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Notes -
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:
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…).
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.
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.
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.
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.
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.
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.
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 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.
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.
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