[Originally posted to my personal blog, reposted here with edits.]
You could call it heroic responsibility, maybe,” Harry Potter said. “Not like the usual sort. It means that whatever happens, no matter what, it’s always your fault. Even if you tell Professor McGonagall, she’s not responsible for what happens, you are. Following the school rules isn’t an excuse, someone else being in charge isn’t an excuse, even trying your best isn’t an excuse. There just aren’t any excuses, you’ve got to get the job done no matter what.” Harry’s face tightened. “That’s why I say you’re not thinking responsibly, Hermione. Thinking that your job is done when you tell Professor McGonagall—that isn’t heroine thinking. Like Hannah being beat up is okay then, because it isn’t your fault anymore. Being a heroine means your job isn’t finished until you’ve done whatever it takes to protect the other girls, permanently.” In Harry’s voice was a touch of the steel he had acquired since the day Fawkes had been on his shoulder. “You can’t think as if just following the rules means you’ve done your duty. –HPMOR
, chapter 75.
I like this concept. It counters a particular, common, harmful failure mode, and that it’s an amazingly useful thing for a lot of people to hear. I even think it was a useful thing for me to hear a year ago.
But... I’m not sure about this yet, and my thoughts about it are probably confused, but I think that there's a version of Heroic Responsibility that you can get from reading this description, that's maybe even the default outcome of reading this description, that's also a harmful failure mode.
A wrong way to think about heroic responsibility
I dealt with a situation at work a while back–May 2014 according to my journal. I had a patient for five consecutive days, and each day his condition was a little bit worse. Every day, I registered with the staff doctor my feeling that the current treatment was Not Working, and that maybe we ought to try something else. There were lots of complicated medical reasons why his decisions were constrained, and why ‘let’s wait and see’ was maybe the best decision, statistically speaking–that in a majority of possible worlds, waiting it out would lead to better outcomes than one of the potential more aggressive treatments, which came with side effects. And he wasn’t actually ignoring me; he would listen patiently to all my concerns. Nevertheless, he wasn’t the one watching the guy writhe around in bed, uncomfortable and delirious, for twelve hours every day, and I felt ignored, and I was pretty frustrated.
On day three or four, I was listening to Ray
’s Solstice album on my break, and the song ‘Something Impossible’ came up.
Bold attempts aren't enough, roads can't be paved with intentions...
You probably don’t even got what it takes,
But you better try anyway, for everyone's sake
And you won’t find the answer until you escape from the
Labyrinth of your conventions.
Its time to just shut up, and do the impossible.
Can’t walk away...
Gotta break off those shackles, and shake off those chains
Gotta make something impossible happen today...
It hit me like a load of bricks–this whole thing was stupid and rationalists should win. So I spent my entire break talking on Gchat with one of my CFAR friends, trying to see if he could help me come up with a suggestion that the doctor would agree was good. This wasn’t something either of us were trained in, and having something to protect
doesn't actually give you superpowers, and the one creative solution I came up with was worse than the status quo for several obvious reasons.
I went home on day four feeling totally drained and having asked to please have a different patient in the morning. I came in to find that the patient had nearly died in the middle of the night. (He was now intubated and sedated, which wasn’t great for him but made my life a hell of a lot easier.) We eventually transferred him to another hospital, and I spent a while feeling like I’d personally failed.
I’m not sure whether or not this was a no-win scenario even in theory. But I don't think I, personally, could have done anything with greater positive expected value. There's a good reason why a doctor with 10 years of school and 20 years of ICU experience can override a newly graduated nurse's opinion. In most of the possible worlds, the doctor is right and I'm wrong. Pretty much the only thing that I could have done better would have been to care less–and thus be less frustrated and more emotionally available to comfort a guy who was having the worst week of his life.
In short, I fulfilled my responsibilities to my patient. Nurses have a lot of responsibilities to their patients, well specified in my years of schooling and in various documents published by the College of Nurses of Ontario. But nurses aren’t expected or supposed to take heroic responsibility for these things.
I think that overall, given a system that runs on humans, that's a good thing.
The Well-Functioning Gear
I feel like maybe the hospital is an emergent system that has the property of patient-healing, but I’d be surprised if any one part of it does.
Suppose I see an unusual result on my patient. I don’t know what it means, so I mention it to a specialist. The specialist, who doesn’t know anything about the patient beyond what I’ve told him, says to order a technetium scan. He has no idea what a technetium scan is or how it is performed, except that it’s the proper thing to do in this situation. A nurse is called to bring the patient to the scanner, but has no idea why. The scanning technician, who has only a vague idea why the scan is being done, does the scan and spits out a number, which ends up with me. I bring it to the specialist, who gives me a diagnosis and tells me to ask another specialist what the right medicine for that is. I ask the other specialist – who has only the sketchiest idea of the events leading up to the diagnosis – about the correct medicine, and she gives me a name and tells me to ask the pharmacist how to dose it. The pharmacist – who has only the vague outline of an idea who the patient is, what test he got, or what the diagnosis is – doses the medication. Then a nurse, who has no idea about any of this, gives the medication to the patient. Somehow, the system works and the patient improves.
Part of being an intern is adjusting to all of this, losing some of your delusions of heroism, getting used to the fact that you’re not going to be Dr. House, that you are at best going to be a very well-functioning gear in a vast machine that does often tedious but always valuable work. –Scott Alexander
The medical system does a hard thing, and it might not do it well, but it does it. There is too much complexity for any one person to have a grasp on it. There are dozens of mutually incomprehensible specialties. And the fact that [insert generic nurse here] doesn't have the faintest idea how to measure electrolytes in blood, or build an MRI machine, or even what's going on with the patient next door, is a feature, not a bug.
The medical system doesn’t run on exceptional people–it runs on average people, with predictably average levels of skill, slots in working memory, ability to notice things, ability to not be distracted thinking about their kid's problems at school, etc. And it doesn’t run under optimal conditions; it runs under average conditions. Which means working overtime at four am, short staffing, three patients in the ER waiting for ICU beds, etc.
Sure, there are problems with the machine. The machine is inefficient. The machine doesn’t have all the correct incentives lined up. The machine does need fixing–but I would argue that from within the machine, as one of its parts, taking heroic responsibility for your own sphere of control isn’t the way to go about fixing the system.
As an [insert generic nurse here], my sphere of control is the four walls of my patient's room. Heroic responsibility for my patient would mean...well, optimizing for them. In the most extreme case, it might mean killing the itinerant stranger to obtain a compatible kidney. In the less extreme case, I spend all my time giving my patient great care, instead of helping the nurse in the room over, whose patient is much sicker. And then sometimes my patient will die, and there will be literally nothing I can do about it, their death was causally set in stone twenty-four hours before they came to the hospital.
I kind of predict that the results of installing heroic responsibility as a virtue, among average humans under average conditions, would be a) everyone stepping on everyone else’s toes, and b) 99% of them quitting a year later.
Recursive Heroic Responsibility
If you're a gear in a machine, and you notice that the machine is broken, your options are a) be a really good gear, or b) take heroic responsibility for your sphere of control, and probably break something...but that's a false dichotomy. Humans are very flexible tools, and there are also infinite other options, including "step out of the machine, figure out who's in charge of this shit, and get it fixed."
You can't take responsibility for the individual case, but you can for the system-level problem, the long view, the one where people eat badly and don't exercise and at age fifty, morbidly obese with a page-long medical history, they end up as a slow-motion train wreck in an ICU somewhere. Like in poker, you play to win money
–positive EV–not to win hands. Someone’s going to be the Minister of Health for Canada, and they’re likely to be in a position where taking heroic responsibility for the Canadian health care system makes things better. And probably the current Minister of Health isn’t being strategic, isn’t taking the level of responsibility that they could, and the concept of heroic responsibility would be the best thing for them to encounter.
So as an [insert generic nurse here], working in a small understaffed ICU, watching the endless slow-motion train wreck roll by...maybe the actual meta-level right thing to do is to leave, and become the freaking Minister of Health, or befriend the current one and introduce them to the concept of being strategic.
But it's fairly obvious that that isn't the right action for all the nurses in that situation. I'm wary of advice that doesn't generalize. What's difference between the nurse who should leave in order to take meta-level responsibility, and the nurse who should stay because she's needed as a gear?
Heroic responsibility for average humans under average conditions
I can predict at least one thing that people will say in the comments, because I've heard it hundreds of times–that Swimmer963 is a clear example of someone who should leave nursing, take the meta-level responsibility, and do something higher impact for the usual. Because she's smart. Because she's rational. Whatever.
Fine. This post isn't about me. Whether I like it or not, the concept of heroic responsibility is now a part of my value system, and I probably am going to leave nursing.
But what about the other nurses on my unit, the ones who are competent and motivated and curious and really care? Would familiarity with the concept of heroic responsibility help or hinder them in their work? Honestly, I predict that they would feel alienated, that they would assume I held a low opinion of them (which I don't, and I really don't want them to think that I do), and that they would flinch away and go back to the things that they were doing anyway, the role where they were comfortable–or that, if they did accept it, it would cause them to burn out. So as a consequentialist, I'm not going to tell them.
And yeah, that bothers me. Because I'm not a special snowflake. Because I want to live in a world where rationality helps everyone. Because I feel like the reason they would react that was isn't because of anything about them as people, or because heroic responsibility is a bad thing, but because I'm not able to communicate to them what I mean. Maybe stupid reasons. Still bothers me.