue ethics celebrating people unusually good at cultivating traits we value. Or it might be a sort of philosophically-informed hedonism along the lines of Epicurus, where we try to enjoy ourselves in the ways that make us most human.

And I think my advice to my suicidal patients, if I were able and willing to express all this to them, would be to stop worrying about being a burden and to start doing all these things now.


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7 comments, sorted by Click to highlight new comments since: Today at 8:35 PM

This also relates to your thrive/survive theory. A society in extreme survive mode cannot tolerate "burdens" - it needs 100% of the populace to contribute. Infants may be a special exception for the few years until they can start contributing, but other than that if you can't work for whatever reason you die - because if the society will have to allocate to you more utility than what you can give back, it'll lose utility and die. This is extreme survive mode, there is no utility to spare.

As we move thriveward, we get more and more room for "burdens". We don't want to leave our disabled and elderly to die once they are no longer useful - we only had to do that in extreme survive mode, but now that we have some surplus we want to use it to avoid casting away people who can't work.

This presents us with a problem - if we can support a small number of people who can't work, it means we can also support a small number of people who don't want to work. Whether or not it's true, the ruling assumption to this very day is that if left unchecked enough lazy people will take up that opportunity that the few willing to work will crumble under their weight.

So we need to create mechanisms for selecting the people that will get more support than they contribute. At first it's easy - we don't have that much slack anyway, so we just pick the obvious people, like the elders and the visible disabled. These things are very hard to fake. But eventually we run out of that, and can afford giving slack to less and less obvious disabilities, and even to people just ran out of luck - e.g. lost their job and are having trouble getting a new one, or need to stay home to take care of family members.

And these things are much easier to fake.

So we do still try to identify these lazy people and make them work, but we also employ deterrents to make faking less desirable. Lower living conditions is a natural occurring deterrent, and on top of that society adds shame and lower social status. If you legitimately can't work there is not much you can do about it so you suffer through these deterrents. If you are just lazy, it might be better to work anyway because while not working won't get you killed it'll still get you shunning looks, disrespect, and that shameful feeling of being a burden on society.

This has false negatives and false positives, of course, but overall it was good enough a filter to let society live and prosper without throwing out too many unfortunate members.

But... thanks to this mechanism, working became a virtue.

This was useful for quite a while, but it makes it harder to move on. If it's shameful not to work, and everyone who don't have a special condition have to work, then society needs to guarantee enough work for everyone or we'll have a problem. Instead of having to conserve the little slack we have and carefully distribute it, we now need to conserve the find ways to get rid of all that slack because people need to feel useful.

(note that this is a first world problem. Humanity is spread out on the thrive/survive axis, and there are many places when you still need to work to survive and not just to feel good about yourself)

Some of the methods we use to achieve that are beneficial (as long as they don't screw up, as they sometimes do) - letting kids study until somewhere in their twenties, letting people retire while they still have some vitality left, letting people have days off and vacations, etc. But there are also wastes for the sake of waste, like workfare or overproducing, which we only do because work is a virtue and we need to be virtuous.

At some point technology will get so far, that we'll be able to allow a majority of the populace to not work. Some say we are already there. So we need to get out of this mentality fast - because we can't let too many people feel like they are a burden on society.

I'm... not really sure how that "virtue" can be rooted out...

I came to a similar conclusion from a different angle. Instead of the past, I considered the future - specifically the future of automation. There is a popular pessimistic scenario of machines taking up human jobs making everyone - save for the tycoons who own the machines - unable to provide for themselves. This prediction is criticized by pointing out that automation in the past created better jobs, replacing the ones it took away. Which is countered by claiming that past automation was mainly replacing our muscles, but now we are working on automation that replaces our brains, which will make humans completely obsolete. And now that I read this post, I realize that these better jobs created by automation left many people behind, so wouldn't better automation leave even more people behind?

So developing automation has ethical problems - even if it benefits society as a whole, is it really okay to sacrifice all these people to attain it?

My ethical framework is based on Pareto efficiency - solutions are only morally acceptable if they are Pareto improvements. I wouldn't call it "fully consistent", because it raises the question of "Pareto improvement compared to what?" and by cleverly picking the baseline you can make anything moral or immoral as you wish. But if you can hand-wave that fundamental issue away it forms this vague basic principle:

A solution where everyone benefits is preferable to a solution where some are harmed, even if the total utility of the latter is higher than that of the former.

Sometimes the difference in total utility is very big, and it seems like a waste to throw away all that utility. Luckily real life is not a simple game theory scenario with a fixed and very small number of strategies and outcomes. We have many tools to create new strategies or just modify existing ones. And if we have one outcome that generates a huge surplus at the expense of some people, we can just take some of that surplus and give it to them, to create a new outcome where we have it all - every individual is better off and the total utility is greatly increased.

Even if a solution without the surplus division can result in more utility overall, I'd still prefer to divide the surplus just so no one will have to get hurt.

And this is where UBI comes in - use a small portion of that great utility surplus we get from automation to make sure even the people who lose their jobs end up at a net benefit.

But if we apply this to the future, why not apply it to the present as well? Use the same principle for the people who already got hurt due to automation?

"And that is: humans don’t owe society anything. We were here first" - not true. Society as an idea was clearly established before human race, before language, before thought, it is an all-ape thing, maybe even wider. And (almost) every individual society is older than its individual members. And you apply an illegitimate operation of comparing the individual society with human as an idea. Maybe your idea in general is good, but you're using a wrong argument - incorrigibly wrong, as far as I can tell.

Human psychology as it was optimized for the ancestral environment has been around longer than modern society.

But modern society is an individual example of the general idea of society, whereas human psychology as optimized is a general idea (performed in every specific individuum to a certain degree).

This feels like a bad faith nit-pick. If we taboo the word "society", you and Scott obviously agree on the sorts of structures that used to exist -- the kinds that exist among most/all primates -- in which the people today who struggle may have easily found a place and a role and acceptance, and you both agree that the kinds of social structures that don't do a good job of making life feel meaningful for these people are pretty new compared to the timeline of modern humans.

Taboo the word, replace it with the idea, and see if you still disagree.

Now for me to exercise good faith and strong-man your argument.

"Hey Scott, I like your idea overall, but worry that using the word "Society" may be too general of a term, and may cause confusion -- since most primates and even ants have societies -- so what you're talking about here is narrower than that. I don't know if there's a better word or term you could use throughout, or if one clarifying remark could avoid that pitfall, but I think it may be worth a small edit. Thank you."

Sorry, but I do not think that this is a term disagreement and that your "strong-manning" is faithful to my comment. I believe that Scott's idea is somewhat inconsistent because he puts an individual example against a general idea; a specific structure against a set of psychologies.