Astral Codex Ten

Oregon

68 min read

Oregon

Article

Oregon is a recurring place in the Astral Codex Ten archive, appearing 18 times across 18 issues between May 12, 2021 and August 29, 2025. The archive places it in contexts such as “Oregon somehow ended up with a law banning self-serving gas stations”; “Washington and Oregon’s farmland”; “#1 through #5 were … Oregon”. It most often appears alongside Australia, California, India.

Metadata

  • Category: Places
  • Mention count: 18
  • Issue count: 18
  • First seen: May 12, 2021
  • Last seen: August 29, 2025

Appears In

Source Context

Recovered passages from the original issue text. When the raw archive preserved outbound links inside the source passage, they are listed directly under the quote.

Welcome To The Terrible World Of Prescription-Only Apps
May 12, 2021 · Original source
Any loss of freedom stings for a few months. Then it’s just The Way Things Have To Be. Oregon somehow ended up with a law banning self-serving gas stations. In 2018, someone tried to repeal the law and legalize them, and was met with outrage: what if there were gas-related injuries? What if people got confused and couldn’t fuel their cars? What if it increased inequality somehow?
Inline links: was met with outrage
Your Book Review: The Accidental Superpower
May 21, 2021 · Original source
We didn’t just get tremendous economic growth though – we got “magical” results, but they were based on a one-time confluence of factors that “overwhelmed the normal rule that lots of twenty-and thirty-somethings make for an expensive-capital environment.” What were these one-time accelerants? He identifies the peace dividend – cuts in military spending that allowed capital to be put to more productive uses – as one such change, along with the emergent dominance of the US dollar, particularly boosted by Russian demand thanks to the collapse of their currency, and a later boost in demand thanks to the East Asian financial crisis. With the Europeans’ decision to eliminate national currencies (agreed upon in a 1992 treaty, with the Euro to be introduced in 1999), they became relatively unattractive, and the Euro itself (an “unprecedented experiment in pan-government planning”) was too risky. Many holders of European currencies switched to the US dollar, such that between 1994 and 2002 (“when the euro finally got some traction and the surge dialed back”) there was a $2 trillion increase in the money supply. Zeihan also points to a collapse in commodities prices influenced by the elimination of Russian demand, but continued Russian production of oil and other commodities, followed by a collapse in demand thanks to the East Asian financial crisis. This story of capital coming to the West (“allowing consumption-driven growth not simply to soar, but to explode”) is one of chance world events. However, the story of capital coming from the Boomer cohort is one of demographics. By the 2000s, they’re the mature workers of Zeihan’s four stages described above – and as the bulge in the demographic pyramid, they started flooding the world with capital. Accordingly, “The cost of credit plummeted to levels never before experienced.” Zeihan suggests that developed-world demographics are the cause of booms in places that haven’t been well-developed, from Southern Europe to Brazil, Russia, and India. But he says it’s quickly coming to an end; Boomer savings into stocks and bonds will be moving to low-risk instruments and then turning into withdrawals rather than savings, and the cohort behind them is too small to replace all of that capital. And it’s a worldwide phenomenon: In every single developed country there is currently an American-style population inversion between the about-to-retire and the about-to-be-mature-workers age groups. Japan’s Boomers bulge is a decade older than the American equivalent, while Spain’s is roughly fifteen years younger. Everyone else falls somewhere in between. It dictates a period of chronically low growth and high credit costs, just not on precisely the same time frame. The undeveloped world is that way because it can’t self-fund, so without foreign capital, their growth will come to an end. In sum, the 1990-2005 period of high growth and easy capital was a historical anomaly; “the post-Cold War financial flight was a once-in-a-generation event” and the demographic bulge that coincided with it won’t come around again for decades, if ever. 4 2: America’s incredible advantages As noted above, Zeihan really likes America’s position in the world. He likes its demographics (relative to other developed countries) and loves its geography. Taking the population question first, in America, “the demographic inversion is only a temporary development.” America is younger than the rest of the developed world, as it urbanized later and its enormous size made having kids easier despite that urbanization (i.e., the suburbs exist). This makes the demographic crunch a single-generation issue, as the Millennials are a huge cohort. And even if they weren’t, America assimilates immigrants more easily than other places – Zeihan attributes this to it being a “settler society” – which can help with demographic problems. The rest of the developed world doesn’t have similar cohorts following their massive Boomer and Gen-X analogues. Accordingly: While the American financial world will be past its period of maximum stress by 2030, for the rest of the world 2030 will simply be another year of an ever-deepening imbalance between retirees and taxpayers, with smaller and smaller generations coming up the ranks generating less and less growth. For the developed world beyond the United States—and even large portions of the developing world—chronic capital poverty and permanent recession will be the new normal from which there is no return. Together with America’s Millennial-led growth and abundant energy (there’s a chapter explaining how shale is a done deal that, as of the mid-2014 writing, already made America the world’s largest energy producer 5), by 2030 Zeihan sees it as practically the only country with an economy worth noting. Anyone who is familiar with American geography should see the argument that’s coming about that aspect of Zeihan’s model. Isn’t the Mississippi River a pretty big deal? And those oceans on the east and west coasts seem like nice borders. Indeed, while he gives us many reasons why there was always going to be an American superpower, geography is central to his story. He has lots to say about America’s internal river systems, farmland, and other geographic features. What mountain barriers exist are apparently better than in other countries in terms of allowing internal transport; the Rockies have major passes, several of which have large cities within them, and the easiest pass in the Appalachians featured America’s first National Road, 130 miles of buried logs that linked two rivers, and thus the east coast with the best farmland in the world. As we saw with his exposition on the Nile, Zeihan puts a lot of emphasis on the value of river systems. He argues that America’s waterway network alone should be sufficient for “global dominance.” The numbers he provides in support of this point are impressive. For example, “the Mississippi is only one of twelve major navigable American rivers. Collectively, all of America’s temperate-zone rivers are 14,650 miles long. China and Germany each have about 2,000 miles, France about 1,000. The entirety of the Arab world has but 120.” He praises US barrier islands that mitigate oceanic destruction and effectively create another river system, as well as the fact that the river system is an actual network. All of this gives America more internal waterways than the rest of the world combined. Thus, we get cheap transportation for “Nebraska corn or Tennessee whiskey or Texas oil or New Jersey steel or Georgia peaches or Michigan cars,” enabling savings that “can be used for whatever Americans (or their government) want, from iPhones to aircraft carrier battle groups.” America doesn’t have to spend on artificial infrastructure, like German roads and rails, but when it does, the competition from the rivers keeps transport costs low. Cheap internal transportation has other benefits. “It’s a recipe for small government and high levels of entrepreneurship,” as small government keeps taxes low, leaving people with plenty of capital. Some people may think of the American consumer with disdain, but it isn’t a new phenomenon. Zeihan points out that America has been the world’s largest consumer market “since shortly after the Civil War.” His observation about a robust food supply forming the base of any civilization bodes well for America, which apparently has the largest connected stretch of quality farmland in the world (the Midwest), the value of which is exponentially increased by the fact that it overlaps with so many of these amazing river systems. It isn’t just the Midwest that he gushes over. California’s Central Valley and the Sacramento River, and Washington and Oregon’s farmland with the Columbia and Snake Rivers get praise. The only major farmland more than 150 miles from a navigable waterway is some of the Great Plains near the Rockies. ***** Zeihan provides a reminder that national security is actually a thing, and that at its most basic level, it’s about protection against invasions. It was something of a shock reading about America’s land borders in that context. “As Santa Anna discovered during the Texas Independence War, there is no good staging location in (contemporary) Mexican territory that could strike at American lands.” And, “Canada’s border with the United States is much longer, more varied, and even more successful at keeping the two countries separated,” thanks to mountains and thick forests over much of it. The mid-continent lands are much more connected, but Zeihan frames these Canadian areas as basically American; they’re physically separated from Canada’s core eastern provinces, so trade with them is weaker than with the closer American states. Then there are the oceans. As much as Zeihan loves deserts for protection, he loves oceans more (particularly in a post-World War II world; more on that below). We get a story about the War of 1812 nearly splitting America into three when the British attacked Baltimore. America learned about “strategic vulnerability and sea approaches,” as the attack “on Baltimore—indeed, the entire war effort—would have been impossible without launching grounds in Canada and the Caribbean.” American foreign policy since then can be understood with respect to this lesson. Zeihan cites it as inspiration for America’s steps to make its ocean borders truly impenetrable, such as working to sever Canada from Britain, and the imperial-era acquisitions of Alaska, Hawaii, Midway, Puerto Rico, and de facto control of Cuba (preventing enemies from cutting off Mississippi River-based trade from the rest of the world). There’s more to Zeihan’s being awestruck by America than his analysis of its balance of transport advantages. He argues that America has been the world leader for agriculture, technology, finance, and industry since the Civil War, and runs through a litany of reasons for its preeminence: America is like a continent-sized island (because of its effective land borders), which is always going to be a more natural naval power than a more landlocked country.
Inline links: 4, 5
Lockdown Effectiveness: Much More Than You Wanted To Know
July 07, 2021 · Original source
But it’s also worth mentioning that US states that seemed kind of like Scandinavia (northern, forested, liberal) also had the lowest number of coronavirus cases in the continental US - #1 through #5 were Vermont, Oregon, Maine, Washington, and New Hampshire. And this isn’t clearly related to household size, so maybe something else is going on.
Inline links: isn’t clearly related to household size
Open Thread 217
March 27, 2022 · Original source
2: The effective altruists I know are really excited about Carrick Flynn for Congress (he’s running as a Democrat in Oregon). Carrick has fought poverty in Africa, worked on biosecurity and pandemic prevention since 2015, and is a world expert on the intersection of AI safety and public policy (see eg this paper he co-wrote with Nick Bostrom). He also supports normal Democratic priorities like the environment, abortion rights, and universal health care (see here for longer list). See also this endorsement from biosecurity grantmaker Andrew SB.
Inline links: Carrick Flynn for Congress, this paper, here, this endorsement
Metaculus currently has him at 40% to win the primary and 29% to win the general. I’m closer to 60/45. Although he’s getting support from some big funders, campaign finance privileges small-to-medium-sized donations from ordinary people. If you want to support him, you can see a list of possible options here - including donations. You can donate max $2900 for the primary, plus another $2900 for the general that will be refunded if he doesn’t make it. If you do donate, it would be extra helpful if the money came in before a key reporting deadline March 31. 3: Every year in autumn I hold a big Meetups Everywhere event, and every time people tell me I should do it more often than once a year. So this time we’ll hold a mini-Meetups-Everywhere this April. It won’t be any different from your usual meetup schedule except that it’ll be the Schelling time for everyone who only wants to come once every few months to come. If you’re a meetups organizer (or want to become one), please fill in this form with the date of a meetup April 11th or later. Next Sunday I’ll put the results on the Open Thread for people to see. 4: Speaking of meetups, the rationalist/EA establishment is trying to promote local meetups. If you’re a local ACX/LW meetups organizer, you’re potentially invited to attend an all-expenses paid retreat in California in July with our meetups czar Mingyuan. Please read more here, then fill in this form to get on her radar. 5: And speaking of Mingyuan, she is going to inspect - sorry, enjoy the hospitality of - the East Coast meetup groups. She’ll be in DC: 4/11–4/13 Baltimore: 4/14 Philadelphia: 4/15–4/16 NYC: 4/17–4/21 Yale: 4/22–4/23 Northampton: 4/24–4/25 Boston: 4/26–5/1. The local groups have already taken care of having meetups at the right time, but she’s looking for people who could host her and drive her between cities . Email meetupsmingyuan@gmail.com if you can help. 6: Last week I tried to figure out the needs of community members in Russia and Ukraine. There are some great resources on the thread, but issues that still need solving: Seven Ukrainian refugees looking for remote work
Inline links: here, donations., fill in this form, here, this form, on the thread, Seven Ukrainian refugees looking for remote work
Highlights From The Comments On Billionaire Replaceability
September 22, 2022 · Original source
I think the political power of billionaires is vastly overestimated. I’ve talked before about how there’s very little money in politics because spending money on politics doesn’t work. Since then I think the case has gotten even stronger. Michael Bloomberg sunk in the 2020 primary despite having $50 billion dollars. And effective altruism tried to use $10 million of Sam Bankman-Fried’s money to get a biosecurity expert elected to Congress in Oregon. They were pretty smart about it: chose a district with no incumbent, found a really amazing candidate with an incredible personal backstory, pulled out all the stops. They spent the third most of any race in the country - about as much as it was possible to spend, I don’t know what else you could even spend the money on - and they lost by a landslide in the primary.
Inline links: talked before about how there’s very little money in politics because spending money on politics doesn’t work.
Book Review: The Arctic Hysterias
April 06, 2023 · Original source
By the eighth grade . . . many youths are sent away from the security of their homes in the village to boarding high schools for American natives, located in various parts of the country. Most go to Mt. Edgecumbe, near Sitka, Alaska, others to Chimawa in Oregon.
Spring Meetups Everywhere 2023
April 10, 2023 · Original source
PORTLAND, OREGON, USA Contact: Samuel Celarek Contact Info: scelarek[at]gmail[dot]com Time: Saturday, May 13th, 05:00 PM Location: 1548 NE 15th Ave, Portland, OR 97232 Coordinates: https://plus.codes/84QVG8MX+JV Event Link: https://www.meetup.com/portland-effective-altruism-and-rationality/events/292690249 Notes: If people would like to give a short presentation or lead a breakout activity, we will have a room set aside specifically for that at the event. Please fill out this google form to let me know what you would like present: https://forms.gle/opTeAXa5esPuxdBP9
Inline links: https://plus.codes/84QVG8MX+JV, https://www.meetup.com/portland-effective-altruism-and-rationality/events/292690249, https://forms.gle/opTeAXa5esPuxdBP9
Your Book Review: The Educated Mind
July 14, 2023 · Original source
Reviewer: He does — but he doesn’t promise it will look shiny. When I toured an Eganian charter elementary program in Oregon — the only one of its kind, and now defunct for the usual awfulness of local politics — I could have missed the magic that was going on there, had I not talked to the kids.
Meetups Everywhere 2023: Times & Places
August 25, 2023 · Original source
TOLEDO, OHIO, USA Contact: Norman Perlmutter Contact Info: NLPerlmutter+ACX[at]gmail[dot]com Time: Sunday, September 10th, 3:00 PM Location: Toledo Botanical Garden. If coming by car, park in the north parking lot (entrance off Elmer Road). We will be at one of the picnic tables near the parking lot. I'll be wearing an orange shirt and carrying or posting on the table a sign reading ACX MEETUP. In case of bad weather, alternate location will be posted on LessWrong and on the Meetup group. Coordinates: https://plus.codes/86HRM89H+43F Group Link: meetup.com/acx_toledo Notes: Please RSVP on LessWrong or on the Meetup group (but not on both, it would make it harder to count RSVPs.) Oregon CORVALLIS, OREGON, USA Contact: Kenan S. Contact Info: kbitikofer[at]gmail[dot]com Time: Saturday, September 9th, 7:00 PM Location: Common Fields (outdoor food truck court). We'll aim for the southeast corner. Coordinates: https://plus.codes/84PRHP5P+RR6
Inline links: https://plus.codes/86HRM89H+43F, meetup.com/acx_toledo, https://plus.codes/84PRHP5P+RR6
CORVALLIS, OREGON, USA Contact: Kenan S. Contact Info: kbitikofer[at]gmail[dot]com Time: Saturday, September 9th, 7:00 PM Location: Common Fields (outdoor food truck court). We'll aim for the southeast corner. Coordinates: https://plus.codes/84PRHP5P+RR6
Inline links: https://plus.codes/84PRHP5P+RR6
EUGENE, OREGON, USA Contact: Ben Smith Contact Info: benjsmith[at]gmail[dot]com Time: Wednesday, September 20th, 6:00 PM Location: Beergarden. we'll have a large silver cuboid balloon with an EA logo. Coordinates: https://plus.codes/84PR3V3W+C7 Group Link: https://www.meetup.com/effective-altruism-eugene
Inline links: https://plus.codes/84PR3V3W+C7
Spring Meetups Everywhere 2024
March 30, 2024 · Original source
COLUMBUS, OHIO, USA Contact: Russell Contact Info: russell[dot]emmer[at]gmail[dot]com Time: Sunday, April 14th, 3:00 PM Location: Clifton Park Shelterhouse, Jeffrey Park, Bexley. We will be at one of the tables with an ACX sign. Coordinates: https://plus.codes/86FVX3C3+QF Notes: Please send an email if you'd like to join our mailing list for future invitations. Oregon CORVALLIS, OREGON, USA Contact: Kenan Contact Info: kbitikofer[at]gmail[dot]com Time: Friday, April 19th, 6:00 PM Location: Laughing Planet, downtown Corvallis, Oregon. Coordinates: https://plus.codes/84PRHP7R+R7C Group Link: Willamette Valley EAs and Rationalists: https://discord.gg/uBCcD7SxUa Notes: Kids/babies welcome.
Inline links: https://plus.codes/86FVX3C3+QF, https://plus.codes/84PRHP7R+R7C, https://discord.gg/uBCcD7SxUa
CORVALLIS, OREGON, USA Contact: Kenan Contact Info: kbitikofer[at]gmail[dot]com Time: Friday, April 19th, 6:00 PM Location: Laughing Planet, downtown Corvallis, Oregon. Coordinates: https://plus.codes/84PRHP7R+R7C Group Link: Willamette Valley EAs and Rationalists: https://discord.gg/uBCcD7SxUa Notes: Kids/babies welcome.
Inline links: https://plus.codes/84PRHP7R+R7C, https://discord.gg/uBCcD7SxUa
PORTLAND, OREGON, USA Contact: Sam Celarek Contact Info: scelarek[at]gmail[dot]com Time: Friday, April 19th, 6:00 PM Location: 1548 NE 15th Ave, Portland, OR 97232 - There will be a large sign outside of a building with the print "Encorepreneur Cafe" on the outside. Call me at 513-432-3310 if you can't find it! Coordinates: https://plus.codes/84QVG8MX+MV4 Group Link: https://www.meetup.com/portland-effective-altruism-and-rationality/ Notes: Please RSVP on Meetup so I know how much food to get.
Inline links: https://plus.codes/84QVG8MX+MV4, https://www.meetup.com/portland-effective-altruism-and-rationality/
Contra Hanson On Medical Effectiveness
April 24, 2024 · Original source
His argument: there have been three big experimental studies of what happens when people get free (or cut-price) health care: RAND, Oregon, and Karnataka. All three (according to him) find that people use more medicine, but don’t get any healthier. Therefore, medicine doesn’t work. If it looks like medicine works, it’s a combination of anecdotal reasoning, biased studies, and giving medicine credit for the positive effects of other good things (better nutrition, sanitation, etc).
Blood pressure They found no effect of insurance on any of the questionnaires, and modest positive effects on vision and blood pressure. How surprising is this? It seems moderately surprising that nobody improved on any of the questionnaires. These seem to measure overall health. Maybe they were bad measures? Maybe 10,000 mostly-healthy people over 8 years doesn’t provide enough power to detect health improvements on questionnaires? I’m not sure. It doesn’t seem surprising to me that nobody improved on smoking, weight, or cholesterol. The 1970s didn’t have any good anti-smoking medication - even the nicotine patch wasn’t invented until after this study was finished. Likewise for weight loss - the 1970s were in the unfortunate interregnum between the fall of methamphetamine and the rise of Ozempic. There were some weak cholesterol medications back then - eg nicotinic acid - but they were rarely used, and doctors weren’t even entirely convinced that cholesterol was bad. For all three of these things, the 1970s state of the art was doctors saying “You should try to stop smoking and eat better.” RAND found that the better insurances led to 1-2 more doctor visits per year. I don’t think that 3 visits to a doctor saying “You should try to stop smoking and eat better” vs. 4 visits to that doctor is going to affect very much. It’s also not surprising that vision improved; the good insurances were more likely to cover glasses, and everyone knows that glasses help your vision. Even Robin admits this is a real effect; he just classifies it as more physics than medicine. Blood pressure is more debatable. The 1970s had some okay blood pressure medications, like the beta-blockers, and doctors weren’t afraid to use them. So it seems possible in theory that better medical care could lead to decreased blood pressure. Still, Robin is skeptical. He says that the improvement in blood pressure found during the study was p = 0.03. In a study with 30 measures, one will be positive at 0.03 by coincidence. The version of the study he’s reading has 30 measures (mine has 5 - 10, depending on how you count the questionnaire). On the other hand, this paper looks into the blood pressure result in more detail. It finds that “plan effects on blood pressure” were three times higher for hypertensives for non-hypertensives; that is, unlike statistical flukes (which we would expect to affect everyone equally), the effect was concentrated in the people we would expect doctors to treat. It also finds that plan effects are higher for poor people; unlike statistical flukes (which would affect everyone equally), the effect was concentrated in the people we would expect insurance to help. And it finds pretty convincing intermediating factors: people with good insurance were 20 percentage points more likely to get hypertension treatment, p < 0.001). So I think it’s a stretch to attribute this one to random noise. This is the study authors’ conclusion as well. They calculate the benefit from this blood pressure improvement and find that: If 1,000 fifty-year-old men at elevated risk were enrolled on a free rather than a cost-sharing plan, then we would anticipate that about 11 of them, who would otherwise have died, would be alive five years later. Still, they describe their study as having a negative result, because: ...these mortality reductions, in and of themselves, are not sufficient to justify free care for all adults. I assume they’re working off of some kind of reasonable cost-effectiveness model for government spending here. Still, if I were a fifty year old adult, I might be willing to personally spend a few hundred extra dollars a year to increase my 5-year-survival-rate by 1%. Certainly I don’t think it’s fair to describe this as “RAND proves medicine doesn’t work.” Robin has a book with more information than I could get from the papers, so I feel bad contradicting him on this one. I’m more confident in my discussion of the next two experiments, which I think are clear enough that we can go back to this one later and apply what we’ve learned. IV. Oregon Health Insurance Experiment In 2008, Oregon had extra money and decided to expand Medicaid, a free insurance program for poor people. Many people applied for the free insurance, the state ran out of money, and they distributed the available Medicaid slots by lottery. This made the expansion a perfect setup for a randomized controlled trial on whether government-provided free insurance helps the poor. Scientists monitored the recipients for two years (why not longer? I think at some point the insurance coverage stopped) and found that the people with Medicaid did in fact use more medical care than the control group. For example, only 69% of the control group described themselves as getting all the medical care they needed, but 93% of the group with insurance did. People with the insurance used more of almost all categories of medication: People who got the free insurance had less medical debt at the end of the study period. They described themselves on questionnaires as having better health (55% vs. 68% at least “good”, p < 0.0001), and were more likely to say their health had improved over the past few months (71% vs. 83%, p < 0.001). They described having better mental health and less depression (25% vs. 33% depressed, p = 0.001). However, Robin notes that many of these subjective changes happened immediately, ie before they even had a chance to use their new insurance. This means they’re more likely to represent mood affiliation (eg “I have insurance now, so I’m optimistic about my health!”). There was no difference on objective health measures, including blood pressure, cholesterol, and HbA1c (a measure of blood sugar / diabetes control). Why not? The authors do the math on diabetes. If you look at the graph above, you see that about 12.5% of controls vs. 17.5% of experimentals took diabetes medications, p < 0.05. Studies find that diabetes medications decrease HbA1c by about one percentage point (normal HbA1c is about 5%, so this is a lot). If 5% of the insurance group took diabetes medications and decreased their HbA1c by 1 pp each, then the HbA1c of the experimental group would decline by 0.05 pp compared to the control group. Their 95% confidence interval of the difference was (-0.1, +0.1 pp), which includes the predicted value. So when they say “insurance didn’t significantly change HbA1c”, what they mean is “the change in HbA1c is completely consistent with the consensus effect of antidiabetic medications”. Could the same be true of the other results, like hypertension? We find that the experimental group was 1.8 percentage points more likely to get a hypertension diagnosis, 0.7 percentage points more likely to get hypertension medications, and had 0.8 points lower blood pressure - but that all of these numbers were nonsignificant. If we take the nonsignificant numbers seriously, 0.7 pp taking antihypertensives caused an 0.8 point blood pressure drop in the full sample, meaning that antihypertensives caused a 100 point blood pressure drop in each user. This definitely isn’t true - a 100 point blood pressure drop kills you - but it means that a plausible pro-medicine result like antihypertensives lowering blood pressure 10 point is well within the study’s confidence interval. Maybe the anti-medicine position is that, for some reason, good insurance doesn’t lead to hypertension diagnosis or antihypertensive medication use? If I understand these numbers right, about 22% of Americans have blood pressure > 140/90, the level at which doctors recommend medication. I expect the marginally-insured poor people in this experiment to be less healthy than average, so let’s say 25 - 30%. In the experiment, about 13.9% of the control group and 14.6% of the experimental group got antihypertension medication. Why so low? This study found that only about 60% of participants in the Oregon study who got the insurance even went to the doctor for non-emergency reasons! Subtract out the ones who refused to take antihypertensives, or who have too many side effects, or whose doctors let this fall through the cracks, and I think the 13 - 15% numbers make sense. This study found that insurance increased hypertension medication use by a central estimate of 0.7 pp, not significant, confidence interval -4.5 to 5.8. Let’s take a convenient central estimate of our likely hypertension rate and say that 28% of our population should have gotten hypertension meds. That means the central estimate increased the percent of people who got recommended hypertension meds from 50% to 53%, and the 95% confidence interval includes up to 71%. So my assessment of the blood pressure results from this study is: At the beginning of the study, about 50% of people who should have been on hypertension meds were. The study had too low power to really figure out how this changed, but the central estimate is +3%, and the 95% CI rules out improvements beyond +21%
Inline links: this paper, and found, used more, https://substackcdn.com/image/fetch/$s_!YvX7!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Ff05b13be-6994-4161-ac81-bed0eac10b4f_1697x790.jpeg, There was no difference on objective health measures, these numbers, This study
People who got the free insurance had less medical debt at the end of the study period. They described themselves on questionnaires as having better health (55% vs. 68% at least “good”, p < 0.0001), and were more likely to say their health had improved over the past few months (71% vs. 83%, p < 0.001). They described having better mental health and less depression (25% vs. 33% depressed, p = 0.001). However, Robin notes that many of these subjective changes happened immediately, ie before they even had a chance to use their new insurance. This means they’re more likely to represent mood affiliation (eg “I have insurance now, so I’m optimistic about my health!”). There was no difference on objective health measures, including blood pressure, cholesterol, and HbA1c (a measure of blood sugar / diabetes control). Why not? The authors do the math on diabetes. If you look at the graph above, you see that about 12.5% of controls vs. 17.5% of experimentals took diabetes medications, p < 0.05. Studies find that diabetes medications decrease HbA1c by about one percentage point (normal HbA1c is about 5%, so this is a lot). If 5% of the insurance group took diabetes medications and decreased their HbA1c by 1 pp each, then the HbA1c of the experimental group would decline by 0.05 pp compared to the control group. Their 95% confidence interval of the difference was (-0.1, +0.1 pp), which includes the predicted value. So when they say “insurance didn’t significantly change HbA1c”, what they mean is “the change in HbA1c is completely consistent with the consensus effect of antidiabetic medications”. Could the same be true of the other results, like hypertension? We find that the experimental group was 1.8 percentage points more likely to get a hypertension diagnosis, 0.7 percentage points more likely to get hypertension medications, and had 0.8 points lower blood pressure - but that all of these numbers were nonsignificant. If we take the nonsignificant numbers seriously, 0.7 pp taking antihypertensives caused an 0.8 point blood pressure drop in the full sample, meaning that antihypertensives caused a 100 point blood pressure drop in each user. This definitely isn’t true - a 100 point blood pressure drop kills you - but it means that a plausible pro-medicine result like antihypertensives lowering blood pressure 10 point is well within the study’s confidence interval. Maybe the anti-medicine position is that, for some reason, good insurance doesn’t lead to hypertension diagnosis or antihypertensive medication use? If I understand these numbers right, about 22% of Americans have blood pressure > 140/90, the level at which doctors recommend medication. I expect the marginally-insured poor people in this experiment to be less healthy than average, so let’s say 25 - 30%. In the experiment, about 13.9% of the control group and 14.6% of the experimental group got antihypertension medication. Why so low? This study found that only about 60% of participants in the Oregon study who got the insurance even went to the doctor for non-emergency reasons! Subtract out the ones who refused to take antihypertensives, or who have too many side effects, or whose doctors let this fall through the cracks, and I think the 13 - 15% numbers make sense. This study found that insurance increased hypertension medication use by a central estimate of 0.7 pp, not significant, confidence interval -4.5 to 5.8. Let’s take a convenient central estimate of our likely hypertension rate and say that 28% of our population should have gotten hypertension meds. That means the central estimate increased the percent of people who got recommended hypertension meds from 50% to 53%, and the 95% confidence interval includes up to 71%. So my assessment of the blood pressure results from this study is: At the beginning of the study, about 50% of people who should have been on hypertension meds were. The study had too low power to really figure out how this changed, but the central estimate is +3%, and the 95% CI rules out improvements beyond +21%
Inline links: People who got the free insurance, There was no difference on objective health measures, these numbers, This study
Highlights From The Comments On Hanson And Health Care
May 10, 2024 · Original source
Robin’s argument is strongest against prevention, least strong against treatment. There probably aren’t enough cancer patients in the RAND or Oregon studies to say anything about the effect of cancer treatment. But there are plenty of hypertensives, diabetics, smokers, etc. This is why most of the effects we’re debating are secondary endpoints like blood pressure, blood sugar, etc. So while you might or might not be right about prevention being better than cure, it’s not a response to Robin in particular.
Your Book Review: Two Arms and a Head
August 02, 2024 · Original source
(Source) A diagram of the human spine next to a diagram of the human body, indicating which parts of the body are innervated by which vertebrae in the spinal column. The cervical, thoracic, lumbar, and sacral regions of the spine are highlighted in different colors, with the corresponding body regions highlighted in the same colors. Starting at the top, the cervical (neck) vertebrae control the head, neck, arms, and fingers. The thoracic (torso) vertebrae control the entire torso and abdomen. The lumbar (lower back) vertebrae control the hips and front muscles of the legs. The sacral (tailbone) vertebrae control the back muscles of the legs and the groin area. The very last vertebra, S5, innervates the anus and genitals. Clayton is injured quite high up on the torso at the T5 vertebra. Let's consider the ramifications of having everything below the nipples be completely numb and limp. To start off, that means that he has no use of the muscles that hold him upright. Nothing keeps me sitting up—no hip flexors, erector spinae, hamstrings, or abdominal muscles. I am arms-and-a-head on a column of Jell-O. He can't put both arms out in front of him, lest he fall over. He has to continuously prop himself up with one arm while doing anything at arm's length. After only 1.5 years of being paralyzed, this has already caused significant repetitive strain injuries in his elbows, shoulders, and ulnar nerves. Clayton still has to deal with all the logistics of life, despite two-thirds of his body being a hunk of corpse-flesh. He dedicates huge swaths of the text to all the little time-wasting tasks he now has to do. How much of his life is ticking away with every delay, every piece of effort, every task that is trivial for an able-bodied person but monstrously difficult for him. Something as simple as getting out of a car is an entire production—let alone running errands, cleaning, doing laundry, cooking. Since the lower two-thirds of his body no longer sends pain signals to his brain, he must proactively tend to all of its physical needs. Complications include pressure sores, infections, and a high chance of blood clots. Aside from suicide, the leading causes of death among paraplegics are all related to poor circulation. In addition to the loss of conscious sensation and muscle control, problems with the autonomic nervous system—heart rate, orthostatic blood pressure, temperature regulation—are common. This is even more pronounced in cervical spine (neck) injuries. Some quadriplegics black out or the blood rushes to their head when being moved from lying down into reclining in a wheelchair. A spinal cord injury wreaks havoc on the body's functioning. Go back to that diagram. The groin area is innervated by the very end of the spinal cord, at the S5 vertebra. We tend to think of our legs as being “below” the crotch, but the nerves that control bowel movements and urination are downstream of the ones for the legs. To keep the party rolling I will tell you about piss and shit. [...] To urinate I have to slide a catheter down my urethra. [...] To defecate I finger myself up the ass and root around and around until the shit comes out. Nuggets, smooshy, whatever it is I’m digging in it. He describes the disgusting, nauseating process at length. For the sake of your lunch, I will refrain from quoting it all. In addition to being unable to open and close his sphincters on command, he also receives no signals of needing to go. If he eats the wrong thing and gets a bout of diarrhea, he will have no warning—no abdominal discomfort and no final urge to rush to the bathroom. One afternoon he "has an accident" while lounging on his couch. In trying to move from the couch to the toilet, he subsequently smears feces all over the couch, the carpet, his wheelchair, the toilet seat, and the shower. After he digs the poop out of his anus and washes himself off, he then has to clean all of that up by himself. From a wheelchair. Bending down, stretching, trying not to fall over, trying to reach the floor to scrub feces off the carpet. From a wheelchair. This episode was hardly the first time. He would routinely wake up in the morning to find that he had soiled himself overnight. Imagine struggling to rip dirty sheets off the bed, stuff them in the laundry, and put a clean sheet on the mattress—from a wheelchair. I don't know about you, but I can barely get a fitted sheet on my own mattress, and I get to do it while standing up. And unless I want to piss or shit myself, there can be no rest from this drudgery, ever, for the rest of my life. No relieving stretch of time without piss-dowsing and fingering myself up the asshole. Nobody told Kid Me that Professor X has to dig turds out of his anus every day. The groin dysfunction doesn't stop there. To be redundant once more, I can’t feel my penis. [...] Men, think how losing your penis would make you feel. Ladies, think of having your clit amputated and never having sex again. [...] True, the unfeeling penis attached to the living corpse I drag around can become erect but what has that to do with me? The one time he tries to have intercourse after his injury, it goes about as well as you'd expect: Watching a woman bob up and down on the penis attached to the corpse that used to be my body struck me as macabre and disturbing. It was like necrophilia. It’s like watching a woman get off by rubbing my amputated foot on herself. The disturbing facts just keep on rolling. One final note about the physical symptoms: spinal cord injuries hurt. Everything below the damage is numb, but the injury itself is a massive tear in the central nerve that controls the body. The pain is insistent, nagging, and so sharp it seems to crackle. [...] It’s just as sharp and intense every time, over and over, like it’s mocking you. Sometimes it happens when I’m lying in bed and it’s like trying to fall asleep with someone sticking a needle between my ribs or the bones of my big toe. But, surely, the only real problem is the physical limitations? Clayton is still the same person he'd always been, right? He has the same brain, same personality he did before the accident. Even if he can't walk anymore, he still has his memories. Not so fast. Yes, Even Worse Than That What kind of mental and emotional toll does all of this take on Clayton? The feeling I experience is a frantic, frenzied, desperate distress. [...] I need to move. I need to move. [...] Not only is two-thirds of my body paralyzed, but so is a huge part of my innermost self. It wants more than anything to feel and experience life. To exist. But it exists now only in a place between reality and nothingness with no hope of ever coming back. [...] All it can do is degenerate in the solitary place it has been forever exiled to. A popular heuristic in neuroscience is "use it or lose it." This is usually in the context of memorization, but it also applies to sensory organs and limbs. When Clayton is injured, his brain's connection to everything below his nipples is severed. Lacking any more sensory input from down there, the brain simply overwrites and repurposes the unused neurons. His injury is not limited to his present and future, but also reaches back into his past: Certain of my memories seem to be disappearing. For example, when I try to remember doing things that involved running, jumping, and sex, the memories seem less real or vivid than they used to. [...] If I imagine taking another person’s hand in mine, or kissing someone’s face, or someone touching my face, I feel something similar to sensation in those parts of my body when I imagine it. [...] But my lower body is now just a void, and its death started the creation of a void in my brain. Not only can I not feel it, but my ability to imagine feeling it is disappearing, as is my capacity to remember feeling it, and doing things with it. He likens himself to a Cartesian brain, a part of the world but outside of it, forever locked away, unable to exert his will on the outside world. Not only has he lost his legs; he is beginning to lose the memory of those legs, too. Everything he ever was, any skills that he ever learned related to being able-bodied, are destined to die over the coming years. His mind is doomed to slowly decay as its neurons do what neurons do: rewrite themselves until none of the person he used to be is left. Toxic Positivity Can Clayton actually talk about any of these things with his peers? Not really. He has a small circle of other recently paralyzed friends who understand, but outside of that, no. American culture has an entire social ecosystem that reinforces the idea that disabled people should be upbeat and optimistic about their life prospects. Almost any interview with a paraplegic ends on some upbeat note about how their disability "doesn't stop them from doing all the things they want to do" and that "they can do anything” an able-bodied person can. In fact, Two Arms and a Head opens with one such quote from Stephen Hawking: “I try to lead as normal a life as possible, and not think about my condition, or regret the things it prevents me from doing, which are not that many.” —Stephen Hawking This is patently absurd. Why do they say these things? Do they actually mean it, or are they just being hyperbolic for rhetorical effect? Surely they all know, secretly, that they’re lying to themselves? Clayton argues that no, they mean it, and they’re not lying to themselves. Remember how disability affects the brain? How all those unused neurons get repurposed, and any concepts of using those paralyzed limbs gets overwritten (if they ever existed in the first place)? They [lifelong paraplegics] tend to only see life in terms of the possibilities that exist for them [...] Their view becomes somewhat tautological. “What I can do is all that is possible, therefore I can do all that is possible.” Just as able-bodied people cannot comprehend what it’s like to be a paraplegic, lifelong paraplegics and quadriplegics simply cannot grasp what it is to be able-bodied. I’m not saying that lightly. The difference is biological. They have different brains. [...] They do not understand the experience of being able-bodied—neither the subtleties or much of what, to observers, is overt and glaring. They can try to imagine it, but they don’t even come close to comprehending the potential that exists there. Hence the common refrain that there are “not many” things that they can’t do. Adding to this dynamic is that it is considered impolite in our culture to call them out on it: If I were still able-bodied and a paraplegic told me he could do everything I could, I would just think “Looks like being crippled fucked up his mind too, because that’s insane.” I’m not sure what I’d actually say to him, but I know it wouldn’t be that. [...] So the disabled are basically allowed to go around saying whatever on Earth they want. They acquire a kind of de facto moral infallibility because nobody is going to argue with them. On top of this, humans have a basic need to belong, stay positive, and avoid people who are negative and miserable. If paraplegics were honest about all the body horror and misery, they would quickly find themselves devoid of friends. So what is a newly paraplegic person to do in order to maintain connections during a time in their life when they desperately need comfort and support? Brainwash themselves, of course! Clayton was staring down the prospect of what he would have to do to his mind in order to survive in our current society as a paraplegic. It was bad enough to be mutilated physically; he didn't also want to be mutilated mentally. What happened to my body is frightful, but no less than what happens to the minds of many disabled people. We have to have some kind of integrity to our views of the world and reality, and the more the better. [...] So my unwillingness to adopt certain “attitudes” or whatever people call them is something like a desperate struggle to evade the clutches of madness. It gets worse. This does not just affect their social lives and beliefs. These dynamics ripple out into the medical community’s attitudes about paraplegia. If every interviewee swears that paralysis doesn’t hold them back in life, then why pour resources into finding a cure? I’ve heard people say that spinal cord injury is not a priority for medical research like cancer because “people can live like that”. No, we can’t live like this. This is not “life”. Which raises the question—have there been any breakthroughs since 2008? The State of the Cure Let’s take a short break from the existential horror to look at the science of spinal cord injuries. Clayton killed himself in 2008 because there was no cure at the time. Have there been any new developments in the ~15 years since? The short and upsetting answer is "not yet"—though there are some glimmers of hope. Why are Spinal Cord Injuries So Hard to Fix? The spinal cord consists of multiple concentric layers of nerve fibers, not unlike an electrical cable. Wherever the spinal cord has trauma, the nerve cells die off and form lesions of scar tissue that block all nerve signals from traveling downstream of whichever thread was damaged. Some patients are lucky in that only parts of the spinal cord are damaged, resulting in paralysis on only one side of the body. Nerve cells in the spinal cord do not regenerate themselves. Once damaged and scarred, there’s nothing anyone can do. The good news is that emergency medicine has come a long way in arresting the formation of scar tissue at the moment of injury. Patients coming into the ER today have a much better prognosis than they did a few decades ago. The interventions are straightforward treatments like stabilizing the spine, surgery to release pressure on the pinched nerves, and shots of corticosteroids to reduce swelling and inflammation. But beyond that, there is no clinically-proven, FDA-approved treatment for an existing injury. Clayton describes the challenge of rebuilding his injury as something similar to “reconstructing a crushed strawberry.” No amount of stabilization would have put his smeared spinal cord back together. The Latest Research Treatments fall into two camps: bridging the injury, and encouraging the injured scar tissue nerves to regenerate. Implanted Nerve Cells In 2012, Prof. Geoffrey Raisman's team at University College London successfully treated a paralyzed man in Poland. The treatment involved removing one of the olfactory bulbs in his brain in order to culture olfactory ensheathing cells (OECs), which are the only nerve cells in the human body that continuously regenerate. The surgeons removed a section of nerve from the patient's ankle, then implanted both the ankle nerve and the OECs into his spine at the injury site. The grafted tissue bridged the gap between his brain and the healthy spinal cord just below the injury. After years of rehab and physical therapy, in 2014 the researchers announced their success to impressive fanfare. As of 2016, the patient could walk, ride a tricycle, and had regained bladder, bowel, and sexual function. He was far from his pre-injury self, but his quality of life had improved immensely compared to before the treatment. The call went out to recruit two more volunteers for another study. And then... crickets. This follow-up study has yet to be performed. It could have been delayed for a number of reasons. Perhaps they never found suitable volunteers whose profiles satisfied the demands of European regulators. Perhaps Brexit threw a bureaucratic wrench in the collaboration between UCL and the research center in Poland. Perhaps they ran out of funding. To make matters worse, Prof. Raisman passed away in 2017. In the years since, the team has been making progress in fits and starts. As of 2022, the current focus at UCL has been on figuring out how to culture OECs from the nasal mucosa instead of needing to crack open the skull to get at the olfactory bulbs directly. They’ve also made improvements in the technique for applying these cells to the injury site. Things are certainly happening, albeit at a glacial pace. This treatment strategy may become widespread in the future, but at the moment, it remains experimental. NervGen's "Wiggling Molecules" In 2021, NervGen Pharma announced a drug that encourages damaged spinal tissue to heal without scarring. A bioengineered molecule, NVG-291, is injected into the spinal cord and acts as a scaffold for the nerve cells to attach to as they regrow. The molecules of this scaffold naturally "wiggle” and stimulate nearby nerve cell receptors, promoting healing. Animal models were extremely promising. NVG-291 is currently in Phase 1b/2a clinical trials, which are scheduled to start in August of 2024. I’m cautiously optimistic. The main impediments to finding a cure are the same ones that plague any other field of medical research: lack of funding and unreasonable requirements from regulators. The main problems at this point in time appear to be bureaucratic rather than strictly biological. Will any of this research pan out within the next 5, 10, or even 20 years? Maybe. Only time will tell. (Someone should start a prediction market about this!) Alas, this is all coming too late to have saved Clayton. The Decision to Die I am absolutely and heartbreakingly in love with life. But this is not life. [...] For those who like to say this one: “Suicide is a permanent solution to a temporary problem.” I reply that suicide in my case is a permanent solution to a permanent problem. [...] I have only one serious problem in life and it’s being paralyzed. Clayton does not come to this decision lightly. He considers it exhaustively and systematically. When deciding whether to keep living, he starts from the premise that there is some amount of suffering past which life stops being worth it. He evaluates where that dividing line is by examining the sources of meaning in his life. He starts by asserting that there is nothing wrong with his mental health or his reasoning abilities: I am not depressed, I am tortured, and there is a difference. [...] If they came up with the cure today and I got better instantly, I could win myself a Nobel Prize in medicine for proving that depression was caused not by anything in the brain as previously thought, but by damage to a few cubic centimeters of nervous tissue in the spinal cord. Because I guarantee I’d pop up and be feeling as merry as a lark in about one second. [...] My problem is not depression. [...] There is no problem with my reasoning powers. [...] So if I say, “Paraplegia prevents me running. A life without running is not worth living. Therefore, my life is not worth living.” you might not agree with one of my premises, but there is no question of whether I’m being reasonable. This is similar to Frankl’s argument in Man’s Search for Meaning, and in fact Clayton spends an entire section talking about Frankl. He has a few disagreements with the book, but he has no gripe with the core message. Clayton decides to die because he had meaning in his life—and then the accident took it all away: Probably the life of a deaf man would be good enough for me, or that of a mute or a man missing a leg or an arm. But not the life of a paraplegic. There is not enough left for me. [...] The life I dreamed of and loved with all my heart is gone forever and there is nothing I can do about it. And it’s not just slightly changed, but utterly devastated. [...] My skills as a carpenter, roofer, plumber, gardener, all devastated. My ability to conduct my everyday life with wonderful efficiency, devastated. The wonderful way I was able to relate to other people, devastated. My sex life, devastated. My social life, devastated. [...] I am who I am, I love what I love, and given what I need from life, existence is no longer tenable for me. Some readers may look at that list and call him shallow. Even if that were so, that doesn't change his argument. Maybe most people don't place having sex, controlling one's bowels, and running through the woods as the quintessence of life-affirming values, but I'd be willing to bet that they're still important. Reading this book should prompt a moment of introspection. If you disagree with Clayton’s list above, then reflect on what does give your life meaning. No, seriously, make a list: family, friends, partners, children, hobbies, skills, etc. Write them down. Cross out one entry at random. How would you feel if you lost that entry? Would you still have enough left over to carry on? Probably. Now cross out a few more. Lose your partner. Lose your children. Lose your parents. Your siblings. Your best friend. Your favorite hobby. How do you feel? Still worth it? Add in some physical negatives: chronic pain. Constant nausea every time you eat. Losing feeling and control of your bowels, your legs, your genitals, your diaphragm, your non-dominant hand, your dominant hand, both arms. What about loss of sight? Hearing? Speaking? Communicating at all? What about ending up like the title character in Johnny Got His Gun, where he is left with no legs, no arms, and is rendered blind, deaf, and mute? What would life be like as a disconnected brain in almost complete sensory deprivation? How much would you have to lose before your life stops being worth living? That list—and the dividing line between "worth it" and "not"—is different for everyone. The decision to end one's life is deeply personal. Clayton happened to draw the line at a particular point. Others may agree or disagree, but Clayton’s judgment was his own. Decision in hand, next comes the hard part. The Roadblocks I did not want much from the world in dying. To be able to put my affairs in order without fear of being taken prisoner and treated like I was insane. To say goodbye to those I loved without the same fear. To die a painless death without worrying about leaving behind something gruesome. And to be comforted as I died. When a person has absolutely nothing left and is facing annihilation, all he wants is not to be alone. For Clayton, killing himself is not a simple matter. At the time only one US state, Oregon, had any kind of “Death With Dignity” law on the books. However, this law only allowed assisted suicide for terminally ill patients with less than six months to live, while Clayton’s condition was stable. The slightest whisper of suicidal ideation would have gotten him locked up in the psych ward. He has to write his book in secret, he has to lay his thoughts out for the world in secret, and he has to die in secret. Becoming paralyzed destroys him on two fronts—the disability itself, and the fact that he is completely, utterly, devastatingly alone with his feelings. He writes Two Arms and a Head because he needs to show the world how agonizing it is to face death alone and how important it is for physical-assisted suicide to become—and stay—legal. How empty to exist in this universe and share your feelings and experience with nobody! But that is how you, the world, have left me to die, alone. But what you don’t realize is this: in turning your backs on me, you have turned your backs on yourselves. [...] Someday you will be on your deathbed and maybe you will remember me. What I say to the world is that if you don’t do something about the way death and assisted suicide are dealt with, you may someday find yourselves in an unimaginably horrible situation with no way out. [...] Beware! There could be a horrible fate waiting for you and if you don’t all get together, look each other in the eye, recognize the insanity, and change the laws, you could wake up tomorrow as a head on a corpse with no way out for the next thirty years. A lingering question you might be asking is: if he cared so much about it, then why didn’t he become an activist to get it legalized? The Overton Window was shifting. Washington state would pass a bill a few months after his death, and it would be legalized in Montana by a court case in 2009. Several more states would follow suit in the mid-2010s. He could have shared his experiences far and wide and joined the burgeoning movement that existed back then. He was a law student at Vanderbilt for crying out loud; surely he could have enlisted the help of at least a couple of his colleagues? No one but him could have answered that, though I suspect that the answer is because he didn’t want to. He found his existence to be so ghastly that he didn’t want to stay in it for a second longer than necessary. The only reason he lasted as long as he did was because he wanted to finish the book. He chose to leave Two Arms and a Head as his legacy for the world, and nothing more. We’ve gone over the state of the cure over the last ~15 years. Has there been any progress on amending the laws for physician-assisted suicide? The State of MAiD Medical Assistance in Dying (MAiD) is currently legal in a patchwork of countries and US states. The exact rules, restrictions, and methods vary. In most places that have legalized it, the patient’s condition must be considered terminal (i.e. death is expected within six months) to be eligible for MAiD. The procedure itself is typically either an IV injection administered by a nurse, or a prescription cocktail of benzodiazepines, digoxin, and opioids which patients drink themselves. In Canada and the Netherlands, MAiD is also available to patients with a disability that does not present as immediately terminal. The Netherlands currently includes severe treatment-resistant mental illness as a qualifying condition, and Canada will follow suit in 2027. So it sounds like Clayton got his wish, at least in Canada and parts of Europe. Now, when a Canadian ends up in a terrible accident, they have a choice in the matter of whether they want to spend the next few decades as a quadriplegic head-on-a-corpse. Phew. However, it’s not all smooth sailing. It seems like every few months there’s another horror story in the press coming out of Canada or Europe. Two news stories came out in quick succession in late March/early April 2024—one from Canada, the other from the Netherlands. In Canada, a 27-year-old autistic woman with no disclosed physical symptoms was granted the right to proceed with MAiD by an Alberta court. The story broke after her father sued to try and stop her. In the Netherlands, a 28-year-old woman has decided to pursue MAiD due to her treatment-resistant clinical depression and borderline personality disorder. Her MAiD is scheduled for sometime in May 2024. At the time of this writing, she has yet to undergo it. These stories are nothing new. They certainly sound dreadful. Diving into every big story from the last ten years would be beyond the scope of this review, but let’s return to the one about the 27-year-old autistic Canadian woman who was granted MAiD. Both the Calgary Herald and CBC framed the story as a grieving father desperately trying to prevent his autistic daughter from being led astray by unethical doctors cherry-picked by the Alberta Health Service. The father insists that his adult daughter is physically healthy, albeit “vulnerable and not competent” to make medical decisions due to her autism and ADHD. Despite this, the judge has allowed MAiD to proceed anyway. Meanwhile, reading the actual court decision shows that the legal issue at hand is whether the woman is required to disclose the physical ailment(s) that led to two doctors approving MAiD. The judge ruled that the woman is competent to make her own medical decisions, and that she is not required to disclose her diagnosis to either her family or the court. The father has since filed an appeal. (July 2024 Update: the appeal hearing was subsequently scheduled for October 7, 2024 - six months in the future. Not willing to wait that long, the woman began a voluntary stoppage of eating and drinking (VSED) on May 28. The hearing was rescheduled for June 24. However, the woman continued to refuse food and water going into June. The father withdrew his appeal on June 11. It is unknown whether the woman has undergone MAiD at this time of this update.) She is not choosing MAiD because of autism or ADHD. We don’t know what her physical diagnosis is. We only have the father’s insistence that “her physical symptoms, to the extent that she has any, result from undiagnosed psychological conditions.” That’s the father’s words, not a physician’s, and not the patient’s. Neurodivergence does not bestow immunity against all the nasty ailments that can cut someone down in their twenties. I’m not accusing every news piece about MAiD of being similarly sensationalized, but I’m not not accusing every MAiD story of being similarly sensationalized. Despite so many of these stories not holding up to their headlines, many remain opposed to the expanded rules. There is a massive contingent of activists who want to keep MAiD illegal. Not Dead Yet Clayton had a particular amount of ire directed at one prominent anti-MAiD disability rights org: Not Dead Yet. Not Dead Yet (NDY) was founded in 1996 by the same people who lobbied to get the Americans with Disabilities Act passed a few years prior. As the name implies, they reject the notion that death could ever be an acceptable response to living with a disability. Like any activist org worth their salt, they have a convenient Talking Points page where they lay out all the reasons why they’re opposed to MAiD. They argue that MAiD is deadly discrimination against disabled patients, with current programs having insufficient safeguards to prevent foul play. NDY argues against a medical field that has decided that death is preferable to disability. They insist that they are not against individual autonomy; patients will always be free to commit “un-assisted” suicide if they truly wish to die. The page opens by explaining that MAiD is necessarily a disability issue, even in places where MAiD is only available to the terminally ill. Although people with disabilities aren’t usually terminally ill, the terminally ill are almost always disabled. When terminally ill patients get polled on why they are choosing MAiD, it turns out that avoiding pain isn’t the primary motivation. In Oregon, where MAiD is only available for the terminally ill, every patient fills out a questionnaire when they apply for the program. Tallying up all the surveys from 1998–2023, to top reasons are: “Losing autonomy” (90%)
Inline links: Source, Prof. Geoffrey Raisman's, As of 2016, As of 2022, NervGen Pharma, Phase 1b/2a clinical trials, Medical Assistance in Dying (MAiD), late March, early April, These stories, are nothing new, CBC, court decision, filed an appeal, May 28, withdrew his appeal on June 11, Not Dead Yet, Talking Points, In Oregon,
“Financial implications of treatment” (7%) The top five all relate to the disabling symptoms that come with dying. “Less able to engage in activities” sounds remarkably similar to Clayton’s reasoning of, “the things that gave my life meaning are no longer possible, therefore it’s time to die.” This isn’t surprising when considering that palliative care is legal in all 50 states. If someone’s condition is judged to be terminal, as Oregon requires, they already get a bottomless supply of morphine. Pain is not really the problem anymore. The problem is that a failing body is, well, failing. Patients become weak and frail. They struggle to walk and use the bathroom. They may become dependent on a feeding tube or a respirator. Somewhere along the way they might lose their minds to dementia. All of these are serious, debilitating symptoms that can suck the meaning out of life, so many patients choose to die before they get to that point. Not Dead Yet condemns this status quo. We Don’t Need To Die to Have Dignity In a society that prizes physical ability and stigmatizes impairments, it’s no surprise that previously able-bodied people may tend to equate disability with loss of dignity. This reflects the prevalent but insulting societal judgment that people who deal with incontinence and other losses in bodily function are lacking dignity. People with disabilities are concerned that these psycho-social disability-related factors have become widely accepted as sufficient justification for assisted suicide. They argue that patients and physicians are merely reflecting a “prevalent but insulting” prejudice when they decide that death is preferable to debility. NDY paints a picture of the type of physicians who provide MAiD to patients: In judging that an assisted suicide request is rational, essentially, doctors are concluding that a person’s physical disabilities and dependence on others for everyday needs are sufficient grounds to treat them completely differently than they would treat a physically able-bodied suicidal person. [...] Legalized assisted suicide sets up a double standard: some people get suicide prevention while others get suicide assistance, and the difference between the two groups is the health status of the individual, leading to a two-tiered system that results in death to the socially devalued group. This is blatant discrimination. There’s a lot to unpack here. NDY is starting from the premise that the desire to end one’s life is always and necessarily the product of an irrational mind, Claytons of the world be damned. Medical professionals, given that they’ve sworn an oath to protect life, have an obligation to treat all suicidal ideation with “suicide prevention” care (i.e. involuntary commitment until the patient comes to their senses). A society that has legalized MAiD still extends this preventive care to the able-bodied who want to die, but then turns around and gladly assists disabled patients in ending their lives. This is discrimination! Doctors are murdering the undesirables! To drive the point home, the Canadian chapter of NDY has this image on their homepage: A line drawing wherein a wheelchair user notices that the office of the Suicide Prevention Program is inaccessible, whereas the office of the Assisted Suicide organization has a wheelchair ramp. Clayton counters this by pointing out that doctors give different treatments for different circumstances all the time. For example, begging for opioids out of the blue is considered “drug seeking” and will get you referred to addiction treatment; begging for opioids while in the ER for a severed leg... will get you opioids. Refusing to provide opioids and instead providing “addiction prevention care” to the able-bodied is not discrimination against the legless. The Canadian chapter of Not Dead Yet has a similar Talking Points page, with this one written in the style of an FAQ. They raise some concerns about a lack of safeguards to prevent foul play. In Canada and parts of the United States, a MAiD patient simply picks up the lethal cocktail at a pharmacy, then takes it home to drink. No witness is required when the drugs are taken. There’s no way to ensure that it’s voluntary. If something goes wrong, there’s no way to help the person. A lethal dose of drugs may sit around the house for weeks or months. ...That’s concerning. I didn’t know any of that before I read the website. An obvious solution to this problem would be to do what the Netherlands does and require a medical professional to be present. That way, said clinician can ensure that the patient gives affirmative consent with no abuser standing over the patient’s shoulder. Once the patient has passed, the clinician can pack up the leftover meds for safe disposal. In the Netherlands, these professionals are part of dedicated teams who travel to patient homes for exactly this purpose. Except NDY does not suggest this. In fact, they do the opposite. NDY condemns the Dutch approach by referring to these clinicians as members of a “mobile euthanasia unit” that dispatches patients in their own homes. Everything seems to circle back to blaming doctors. But why? Ableism Underpinning Not Dead Yet’s objections to MAiD is the belief that society has a prejudice against disabilities. This prejudice is so strong that the average person believes that being disabled is sufficiently miserable to justify death. The disability rights community has a name for this bigotry: ableism. Ableism is: “A system of assigning value to people’s bodies and minds based on societally constructed ideas of normalcy, productivity, desirability, intelligence, excellence, and fitness.” When Clayton concludes that his paraplegic life is less “valuable” than his pre-accident life, he is invoking the societally constructed premise that “being able to walk, have sex, and control one’s bowel movements are good and desirable traits.” That is indeed one of his core values, and he is indeed being ableist. The anti-ableist framework holds that a value judgment like “being able to walk, have sex, and control one’s bowel movements are good and desirable traits” is arbitrary bigotry on par with “having white skin is a good and desirable trait.” When disability activists argue that our society should reject ableism, what they are saying is that we should reject the notion that “being able to walk, have sex, and control one’s bowel movements are good and desirable traits.” Given what Clayton has told us of his life, that argument is cosmically, outlandishly insane. So... why do they make it? What’s going on? They can’t really believe this, can they? The knee jerk response is to dismiss them as just being in denial, but Clayton offers a much more horrifying explanation: they do mean it. I have no desire to begrudge other paraplegics their happiness, though many of them evidently have every desire to begrudge me my feelings. I find them monstrous and inhuman the moment they want to insist that my feelings indicate from some kind of defect within me. [...] A clam is comfortable in its shell and thinks all of the other animals should envy it. A clam does not see why an eagle would rather die than be a clam. Let’s explore this with a thought experiment. The Four-Armed Alien You probably don't fantasize on a daily basis about what life would be like with four arms. If you really try, you could imagine a few ways that life would be easier: You could chop ingredients with two hands and stir the skillet with a third.
Inline links: Canadian chapter, https://substackcdn.com/image/fetch/$s_!xOGz!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fcd23bfaf-4b86-485f-ad54-8cb48b2420fa_900x695.jpeg, FAQ, ableism
Meetups Everywhere 2024: Times & Places
August 29, 2024 · Original source
Contact: Amber Contact Info: act114[at]case[dot]edu Time: Saturday, October 19th, 12:30 PM Location: Floor 2, Think[Box], Case Western Reserve University, Cleveland, Ohio, 44106, USA (Tentative location, to be confirmed closer to the time) Coordinates: https://plus.codes/86HWG92V+6P Notes: Please RSVP on LessWrong by the 16th of October. You can bring guests, but please indicate the number on RSVP. Light snacks and coffee will be provided. Park in the Veale Parking Garage (Lot 53) at 2158 Adelbert Road near the wind turbine. Parking in the Veale Parking Garage is not free. Go into Veale Athletic Center and speak with the front desk for assistance in reaching think[box]. Oregon CORVALLIS, OREGON, USA Contact: Kenan Contact Info: kbitikofer[at]gmail[do t]com Time: Friday, September 27th, 06:00 PM Location: At a table in Laughing Planet, 127 NW 2nd St, Corvallis, OR 97330, or just outside if the weather is nice. I will have a paper with "ACX Meetup" written on it. Car parking is sometimes hard to find. Coordinates: https://plus.codes/84PRHP7R+R6P Group Link: https://discord.com/invite/ks3KxB3TCM
Inline links: https://plus.codes/86HWG92V+6P, LessWrong, https://plus.codes/84PRHP7R+R6P, https://discord.com/invite/ks3KxB3TCM
Contact: Kenan Contact Info: kbitikofer[at]gmail[do t]com Time: Friday, September 27th, 06:00 PM Location: At a table in Laughing Planet, 127 NW 2nd St, Corvallis, OR 97330, or just outside if the weather is nice. I will have a paper with "ACX Meetup" written on it. Car parking is sometimes hard to find. Coordinates: https://plus.codes/84PRHP7R+R6P Group Link: https://discord.com/invite/ks3KxB3TCM EUGENE, OREGON, USA Contact: Kapa Contact Info: astralx[dot]yt[at]gmail[do t]com Time: Sunday, September 01st, 03:00 PM Location: 3625 Kincaid St, Eugene, OR 97405 Coordinates: https://plus.codes/84PR2W8F+PJ Notes: Please join us for a pre-Labor Day barbecue - we will have food, games, and conversation! Kids are welcome, but no pets please. This is a private house with a large backyard and plenty of shade - so we will mainly be outside.
Inline links: https://plus.codes/84PRHP7R+R6P, https://discord.com/invite/ks3KxB3TCM, https://plus.codes/84PR2W8F+PJ
Contact: Kapa Contact Info: astralx[dot]yt[at]gmail[do t]com Time: Sunday, September 01st, 03:00 PM Location: 3625 Kincaid St, Eugene, OR 97405 Coordinates: https://plus.codes/84PR2W8F+PJ Notes: Please join us for a pre-Labor Day barbecue - we will have food, games, and conversation! Kids are welcome, but no pets please. This is a private house with a large backyard and plenty of shade - so we will mainly be outside. PORTLAND, OREGON, USA Contact: Sam Celarek Contact Info: scelarek[at]gmail[dot]com Time: Friday, September 13th, 05:30 PM Location: The Encorepreneur Cafe, 1548 NE 15th Ave, Portland, OR 97232 Coordinates: https://plus.codes/84QVG8MX+MV Group Link: https://www.meetup.com/portland-effective-altruism-and-rationality/events/302889901 Notes: Feel free to bring food, but make sure to know what common allergies/animal products are in it so we can label it. Kids are welcome! Dogs are not.
Inline links: https://plus.codes/84PR2W8F+PJ, https://plus.codes/84QVG8MX+MV, https://www.meetup.com/portland-effective-altruism-and-rationality/events/302889901
Links For September 2024
September 12, 2024 · Original source
10: After a four year experiment with Portugal-style decriminalization of hard drugs, Oregon has declared defeat and recriminalized them. Reasons cited include: they didn’t actually have enough substance abuse programs to send abusers to treatment instead of jail, the state mismanaged grants intended to create such programs, attempts to punish drugs with simple fines didn’t work because abusers didn’t pay them, and the fentanyl crisis is getting sufficiently bad that Oregonians felt less comfortable with experimental solutions.
Inline links: Oregon has declared defeat and recriminalized them
Open Thread 347
September 16, 2024 · Original source
1: Good comments on last week’s links post: Andy McKenzie on whether selection really disproves balancing theories of personality and schizophrenia, and multiple layers of clarification on the Australia/Jews/NYT doxxing story. And several people had good comments on Oregon’s now-repealed drug decriminalization law. Banjo Kildeer blames the law for offering addicts the choice between a $100 fine vs. treatment; the fine was so low that almost everyone paid and kept using. Kerry blames the police for not enforcing it properly. And an email correspondent linked this study suggesting that Oregon’s increase in drug deaths had nothing to do with the law, but was a simple effect of growing fentanyl availability.
Inline links: links post, on whether selection really disproves balancing theories of personality and schizophrenia, multiple layers of clarification on the Australia/Jews/NYT doxxing story, blames the law for, blames the police for, this study suggesting that
Meetups Everywhere Spring 2025: Times & Places
March 25, 2025 · Original source
Contact: bean Contact Info: battleshipbean[a t]gmail[period]com Time: Saturday, April 05th, 01:00 PM Location: Pavilion by the planes at the 45th infantry division museum. Coordinates: https://plus.codes/8674GG5G+8H Notes: I will be wearing a USS Iowa hat. Oregon CORVALLIS Contact: Kenan Contact Info: kbitikofer[a t]gmail[period]com Time: Friday, April 04th, 06:00 PM Location: Laughing Planet, 127 NW 2nd St, Corvallis, OR 97330. Table outside if it's nice, Table by the windows inside otherwise. Coordinates: https://plus.codes/84PRHP7R+R63 Group Link: https://discord.gg/y7N [remove this bit] FhYKYRP
Inline links: https://plus.codes/8674GG5G+8H, https://plus.codes/84PRHP7R+R63
Meetups Everywhere 2025: Times and Places
August 29, 2025 · Original source
Contact: Michael Bond Contact Info: bond[a t]spokenaac[period]com Time: Saturday, September 20th, 12:00 PM Location: McKenna's - Outside on the back patio if the weather is nice, inside in the back if it's not. Coordinates: https://plus.codes/86FWCG7W+5C Notes: Sandwiches and drinks alcoholic and non- will be available for purchase at the counter, I'll be wearing a baseball cap with something odd on it. The park across the street will be having their annual dachshund races, so a good time is guaranteed for all. Oregon CORVALLIS Contact: Kenan Contact Info: kbitikofer[a t]gmail[period]com Time: Friday, October 3rd, 6:00 PM Location: Tacovore @ 2503 NW Kings Blvd, Corvallis, OR 97330. If possible we'll sit at the outdoor tables. An "ACX Corvallis" paper will be visible on the table. Coordinates: https://plus.codes/84PRHPRG+WH6 Group Link: ACX/EAs of Willamette Valley Discord: https://discord.gg/AmQ [remove this bit] rjrrHQu
Inline links: https://plus.codes/86FWCG7W+5C, https://plus.codes/84PRHPRG+WH6