(2010-05-30) Alexander Diseased Thinking Dissolving Questions About Disease

Scott Alexander: Diseased thinking: dissolving questions about disease... host of other marginal conditions that some consider character flaws, others diseases, and still others normal variation in the human condition. (shadow syndromes)

Attention deficit disorder (ADD), 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.

In Disguised Queries, Eliezer Yudkowsky demonstrates how a word refers to a cluster of objects related upon multiple axes

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*

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)

Calling homosexuality a disease is a poor choice for many reasons, but one of them is certainly (4): it's not necessarily unpleasant. (sex and gender)

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).

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...

we make value decisions based on whether we call something a "disease" or not.

patient deserves our sympathy and support

it is socially acceptable (maybe even mandated) to seek medical treatment for

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

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

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.

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

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

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

Katja Grace: Some people make personal sacrifices, supposedly toward solving problems that don’t threaten them personally. They sort recycling... 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.

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

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

*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.*