disability

Updating your moral software

pnrj core principles, ethics, politics, tribal paradigm , , , , , , , , , , , , , , , , , , , ,

Oct 23 JDN 2459876

I’ve noticed an odd tendency among politically active people, particular social media slacktivists (a term I do not use pejoratively: slacktivism is highly cost-effective). They adopt new ideas very rapidly, trying to stay on the cutting edge of moral and political discourse—and then they denigrate and disparage anyone who fails to do the same as an irredeemable monster.

This can take many forms, such as “if you don’t buy into my specific take on Critical Race Theory, you are a racist”, “if you have any uncertainty about the widespread use of puberty blockers you are a transphobic bigot”, “if you give any credence to the medical consensus on risks of obesity you are fatphobic“, “if you think disabilities should be cured you’re an ableist”, and “if you don’t support legalizing abortion in all circumstances you are a misogynist”.

My intention here is not to evaluate any particular moral belief, though I’ll say the following: I am skeptical of Critical Race Theory, especially the 1619 project which seems to be to include substantial distortions of history. I am cautiously supportive of puberty blockers, because the medical data on their risks are ambiguous—while the sociological data on how much happier trans kids are when accepted are totally unambiguous. I am well aware of the medical data saying that the risks of obesity are overblown (but also not negligible, particular for those who are very obese). Speaking as someone with a disability that causes me frequent, agonizing pain, yes, I want disabilities to be cured, thank you very much; accommodations are nice in the meantime, but the best long-term solution is to not need accommodations. (I’ll admit to some grey areas regarding certain neurodivergences such as autism and ADHD, and I would never want to force cures on people who don’t want them; but paralysis, deafness, blindness, diabetes, depression, and migraine are all absolutely worth finding cures for—the QALY at stake here are massive—and it’s silly to say otherwise.) I think abortion should generally be legal and readily available in the first trimester (which is when most abortions happen anyway), but much more strictly regulated thereafter—but denying it to children and rape victims is a human rights violation.

What I really want to talk about today is not the details of the moral belief, but the attitude toward those who don’t share it. There are genuine racists, transphobes, fatphobes, ableists, and misogynists in the world. There are also structural institutions that can lead to discrimination despite most of the people involved having no particular intention to discriminate. It’s worthwhile to talk about these things, and to try to find ways to fix them. But does calling anyone who disagrees with you a monster accomplish that goal?

This seems particularly bad precisely when your own beliefs are so cutting-edge. If you have a really basic, well-established sort of progressive belief like “hiring based on race should be illegal”, “women should be allowed to work outside the home” or “sodomy should be legal”, then people who disagree with you pretty much are bigots. But when you’re talking about new, controversial ideas, there is bound to be some lag; people who adopted the last generation’s—or even the last year’s—progressive beliefs may not yet be ready to accept the new beliefs, and that doesn’t make them bigots.

Consider this: Were you born believing in your current moral and political beliefs?

I contend that you were not. You may have been born intelligent, open-minded, and empathetic. You may have been born into a progressive, politically-savvy family. But the fact remains that any particular belief you hold about race, or gender, or ethics was something you had to learn. And if you learned it, that means that at some point you didn’t already know it. How would you have felt back then, if, instead of calmly explaining it to you, people called you names for not believing in it?

Now, perhaps it is true that as soon as you heard your current ideas, you immediately adopted them. But that may not be the case—it may have taken you some time to learn or change your mind—and even if it was, it’s still not fair to denigrate anyone who takes a bit longer to come around. There are many reasons why someone might not be willing to change their beliefs immediately, and most of them are not indicative of bigotry or deep moral failings.

It may be helpful to think about this in terms of updating your moral software. You were born with a very minimal moral operating system (emotions such as love and guilt, the capacity for empathy), and over time you have gradually installed more and more sophisticated software on top of that OS. If someone literally wasn’t born with the right OS—we call these people psychopaths—then, yes, you have every right to hate, fear, and denigrate them. But most of the people we’re talking about do have that underlying operating system, they just haven’t updated all their software to the same version as yours. It’s both unfair and counterproductive to treat them as irredeemably defective simply because they haven’t updated to the newest version yet. They have the hardware, they have the operating system; maybe their download is just a little slower than yours.

In fact, if you are very fast to adopt new, trendy moral beliefs, you may in fact be adopting them too quickly—they haven’t been properly vetted by human experience just yet. You can think of this as like a beta version: The newest update has some great new features, but it’s also buggy and unstable. It may need to be fixed before it is really ready for widespread release. If that’s the case, then people aren’t even wrong not to adopt them yet! It isn’t necessarily bad that you have adopted the new beliefs; we need beta testers. But you should be aware of your status as a beta tester and be prepared both to revise your own beliefs if needed, and also to cut other people slack if they disagree with you.

I understand that it can be immensely frustrating to be thoroughly convinced that something is true and important and yet see so many people disagreeing with it. (I am an atheist activist after all, so I absolutely know what that feels like.) I understand that it can be immensely painful to watch innocent people suffer because they have to live in a world where other people have harmful beliefs. But you aren’t changing anyone’s mind or saving anyone from harm by calling people names. Patience, tact, and persuasion will win the long game, and the long game is really all we have.

And if it makes you feel any better, the long game may not be as long as it seems. The arc of history may have tighter curvature than we imagine. We certainly managed a complete flip of the First World consensus on gay marriage in just a single generation. We may be able to achieve similarly fast social changes in other areas too. But we haven’t accomplished the progress we have so far by being uncharitable or aggressive toward those who disagree.

I am emphatically not saying you should stop arguing for your beliefs. We need you to argue for your beliefs. We need you to argue forcefully and passionately. But when doing so, try not to attack the people who don’t yet agree with you—for they are precisely the people we need to listen to you.

The injustice of talent

pnrj core principles, ethics, inequality, mathematical models, personal , , , , , , , , , , , , , , , ,

Sep 4 JDN 2459827

Consider the following two principles of distributive justice.

A: People deserve to be rewarded in proportion to what they accomplish.

B: People deserve to be rewarded in proportion to the effort they put in.

Both principles sound pretty reasonable, don’t they? They both seem like sensible notions of fairness, and I think most people would broadly agree with both them.

This is a problem, because they are mutually contradictory. We cannot possibly follow them both.

For, as much as our society would like to pretend otherwise—and I think this contradiction is precisely why our society would like to pretend otherwise—what you accomplish is not simply a function of the effort you put in.

Don’t get me wrong; it is partly a function of the effort you put in. Hard work does contribute to success. But it is neither sufficient, nor strictly necessary.

Rather, success is a function of three factors: Effort, Environment, and Talent.

Effort is the work you yourself put in, and basically everyone agrees you deserve to be rewarded for that.

Environment includes all the outside factors that affect you—including both natural and social environment. Inheritance, illness, and just plain luck are all in here, and there is general, if not universal, agreement that society should make at least some efforts to minimize inequality created by such causes.

And then, there is talent. Talent includes whatever capacities you innately have. It could be strictly genetic, or it could be acquired in childhood or even in the womb. But by the time you are an adult and responsible for your own life, these factors are largely fixed and immutable. This includes things like intelligence, disability, even height. The trillion-dollar question is: How much should we reward talent?

For talent clearly does matter. I will never swim like Michael Phelps, run like Usain Bolt, or shoot hoops like Steph Curry. It doesn’t matter how much effort I put in, how many hours I spend training—I will never reach their level of capability. Never. It’s impossible. I could certainly improve from my current condition; perhaps it would even be good for me to do so. But there are certain hard fundamental constraints imposed by biology that give them more potential in these skills than I will ever have.

Conversely, there are likely things I can do that they will never be able to do, though this is less obvious. Could Michael Phelps never be as good a programmer or as skilled a mathematician as I am? He certainly isn’t now. Maybe, with enough time, enough training, he could be; I honestly don’t know. But I can tell you this: I’m sure it would be harder for him than it was for me. He couldn’t breeze through college-level courses in differential equations and quantum mechanics the way I did. There is something I have that he doesn’t, and I’m pretty sure I was born with it. Call it spatial working memory, or mathematical intuition, or just plain IQ. Whatever it is, math comes easy to me in not so different a way from how swimming comes easy to Michael Phelps. I have talent for math; he has talent for swimming.

Moreover, these are not small differences. It’s not like we all come with basically the same capabilities with a little bit of variation that can be easily washed out by effort. We’d like to believe that—we have all sorts of cultural tropes that try to inculcate that belief in us—but it’s obviously not true. The vast majority of quantum physicists are people born with high IQ. The vast majority of pro athletes are people born with physical prowess. The vast majority of movie stars are people born with pretty faces. For many types of jobs, the determining factor seems to be talent.

This isn’t too surprising, actually—even if effort matters a lot, we would still expect talent to show up as the determining factor much of the time.

Let’s go back to that contest function model I used to analyze the job market awhile back (the one that suggests we spend way too much time and money in the hiring process). This time let’s focus on the perspective of the employees themselves.

Each employee has a level of talent, h. Employee X has talent hx and exerts effort x, producing output of a quality that is the product of these: hx x. Similarly, employee Z has talent hz and exerts effort z, producing output hz z.

Then, there’s a certain amount of luck that factors in. The most successful output isn’t necessarily the best, or maybe what should have been the best wasn’t because some random circumstance prevailed. But we’ll say that the probability an individual succeeds is proportional to the quality of their output.

So the probability that employee X succeeds is: hx x / ( hx x + hz z)

I’ll skip the algebra this time (if you’re interested you can look back at that previous post), but to make a long story short, in Nash equilibrium the two employees will exert exactly the same amount of effort.

Then, which one succeeds will be entirely determined by talent; because x = z, the probability that X succeeds is hx / ( hx + hz).

It’s not that effort doesn’t matter—it absolutely does matter, and in fact in this model, with zero effort you get zero output (which isn’t necessarily the case in real life). It’s that in equilibrium, everyone is exerting the same amount of effort; so what determines who wins is innate talent. And I gotta say, that sounds an awful lot like how professional sports works. It’s less clear whether it applies to quantum physicists.

But maybe we don’t really exert the same amount of effort! This is true. Indeed, it seems like actually effort is easier for people with higher talent—that the same hour spent running on a track is easier for Usain Bolt than for me, and the same hour studying calculus is easier for me than it would be for Usain Bolt. So in the end our equilibrium effort isn’t the same—but rather than compensating, this effect only serves to exaggerate the difference in innate talent between us.

It’s simple enough to generalize the model to allow for such a thing. For instance, I could say that the cost of producing a unit of effort is inversely proportional to your talent; then instead of hx / ( hx + hz ), in equilibrium the probability of X succeeding would become hx2 / ( hx2 + hz2). The equilibrium effort would also be different, with x > z if hx > hz.

Once we acknowledge that talent is genuinely important, we face an ethical problem. Do we want to reward people for their accomplishment (A), or for their effort (B)? There are good cases to be made for each.

Rewarding for accomplishment, which we might call meritocracy,will tend to, well, maximize accomplishment. We’ll get the best basketball players playing basketball, the best surgeons doing surgery. Moreover, accomplishment is often quite easy to measure, even when effort isn’t.

Rewarding for effort, which we might call egalitarianism, will give people the most control over their lives, and might well feel the most fair. Those who succeed will be precisely those who work hard, even if they do things they are objectively bad at. Even people who are born with very little talent will still be able to make a living by working hard. And it will ensure that people do work hard, which meritocracy can actually fail at: If you are extremely talented, you don’t really need to work hard because you just automatically succeed.

Capitalism, as an economic system, is very good at rewarding accomplishment. I think part of what makes socialism appealing to so many people is that it tries to reward effort instead. (Is it very good at that? Not so clear.)

The more extreme differences are actually in terms of disability. There’s a certain baseline level of activities that most people are capable of, which we think of as “normal”: most people can talk; most people can run, if not necessarily very fast; most people can throw a ball, if not pitch a proper curveball. But some people can’t throw. Some people can’t run. Some people can’t even talk. It’s not that they are bad at it; it’s that they are literally not capable of it. No amount of effort could have made Stephen Hawking into a baseball player—not even a bad one.

It’s these cases when I think egalitarianism becomes most appealing: It just seems deeply unfair that people with severe disabilities should have to suffer in poverty. Even if they really can’t do much productive work on their own, it just seems wrong not to help them, at least enough that they can get by. But capitalism by itself absolutely would not do that—if you aren’t making a profit for the company, they’re not going to keep you employed. So we need some kind of social safety net to help such people. And it turns out that such people are quite numerous, and our current system is really not adequate to help them.

But meritocracy has its pull as well. Especially when the job is really important—like surgery, not so much basketball—we really want the highest quality work. It’s not so important whether the neurosurgeon who removes your tumor worked really hard at it or found it a breeze; what we care about is getting that tumor out.

Where does this leave us?

I think we have no choice but to compromise, on both principles. We will reward both effort and accomplishment, to greater or lesser degree—perhaps varying based on circumstances. We will never be able to entirely reward accomplishment or entirely reward effort.

This is more or less what we already do in practice, so why worry about it? Well, because we don’t like to admit that it’s what we do in practice, and a lot of problems seem to stem from that.

We have people acting like billionaires are such brilliant, hard-working people just because they’re rich—because our society rewards effort, right? So they couldn’t be so successful if they didn’t work so hard, right? Right?

Conversely, we have people who denigrate the poor as lazy and stupid just because they are poor. Because it couldn’t possibly be that their circumstances were worse than yours? Or hey, even if they are genuinely less talented than you—do less talented people deserve to be homeless and starving?

We tell kids from a young age, “You can be whatever you want to be”, and “Work hard and you’ll succeed”; and these things simply aren’t true. There are limitations on what you can achieve through effort—limitations imposed by your environment, and limitations imposed by your innate talents.

I’m not saying we should crush children’s dreams; I’m saying we should help them to build more realistic dreams, dreams that can actually be achieved in the real world. And then, when they grow up, they either will actually succeed, or when they don’t, at least they won’t hate themselves for failing to live up to what you told them they’d be able to do.

If you were wondering why Millennials are so depressed, that’s clearly a big part of it: We were told we could be and do whatever we wanted if we worked hard enough, and then that didn’t happen; and we had so internalized what we were told that we thought it had to be our fault that we failed. We didn’t try hard enough. We weren’t good enough. I have spent years feeling this way—on some level I do still feel this way—and it was not because adults tried to crush my dreams when I was a child, but on the contrary because they didn’t do anything to temper them. They never told me that life is hard, and people fail, and that I would probably fail at my most ambitious goals—and it wouldn’t be my fault, and it would still turn out okay.

That’s really it, I think: They never told me that it’s okay not to be wildly successful. They never told me that I’d still be good enough even if I never had any great world-class accomplishments. Instead, they kept feeding me the lie that I would have great world-class accomplishments; and then, when I didn’t, I felt like a failure and I hated myself. I think my own experience may be particularly extreme in this regard, but I know a lot of other people in my generation who had similar experiences, especially those who were also considered “gifted” as children. And we are all now suffering from depression, anxiety, and Impostor Syndrome.

All because nobody wanted to admit that talent, effort, and success are not the same thing.

The economic impact of chronic illness

pnrj core principles, ethics, inequality, market failure, personal, public policy , , , , , , , , , ,

Mar 27 JDN 2459666

This topic is quite personal for me, as someone who has suffered from chronic migraines since adolescence. Some days, weeks, and months are better than others. This past month has been the worst I have felt since 2019, when we moved into an apartment that turned out to be full of mold. This time, there is no clear trigger—which also means no easy escape.

The economic impact of chronic illness is enormous. 90% of US healthcare spending is on people with chronic illnesses, including mental illnesses—and the US has the most expensive healthcare system in the world by almost any measure. Over 55% of adult Medicaid beneficiaries have two or more chronic illnesses.

The total annual cost of all chronic illnesses is hard to estimate, but it’s definitely somewhere in the trillions of dollars per year. The World Economic Forum estimated that number at $47 trillion over the next 20 years, which I actually consider conservative. I think this is counting how much we actually spend and some notion of lost productivity, as well as the (fraught) concept of the value of a statistical life—but I don’t think it’s putting a sensible value on the actual suffering. This will effectively undervalue poor people who are suffering severely but can’t get treated—because they spend little and can’t put a large dollar value on their lives. In the US, where the data is the best, the total cost of chronic illness comes to nearly $4 trillion per year—20% of GDP. If other countries are as bad or worse (and I don’t see why they would be better), then we’re looking at something like $17 trillion in real cost every single year; so over the next 20 years that’s not $47 trillion—it’s over $340 trillion.

Over half of US adults have at least one of the following, and over a quarter have two or more: arthritis, cancer, chronic obstructive pulmonary disease, coronary heart disease, current asthma, diabetes, hepatitis, hypertension, stroke, or kidney disease. (Actually the former very nearly implies the latter, unless chronic conditions somehow prevented one another. Two statistically independent events with 50% probability will jointly occur 25% of the time: Flip two coins.)

Unsurprisingly, age is positively correlated with chronic illness. Income is negatively correlated, both because chronic illnesses reduce job opportunities and because poorer people have more trouble getting good treatment. I am the exception that proves the rule, the upper-middle-class professional with both a PhD and a severe chronic illness.

There seems to be a common perception that chronic illness is largely a “First World problem”, but in fact chronic illnesses are more common—and much less poorly treated—in countries with low and moderate levels of development than they are in the most highly-developed countries. Over 75% of all deaths by non-communicable disease are in low- and middle-income countries. The proportion of deaths that is caused by non-communicable diseases is higher in high-income countries—but that’s because other diseases have been basically eradicated from high-income countries. People in rich countries actually suffer less from chronic illness than people in poor countries (on average).

It’s always a good idea to be careful of the distinction between incidence and prevalence, but with chronic illness this is particularly important, because (almost by definition) chronic illnesses last longer and so can have very high prevalence even with low incidence. Indeed, the odds of someone getting their first migraine (incidence) are low precisely because the odds of being someone who gets migraines (prevalence) is so high.

Quite high in fact: About 10% of men and 20% of women get migraines at least occasionally—though only about 8% of these (so 1% of men and 2% of women) get chronic migraines. Indeed, because ti is both common and can be quite severe, migraine is the second-most disabling condition worldwide as measured by years lived with disability (YLD), after low back pain. Neurologists are particularly likely to get migraines; the paper I linked speculates that they are better at realizing they have migraines, but I think we also need to consider the possibility of self-selection bias where people with migraines may be more likely to become neurologists. (I considered it, and it seems at least as good a reason as becoming a dentist because your name is Denise.)

If you order causes by the number of disability-adjusted life years (DALYs) they cost, chronic conditions rank quite high: while cardiovascular disease and cancer rate by far the highest, diabetes and kidney disease, mental disorders, neurological disorders, and musculoskeletal disorders all rate higher than malaria, HIV, or any other infection except respiratory infections (read: tuberculosis, influenza, and, once these charts are updated for the next few years, COVID). Note also that at the very bottom is “conflict and terrorism”—that’s all organized violence in the world—and natural disasters. Mental disorders alone cost the world 20 times as many DALYs as all conflict and terrorism combined.

Love the disabled, hate the disability

pnrj core principles, ethics, heuristics and biases, personal , , , , , , , ,

Aug 1 JDN 2459428

There is a common phrase Christians like to say: “Love the sinner, hate the sin.” This seems to be honored more in the breach than the observance, and many of the things that most Christians consider “sins” are utterly harmless or even good; but the principle is actually quite sound. You can disagree with someone or even believe that what they are doing is wrong while still respecting them as a human being. Indeed, my attitude toward religion is very much “Love the believer, hate the belief.” (Though somehow they don’t seem to like that one so much….)

Yet while ethically this is often the correct attitude, psychologically it can be very difficult for people to maintain. The Halo Effect is a powerful bias, and most people recoil instinctively from saying anything good about someone bad or anything bad about someone good. This can make it uncomfortable to simply state objective facts like “Hitler was a charismatic leader” or “Stalin was a competent administrator”—how dare you say something good about someone so evil? Yet in fact Hitler and Stalin could never have accomplished so much evil if they didn’t have these positive attributes—if we want to understand how such atrocities can occur and prevent them in the future, we need to recognize that evil people can also be charismatic and competent.

Halo Effect also makes it difficult for people to understand the complexities of historical figures who have facets of both great good and great evil: Thomas Jefferson led the charge on inventing modern democracy—but he also owned and raped slaves. Lately it seems like the left wants to deny the former and the right wants to deny the latter; but both are historical truths that important to know.

Halo Effect is the best explanation I have for why so many disability activists want to deny that disabilities are inherently bad. They can’t keep in their head the basic principle of “Love the disabled, hate the disability.”

There is a large community of deaf people who say that being deaf isn’t bad. There are even some blind people who say that being blind isn’t bad—though they’re considerably rarer.

Is music valuable? Is art valuable? Is the world better off because Mozart’s symphonies and the Mona Lisa exist? Yes. It follows that being unable to experience these things is bad. Therefore blindness and deafness are bad. QED.


No human being is made better of by not being able to do something. More capability is better than less capability. More freedom is better than less freedom. Less pain is better than more pain.

(Actually there are a few exceptions to “less pain is better than more pain”: People with CIPA are incapable of feeling pain even when injured, which is very dangerous.)

From this, it follows immediately that disabilities are bad and we should be trying to fix them.

And frankly this seems so utterly obvious to me that it’s hard for me to understand why anyone could possibly disagree. Maybe people who are blind or deaf simply don’t know what they’re missing? Even that isn’t a complete explanation, because I don’t know what it would be like to experience four dimensions or see ultraviolet—yet I still think that I’d be better off if I could. If there were people who had these experiences telling me how great they are, I’d be certain of it.

Don’t get me wrong: A lot of ableist discrimination does exist, and much of it seems to come from the same psychological attitude: Since being disabled is bad, they think that disabled people must be bad and we shouldn’t do anything to make them better off because they are bad. Stated outright this sounds ludicrous; but most people who think this way don’t consciously reflect on it. They just have a general sense of badness related to disability which then rubs off on their attitudes toward disabled people as well.

Yet it makes hardly any more sense to go the other way: Disabled people are human beings of value, they are good; therefore their disabilities are good? Therefore this thing that harms and limits them is good?

It’s certainly true that most disabilities would be more manageable with better accommodations, and many of those accommodations would be astonishingly easy and cheap to implement. It’s terrible that we often fail to do this. Yet the fact remains: The best-case scenario would be not needing accommodations because we can simply cure the disability.

It never ceases to baffle me that disability activists will say things like this:

“A wheelchair user isn’t disabled because of the impairment that interferes with her ability to walk, but because society refuses to make spaces wheelchair-accessible.”

No, the problem is pretty clearly the fact that she can’t walk. There are various ways that we could make society more accessible to people in wheelchairs—and we should do those things—but there are inherently certain things you simply cannot do if you can’t walk, and that has nothing to do with anything society does. You would be better off if society were more accommodating, but you’d be better off still if you could simply walk again.

Perhaps my perspective on this is skewed, because my major disability—chronic migraine—involves agonizing, debilitating chronic pain. Perhaps people whose disabilities don’t cause them continual agony can convince themselves that there’s nothing wrong with them. But it seems pretty obvious to me that I would be better off without migraines.

Indeed, it’s utterly alien to my experience to hear people say things like this: “We’re not suffering. We’re just living our lives in a different way.” I’m definitely suffering, thank you very much. Maybe not everyone with disabilities is suffering—but a lot of us definitely are. Every single day I have to maintain specific habits and avoid triggers, and I still get severe headaches twice a week. I had a particularly nasty one just this morning.

There are some more ambiguous cases, to be sure: Neurodivergences like autism and ADHD that exist on a spectrum, where the most extreme forms are utterly debilitating but the mildest forms are simply ordinary variation. It can be difficult to draw the line at when we should be willing to treat and when we shouldn’t; but this isn’t fundamentally different from the sort of question psychiatrists deal with all the time, regarding the difference between normal sadness and nervousness versus pathological depression and anxiety disorders.

Of course there is natural variation in almost all human traits, and one can have less of something good without it being pathological. Some things we call disabilities could just be considered below-average capabilities within ordinary variation. Yet even then, if we could make everyone healthier, stronger, faster, tougher, and smarter than they currently are, I have trouble seeing why we wouldn’t want to do that. I don’t even see any particular reason to think that the current human average—or even the current human maximum—is in any way optimal. Better is better. If we have the option to become transhuman gods, why wouldn’t we?

Another way to see this is to think about how utterly insane it would be to actively try to create disabilities. If there’s nothing wrong with being deaf, why not intentionally deafen yourself? If being bound to a wheelchair is not a bad thing, why not go get your legs paralyzed? If being blind isn’t so bad, why not stare into a welding torth? In these cases you’d even have consented—which is absolutely not the case for an innate disability. I never consented to these migraines and never would have.

I respect individual autonomy, so I would never force someone to get treatment for their disability. I even recognize that society can pressure people to do things they wouldn’t want to, and so maybe occasionally people really are better off being unable to do something so that nobody can pressure them into it. But it still seems utterly baffling to me that there are people who argue that we’d be better off not even having the option to make our bodies work better.

I think this is actually a major reason why disability activism hasn’t been more effective; the most vocal activists are the ones saying ridiculous things like “the problem isn’t my disability, it’s your lack of accommodations” or “there’s nothing wrong with being unable to hear”. If there is anything you’d be able to do if your disability didn’t exist that you can’t do even with accommodations, that isn’t true—and there basically always is.

Valuing harm without devaluing the harmed

pnrj core principles, ethics, public policy , , , , , ,

June 9 JDN 2458644

In last week’s post I talked about the matter of “putting a value on a human life”. I explained how we don’t actually need to make a transparently absurd statement like “a human life is worth $5 million” to do cost-benefit analysis; we simply need to ask ourselves what else we could do with any given amount of money. We don’t actually need to put a dollar value on human lives; we need only value them in terms of other lives.

But there is a deeper problem to face here, which is how we ought to value not simply life, but quality of life. The notion is built into the concept of quality-adjusted life-years (QALY), but how exactly do we make such a quality adjustment?

Indeed, much like cost-benefit analysis in general or the value of a statistical life, the very concept of QALY can be repugnant to many people. The problem seems to be that it violates our deeply-held belief that all lives are of equal value: If I say that saving one person adds 2.5 QALY and saving another adds 68 QALY, I seem to be saying that the second person is worth more than the first.

But this is not really true. QALY aren’t associated with a particular individual. They are associated with the duration and quality of life.

It should be fairly easy to convince yourself that duration matters: Saving a newborn baby who will go on to live to be 84 years old adds an awful lot more in terms of human happiness than extending the life of a dying person by a single hour. To call each of these things “saving a life” is actually very unequal: It’s implying that 1 hour for the second person is worth 84 years for the first.

Quality, on the other hand, poses much thornier problems. Presumably, we’d like to be able to say that being wheelchair-bound is a bad thing, and if we can make people able to walk we should want to do that. But this means that we need to assign some sort of QALY cost to being in a wheelchair, which then seems to imply that people in wheelchairs are worth less than people who can walk.

And the same goes for any disability or disorder: Assigning a QALY cost to depression, or migraine, or cystic fibrosis, or diabetes, or blindness, or pneumonia, always seems to imply that people with the condition are worth less than people without. This is a deeply unsettling result.

Yet I think the mistake is in how we are using the concept of “worth”. We are not saying that the happiness of someone with depression is less important than the happiness of someone without; we are saying that the person with depression experiences less happiness—which, in this case of depression especially, is basically true by construction.

Does this imply, however, that if we are given the choice between saving two people, one of whom has a disability, we should save the one without?

Well, here’s an extreme example: Suppose there is a plague which kills 50% of its victims within one year. There are two people in a burning building. One of them has the plague, the other does not. You only have time to save one: Which do you save? I think it’s quite obvious you save the person who doesn’t have the plague.

But that only relies upon duration, which wasn’t so difficult. All right, fine; say the plague doesn’t kill you. Instead, it renders you paralyzed and in constant pain for the rest of your life. Is it really that far-fetched to say that we should save the person who won’t have that experience?

We really shouldn’t think of it as valuing people; we should think of it as valuing actions. QALY are a way of deciding which actions we should take, not which people are more important or more worthy. “Is a person who can walk worth more than a person who needs a wheelchair?” is a fundamentally bizarre and ultimately useless question. ‘Worth more’ in what sense? “Should we spend $100 million developing this technology that will allow people who use wheelchairs to walk?” is the question we should be asking. The QALY cost we assign to a condition isn’t about how much people with that condition are worth; it’s about what resources we should be willing to commit in order to treat that condition. If you have a given condition, you should want us to assign a high QALY cost to it, to motivate us to find better treatments.

I think it’s also important to consider which individuals are having QALY added or subtracted. In last week’s post I talked about how some people read “the value of a statistical life is $5 million” to mean “it’s okay to kill someone as long as you profit at least $5 million”; but this doesn’t follow at all. We don’t say that it’s all right to steal $1,000 from someone just because they lose $1,000 and you gain $1,000. We wouldn’t say it was all right if you had a better investment strategy and would end up with $1,100 afterward. We probably wouldn’t even say it was all right if you were much poorer and desperate for the money (though then we might at least be tempted). If a billionaire kills people to make $10 million each (sadly I’m quite sure that oil executives have killed for far less), that’s still killing people. And in fact since he is a billionaire, his marginal utility of wealth is so low that his value of a statistical life isn’t $5 million; it’s got to be in the billions. So the net happiness of the world has not increased, in fact.

Above all, it’s vital to appreciate the benefits of doing good cost-benefit analysis. Cost-benefit analysis tells us to stop fighting wars. It tells us to focus our spending on medical research and foreign aid instead of yet more corporate subsidies or aircraft carriers. It tells us how to allocate our public health resources so as to save the most lives. It emphasizes how vital our environmental regulations are in making our lives better and longer.

Could we do all these things without QALY? Maybe—but I suspect we would not do them as well, and when millions of lives are on the line, “not as well” is thousands of innocent people dead. Sometimes we really are faced with two choices for a public health intervention, and we need to decide which one will help the most people. Sometimes we really do have to set a pollution target, and decide just what amount of risk is worth accepting for the economic benefits of industry. These are very difficult questions, and without good cost-benefit analysis we could get the answers dangerously wrong.

Oppression is quantitative.

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JDN 2457082 EDT 11:15.

Economists are often accused of assigning dollar values to everything, of being Oscar Wilde’s definition of a cynic, someone who knows the price of everything and the value of nothing. And there is more than a little truth to this, particularly among neoclassical economists; I was alarmed a few days ago to receive an email response from an economist that included the word ‘altruism’ in scare quotes as though this were somehow a problematic or unrealistic concept. (Actually, altruism is already formally modeled by biologists, and my claim that human beings are altruistic would be so uncontroversial among evolutionary biologists as to be considered trivial.)

But sometimes this accusation is based upon things economists do that is actually tremendously useful, even necessary to good policymaking: We make everything quantitative. Nothing is ever “yes” or “no” to an economist (sometimes even when it probably should be; the debate among economists in the 1960s over whether slavery is economically efficient does seem rather beside the point), but always more or less; never good or bad but always better or worse. For example, as I discussed in my post on minimum wage, the mainstream position among economists is not that minimum wage is always harmful nor that minimum wage is always beneficial, but that minimum wage is a policy with costs and benefits that on average neither increases nor decreases unemployment. The mainstream position among economists about climate policy is that we should institute either a high carbon tax or a system of cap-and-trade permits; no economist I know wants us to either do nothing and let the market decide (a position most Republicans currently seem to take) or suddenly ban coal and oil (the latter is a strawman position I’ve heard environmentalists accused of, but I’ve never actually heard advocated; even Greenpeace wants to ban offshore drilling, not oil in general.).

This makes people uncomfortable, I think, because they want moral issues to be simple. They want “good guys” who are always right and “bad guys” who are always wrong. (Speaking of strawman environmentalism, a good example of this is Captain Planet, in which no one ever seems to pollute the environment in order to help people or even in order to make money; no, they simply do it because the hate clean water and baby animals.) They don’t want to talk about options that are more good or less bad; they want one option that is good and all other options that are bad.

This attitude tends to become infused with righteousness, such that anyone who disagrees is an agent of the enemy. Politics is the mind-killer, after all. If you acknowledge that there might be some downside to a policy you agree with, that’s like betraying your team.

But in reality, the failure to acknowledge downsides can lead to disaster. Problems that could have been prevented are instead ignored and denied. Getting the other side to recognize the downsides of their own policies might actually help you persuade them to your way of thinking. And appreciating that there is a continuum of possibilities that are better and worse in various ways to various degrees is what allows us to make the world a better place even as we know that it will never be perfect.

There is a common refrain you’ll hear from a lot of social justice activists which sounds really nice and egalitarian, but actually has the potential to completely undermine the entire project of social justice.

This is the idea that oppression can’t be measured quantitatively, and we shouldn’t try to compare different levels of oppression. The notion that some people are more oppressed than others is often derided as the Oppression Olympics. (Some use this term more narrowly to mean when a discussion is derailed by debate over who has it worse—but then the problem is really discussions being derailed, isn’t it?)

This sounds nice, because it means we don’t have to ask hard questions like, “Which is worse, sexism or racism?” or “Who is worse off, people with cancer or people with diabetes?” These are very difficult questions, and maybe they aren’t the right ones to ask—after all, there’s no reason to think that fighting racism and fighting sexism are mutually exclusive; they can in fact be complementary. Research into cancer only prevents us from doing research into diabetes if our total research budget is fixed—this is more than anything else an argument for increasing research budgets.

But we must not throw out the baby with the bathwater. Oppression is quantitative. Some kinds of oppression are clearly worse than others.

Why is this important? Because otherwise you can’t measure progress. If you have a strictly qualitative notion of oppression where it’s black-and-white, on-or-off, oppressed-or-not, then we haven’t made any progress on just about any kind of oppression. There is still racism, there is still sexism, there is still homophobia, there is still religious discrimination. Maybe these things will always exist to some extent. This makes the fight for social justice a hopeless Sisyphean task.

But in fact, that’s not true at all. We’ve made enormous progress. Unbelievably fast progress. Mind-boggling progress. For hundreds of millennia humanity made almost no progress at all, and then in the last few centuries we have suddenly leapt toward justice.

Sexism used to mean that women couldn’t own property, they couldn’t vote, they could be abused and raped with impunity—or even beaten or killed for being raped (which Saudi Arabia still does by the way). Now sexism just means that women aren’t paid as well, are underrepresented in positions of power like Congress and Fortune 500 CEOs, and they are still sometimes sexually harassed or raped—but when men are caught doing this they go to prison for years. This change happened in only about 100 years. That’s fantastic.

Racism used to mean that Black people were literally property to be bought and sold. They were slaves. They had no rights at all, they were treated like animals. They were frequently beaten to death. Now they can vote, hold office—one is President!—and racism means that our culture systematically discriminates against them, particularly in the legal system. Racism used to mean you could be lynched; now it just means that it’s a bit harder to get a job and the cops will sometimes harass you. This took only about 200 years. That’s amazing.

Homophobia used to mean that gay people were criminals. We could be sent to prison or even executed for the crime of making love in the wrong way. If we were beaten or murdered, it was our fault for being faggots. Now, homophobia means that we can’t get married in some states (and fewer all the time!), we’re depicted on TV in embarrassing stereotypes, and a lot of people say bigoted things about us. This has only taken about 50 years! That’s astonishing.

And above all, the most extreme example: Religious discrimination used to mean you could be burned at the stake for not being Catholic. It used to mean—and in some countries still does mean—that it’s illegal to believe in certain religions. Now, it means that Muslims are stereotyped because, well, to be frank, there are some really scary things about Muslim culture and some really scary people who are Muslim leaders. (Personally, I think Muslims should be more upset about Ahmadinejad and Al Qaeda than they are about being profiled in airports.) It means that we atheists are annoyed by “In God We Trust”, but we’re no longer burned at the stake. This has taken longer, more like 500 years. But even though it took a long time, I’m going to go out on a limb and say that this progress is wonderful.

Obviously, there’s a lot more progress remaining to be made on all these issues, and others—like economic inequality, ableism, nationalism, and animal rights—but the point is that we have made a lot of progress already. Things are better than they used to be—a lot better—and keeping this in mind will help us preserve the hope and dedication necessary to make things even better still.

If you think that oppression is either-or, on-or-off, you can’t celebrate this progress, and as a result the whole fight seems hopeless. Why bother, when it’s always been on, and will probably never be off? But we started with oppression that was absolutely horrific, and now it’s considerably milder. That’s real progress. At least within the First World we have gone from 90% oppressed to 25% oppressed, and we can bring it down to 10% or 1% or 0.1% or even 0.01%. Those aren’t just numbers, those are the lives of millions of people. As democracy spreads worldwide and poverty is eradicated, oppression declines. Step by step, social changes are made, whether by protest marches or forward-thinking politicians or even by lawyers and lobbyists (they aren’t all corrupt).

And indeed, a four-year-old Black girl with a mental disability living in Ghana whose entire family’s income is $3 a day is more oppressed than I am, and not only do I have no qualms about saying that, it would feel deeply unseemly to deny it. I am not totally unoppressed—I am a bisexual atheist with chronic migraines and depression in a country that is suspicious of atheists, systematically discriminates against LGBT people, and does not make proper accommodations for chronic disorders, particularly mental ones. But I am far less oppressed, and that little girl (she does exist, though I know not her name) could be made much less oppressed than she is even by relatively simple interventions (like a basic income). In order to make her fully and totally unoppressed, we would need such a radical restructuring of human society that I honestly can’t really imagine what it would look like. Maybe something like The Culture? Even then as Iain Banks imagines it, there is inequality between those within The Culture and those outside it, and there have been wars like the Idiran-Culture War which killed billions, and among those trillions of people on thousands of vast orbital habitats someone, somewhere is probably making a speciesist remark. Yet I can state unequivocally that life in The Culture would be better than my life here now, which is better than the life of that poor disabled girl in Ghana.

To be fair, we can’t actually put a precise number on it—though many economists try, and one of my goals is to convince them to improve their methods so that they stop using willingness-to-pay and instead try to actually measure utility by something like QALY. A precise number would help, actually—it would allow us to do cost-benefit analyses to decide where to focus our efforts. But while we don’t need a precise number to tell when we are making progress, we do need to acknowledge that there are degrees of oppression, some worse than others.

Oppression is quantitative. And our goal should be minimizing that quantity.