Related to: Disguised Queries, Words as Hidden Inferences, Dissolving the Question, Eight Short Studies on Excuses
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.
Or as Oliver Wendell Holmes put it more poignantly:
(I am not a consequentialist, much less a big fan of Holmes, but he sure had a way with words.)
In this case, the law must "keep its promises" because of what would follow if it turned out that the law didn't actually matter. That's a very consequentialist notion.
I'm not sure what exactly you mean by "can't". Imagine a program that searches for the maximum element of an array. From our perspective there's only one value the program "can" return. But from the program's perspective, before it's scanned the whole array, it "can" return any value. Purely deterministic worlds can still contain agents that search for the best thing to do by using counterfactuals ("I could", "I should"), if these agents don't have complete knowledge of the world and of themselves. The concept of "free will" was pretty well-covered in the sequences.
That depends a lot on whether or not the reason they're not working is because they already feel they're worthless... in which case the result isn't likely to be an improvement.
Here's a perfect illustration: Halfbakery discusses the idea of a drug for alleviating unrequited love. Many people speak out against the idea, eloquently defending the status quo for no particular reason other than it's the status quo. I must be a consequentialist, because I'd love to have such a drug available to everyone.
Thanks for the link-- very entertaining discussion.
I don't think anyone came out explicitly with the idea that unrequited love works well in some people's lives and badly in others, and people would have their own judgement about whether to take a drug for it.
Instead, at least the anti-drug contingent reacted as though the existence of the drug meant that unrequited love would go away completely.
For another example, see The End of My Addiction, a book by a cardiologist who became an alcoholic and eventually found that Baclofen, a muscle relaxant, eliminated the craving and also caused him to quit being a shopoholic. He's been trying to get a study funded to see whether there's solid evidence that high doses of the drug undo addictions, but there isn't sufficient interest. It isn't just that the drug is off patent, it's that most people don't see alcohol craving as a problem in itself.
There are a few randomized trials of baclofen, if those count:
Addolorato et al. 2006. 18 drinkers got baclofen, 19 got diazepam (the 'gold standard' treatment, apparently). Baclofen performed about as well as diazepam.
Addolorato et al. 2007.61814-5) 42 drinkers got baclofen, 42 got a placebo. More baclofen patients remained abstinent than placebo patients, and the baclofen takers stayed abstinent longer (both results were statistically significant).
Assadi et al. 2003. 20 opiate addicts got baclofen, 20 got a placebo. (Statistically) significantly more of the baclofen patients stayed on the treatment, and lessened depressive & withdrawal symptoms. The baclofen patients also did insignificantly better on 'opioid craving and self-reported opioid and alcohol use.'
Shoptaw et al. 2003. 35 cokeheads got baclofen, 35 a placebo. 'Univariate analyses of aggregates of urine drug screening showed generally favorable outcomes for baclofen, but not at statistically significant levels. There was no statistical significance obs
Someone once quipped about a Haskell library that "You know it's a good library when just reading the manual removes the problem it solves from your life forever." I feel the same way about this article. That's a compliment, in case you were wondering.
The one criticism I would make is that it's long, and I think you could spread this to other sites and enlighten a lot of people if you wrote an abridged version and perhaps illustrated it with silly pictures of cats.
Thank you very much. That's exactly the feeling I hoped people would have if this dissolved the question and it's great to hear.
I can't think of how to make this shorter without removing content (especially since this is already pitched at an advanced audience - anything short of LW and I'd have to explain status quo biases, preference reversal tests, and actually justify determinism).
I can, however, give you an lolcat if you want one.
This is a really interesting post and I will most likely respond on my own blog sometime. In the meantime, I haven't read the whole comment thread, but I don't think this article has been linked yet (I did search for the title): http://www.nytimes.com/2010/01/10/magazine/10psyche-t.html?pagewanted=all
It's called "The Americanization of Mental Illness". Definitely worth a read; in particular, here is an excellent quotation:
It turns out that those who adopted biomedical/genetic beliefs about mental disorders were the same people who wanted less contact with the mentally ill and thought of them as more dangerous and unpredictable. This unfortunate relationship has popped up in numerous studies around the world. In a study conducted in Turkey, for example, those who labeled schizophrenic behavior as akil hastaligi (illness of the brain or reasoning abilities) were more inclined to assert that schizophrenics were aggressive and should not live freely in the community than those who saw the disorder as ruhsal hastagi (a disorder of the spiritual or inner self). Another study, which looked at populations in Germany, Russia and Mongolia, found that “irrespective of place . . . ... (read more)
Perhaps I'm misunderstanding, but
seems to summarise to:
(1) Medical treatments (drugs, surgery, et cetera) for conditions that can be treated in other ways can have negative consequences. (2) But so do those for conditions without other treatments and we use those. (3) Therefore: we should not object to these treatments on the grounds of risks.
I'd question the validity of this argument. Consider a sc... (read more)
If I understand you right, you're saying that allowing drugs might discourage people from even trying the willpower-based treatments, which provides a cost of allowing drugs that isn't present in diseases without a willpower-based option.
It's a good point and I'm adding it to the article.
I would say "utilitarians" rather than "consequentialists" here; while both terms are vague, consequentialism is generally more about the structure of your values, and there's no structural reason a consequentialist (/ determinist) couldn't consider it desirable for blameworthy people to be punished. (Or, with regard to preventative imprisonment of innocents, undesirable for innocents to be punished, over and above the undesirability of the harm that the punishment constitutes.)
I installed a mental filter that does a find and replace from "utilitarian" to "consequentialist" every time I use it outside very technical discussion, simply because the sort of people who don't read Less Wrong already have weird and negative associations with "utilitarian" that I can completely avoid by saying "consequentialist" and usually keep the meaning of whatever I'm saying intact.
Less Wrong does deserve better than me mindlessly applying that filter. But you'd need a pretty convoluted consequentialist system to promote blame (and if you were willing to go that far, you could call a deontologist someone who wants to promote states of the world in which rules are followed and bad people are punished, and therefore a consequentialist at heart). Likewise, you could imagine a preference utilitarian who wants people to be punished just because e or a sufficient number of other people prefer it. I'm not sufficiently convinced enough to edit the article, though I'll try to be more careful about those terms in the future.
Now that's a good use of the reversal test!
I remember being in a similar argument myself. I was talking with someone about how I had (long ago!) deliberately started smoking to see if quitting would be hard , and I found that, though there were periods where I'd had cravings, it wasn't hard to distract myself, and eventually they went away and I was able to easily quit.
The other person (who was not a smoker and so probably didn't take anything personally) said, "Well, sure, in that case it's easy to quit smoking, because you went in with the intent to prove it's easy to quit. Anyone would find it easy to stay away from cigarettes in that case!"
So I said, "Then shouldn't that be the anti-smoking tactic that schools use? Make all students take up smoking, just to prove they can quit. Then, everyone will grow up with the ability to quit smoking without much effort."
 and many, many people have told me this is insane, so no need to remind me
I met someone who started smoking for the same reason you did once and is still addicted, so you couldn't have been at that much of an advantage.
I am torn between telling you you're insane and suggesting you take up crack on a sort of least convenient possible world principle.
"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."
Yeah! The hell with that Robin Hanson guy! He's nothing but a signaller trying to signal that he's better than signalling by talking about signals!
I am so TOTALLY not like that.
Great article, by the way; I just can't resist metahumour though.
I recently wrote a blog article arguing that 95% of psychology and psychiatry is snake-oil and pseudoscience; primarily I was directing my ire at the incoherency of much of it, but I had the implicit premise of dismissing the types of 'conditions' you wrote about as pathologizing the mundane.
While on the one hand, I object to much of classifying these conditions as such - if the government ever manages to mindprobe me I know they'll classify me as an alcoholic paranoid with schizoid tendencies (something that I see nothing wrong with), you present a powerful argument of "Hey, if it works, what's wrong with that?" (The day they invent a workout pill, is the day I stop going for bloody stupid jogs.)
I'd wager that most people her... (read more)
I think you said it better earlier when you talked about whether the reduction in incidence outweighs the pain caused by the tactic. For some conditions, if it wasn't for the stigma there would be little-to-nothing unpleasant about it (and we wouldn't need to talk about reducing incidence).
I agree with your general principle, ... (read more)
Very good article. One thing I'd like to see covered are conditions that are "treatable" with good lifestyle choices, but whose burden is so onerous that no one would consider them acceptable. Let's say you have a genetic condition which causes you to gain much more weight (5x, 10x - the number is up to the reader) than a comparable non-affected person. So much that the only way you can prevent yourself from becoming obese is to strenuously exercise 8 hours a day. If a person chooses not to do this, are they really making a "bad" choice... (read more)
If there's some cure for the genetic condition, naturally I'd support that. Otherwise, I think it would fall under the category of "the cost of the blame is higher than the benefits would be." It's not part of this person's, or my, or society's, or anyone's preferences that this person exercise eight hours a day to keep up ideal weight, so there's no benefit to blaming them until they do.
As for the second example, regarding "is it still right to hold someone so treated /morally/ responsible for doing poorly in their life", this post could be summarized as "there's no such thing as moral responsibility as a primitive object". These people aren't responsible if they're poor, just like a person with a wonderful childhood isn't responsible if they're poor, but if we have evidence that holding them responsible helps them build a better life, we might as well treat them as responsible anyway.
(the difference, I think, is that we have much more incentive to help the person with the terrible childhood, because one could imagine that this person would respond well to help; the person with the great childhood has already had a lot of help and we have no reason to think that giving more will be of any benefit)
I agree on the cause of genetic obesity, but my answer may be different for the case of an extremely impoverished childhood. Part of my response is reflected in the fact that neither I (nor anyone I personally know) grew up in that level of poverty so that in imagining the poverty situation I have to counter-factually modify the world and I'm not sure how to do it.
In one imaginary scenario I would find someone facing facing malnutrition, violently abusive parents, mental retardation, in an environment with no effective police services in the actual world and imagine myself helping them from a distance as a stranger. This is basically "how to help the comprehensively poor as an external intervention". There are a lot of people like this on the planet and helping them is a really hard problem that is not very imaginary at all. I don't think I have any kind of useful answer that fits in this space and meshes with the themes in the OP.
A second imaginary scenario would be that I am also in the same general situation but only slightly better off. Perhaps there is rampant crime and poverty but my parents gave me minimally adequate nutrition and they weren't abusive (yet I m... (read more)
I think that this rule contains the sub-rule "condemn conditions such that people are aware of the actions that lead to them" almost all the time, because our condemnation cannot possibly create positive externalities otherwise. It's similar to how jails represent no deterrence if you don't know what actio... (read more)
You're homing in on the one fuzzy spot in this essay that jumped out at me, but I don't think you're addressing it head on because you (as well as Yvain) seem to be assuming that there are, in point of fact, many situations where condemnation and lack of sympathy will have net positive outcomes.
It seems to me that there are a minuscule number of circumstances where yelling insults that fall afoul of the fundamental attribution error is going to have positive consequences taking everything into account.
In general, people do things that are logical reactions to their environments, given their limited ti
I got the impression from OP that the "condemned condition vs. disease" dichotomy primarily manifests itself as society's general attitudes, a categorization that determines people's modes of reasoning about a condition. I think the Sandy example was exaggerated for the purpose of illustration and Yvain probably does not advocate yelling insults in real life.
If someone is already in a a woeful condition it is unlikely that harsh treatment does any good, for all the reasons you wonderfully wrapped up. But nonetheless an alcoholic has to expect a great deal of silent and implied condemnation and a greatly altered disposition towards him from society - a predictable deterrence. Another very important factor is the makeup of the memepool about alcoholism. If the notion that drinking leads to "wrecking one's life" and "losing human dignity" thoroughly permeates society, an alcoholic candidate may be more likely to attempt overcoming their addict... (read more)
Very late reply here, but
It is not my experience that people who support obesity as a valid life choice and decry "fat-ism" as akin to sexism and racism tend to take this next step.
Excellent article, though there is a point I'd like to see adressed on the topic.
One salient feature of these marginal, lifestyle-relaed conditions is the large number of false positives that comes with diagnosis. How many alcoholics, chronic gamblers, and so on, are really incapable of helping themselves, as opposed to just being people who enjoy drinking or gambling and claim to be unable to help themselves to diminish social disapproval? Similarly, how many are diagnosed by their peers (He's so mopey, he must be depressed) and possibly come to believ... (read more)
The graph image is broken. Does anyone have a copy of the image file? I remember what it looked like, and it was super-useful for demonstrating the concept.
The condition of rarity does not appear to be a necessary condition for a disease. If 90% of the population had AIDS, AIDS would still be a disease. Or the flu, or gonorrhea. Perhaps, "It needs to be something where, if everyone had it, it would still be called a disease" is the point you're aiming for. Plenty of psychiatric "problems" are problems principally because they go against current social norms - this is why homosexuality was previously classified as a disease - and it seems like that's what you're going for. I think this issue may already be covered in your non-normal distribution condition, which is brilliant.
None of the conditions are absolutely necessary. On the other hand, the rarity condition is at least as important as the others. If all people had a third functional hand, nobody would think it was a disease. But now virtually all people have two hands and most of the hypothetical three-handers would opt to surgically remove the superfluous limb, even if the third hand can be useful to perform several jobs.
Or more realistically, almost all people have the appendix, which is of no use, except it can host appendicitis. If only 1% of people had the appendix, I am pretty sure that having appendix would be classified as potentially life-threatening congenital disease.
As for your example, if 99% of people has AIDS since time immemorial, are you sure it would be classified as disease? People would have weaker immunity and die younger than they do today - that's all difference. Now we die at 75, with few long-livers who manage to remain healthy up to 90 and die at 100. In the AIDS-permeated society we would die at 25, and those few without AIDS who would manage it to their 50 or 70 would be viewed as anomalies.
A very interesting article that made me think. I am not sure exactly where my thoughts line up with yours, so this will be primarily a means of clarifying what I think.
It seems to me that the entire purpose of framing obesity as a disease is a means to deflect the "blame" for obesity elsewhere. The disease-ness alone may not be the entire issue.
Person A bothers morbidly obese person B about trying to lose weight.
Person B says that obesity is a disease and not her fault.
Person A objects to obesity being a disease, in their mind per... (read more)
I think someone read your article: http://www.theatlantic.com/magazine/print/2011/07/the-brain-on-trial/8520/
He comes at it from a slightly different angle - the criminal justice system - but approaches it the same way, dissolving the question down to blameworthiness and free will. He also reaches the same conclusion; our reaction as a society should be based on influencing future outcomes, not punishing past actions.
This is, quite obviously, a terrific article. One major quibble: your conclusion is rather circular. You assume a consequentialist utilitarian ethics, and then conclude, "Therefore, the optimal solution is to maximize the outcome under consequentialist utilitarian ethics!" I'm not sure it's actually possible to avoid such circularity here, but it does feel a little unsatisfying to me.
On top of this, your dismissal of the "personal development" issue is a bit hand-wavy. That is, it's one thing if I make a decision to go smoke crack - the... (read more)
Anyway, on to the obligatory quibble. "throwing biological solutions at spiritual problems might be disrespectful or dehumanizing, or a band-aid that doesn't affect the deeper problem" The 6 criteria for disease, including 'biological' in so far as that means caused by biological processes simple enough to understand relatively easily and confidently, do seem to me to each provide weak evidential support for any given treatment not being disrespectful, dehumanizing, or superficial. They also seem to provide weak evidence against the l... (read more)
I like this because it dissolves the question quite effectively. I'm not sure the question should be dissolved, though ... what about the sister?
This is why I'm not a consequentialist all the way. We may regard it as obvious that cancer is undesirable, but there really may be some who disagree. There are some who disagree that obesity is undesirable. There are some who disagree that depression is undesirable. Health is one issue where most people (in our society) are particularly unlikely to take account of differences in opinion.
Praise and blame are... (read more)
Yvain, you have a couple of instances of "(LINK)" in your text. I expect you intended to replace them with links :-).
I think a lot of you are missing that (a version of) this is already happening, and the connotations of the words "jail" and "imprison" may be misleading you.
Typically, jail is a place that sucks to be in. But would your opinion change if someone were preventatively "imprisoned" in a place that's actually nice to live in, with great amenities, like a gated community? What if the gated community were, say, the size of a country?
And there, you see the similarity. Everybody is, in a relevant sense, "imprisoned" in their own country (or international union, etc.). To go to another country, you typically must be vetted for whether you would be dangerous to the others, and if you're regarded as a danger, you're left in your own country. With respect to the rest of the world, then, you have been preventatively imprisoned in ... (read more)
So if there existed a hypothetical institution with the power to mete out preventive imprisonment, and which would reliably base its decisions on mathematically sound consequentialist arguments, would you be OK with it? I'm really curious how many consequentialists here would bite that bullet. (It's also an interesting question whether, and to what extent, some elements of the modern criminal justice system already operate that way in practice.)
[EDIT: To clarify a possible misunderstanding: I don't have in mind an institution that would make accurate predictions about the future behavior of individuals, but an institution that would preventively imprison large groups of people, including many who are by no means guaranteed to be future offenders, according to criteria that are accurate only statistically. (But we assume that they are accurate statistically, so that its aggregate effect is still evaluated as positive by your favored consequentialist calculus.)]
This seems to be the largest lapse of logic in the (otherwise very good) above post. Only a few paragraphs above an argument involving the reversal test, the author apparently fails to apply it in a situation where it's strikingly applicable.
However, I have the following problem with the scenario - I have hard time trusting a doctor, who prescribes a diet pill and consultation with a surgeon, but omits healthy diet and exercise. (Genetic predisposition does not trump the laws of thermodynamics!)
In general, I don't know of any existing medicine that can effectively replace willpower when treating addiction - which is why treatment is so difficult in the first place.
Psychology tells us that, on the individual level, encouragement works better than blame. Although both have far less impact than one would hope.
The way I see it, we are blaming the 'intelligence' process for the things that this process had caused or had the power to prevent, and we aren't blaming it for other things where it was powerless. A bad outcome (like obesity) implies character flaw if less flawed character would not end up with this outcome. And it is perfectly consistent with the notion that the process itself had been shaped by things outside it's control. A bad AI is a bad AI even though it's programmer's fault; a badly designed bridge is a bad bridge even though it is architect's fau... (read more)
Very good article!
A couple of comments:
Almost agreed: It is also important to recheck criterion 4:
to see if reducing the incidence of the disease is actually a worthwhile goal.
On another note:... (read more)
Slightly off-topic, but I was reading in Bernard Williams's Ethics and the Limits of Philosophy last night and this quote about a difference between deontological and consequentialist ethics caught my attention:
This sounds a little timid; being a determinist consequentialist is not an instrument that allows us some goal (an accidental implication I am sure), it is an honest outlook by itself.
Please feel free to correct me in case I misunderstood your point here, but I think that's an unfair one you raise because originally it's about the choice between the application of two different approaches (help on a biological vs. help on a social level) in case they both produce the same output—in your example, however, you adjust the outcome according to your desired conclusion (and it's fairly obvious to chose the one that actually helps).
Edit: I'm new to this site and just realized I'm a little bit late for this discussion, sorry about that.
This is a very well written post which I enjoyed reading quite a bit. The writing is clear, the (well cited!) application of ideas developed on LW to the problem is great to support further building on them, and your analysis of the conventional wisdom regarding disease and blameworthiness as a consequence of a deontologist libertarian ethics rang true for me and helped me to understand my own thinking on the issue better.
Thanks for the care you put into this post.
Great post. I try to give the nutshell version of this type of reasoning every time I get dragged into an abortion debate or the debate addressed in this post. People are much more receptive to this sort of thinking for diseases than they are for abortion.
No, that's not the same question at all. Suppose we agree that a fetus is a person: that is, that a fetus should have the same moral rights as an adult. It's still not at all clear whether abortion should be legal. One of J. J. Thomson's thought experiments addresses this point: suppose you wake up and find yourself being used as a life support machine for a famous violinist. Do you have the right to disconnect the violinist? Thompson argued that you did, and thus people should have the right to an abortion, even if a fetus is a person.
Alternatively, consider something like the endangered species act: no one thinks that a spotted owl or other endangered species is a person, but there are many people who think that we shouldn't be allowed to kill them freely.
You're missing my point. I'm not saying that it's the same question. Many times when people get into the abortion debate, they start arguing over whether a fetus is a person. The pro-choice side will point out the dissimilarities between a fetus and a human. The pro-life side will counter with the similarities. All of this is in an effort to show that a fetus is a "person." But that isn't really the relevant question. Say they finally settle the issue and come up with a suitable definition of "person" which includes fetuses of a certain age. Should abortion be allowed? Well, they don't really know. But they will try to use the definition to answer that question.
This is what I mean when I say that "is a fetus a person?" is a disguised query. The real question at issue is "should abortion be allowed?" They aren't the same question at all, but in most debates, once you have the answer to the first you have the answer to the second, and it shouldn't be that way because the first question is mostly irrelevant.
Test for Consequentialism:
Suppose you are a judge in deciding whether person X or Y commited a murder. Let's also assume your society has the death penalty. A supermajority of society (say, encouraged by the popular media) has come to think that X committed the crime, which would decrease their confidence in the justice system if he is set free, but you know (e.g. because you know Bayes) that Y was responsible. We also assume you know that Y won't reoffend if set free because (say) they have been too spooked by this episode. Will you condemn X or Y? (Befor... (read more)
The disease characteristics is where this essay breaks down. Those don't really line up with any medical definition of disease. Seems like he redefines disease in order to deconstruct it a bit.
Disease does mean something specific to doctors, but doctors aren't the only ones asking questions like "Is obesity really a disease?"
And when people ask that question, what matters to them isn't really whether obesity matches the dictionary definition. In practice, it does boil down to trying to figure out whether the obesity should be treated medically, and whether obese people deserve sympathy. (On occasion, another question that is asked is "Does the condition need to be 'fixed' at all?")
You can't answer these questions by checking the dictionary to see if obesity is a disease. In general, thinking of "disease" as a basic concept results in confusion. If you're not certain whether obesity is a disease, and what you really want to know is whether it should be treated medically, then the right thing to do is to first figure out "What about diseases makes medical intervention a good idea?" And then you figure out whether obesity satisfies the criteria you come up with.
I generally agree with your article, but it has at least one false premise:
But many undesirable conditions that are caused by genetic or environmental sources are continuous. Cancer is actually one of them, as far as I understand: there are many different kinds of cancer, and the symptoms can vary in severity (though all are fatal if left untreated). The common cold is another example, though of course it is rarely fatal.
In the mental health area the polar extreme from the pathology model is the "neurodiversity" model. The point about allowing treatment when it is available and effective, whether the treatment is an "enhancement" or a "cure" is also worthwhile.
In the area of obesity, I think we are pretty open, as a society, to letting the evidence guide us. In the area of mental health, we are probably less so, although I do think that empirical evidence about the nature of homosexuality has been decisive in driving a dramatic change in pub... (read more)
And then someone points out how bacteria might be involved in creating obesity.
It was an interesting read. I am a little confused about one aspect, though, that is determinist consequentialism.
From what I read, it appears a determinist consequentialist believes it is 'biology all the way down' meaning all actions are completely determined biologically. So where does choice enter the equation, including the optimising function for the choice, the consequences?
Or are there some things that are not biologically determined, like whether to approve someone else's actions or not, while actions physically impacting others are themsleves com... (read more)
The correct answer to this is "both" (and it is a false dichotomy). My consciousness is a property of a certain collection of matter which can be most compactly described by reference to the regularities we call "biology". Choosing to answer (or not to answer) is the result of a decision procedure arising out of the matter residing (to a rough approximation) in my braincase.
The difference between me and a coin is that a coin is a largely homogenous lump of metal and does not contain anything like a "choice mechanism", whereas among the regularities we call "biology" we find some patterns that reliably allow organisms (and even machines) to steer the future toward preferred directions, and which we call "choosing" or "deciding".
Wrong. If Alice orders the fettucini in world A, she gets fettucini, but if Alice' orders eggplant in world A, she gets eggplant. The future is not fixed in advance - it is a function of the present, and your acts in the present create the future.
There's an old Nozick quote that I found in Daniel Dennett's Elbow Room: "No one has ever announced that because determinism is true thermostats do not control temperature." Our actions and beliefs have exactly the same ontological significance as the switching and setting of the thermostat. Tell me in what sense a thermostat does not control the temperature.
Very good article!
A couple of comments:
Almost agreed: It is also important to recheck
On another note... (read more)
Nicely done. (If I had anything else to add, I would add it.)
PracticalEthicsNews.com has a few recent posts, a talk, and an interview about whether addiction is a disease. It becomes quite obvious that there is always more at stake in these debates than just the appropriate definition of a medical concept.
Does that mean naturalistic theories of free will like Robert Kane's are false by definition.