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PaperclipPerfector  2mo ago (text post)   38860 thread views

Culture War Roundup for the week of February 24, 2025

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Two case studies in government waste:

As you can likely imagine right now a lot of people in medicine are sharing tales and taking sides in the great DOGE debate. Two that popped up on my radar and stuck out to me:

  1. One of my medical school classmates is a psychiatrist at redacted city hospital. He has been informed that the state Medicaid will no longer pay for psychiatric emergency room visits if the patients do not go to their aftercare appointments within 30 days. They have been informed that they could lose their government funding if enough patients fail to do this.

Some problems: -As an emergency room most of their patients have no insurance or Medicare or Medicaid, meaning the facility often get paid less than cost. They only stay open at all because of their state grants.

-Many of the patients are drug addicts or malingering (because of homelessness for example). Every day you’ll hear something like “you’ve been here every day for the last three weeks” or “have you considered stopping using PCP? You always seem to fight with the police when you do” and “here’s your follow-up appointment, will you go? No? Fuck me? Okay thank you have a nice day.”

-Many of the patients who do actually have mental illness are in denial about it, or have some sort of limitation that prevents them from attending aftercare appointments.

-The “best” solution is probably to violate patient rights and involuntarily commit them to make someone else be on the hook for making sure they go to their aftercare.

-In the meantime, the hospital has hired several additional staff to manage some of the administrative complexities associated with this change (for example hammer calling the patients to remind them to come to the appointment). They have also hired night staff whose job is to sit in an office overnight purely to schedule appointments with an outpatient program (otherwise no patient could be discharged overnight because they wouldn’t have an appointment to go to…).

  1. One of the residents I mentor is about to do a rotation at the VA. This is pretty common for residents. His rotation starts in a few weeks. A few months ago, he got an email that included the instructions “it is imperative that you start your onboarding process for the VA right now otherwise your onboarding may not be finished by the time of your rotation” and “it is important that you not start your onboarding right now as it is too early to start onboarding and your onboarding may not be valid if you complete it too early.” This is not a joke or an exaggeration.

Anyway, he dutifully completed his requirements in a timely fashion (which were all pointless! Ex: what is the motto of the VA???). So, months later his rotation is starting soon. He begins the process of emailing the education team once every 2-4 business days. You have to email them multiple times before they respond. The conversation goes something like this over the course of multiple weeks, “I think I’ve completed my onboarding do I have to do anything else?” “no” “okay is my onboarding done” “no” “okay when can I pick up my ID card” “when your onboarding is done” “I thought my onboarding was done” “yes” “okay what I am waiting on” “nothing.” I have seen the emails; it really looks like this.

At this point his program tells him to CC the chief of medicine at the VA hospital, at which point the person responds with “okay we put in a ticket for this a month ago, your training is complete but your training is marked as incomplete.” A screenshot has been attached that shows the request and an automatic response that says something about high ticket volume and that they will get to it at some point. The chief of medicine replies “….does the trainee need to do anything?” (we are here).

The resident will be able to rotate but will not be able to do any work without computer access.

It’s worth noting that the VA is paying for this resident to be there, despite the fact he will in fact not be able to do anything. At his last VA rotation (yes they go through this for every resident every time) he was six weeks into an eight week rotation before he got access.

Edit: Replied to wrong comment.

Did you mean to reply to someone else? I am very deliberately not taking a stance on that side of things.

Oh yeah my comment was for 2rafa thanks for letting me know I fat fingered it.

Dysfunctional social policies cause/exasperate problems.

Problems are incompetently addressed with system bloat.

System bloat starts weighing the functional parts of society down.

Functional society members want bloat cut down.

Dysfunctional social policy advocates say system bloat cannot be cut down, citing: Who will address the problems?

The correct way to contextualize this predicament is through hate and sympathetic horror. Government waste is just a symptom.

The correct way to contextualize this predicament is through hate and sympathetic horror. Government waste is just a symptom.

Can you expand on this? I don't follow.

He's not speaking clearly, but basically gesturing at the classes of people he thinks are responsible and advocating we Do Something about them and their enablers, using abstruse language.

the classes of people he thinks are responsible

Turbulent priests?

You should immerse yourself in the horror that is being facilitated, sympathize with the victims and hate the root cause

Widespread narcan use is surely one of the biggest disasters in the history of modern America.

Imagine if tomorrow, a new medicine called Dementiolab or whatever comes out. It doesn’t prevent or cure Dementia, it doesn’t even slow its progression while someone still has a personality and life to hold on to. But, at the second-to-very-last-stage of the disease, the “giant violent baby” phase, the nightmare phase, Dementiolab prolongs life by 10x, keeping patients alive for many years. American hospitals rush to prescribe this new treatment, after all it literally prolongs the lifespan of dementia patients by a huge amount.

But for insurers, the public purse, families of patients and (I would argue) the patients themselves, it would of course be a disaster. It even further fuels the drug market because when customers don’t die, they come back to buy another day.

Narcan is like this for hard drug addicts. For generations, addicts who got into a really bad way, the kind you can’t really recover from (in 99% of cases), just died. But in Narcan, we invented a Dementiolab, a means to keep people alive in a horrific condition, resurrected again and again to keep suffering, and to keep making everyone else’s life worse.

Humanity, decency, even empathy requires that we stop giving addicts Narcan. If a 7 year old accidentally ingests some fentanyl then sure, otherwise no.

What prevents a helpful billionaire from buying out Narcan and jacking up the price 100x?

Doesn't help the billionaire in daily life, probably not profitable, terrible optics?

Principally I don't really have a bone to pick with you here, and many others are discussing the implications. However, still loads of addicts die all the time from overdose. Narcan prevents very few deaths, as you need to have it available, someone who uses it, and then having them actually contact 911 so they can get a second dose is not very common. Dementia is a progressive incurable disease, drugs aren't and the 99% number needs a lot of qualifying by you. Also there are alternatives to Narcan. E.g. intubation. We actually do this with specific overdoses of carfentanil. If a machine can breath for you, it doesn't matter if you're fucked up on opioids. Its the same — effectively — as Narcan.

https://www.usatoday.com/pages/interactives/seven-days-of-heroin-epidemic-cincinnati/

8:35 p.m.

The police officers and medics find the man on the floor of the Speedway bathroom on West Main Street in Newark, sprawled next to the toilet, head under the sink.

They’ve tried spraying naloxone into his nostrils, but it’s had no effect. He’s not breathing. They’re running out of time.

One of the medics takes a drill out of his bag and turns it on. It whirs like a dental drill as he pushes it into the man’s shin bone, trying to create a more direct path for the naloxone to enter the bloodstream.

The medics install a stent and start pushing in doses of the life-saving drug.

The man rouses and tries to stand.

“Lay down, buddy. You overdosed,” a medic says. “We just brought you back to life.”

Later, at the hospital, the man hops off the gurney and runs outside, the stent still embedded in his leg.

Narcan is a wonder drug that brings ODing opiate addicts back to life. So of course there are frequent fliers who keep ODing and being revived.

Some localities have limited how many publicly-funded narcan doses cops will give to someone. Which is an eventual death sentence for an addict.

So yes, this wonder drug stretches out the terminal phase of an addict's life.

You're assuming that everyone who ODs is a hopeless junkie, and that all hopeless junkies are incapable of being anything other than bums. Pretty much every jazz musician who came up in the late 40s and early 50s was a heroin addict, and some were truly hopeless. Yet a good deal of them were extraordinarily productive. Same with any number of rock musicians who OD'd. Same with my brother's neighbor, who had a good job and had been to treatment but fell of the wagon and OD'd because she no longer had the tolerance for her old dose. My friend's ex-husband overdosed in a gas station bathroom despite having a good job and leading an otherwise normal life. You can't paint everyone who has a serious drug habit with a broad brush and say that there's no hope for recovery and that their lives have no value.

But what percentage of cases are even remotely functional, let alone high functioning? If we’re saving people who are somewhat functioning, it might make sense, but if we’re saving people who will dig through trash cans and sleep in the streets and can’t afford medical care, we aren’t saving people, just prolonging the suffering stage.

You can't separate them. The benefits to society from saving the more functional addicts are a karmic reward for being a society that regards human lives as worth effort to save even if they don't benefit society.

Well that's the question isn't it? What percentage of addicts do you think have to be functional before it's worth spending $25 worth of Narcan on them?

Yes, obviously many great musicians have been drug addicts. The frontman of my favorite band, a man whose music has brought much joy to my life, is a former heroin addict. I don’t know if he ever OD’d to the point of needing Narcan, but if he did, I’m glad they saved him!

However, such individuals represent only a very small percentage of total hard drug addicts. More importantly, they are important enough to a large amount of people — and are paid accordingly — such that they have a support system and financial cushion. In other words, if they OD and the police and EMTs show up to save them, they can pay for the Narcan themselves out-of-pocket, or else have someone else pay on their behalf. If they want to pursue a personal habit which is not only expensive but also extremely dangerous, they better have some money saved away for just such an occasion. I’m sure Jimmy Page and Kurt Cobain could have afforded it.

They can pay for it on credit, of course, and if the expense is too onerous, they can appeal to their fans to crowd-fund the payment of the subsequent debt. If the fans aren’t willing to bankroll it, I guess that particular musician was not generating enough fan enthusiasm to be worth saving. And if they can’t pay the debt, they go to debtors’ prison, which we also need to reintroduce.

It's not that every drug addict is a great musician as much as it is that more than you think are perfectly capable of being productive. Naloxone is trivially inexpensive; I don't think that letting someone die over a perceived inability to pay a small sum is any way for a civilized society to operate. This isn't like cancer treatment.

And if they can’t pay the debt, they go to debtors’ prison, which we also need to reintroduce.

No, we don't. There's a reason we abolished these in the 1800s and established a bankruptcy code. Hell, for how much it costs to imprison someone, we'd better off just having the state pay the debt in all but the most serious cases. The only thing we really have that's comparable to debtor's prison in Pennsylvania is jailing people for failure to pay child support, and this isn't taken lightly. Basically, it's threatened repeatedly, but only against people who obviously have the ability to pay and are just refusing to do so. I used to practice bankruptcy, and believe me, these people are trying to pay. They've usually put themselves in a much worse spot than they could have been in if they had filed earlier. Fraud is rare, and it's rarer still to find a bankruptcy attorney who would file a case in which fraud was evident.

Under EMTALA this would be explicitly illegal.

Given that he's advocating the return of debtor's prisons, I don't think he cares too much about EMTALA.

There is in fact a reason for EMTALA- people experiencing severe medical emergencies are often unable to confirm that they will be able to pay the bill not because of inability to pay the bill, but because of the severe medical emergency.

Lots of people are ok with letting the poor die. Far fewer are ok with letting the unlucky die from being mistaken for poor.

I've mentioned before that Mexico allegedly limits naloxone supply. By "limits" I mean it doesn't allow US advocacy groups to mule across a bunch of drugs to clinics at will. AMLO also said a few things that was skeptical of harm reduction and Narcan's role in the opioid crisis. Not exactly prohibition, but legacy scheduling laws that haven't changed looks like something less than harm reduction.

Humanity, decency, even empathy requires that we stop giving addicts Narcan.

Narcan is the cheaper, easier solution to overdose treatment. A 20 year old EMT can administer it. Your little sister can administer it. Take Narcan out of the equation and EMS will still respond to overdose calls. They'll pick up junkies, apply whatever alternative medical attention they are able, then go and stick them in the ER.

Napkin math. Around 80,000 opiate overdose deaths in the US as of late. Pick one of the guesstimates, say the NSDUH surveys, on number of opiate users and decide to 2 million opiate addicts is fair enough. At 82,000 deaths a year we get an annual mortality rate of ~4%. To me, this suggests addicts are actually pretty good at not dying from drugs given the drugs are as potent, addictive, and dangerous as ever. If we want to be extra generous with the numbers (decidedly not generous to addicts) then what do you think happens when Narcan is removed as a treatment? My guess would be the annual mortality rate of addicts rises by 2 percentage points for a time. Possibly less. What do we solve with such policy?

You suggest we stop treating overdoses with the best, relatively cheap treatments we have available. Enabling drug use is bad so we should remove tools that enable drug use. Medicine is one such tool, because it enables an addict to live longer to do more drugs. You do not suggest we don't provide medical treatment at all. If we wave the magic wand and blink Narcan out of existence we still the same stressors in the system. EMS arrives, does all the not-Narcan treatments, keeps someone alive if they can, and drives them to the ER. Some greater number of addicts are dead on arrival, but the rest receive the same or possibly greater treatment.

As I've gotten older I find myself more sympathetic to moral hazards. If the cost to widely available, easy to use treatments such as Narcan nasal spray is a 60% increase in opiate deaths (50k in 2015, now 82k) then, yeah you may have a point. The obvious incentives fire up my neurons, too. That said, in writing this post I did not find a study or review that gives Narcan substantial responsibility for the rise opiate use (now plateauing) and deaths. Even if we remain skeptical of harm reduction as an industry, lobbying group, and advocacy movement-- of the motivations of researchers in the field -- Narcan is so widely used there ought to be some. It's an old drug that was subject to innovation in response to increasing opiate use.

Wand waving Narcan does not look like compassion or tough love to me. Withholding the best medicine available doesn't sound decent to me. Tough love is giving someone Narcan, then immediately throwing them in the back of a paddy wagon to some farm in California to get clean and clear wildfire brush as punishment. Zero tolerance prison might work as well, but the cost of addicts taking up space in prison is fairly high. Withholding emergency medical treatment is a half-measure against a population that is filled with friends and family. Psycho Joe on the corner who demands medical attention twice a month is but a slice of the drug addict pie.

That said, in writing this post I did not find a study or review that gives Narcan substantial responsibility for the rise opiate use (now plateauing) and deaths

Here's one that made the rounds a few years ago: The Effects of Naloxone Access Laws on Opioid Abuse, Mortality, and Crime

In this paper, we use the staggered timing of state-level naloxone access laws as a natural experiment to measure the effects of broadening access to this lifesaving drug. We find that broadened access led to more opioid-related emergency room visits and more opioid-related theft, with no net measurable reduction in opioid-related mortality

Author's website has some additional commentary and appendices. Most interesting is the regional analysis where their estimates are that naloxone access led to a 14% increase in opioid-related mortality in the Midwest in particular (in the West and Northeast: insignificant decrease in mortality; South: insignificant increase). They give two explanations:

  • In the West, black tar heroin is more commonly used. In the Midwest, powder heroin. Black tar heroin doesn't mix easily with fentanyl which removes one avenue by which drug users could engage in riskier behavior in response to narcan access.
  • In the West and Northeast, drug treatment programs are more accessible:

We find suggestive evidence that greater availability of drug treatment may be important. That is, broadening naloxone access increases mortality more in places where less drug treatment is available. This makes sense if we think that the primary goal of naloxone is to give individuals a chance to get treatment for their addiction — if there is no treatment available, then perhaps it’s unsurprising if naloxone does more harm than good.

Their main policy recommendation is to expand drug treatment programs and find ways to ensure people get help post-overdose. Your paddy-wagon idea might have legs.

Thanks, register as Seen. Felt like they should be some push-back in this direction somewhere.

I can't take a major gander today but will come back. Curious how they control for all the gunk and if they look internationally at all. Estonia was a yuge fentanyl place for a time, but they went at the issue hard as I recall -- law enforcement wise -- and its OD rates got better. Canada, like the US, is bad and I assume has similar maximal harm reduction approaches.

In the West, black tar heroin is more commonly used. In the Midwest, powder heroin. Black tar heroin doesn't mix easily with fentanyl which removes one avenue by which drug users could engage in riskier behavior in response to Narcan access.

This is interesting and makes sense.

Their main policy recommendation is to expand drug treatment programs and find ways to ensure people get help post-overdose. Your paddy-wagon idea might have legs.

This is what people always say though, hehe. I commiserate with the people tired of hearing it as things progressively get worse. Sounds rather uncontroversial to say that involuntary commitment will save some number of souls. This doesn't have to be attached to naloxone prohibition.

Tough love is giving someone Narcan, then immediately throwing them in the back of a paddy wagon to some farm in California to get clean and clear wildfire brush as punishment.

That's two things. They'll get separated, so they get the Narcan but not the punishment.

While I certainly have little sympathy for hard drug addicts who don’t try to quit- I think repeat offenders of drug use laws should be executed- I don’t know how much difference narcan makes. These people live outside, exposed to the elements, not eating regularly, using substances that fuck up their hearts and breathing and nerves, passing STD’s back and forth and getting in fights. They are not long for this world even with narcan.

Absent certain diseases the human body is extremely resilient and adapted to not eating for long periods, to the cold and the elements (across the world), to getting into fights, to unhygienic environments and so on. The homeless addicts live in poor conditions for us, but conditions not particularly worse than those many humans historically lived for 50+ years in. The drugs complicate it, but that’s where Narcan comes in.

These people get certain diseases a lot, though.

I’ll also point out that while humans are resilient, only to a point- and individuals often aren’t. Drug addicts are taking high fatality rates even with life-saving medical care being administered to them regularly. Scurvy is on the uptick, I’m surprised these encampments haven’t already seen typhus outbreaks, and they get lots of STD’s.

Plus, historically normal people had far better nutrition and slept in better shelter than these types do; peasants a thousand years ago had a roof and ate whole grains.

Edit: the response above me points to a 4% annual mortality rate among addicts. This is already quite high, considering most addicts are young.

I am skeptical of any plan that involves causing large numbers of people to die on the basis that the world would be better off without them. What if it isn't? You would have just caused a bunch of deaths for no reason.

It'd be pretty embarrassing if you wiped out all the heroin addicts, then a few months later someone came out with a new AI-devised wonderdrug that can cure all addictions with a single pill.

It’s not that the world would be better without them. It’s that you’re simply delaying the inevitable while increasing the suffering of the individual. Drug addicts suffer a lot, they have serious diseases, they’re often homeless, they have to scrounge for food in trash cans, they can be covered in sores. At some point, I think you end up keeping someone living that life alive because it’s good for you, rather than good for them specifically.

causing large numbers of people to die

Your framing of the problem is wrong.
In a suicide, the fault for the death ultimately lies with the one who pulls the trigger.

Overdose deaths are suicides.

It'd be pretty embarrassing if [all the heroin addicts killed themselves], then a few months later someone came out with a new AI-devised wonderdrug that can cure all addictions with a single pill.

That was their choice to make, and an isolated demand for rigor: if we actually cared about this for human beings more generally, cryopreservation would be a much larger industry.

If overdose deaths are suicides, then they're accidental suicides. The proper term for an accidental suicide is "fatal accident". Normally, when someone suffers a serious accident but survives, we give them medical attention to try to keep them alive.

I actually don't have a problem with suicide, provided it's intentional and done right. I think the authorities should make you wait a few weeks to confirm you're really sure you want to die, then shoot you up with lots of fun but deadly drugs.

What I do have a problem with is denying lifesaving treatment to people on the (unproven!) basis that they're a drain on society.

If you choose to repeatedly engage in an activity that you know has a high risk of death, that's just suicide with plausible deniability. I don't consider someone who loses a game of Russian roulette to have suffered a "fatal accident".

No, mere thrill-seeking is not "suicide with plausible deniability" nor is engaging in dangerous activities with more tangible rewards (e.g. tower-climbing as a job). Probably most addicts aren't trying to kill themselves either, they're just chasing a high. But since they aren't sharing the reward with the rest of us, I don't see why we should socialize the risk either.

I would distinguish activities that have a tangible, elevated risk of death from ones that have a risk of death high enough that the odds of dying in repeated acts over time approaches 1. Riding a motorcycle or smoking is risky, but someone who does those things, even their whole life, is not likely to die from them even though they might. Consuming recreational doses of street narcotics is something that, if you do it frequenlty enough, is very likely to kill you sooner or later.

I believe your distinction is arbitrary. And in any case I suspect the actual value of the thing you're trying to compute (probability of dying from the drugs instead of something else) is not something available, or even well-defined.

Overdose deaths are suicides.

Philosophy question: to what extent do we as people owe each other to stop suicide attempts? Discuss.

On one hand, we've put up nets and installed phones and nationwide hotlines and circulated narcan. On the other, some Western states have legalized euthanasia for increasingly minor medical issues. To me, the former feels reasonable (although I find OPs argument about narcan to be at least darkly intriguing), and the latter feels like it starts reasonably but quickly slides down the slippery slope. I know some moral codes (Catholicism, for one) are blanket-opposed to aiding suicide.

I'm interested to hear other opinions on where the line should be.

I think euthanasia should be legal. I think there should be quite a lot of oversight of the process, but I'm not against governments doing cost-benefit analyses of who gets care.

By revealed preferences, it's impossible to care infinitely about a given life. If that wasn't the case, then the entire global economic output would be spent on the first kid who showed up with terminal cancer. Not even those who claim that Life Is Priceless act like that's true. The Pope isn't selling his mobile to save one more starving child in Africa. Even the Dalai Lama has personal possessions, and expensive ones.

Once you accept that (and no population on earth could function without doing so) , all that remains is figuring out how much society implicitly or explicitly values life and making it legible. Yes, it sucks. But we're not gods with unlimited resources.

(If you wish to spend your own funds on your care, then I have no objection to you spending as much as you can afford, your money, your choice. But if you're spending my money, through taxes..)

I also think that anyone who can prove they possess capacity (in the medicolegal sense) should have the right to end their lives.

I'd be open to that being a difficult process, you'd need doctors to sign you off as sane and not suffering from a disease that impairs judgement (and can be cured).

No, I avoid tautology by not claiming that just wanting to die is sufficient grounds to be diagnosed with a mental illness and hence lack capacity. I think there are philosophical reasons that are consistent with wanting to die, for reasons other than depression.

(Severe depression that is resistant to all treatment is, IMO, a terminal illness)*

I hold this position despite being severely depressed, with occasional suicidal ideation. I recognize that I don't want to be depressed or suicidal, and want that part of me excised. I'm quite confident I would never act on that (and doctors know how to make it quick, painless, and irreversible), and if my disease somehow overwhelmed my true volition, I would want to be saved.

I think that unless someone has formally applied for a Suicide License, the default presumption should be that something is wrong with them, and they don't actually want it. This allows us to try and save people who jump off bridges or take paracetamol after a bad breakup. I differ from most people in that I would accept people wanting to die for more considered reasons.

Of course, in the Real World, my hands are tied by laws and code of conducts that physicians must agree to if they want to stay out of jail and in their job. But that's my stance on the matter.

*I haven't exhausted all options, far from it. I even expect that we'll have a generalized cure for depression in my lifetime. I still am not comfortable with telling someone with depression so bad life has lost meaning that they must hold out in hopes of a cure, suffering all the way.

"Safe, lethal legal, and rare." I've been fooled by this before.

That is to say, I believe you and believe your earnestness, but I just cannot conceive of how you would stop cultural slide on this without a solid Chesterton fence.

I'm a radical transhumanist who aspires to live forever, and wants that for everyone else. I can't think of any conclusive argument that proves beyond reasonable doubt that such measures won't be taken to a place that's not palatable for me, and I really wish I had them.

I just think it's worth a shot, even as a small pilot program.

Even if this never happens, I wouldn't lose sleep over it. I think that the kind of person who was that intent on dying would find a way, you don't have to be a doctor to figure out ways to kill yourself. It just makes it easier to achieve without leaving a mess.

Clayton Atraeus managed it, and he was down to two arms and a head.

I hold this position despite being severely depressed, with occasional suicidal ideation. I recognize that I don't want to be depressed or suicidal, and want that part of me excised. I'm quite confident I would never act on that (and doctors know how to make it quick, painless, and irreversible), and if my disease somehow overwhelmed my true volition, I would want to be saved.

But how confident are you that you would never act on that if you had been raised in a society that not only tolerates suicide but excuses and justifies it? In the depths of despair, when the abyss swallows your vision and knowing that doctors could do it quickly, easily and painlessly, then are you confident you would never go through with it?

Quite confident. If my heterodox views are any indication, I'm not someone particularly susceptible to conformity or peer pressure. How many people do you think were born and raised in my circumstances and turned out the way I did? I defy neat classification.

If society was unchanged in terms of medical technology and overall technological progress, but actively encouraged suicide, I still don't think I'd opt for it. I'd demand that every possible treatment be tried first, then possibly ask for a legal document put in place that debarred me from applying for a lengthy period of time, no matter the cause. I'd spend the rest of my life hoping for a cure, and wouldn't give up until I was dying of other causes. If I really wanted to die, I already have more opportunities than I can count (not that the average person doesn't, bridges and busses aren't rare objects).

Do note that I would prefer that even if euthanasia on demand was an option, that there were multiple safe-guards in place to minimize impulse decisions. That would include medical review for reversible causes, counseling with therapists paid a bonus for every patient they talk out of it (to align incentives), and a wait time of a few months. If at any point someone has second thoughts, the wait time gets pushed back another few months.

Hell, keep it a secret under NDA that the first time they put you in the suicide pod, it's actually a drill. If you start screaming and want to be let out, that's when they tell you and swear you to secrecy. Even during the real thing, leave a big red button that would stop the process, if it's a lethal drug, have a bottle of antidote by their side when they're given it.

There was an incredibly poignant video of an elderly francophone lady taking her euthanasia meds for a terminal illness. She was lucid and in absolute control, and speaking till she went to sleep and never woke up. That's what I want the average person who takes this route to look like.

At that point, I'd be content that we're looking at people with incurable illnesses who can't be talked out of their intent. My confidence in an eventual cure for almost all disease isn't so strong that I would demand people hold out for it, that's their choice to make. My choice, at every point in the 10+ years I've been depressed, is to live for a better future.

Those are good measures, although like pusher_robot I would expect them to scope creep a lot. Rules or laws with any ambiguity seem to inevitably fall victim to the death of a thousand cuts. We've already seen euthanasia for a depressed 29 year old in the Netherlands.

But I'm not so worried about patients requesting assisted suicide as I am about the people with access to buses and bridges who suffer in silence and don't have educated medical professionals to help them. It's not really peer pressure, I'm talking more about a society where the emotional valence of suicide is not negative and how that will impact the depressed in general. A world where the water we breathe says 'suicide is an option actually' instead of 'suicide is a tragedy'. I am strong enough in this world to not submit to despair, but I don't know if I would be strong enough in that world. Not when that black dog has me and suicide seems like the only chance for something resembling relief.

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I think euthanasia should be legal

I think importing doctors from poor countries gives you doctors with lower than average amounts of empathy. Seeing human misery up close creates calloused human beings.

I'd be ok with writing a 30 day high dose script of dilaudid that a terminal patient could take all at once to kill themselves with, but the physical act of administering that lethal dose is where I draw the line. If they need help let the family do it.

I hope euthanasia never becomes legal here because I wouldn't like that in my job description and I wouldn't like to interact professionally with anybody who is ok with that. I wouldn't want to work alongside a high-kill-count sniper or kamikaze-drone operator either.

I think importing doctors from poor countries gives you doctors with lower than average amounts of empathy.

I think I've got plenty of empathy, or at least the average as doctors go. That being said, while empathy is always nice to have in a doctor, I'd personally prefer one that was incredibly competent at addressing your problems even if they weren't tearing up over your plight.

Seeing human misery up close creates calloused human beings.

Would you say that a doctor who volunteers for the MSF has lower empathy because of their experience with crushing poverty and disease? Probably not, though I'm happy to note there are selection effects involved. What about one that grew up in an inner-city ghetto but was bright enough to enter med school? Is that a bad thing?

I've seen crushing poverty, and when I volunteered to transfer to one of the largest hospitals in my home country (to work for free), I saw things that emotionally wrecked me. As the essay notes, you either harden your heart or exsanguinate.

It didn't make me a worse doctor, quite the contrary. I went out of my way to help people, and still do.

I think it’s probably good to help create a minimum effort threshold for suicide; things like putting railings on bridges and nets on high buildings make it so that individuals struck by an acute but fleeting suicidal urge are protected from doing something they’d almost immediately regret.

The people accessing medically-assisted suicide, or using other high-effort methods of suicide requiring persistent and focused intent, are probably people who genuinely are better off dead. Not every human life is destined to last until a peaceful death in old age. Not every person is psychologically constituted in a way that’s resilient to all of the various tribulations that life throws at us. I probably wouldn’t personally pull the trigger or inject the deadly solution myself if one of those people asked me, but I’m fine with professionals existing who are willing and able to do so.

As for hard drug addicts, my impression is that only a small percentage of junkies are the sorts of people who’d be very valuable contributors to society if we managed to fix their addictions. Drugs are not taking our best, in other words. I’m aware that there are some unknown number of totally normal middle-class individuals who got hooked on opiates because they were led astray by unscrupulous doctors overprescribing them; my impression is that this represents only a very small percentage of addicts, and that their numbers are being inflated by a populist coalition determined to treat impoverished white Americans as hypoagentic victims.

Junkies killing themselves, whether through overdoses or other means, is overwhelmingly a boon to society, and I think almost zero effort should be taken to prevent them from doing so.

Suicide is a form of murder: self-murder. We make efforts to stop murders, we should make efforts to stop suicide. Overall, society must signal disapproval of suicide. Cultures that honor or otherwise approve (even the implied approval of not bothering to do anything about it) fall into failure modes that our current society doesn't, without much obvious benefit. See Imperial Japan, for instance, which continued fighting long past the point where there was no hope of victory because their culture venerated honorable death over defeat. It did their society active harm. Their suicide rate remained high up until around 2010, when it began to drop and has continued to drop until today, where the suicide rate is actually a little less than the United States (it went from a high of 25.6 per 100K people in 2003 to around 12.2 today, compared to the US's 14.5).

Why did suicide rates drop so significantly in Japan? Well, in 2007 the government released a nine-step plan to lower suicide rates. Since then they funded suicide prevent services, suicide toll lines, mental health screenings for postpartum mothers, counseling services for depression, and in 2021 created a Ministry of Loneliness whose job is to reduce social isolation. In other words, when the Japanese government tried to make a societal effort towards preventing suicide, suicide rates dropped.

Which is good, because Japan needs every citizen it can get. Population is still dropping, and everyone who kills themselves can no longer contribute to society nor create and raise society's next generation.

Which is good, because Japan needs every citizen it can get. Population is still dropping, and everyone who kills themselves can no longer contribute to society nor create and raise society's next generation.

Those people don't owe Japan their lives. Maybe if Japan wants them to contribute to society or create and raise society's next generation, it can make doing those things seem better than literal oblivion.

People owe the societies they live in, actually. If you want to go live in the woods with wolves and bears for neighbors then more power too you, that’s the condition for opting out.

Giving someone a service they never asked for, then claiming they owe you for it, is a classic scam. And this isn't the 16th century. There is nowhere you can run that a government won't find you. They own everything.

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If the world owes you nothing, you owe nothing to the world.

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Why is living in the woods a valid way to opt out, but killing yourself isn't?

People owe the societies they live in, actually.

No. Communistsitarians tend to think this because it allows them to demand infinite sacrifice for zero benefit, but the social contract is continually and constantly renegotiated.

In this case, society isn't holding up its end of the bargain- the "owes its members a future that's at least as good as it was before" part- and as a result, the individuals that make up society will under-deliver in TFR until it starts delivering.

Kind of seems that that is exactly what they are doing: providing mental health services, attempting to find ways to reduce social isolation, trying to change social norms so that literal oblivion does not look like such a nice choice in comparison to social disgrace, etc.

No, they're trying to convince them not to choose oblivion despite not actually changing the conditions. That is, they're trying to get some marginal people from "life sucks so bad I'd rather be dead" to "life sucks almost bad enough I'd rather be dead", not generally improving conditions.

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Advances in medical technology twist the knife for families that have lost loved ones no matter what you do. Some people hold out for a miracle. Some people just receive fresh new horrors to endure daily. I pulled my dad off life support a few years before a cure for him was discovered. Not sure there would have been much of him left though had I waited it out. Sometimes the merciful thing is to let people go.

It'd be pretty embarrassing if you wiped out all the heroin addicts, then a few months later someone came out with a new AI-devised wonderdrug that can cure all addictions with a single pill.

Ozempic already seems to do this. What if we just forced addicts to go on Ozempic?

There's preliminary evidence that Ozempic helps with addictions, but it's far from conclusively established, and won't be for another year or three.

Ahh interesting. Yeah and there is a lot of hype around it rn.

It unfortunately doesn't do that. Source: am on Ozempic, but I still have to fight tooth and nail to keep my sugar addiction under control. It does make you get full faster, but the cravings are just as strong as ever.

Wild. The effect it had on me is making me find sugar kind of gross. I consistently add only one teaspoon to coffee from now on whereas I used to always add two. Additionally I used to take my kids to a coffee shop in the mornings for some goodies a few times a week and now everything in there seems gross. I haven't had a thing from there since starting Semaglutide for weight loss.

It hasn't affected my interest in alcohol though. I can still have a beer or two with dinner, though alcohol never had a grip on me.

When it comes to snacking I find my behavior changed. I can lay in bed now at night and think "hmm I'm feeling a bit hungry. there's some delicious vanilla yogurt in the fridge. I should go have some. go on, go have some" and ... the actual urge to get up and do this is just gone. The abstract thought of pleasure around snacking is still there but the dopamine boost to get me to jump out of bed is missing.

This seems like it could have profound positive effects on addiction, but it's kind of weird how selective it is.

Huh. More proof of my personal theory that different people react differently to the same drug.

(I just got on Semaglutide for a number of reasons, and the difference is astounding.)

Man, I envy you. I really was hoping it would have good effects for me in terms of making it take less willpower to not binge on sweets, but no such luck I'm afraid. Obviously it still does me good in terms of blood sugar control, but I didn't get the fringe benefits I was hoping for.

Amazing.

I've only been on it for a short time so far, but I've already gotten to the point where I can literally forget to eat. The effects have been so beneficial overall I'm kinda waiting for the other shoe to drop.

Don’t copious amounts of diet soda help?

Diet soda doesn't taste like sugar. It tastes like a nasty off-sweet thing, maybe some sort of byproduct of sugar production.

Everybody has a different response to medicine, and food. Some people metabolize certain medications well or poorly. Some people get a good response from Ozempic for all kinds of shit, some don't

Some people think Cilantro tastes like soap and we know exactly why.

Personally I am not offended at all by diet soda but I do know plenty of people who are. It does work for some people!

Not really? I've been able to replace regular Coke with Coke zero, even before Ozempic. But it tastes kinda nasty by itself, so I only drink it with food (as food masks the bad taste). I wouldn't really have much luck using it to fulfill cravings for sweets.

then a few months later someone came out with a new AI-devised wonderdrug that can cure all addictions with a single pill.

As long as we're proposing fantasies, let's counter with a similarly-absurd nightmare: all the heroin addicts on their umpteenth narcan turn into 28 Days Later rage zombies, and you could've avoided the apocalypse if you'd just let them die of their previous overdoses instead. Embarrassing!

Hey, we’re talking about opioids, not PCP!

If were "cause to die" only in the extended consequentialist sense, then Im not sure theres much reason for this skepticism.

We've been making the mistake of enabling drug addicts for a very long time, and IMO it's more than fair to err on the different side for a while before we determine that we need the addicts after all.

It’s worth noting that the VA is paying for this resident to be there, despite the fact he will in fact not be able to do anything.

As always, American doctors have it better. In the UK, the spectrum of duties for psychiatry residents includes pigeon-control.

Now, I can easily see a British trainee ending up stuck on a placement because they haven't been signed-off to do the work, but the extent of the dysfunction would include not being paid for that month.

I thought this was the med reg's job in the UK?

Is this scope creep?!?!

You call the med reg when you want a pigeon removed from the ward. You call the psych reg when you want the pigeon removed from existence.

(With your username, you're best off avoiding the UK like the plague.)

I remember when Canary Wharf (the secondary London financial district with the skyscrapers, for Americans who don't know) hired a falconer for pigeon control duties. If you decapitate or shoot them you have to kill an awful lot of them before the problem is solved, but pigeons have an innate fear of sparrowhawks and after the first bird-on-bird nomming incident les autres are effectively encouraged.

That said, if you hang around Trafalgar Square you will probably still be fed illegally by tourists.

That said, if you hang around Trafalgar Square you will probably still be fed illegally by tourists.

And here I was thinking the London banding didn't nearly account for additional cost of living, I appreciate the culinary advice!

Unfortunately that offer is only good for pigeons.

Good enough for me!

Reading that link was interesting and disturbing but wasn't totally worth it until I made it to this comment.

You might as well be feared, if you can't be loved, and there's little love lost for resident doctors on NHS wards.

You might get a kick out of reading this Very Serious case presentation in the BMJ:

https://pmc.ncbi.nlm.nih.gov/articles/PMC7839907/

LOL this is amazing. Reads like a fiction story. This is so fun omg.

And not even the Christmas BMJ. I had high hopes after seeing it came out on the 25th, but wrong month.

https://www.bmj.com/content/363/bmj.k5094

For non BMJ:

https://pmc.ncbi.nlm.nih.gov/articles/PMC4773691/

The original Christmas BMJ parachute metanalysis that the linked 2018 paper is satirising is also a classic of the genre, although now unfortunately paywalled. Magic internet points to anyone who has a pirate link.

I do enjoy that the one I linked has a correction haha.

What is a VA?

The VA is a government run hospital system which provides free treatment to veterans, at very low standards. Veterans certainly use it, but it’s most popular among those who are either desperate or who have issues that won’t kill you if someone f’s them up.

If you are asking this question you are likely not from the U.S., so some details:

The VA is the U.S.'s primary "socialized" medicine - health care for veterans.

It's been criticized for having amazingly poor care (what's the difference between a VA nurse and a bullet? A bullet can only kill one person), being more of a job program than a health system, at the same time some people love it (everyone involved understands the veteran experience).

It's a huge system with a ton of rot that is essentially a preview of what would happen with single payor in the U.S.

It's a huge system with a ton of rot that is essentially a preview of what would happen with single payor in the U.S.

The VA isn't just a single-payer system - it's a "fully socialised" - i.e. single-payer, single-provider system. Among 1st-world countries, only the UK, Denmark and (for the publicly-subsidised part of their system) Singapore do this. Medicare is a single-payer, multiple-provider system as are the national healthcare systems (also called Medicare) in Canada and Australia. Canada goes further and bans most self-paid top-up care, something very few countries do (and in particular the UK and Australia don't).

All serious proposals I have seen for single-payer healthcare in the US are basically Medicare for all. We know what that looks like (Canada or Australia) - it offers a much better patient experience, at a much higher cost to the taxpayer, than the UK NHS.

I'm a member of a VFW and the VA is popular enough that we have people who assist veterans in applying for VA benefits. I don't doubt that media reports of incompetence are accurate, but the impression I get is that this is largely dependent on the hospital and the doctor. I'd certainly prefer the VA over any of the smaller rural hospitals and over most of the suburban regional hospitals.

It's popular because the financial benefits are great: for many (maybe even most) veterans the care they get through the VA system is either free or close to it. And the VA Community Care Network program means that for outpatient stuff you can actually get seen by a non-VA doctor and the VA wills still pay the whole bill (there are hoops you have to jump through, but a lot of people are motivated to jump if it means they don't have to pay a cent of their healthcare bills).

Context

Commented somewhere else but there are things to like about the VA, I suspect that part of the issue is that the part where it is weakest (inpatient care) is the part most patients know the least and where its hardest to tell when your care is ass.

It's been criticized for having amazingly poor care (what's the difference between a VA nurse and a bullet? A bullet can only kill one person), being more of a job program than a health system, at the same time some people love it (everyone involved understands the veteran experience).

One important thing to consider with the VA is that its level of care is pretty consistent over the entire country. It is "amazingly poor care" relative to many comparable institutions in some urban areas with high quality clinics and hospitals, but amazingly good care relative to what is available privately in many rural communities.

Much as I hate defending the VA I should say that the care can actually be very good at times. Inpatient medical care? Almost always awful. Outpatient care? Some of the clinics are actually excellent. PTSD treatment? Some of those programs are clearly best in the world in class.

Much of this had to do with the specific specialties and staff. Many people at the VA work at a slow pace because they want to be lazy and can get away with it, but some use that slow pace to do things like spending more time with patients which means satisfaction and care can sometimes be better.

Most of us train at the VA at some point though and the VA training experience is comically poor.

My grandmother used to work as an Occupational Therapist at the VA. They were way ahead of most of the rest of the country with a lot of the things she was doing. And, say what you will about the quality of care, the free van trip to the VA for those who needed it was a literal lifesaver.

Department of Veterans' Affairs

-The “best” solution is probably to violate patient rights and involuntarily commit them to make someone else be on the hook for making sure they go to their aftercare.

We have gotten to an odd place where people can nonchalantly talk about fighting police weekly and utilizing millions of dollars of public resources as "rights". This seems like yet another example of why the left and Democrats are so alienated from "the working class", as far as such a thing exists. Relaying a story like this to an Amazon delivery guy, a stay at home mom of 3+, a legal secretary, or a midlevel real estate agent and they'd very likely be seething with rage, thinking about how they just got a $3000 bill from a hospital because their kid had an asthma attack, which came just after finished paying off the bill for their other kid's birth.

Why didn't they just pretend to be homeless again? That is the question they ask. Why is the violent drug user getting better treatment from the state?

Why didn't they just pretend to be homeless again? That is the question they ask. Why is the violent drug user getting better treatment from the state?

That drug addicted hobo is theoretically liable for the cost of his treatment. Obviously he won’t pay it, the hospital knows he won’t, the government knows he won’t, but it’s illegal to consider that up front so they don’t. Instead he receives treatment and the hospital doesn’t bother trying to collect because it’s a waste of time.

So why collect from anyone who isn't a millionaire?

Because most people have insurance, and the rest will make partial payments.

The few eccentric middle class people who don’t have health insurance know the game and will probably negotiate the bill, but not refuse.

One of the other posters hit on this but basically in most states people have a right to be not forced into treatment (of any kind, not just psychiatric) as long as they are not actively suicidal or homicidal (gross oversimplification the laws around this are very state specific and complicated).

Drugs don't count for this. We can't force someone to take their diabetes medication. We can't force someone to go to a psychiatrist (again with above caveats).

This is generally good despite the edge cases.

Its not forcing anyone. The hospital has a clear need to have a minimum treatment program of 30 days. You can accept that program or not

If a patient comes into the emergency department the options are (loosely) you discharge or admit them.

People are allowed to go home even if doing so may result in death or bad outcomes. We typically calling this leaving AMA (against medical advice). Common reasons for this are illness disrupting decision making, denial, and needs (like drug use, or I have a flight to catch, or I gotta go to work).

If people in the hospital think a patients decision making is impaired (for instance: dementia, medical illness resulting in confusion so they can't make a decisions with full thought) they can do a capacity assessment. This usually involves calling psychiatry for help but you don't need to. If the patient understands the ramifications of their decision (oversimplification again) they get to go home and die or have their frostbitten fingers fall off or do too much heroin.

A sub category of this is psychiatric extremity.

If a patient comes to the ED and has a psychiatric history or has psychiatric symptoms then psychiatry needs to see them and say they are safe to go home. Some critical thought should be used to determine if psychiatry is actually needed but for various reasons (including the ED being overworked, midlevels, and liability concerns) no critical thought is used.

For instance "I'm sorry I said I wanted to die, but I had fallen off of a dump truck and could see all the bones in my legs going the wrong direction and it was very painful" "or I came here because I was looking for a therapist" now generate a need for an outpatient follow-up appointment. Also "I have no psychiatric problems but I was confused because I have early onset dementia" and "I came here because prison lore is that I don't have to go to jail if you guys say I have psychiatric problems" or "no I'm fine, that was some good heroin, let me out so I can go get more before they run out." None of these people necessarily need a psychiatrist, the ED psychiatrist's job is to determine if they do and if they are safe to go home.

Now they are required to see someone (supposedly, I don't know the legislative details), wasting everyone's time.

The other primary option is admission. If the patient is a threat to themselves, others, and in some states property (with a lot of at times hazy and at times specific clarification on what all of that means) then they can be involuntarily committed. You can also just ask the patient if they want to stay, which depending on resource availability may involve admitting someone who really doesn't need it. All kinds of complications fall out here, for instance some patient's say they want to be admitted but are admitted involuntarily any way.

In past times the U.S. was very free with involuntarily admitting people, very resistant to actually discharging people (from the ED and from the psychiatric hospital) and abused people in various ways, our current legal framework exists to protect against those abuses, some of which were very very serious (gang rape of patients at state hospital for example).

The downside of reforms was that homeless people who are too mentally ill to function or chronically treatment non-compliant are allowed to wander the street.

You may not care about those people, but we also used to accidentally catch people who really weren't mentally ill or were definitely safe to be at home. Not making this mistake is harder than you think because its very common for people with no mental illness, mild mental illness, and severe mental illness to all say the same things (especially when someone is taking the medication only because they are locked in a state hospital and will stop as soon as they leave and start murdering again).

Its not about caring/not caring about these people. Its about not elevating them above everyone and everything else

It's not that simple. It's not always clear who is who. Some frequent flyers are coming back because they don't want to go to the shelter. Some are coming back because the ED keeps not treating them because they think the problem is mental illness and they never did a basic work up...

It may be helpful to model this similarly to however you feel about the legal system, letting guilty go free and so on.

The legal system doesn't involve people coming into my house, stealing tens of thousands of dollars, and then the next time they are at the front door I am supposed to let them back in. In fact, most of the more sane jurisdictions allow for pretrial detention of something as serious as a burglary or theft by deception.

The problem is the state blatantly violating freedom of contract by forcing these victims to treat these menaces, and then trying to fudge away the actual cost of the insane policy by smuggling it through various re-distributive schemes as opposed to a budgetary line item.

$100 billion for ER visits from meth heads and heroin addicts is less defensible then "we can't have people dying in the streets (ignore this massive cost we've hidden with subterfuge)"

The problem isn't necessarily your idea (although I'm sure some would take issue with it), the issue is the implementation. How do you decide? Some people with chronic medical illness look like a mental health patient, some mental health patients try repeatedly to get medical care and get ignored... when the issue is "live or die" you have to get things absolutely right.

We have gotten to an odd place where people can nonchalantly talk about fighting police weekly and utilizing millions of dollars of public resources as "rights".

I think OP is referring to the 'negative' rights, such as 'not being involuntarily committed unless a danger to oneself or others'. (Mr Have-you-considered-stopping would fall under that exception; Ms Here's-your-follow-up-appointment wouldn't.)

That's a nonsensical frame. The hospital is already being forced to interact with him. They should at least have the tiny freedom of determining the length and course of the imposition

We have gotten to an odd place where people can nonchalantly talk about fighting police weekly and utilizing millions of dollars of public resources as "rights".

Get on our level. British Columbia got into a bit of a kerfuffle when it tried to ban people from injecting drugs in playgrounds. Apparently it would cause "irreparable harm" if they had to shoot up elsewhere, so the BC Supreme Court filed an injunction against that amendment.

(They eventually got it banned, eight months after their first attempt. Having Health Canada do it instead of the BC government was the secret sauce to make it stick, because it matters which government is violating the Canadian Charter of Rights and Freedoms, or something.)

I think this anecdote shows there is an interesting debate to be had about the role of "science" in governance. When the court defers to "experts" opaquely like this, it subverts the intentional democratic structure of government. As someone who has had "scientist" in their job title before, I'm actually of mixed feelings about this. It might feel better if we pushed for science literacy on the courts, or maybe just published the science and let The People decide what to do with it.

I think the misunderstanding, IMO is that "science" is, as-designed, value neutral. It should inform political decisions, not make them directly.

Although maybe this was a question of federalism? Certain powers in the US are reserved for states or feds (regulating alcohol sales vs. international trade). But that doesn't seem like what happened in Canada here.

Well, you've got to give them points for intellectual consistency and being willing to bite bullets! If a the Parks department wants to do something to improve general community wellbeing and make parks enjoyable for normal people, we have to think carefully about the rights of junkies to shoot up in parks. If the Health department says that it's about health, there is absolutely nothing that will counterbalance that and they have an arbitrary level of power to dictate who goes where when.

If the Health department says that it's about health, there is absolutely nothing that will counterbalance that

In Canada, as with the rest of the Western world, 3 Goddesses are worshipped: Safety, Equality, and Consent.

The Parks department's approach contradicted Equality, so what they wanted was bad and denied.

But the Health department are Safety's priests, so what they wanted was good and applied.

I do find myself occasionally wondering if the local abandoned Walmart (shoplifting killed it) might be a fine place for a novel nonprofit to set up an indoor tent city for the local homeless, with security guards and nurses on staff, a doctor dropping by every day for prescriptions, and the in-store pharmacy restored to full functionality. The big outdoor parking lot might be additional space for the hardier hobos willing to rough it.

Why would they go there? Homeless who will accept not doing drugs or fighting already have shelters.

abandoned Walmart (shoplifting killed it)

That’s impressive. It is difficult to kill a Walmart.

I don't know about the US, but the toughest stores here are dollar stores. I don't think I've ever seen one die.

I’ve seen dollar stores die. It’s gas station convenience stores(in local parlance- ‘corner stores’) that won’t die.

Near where I used to live we had an intersection where three corners were gas stations and the other corner was a 7-11, no gas.

It's a four lane divided road. The gas stations on the far side of the intersection, where one could take a right after passing through the intersection, and then take another right to continue on the same route, have always had the same branding and ownership.

The one gas station that was on the near side, where you'd have to exit and be immediately at the stop light, would change ownership every couple of years, and eventually failed completely.

Traffic gets very backed up in this area, and I'm guessing people didn't want to deal with re-entering with a line of cars that wouldn't be kind enough to let them in. Just a few seconds further would take you to a station where eventually traffic would get blocked by a red and you could re-enter without depending on the kindness of strangers.

That property sat unused for about a decade, reportedly because of the great expense involved in neutralizing the underground gas tanks to meet environmental standards.

eventually traffic would get blocked by a red

Fun fact: One of the downsides of roundabouts is that they do not provide these breaks in traffic, so they can cause problems downstream.

They can also cause problems upstream:

(Assumes driving on the right / CCW flow through the roundabout.) If you have a roundabout with heavy traffic flow from, say, the South entrance to the West exit, you can get perpetual backups for traffic coming from the East.

And then you have to do goofy stuff like "traffic-metering signals", which turn the roundabout back into an old-fashioned traffic circle…

I’ve heard the trick is to make sure you have an area of effect anti-regeneration ward.

Does a section of the city commonly called “the warzone” and officially termed “The International District” count as “an area of effect anti-regeneration ward”?

Not sure but it does sound like it would at least disrupt worker drones trying to cast healing spells. A tactic worth trying when faced with such enemy!

Last time I saw it done, breaking a mirror worked.

Actual quote from my last time talking to a patient in the ED:

"A shelter, why the fuck would I go to a shelter doc? It's fucking filled with homeless people, besides they won't let me get high on crack!"

In order to fix the problem you need to be willing to violate some people's rights and to discriminate, the former is something that you do sometimes see flexibility on in the left but the later...

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