"Talks a good game about freedom when out of power, but once he’s in – bam! Everyone's enslaved in the human-flourishing mines."

Apologia Pro Vita Sua

I do occasional work for my hospital’s Addiction Medicine service, and a lot of our conversations go the same way.

My attending tells a patient trying to quit that she must take a certain pill that will decrease her drug cravings. He says it is mostly covered by insurance, but that there will be a copay of about one hundred dollars a week.

The patient freaks out. “A hundred dollars a week? There’s no way I can get that much money!”

My attending asks the patient how much she spends on heroin.

The patient gives a number like thirty or forty dollars a day, every day.

My attending notes that this comes out to $210 to $280 dollars a week, and suggests that she quit heroin, take the anti-addiction pill, and make a “profit” of $110.

At this point the patient always shoots my attending an incredibly dirty look. Like he’s cheating somehow. Just because she has $210 a week to spend on heroin doesn’t mean that after getting rid of that she’d have $210 to spend on medication. Sure, these fancy doctors think they’re so smart, what with their “mathematics” and their “subtracting numbers from other numbers”, but they’re not going to fool her.

At this point I accept this as a fact of life. Whatever my patients do to get money for drugs – and I don’t want to know – it’s not something they can do to get money to pay for medication, or rehab programs, or whatever else. I don’t even think it’s consciously about them caring less about medication than about drugs, I think that they would be literally unable to summon the motivation necessary to get that kind of cash if it were for anything less desperate than feeding an addiction.

There’s a rationalist saying about making a desperate effort, as if the life of your child was at stake. Nowadays I tend to think of this in terms of “Make a desperate effort, as if you were a heroin addict and your next fix depended on it.”

Anyway, it might sound like I’m mocking my patients, but I’m not. I’m meandering my way into an apology.

I have had a really busy few months. I think it will be letting up soon, but I’m not sure. And I’ve told a lot of people who needed things from me, for one reason or another, “I’m sorry, I’m too busy to take care of this right now.”

And I worry that some of those people read my blog and think “Wait, if you have enough time to write blog posts nearly every day, some of which are up to six thousand words long, why don’t you have enough time to do a couple of hours work for me?”

And the answer is – you fancy doctors with your mathematics and subtraction might say that I could just take a couple of hours away from blogging and use those free hours to write that one thing or analyze that one study or whatever, but you’re not going to fool me.

Just as drugs mysteriously find their own non-fungible money, enjoyable activities mysteriously find their own non-fungible time. If I had to explain it, I’d say the resource bottleneck isn’t time but energy/willpower, and that these look similar because working hard saps energy/willpower and relaxing for a while restores it, so when I have less time I also have less energy/willpower. But some things don’t require energy/willpower and so are essentially free.

This is unfair to you guys, but I should be substantially freer in the next couple of weeks and we can see what happens.

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35 Responses to Apologia Pro Vita Sua

  1. J says:

    If you were king, how would you handle drug seeking behavior in patients? Is it worth holding them back, or would we be better off letting them have all they want?

  2. Ialdabaoth says:

    Just as drugs mysteriously find their own non-fungible money, enjoyable activities mysteriously find their own non-fungible time. If I had to explain it, I’d say the resource bottleneck isn’t time but energy/willpower, and that these look similar because working hard saps energy/willpower and relaxing for a while restores it, so when I have less time I also have less energy/willpower. But some things don’t require energy/willpower and so are essentially free.

    This is unfair to you guys, but I should be substantially freer in the next couple of weeks and we can see what happens.

    I think this is completely fair. Doing things that restore your energy/willpower is what allows you to be the person that is good to others. It is completely fair to others that you spend time to earn the currency that you then generously spend on them.

    Also, I don’t think I’ve thanked you lately for this blog, and for your insight.

    Thank you for this blog, and for your insight.

    • Sniffnoy says:

      Thank you for this blog, and for your insight.

      Seconded!

      • Paul Torek says:

        Nthed! (I feel about it so strongly it counts many times)

        As a quasi-semi-sorta-Kantianesque ethicist, I’d also say you owe it to yourself to restore your energy this way.

  3. Ghatanathoah says:

    Considering how many comments worth of discussion one of your blog posts generates, I wouldn’t be at all surprised if the amount of benefit you confer on others by writing them is comparable to the amount of benefit you confer on your face-to-face acquaintances by helping them directly. I have no idea how many people read this blog, but if two or three dozen people get a three or four minutes of intellectually stimulating entertainment per post that is equivalent to entertaining one person for a couple hours.

    • Oligopsony says:

      I’d be inclined to agree – Scott is an excellent writer, and the LW crowd is a lot funner when you get to drink and mindkill and call each other Enemies of Freedom – but people’s next-best reading option is probably nearly as good (there is no reason to expose yourself to anything but the best of the best, after all, and modulo whatever “best” is for you) while the same is probably not as true for real-life hangouts.

  4. @JohnWBH says:

    I feel like the moral of this story is that we should use Heroin to incentivise socially beneficial activities. E.g. give people Heroin in exchange for a $1000 donation to the Against Malaria Foundation, or whatever the most effective charity we can find is.

    If we have this way of overcoming all normal effort restraints and akrasia it seems a shame not to use it.

    • Daniel Armak says:

      How could that work? If heroin is cheaper on the market, the addicts will buy it there and not from you. If it’s not cheaper on the market, how can you sell it to them for $1000 and not lose money?

  5. Paul Crowley says:

    Also, when you’re too stuffed to eat another bite, there’s a whole empty compartment for pudding.

  6. Q says:

    I might be extremely gullible… But there is a person in Slovakia, a laic therapist, who treats heroin addiction by abstinence, i.e. “cold turkey”. He just entertains the patient during the crisis with several placebo activities, like hot bath, aromatherapy, feet massage, acupuncture, showing funny pictures on computer screen. This sequence is repeated cca every 2 hours. He claims 80 % success, although I never saw any real publication, plus the percentage is not from general public, but from those patients, who “voluntarily” enter his treatment. He is kind of good in manipulating people to believe they want to quit.

    Anyway, he very much opposes using drugs (particularly methadon) to help withdrawal from heroin addiction, at least not before the “cold turkey” had a fair chance.

    I have seen also this article, saying similar thing: http://www.spectator.co.uk/features/3212846/withdrawal-from-heroin-is-a-trivial-matter/

    What do You think about that ?

    • Scott Alexander says:

      It sounds like you might be confusing “withdrawal” and “addiction”.

      I don’t know if I would agree with the article saying withdrawal is “trivial” – it’s certainly very very very unpleasant. But the article is basically correct that it won’t kill you and that after a couple of bad days you’ll be fine and everyone knows this and getting people through withdrawal is not at all hard from a medical perspective.

      But fear of physical withdrawal is only a small part of mental addiction – the tendency of people who have used a lot of heroin to want to use more. You can get someone through physical withdrawal any way you want – with or without methadone – and if they get through, and you let them go a week later, chances are within a few weeks or MAYBE months they’ll be using exactly as much heroin as they did before if not more.

      The reason we have all these rehab programs and stuff is to teach people the coping skills they need to stay off drugs long term. And the reason we have things like methadone is so that we can give it to people long-term to indefinitely so that there’s no temptation to get back on heroin.

      • Q says:

        “the reason we have things like methadone is so that we can give it to people long-term to indefinitely so that there’s no temptation to get back on heroin.”

        Supposedly, many addicts take both methadon and heroin, methadon is sold on black market, etc. Maybe in the USA, you have a bulletproof program to prevent that…

        (Probably I am unfair, and should look up studies – lazy to do that right now – what percentage of methadon users use no heroin, or how methadon guys are doing, compared to cold turkey guys…)

        • Scott Alexander says:

          All right, let me rephrase that.

          There is less temptation to get back on heroin, in the sense that they are not miserable and craving heroin all the time. Heroin is still fun.

          Lots of studies have been done on this and methadone treatment reduces heroin relapse. See for example this study in China, where users attached to a methadone clinic had an 8% relapse rate compared to 60% in the control group.

    • Anonymous says:

      My first guess is that he’s just wrong, so I haven’t bothered to read the article. But even if it is true that he can easily cure people, that doesn’t make it a trivial matter.

      What good would attention do? If he thinks that he can convey his abilities to other therapists by writing a book, he should write that book and convince others to read it. News coverage could be helpful in getting many people to read that book, but not until it exists. And I very much doubt that he thinks that nor that a book will ever exist. More likely, he thinks that he can train people to be like him. If so, he should do that, but he cannot train many people at once, so news coverage is not so helpful.

      Incidentally, I don’t think the drug Scott mentioned is methadone.

      • Q says:

        No book, but a lot of repetitive blog posts on prominent blogging site, plus nobody saying that it is a bullshit. Only in private conversation, I have heard one psychologist express his disgust, but in a rather unspecific way.

  7. Kaj Sotala says:

    This sounds like the exploration-exploitation model of willpower. Basically, the model says that we perceive different tasks as either “want to do” tasks, which replenish willpower if we do them, or as “should do” tasks, which require willpower to carry out.

    The heroin addict would then view acquiring money for heroin as a “want to do” task and acquiring money for medicine as a “should do” task. Similarly, you’d view the act of writing blog posts as a “want to do” task, with the other things as “should do” tasks.

  8. Stephen says:

    Now you’ve gotten me curious about your writing process. Do you usually have a bunch of posts that you’re working on simultaneously that go up as you finish them, or is it all done sequentially? And more to the point, how the heck do you maintain such a high level of quality while posting so much, so quickly? It seems to me like you post way more often than you did during your livejournal days (though admittedly I read those posts after the fact, and wasn’t checking dates very carefully), and the writing quality has only gone up. So I’m wondering: how much of that is just you devoting more time to blogging, and how much is due to an actual decrease in writing time/blog post? And if you have become a more efficient writer, did that require concerted effort on your part, or did it happen naturally as you wrote more?

  9. Thasvaddef says:

    Do you believe that being freer will lead to more time being devoted to doing those things?
    Work expands to fill the time available for its completion, after all.

  10. Army1987 says:

    If I had to explain it, I’d say the resource bottleneck isn’t time but energy/willpower, and that these look similar because working hard saps energy/willpower and relaxing for a while restores it, so when I have less time I also have less energy/willpower.

    That’s why it annoys me when people, e.g. Randall Munroe or Eliezer Yudkowsy or Anna Salomon, assume that time is scarce but fungible.

    Maybe for some people time actually is the limiting factor, and for other people stamina actually is the limiting factor, and certain people generalize from one example.

    (More speculatively, I’d guess that people for whom time is the limiting factor should try to sleep less and people for whom stamina is the limiting factor should try to sleep more.)

    • Creutzer says:

      I’d guess that […] people for whom stamina is the limiting factor should try to sleep more.

      Doesn’t do anything for me.

  11. Since you didn’t state this explicitly, I want to point out that this whole post is really an expansion on the comment you made in Right Is The New Left:

    “(writing blog entries doesn’t require free time. They just appear.)”

  12. Leo says:

    I’m curious, what do people do to get heroin money, that they wouldn’t be willing to do otherwise? I expect working overtime, working two jobs, begging, borrowing, theft, prostitution, from stereotypes, but real people are probably more interesting.

    • Anonymous says:

      Asking for money loans from friends and family (which they may or may not plan to repay), or theft in more extreme cases, in my experience.

    • Anonymous says:

      Asking for money or loans from friends and family (which they may or may not plan to repay), or theft in more extreme cases, in my experience.

  13. Lorxus says:

    Better yet – “Make a desperate effort, as if you just noticed your scuba tank was empty.”

  14. PoignardAzur says:

    Heh. I actually wondered for a long time why I had such a long todo-list of things I did not have time to do because I was busy studying hard, except I kept staying late at night browsing philosophy blogs and webcomics. I realized the same thing (time is not my bottleneck, willpower is) a few weeks ago. It’s nice to read someone developing the same reasoning.

    The obvious conclusion is that I need to rearrange my productive activities, to make them less energy consuming, or at least have easy productive activities for when I have a lot of time and no willpower left. I made that one years ago, and I still have no idea how to implement it.