Diseases, Disorders and Illnesses, Oh My

This will serve as an addendum of sorts to my article, The Harmless Psychopaths.

Medicine as a science is a modern phenomenon. It was not all that long ago that going to a doctor was more likely to hurt than help, a fact which persisted, some think, until as late as the 1930s. Medical researchers tend to just keep plugging away at their specialist interest and are unconcerned with what to them seem like instrumentally useless philosophical minutiae. Moral philosophers might argue about meta-ethics: the essence of moral statements, but this does not seem a necessary prerequisite to a relatively harmonious social order. One might just as well ask what is the use of “meta-medicine,” to wonder at the underlying assumptions of medical diagnoses, when scientists are quite happy getting on with finding cures for cancer, and whatever else.

Unfortunately, medicine is as subject to such human frailties as status-seeking and fashion as anything else. It became unfashionable in the 20th century to look for pathogenic causation to diseases thanks to the then nascent science of genetics, which is why it was not accepted as common knowledge that bacteria cause peptic ulcers until the 1980s despite this having been suspected, on good evidence, for well over a hundred years. Note that most cancers are only dimly heritable, in contrast with, say, autism, and have no clear Mendelian inheritance pattern. (Fill in the blank.)

Medicine is an applied science and so obviously has a prescriptive dimension to it, i.e. what is worth treating? Call this is the meta-medical question if one likes. The answer to this is not so complicated when dealing with physical disorders which glaringly go against the sufferer’s interests and those of peers, such as the flu, atherosclerosis, whatever. But what about disorders of the mind? Surely a meaningful concept, but surely far more prone to spurious theorising and fashion-biases in answering the meta-medical question, due to the diversity of moral viewpoints about what is “disordered” behaviour. For the purposes of this post, I use the terms disease, disorder, and illness interchangeably – which they more or less are in everyday usage.

This is how the DSM-IV defines mental disorder:

A. a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual

B. is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom

C. must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one

D. a manifestation of a behavioral, psychological, or biological dysfunction in the individual

E. neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual

The inadequacies of this are manifold and torturously obvious. Childbirth seems to fit quite snugly with condition B. Also, it is generally unhelpful to include a word itself or its synonyms in its own definition, such as in D. with “dysfunction.” E. seems to take it as read that the distinction between biological dysfunction and normal deviance is obvious, yet it is apparently not to most psychiatrists. It is for that reason that the traits branded “psychopathy,” for example, are continuously distributed in the population and usually harmless, but there exists an arbitrarily defined cut-off at the right tail of the distribution where it is conveniently labelled “disorder,” and the relevant convenience is just relative to the interests of whosoever finds these traits unappealing or whoever lacks the theory of mind to understand them. See also: ADHD, and teachers.

How to get around this arbitrariness? If ADHD and psychopathy are not useful to us WEIRDos, who or what are they useful to? Well, they are adaptations: they have a fitness benefit, i.e. a reproductive edge, in at least some environments, even if they are unpalatable to individual persons. This evolutionary view is what tempts some to propose a purely Darwinian definition of disease in which disease is conceived as any embodied phenomenon that is counter-adaptive across all environments. This would make homosexuality a disease, but “Asperger’s syndrome,” “ADHD,” and “psychopathy” not. This could certainly be illuminating from a solely descriptive angle where the only interest is to scientifically describe the causes of disease, but it is useless to practitioners of medicine and psychiatry, for whom the relevant question is “What ought to be treated?” If one asks doctors what the problem is with flu, they are unlikely to say anything about how it affects one’s reproductive chances, and, well, it doesn’t. Not much.

Whether one finds this distasteful to mention as a dispassionate intellectual, it is also a fact that the word “diseased” in popular usage carries a certain moral valence, even when applied to activities that one does not think morally important. To say that “Behaviour X is a disease” is not simply to say that it is evolutionarily maladaptive, but that it is wrong. This would seem an unhelpful confusion.

For the application of medicine, I tentatively suggest that what I think is the best formulation of the conventional usage of “disorder” be merged with the Darwinian definition: anything, internally generated (which may be another bone of contention, but that is a separate topic), which leads to non-trivial suffering in the individual and also has no conceivable fitness benefit. As for the descriptive-only theorists and researchers, the Darwinian definition is fine on its own, although perhaps it is worth while to find a word other than “disease.”

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Unrealistic Adaptations

Of all the mental shortcuts embedded in human languages which impede understanding of mindless processes (such as natural selection), few are more obnoxious than “because.” From this comes a tendency to anthropomorphise, and read all outcomes in nature as if they were ordained by something approximating an “intention.” Religion has to be an adaptation, because the religious (currently) outbreed the irreligious.” The second clause in that sentence is (currently) correct, but the “because” makes it sound as though the current religious selection advantage represents some “design feature” with the desired (by what?) end of promoting reproductive fitness (adaptation). And fitness is where the matter rests. Contrast with the following sentence:

“Under current conditions in which the religious outbreed the irreligious, religion is adaptive.” This statement is of course tautologous, since to say that a trait or behaviour is adaptive means merely that under condition X it gives one a reproductive edge. The term “adaptation,” though, is often applied to traits or behaviours which are selectively neutral or even counter-adaptive in particular environments. Genes which contribute to an overzealous appetite may be fitness-neutral to a subsistence farmer but become obesogenic in the modern world of easily available food. The genes’ carrier still exercises this “adaptation,” but it is no longer adaptive, reproductively useful, except in an environment full of fat-fetishists.

Human society has changed so dramatically in the last two centuries that it would be hasty to say the least to assume that everything with a current selective disadvantage is an “illness” (due to pathogens, mutational load, or whatever). Just as equally, one cannot assume that something with a current advantage exists having evolved by resolving an adaptive problem. Religion was ubiquitous across cultures before the 20th century, yet now the religious fraction represent an ever tinier percentage of the population in many countries, and it remains to be seen just how tiny the “genetic hard core of religiosity” will get before the trend is reversed. If the presence of religion were explicable in terms of fitness benefit, why are the genes not already more widespread? This alone should be enough to tell you that genes (and thus, adaptation) per se had little to do with religion’s evolution.

But apparently this is not obvious to some. Many people are inclined to view adaptations as intricate mechanisms, which by dint of their intricacy are delicate and susceptible to dysfunction, rather like the springs and levers of a pocket-watch. All analogies are imperfect, but this is a useless one. Some traits, and indeed behaviours, are more prone to changing by exogenous insults than others. For instance, a particularly naive person might imagine that in a pandemic of severe endometriosis, whereby female beauty and youth cease to be predictive as indicators of fertility, males would be disincentivised from their sexual attraction to these traits because the attraction would no longer perform its original “functions.” Needless to say, this would not happen. Male callogamy (“attention to beauty”) has proven so reliably fitness-enhancing over the eons, since even before the human species, that it is extraordinarily resilient to any incentive change: selection will always favour a deterministic developmental pathway for such consistently valuable traits. General intelligence is yet another example: the current dysgenic trend is a product of the last few generations and on the order of ~1 point per generation despite ramping up of mutational load globally (we’ll see how long it can last), and almost no non-genetic factors seem capable of depressing its expression to any appreciable degree. Lead looked plausible at some point, but then you remember that Victorians liked to use mercury in their make-up, and yet the 19th century was the most intellectually productive in human history.

Viewed under this light, the “religion as adaptation” thesis looks all the more dubious. Evolutionary forces – selection, mutation, drift, etc – are just as capable of acting on general intelligence and other psychological traits as anything else, hence the well-documented evolved changes in the European peoples since around AD1000: declines in violence, and probably gains in intelligence, culminating ultimately in the zenith of the 19th century. Evolution can indeed happen fast, but not that fast. The bulk of these changes took place over a period of, at minimum, 20 generations, not 2-3, and our intelligence has more or less survived the last 2-3 generations intact. Religion has not. It has none of the hallmarks of an adaptation, but all the hallmarks of a complex socially learned behaviour, maintained by powerful norm-enforcers and epistemic authorities, which has lost currency in recent decades for a variety of reasons, the most commonsense explanation being that it no longer appeals to the educated because the answers it gives are inferior to those of other epistemic authorities, i.e. scientists.

The human capacity for cultural transmission through language makes a nonsense of the notion that anything which is not adaptive, even across all environments, should be impossible to sustain. The most obvious example in Christian cultures is the vow of celibacy, and there are numerous others such as taboos against eating highly nutrient-dense foods, which persist among the undernourished tribes of Papua New Guinea. So too with the European wars of religion, which resulted in millions of young men dying childless in their haste to protect a non-existent natural resource, i.e. God’s favour.

Group selection is another temptation when formulating theories about the origin of religion – the idea that even a behaviour which reduces fitness at the individual level can persist if it provides some advantage at the level of the social group. It is a neat idea, but clearly unworkable in practice. Suppose some cohort of one’s country likes spreading the word of God through warfare – call this behaviour X. They can seize new territory in God’s name and provide new land for others in their group who are not quite so zealous, and this may look like a “success” to the people who reap those rewards, but at the end of the day: the behaviour is still going to diminish because everyone who engages in it is at a massively elevated risk of dying before reproduction. Evolution does not care about states or dominions.

It is understandable why post hoc stories about religion as adaptation are popular, even among well-informed people. Intelligence is not a good predictor of having sensible views where political matters are concerned, since politics is about group loyalty more than anything else. This is why the number of US Democrats who thought immigration was an important social issue declined precipitously in the 2010s when it became the issue “of” the right; what mattered was showing solidarity against rival political coalitions (i.e. the right) rather than the truth. Adaptive stories about religion seem to appeal an awful lot to European traditionalist-nationalists who are hoping to use Christianity as the conduit for some kind of renewed ethnocentrism to uplift the European spirit. The Chinese do not seem to need it, oddly enough. Nor even the Czechs, much closer to home. It did not work for Rome, and it sure as fuck won’t for us.

The Age of Orangutans

There is much talk of incentivising fecundity. It did not work for Imperator Augustus, nor will it for us, for a simple reason: kids are a pain in the arse. And land grants for chavs are probably not the best idea; need I explain why? One must differentiate based on intelligence or education level (a proxy for the former) to avoid pouring money into the sewer, and since no earthly government has the balls for that, we can forget it.

Alternatively, technology promises that which the Romans could scarcely have dreamt of. The demographic “problem” is not low fertility. Only in light of mass migration, which need not be, is low average fertility bad, and selection pressure will deal with that regardless. The problem is that the cognitive elite are infertile. Conversely, would the African population explosion be worrisome if the children all had IQs upwards of 180?

Even if you adhere to an ethical system such as libertarianism and so place all emphasis on freedom from coercion, there is a lot to be said for a state-enforced rewriting of human genetics, perhaps even a global one – setting aside the practicalities thereof. If the rewrite is imposed on all, well, there goes the problem of an inherited continuity of stupid. I am sympathetic to a lot of anti-paternalist intuitions where paternalism is liable to exacerbate a problem or make no odds, but it does make odds when one contemplates a future of regression to the mental acuity of orangutans. There will be no liberty then, nor indeed anything worth speaking of (assuming people could still speak). The desire for paternalism often arises from the knowledge that most people have poor reasoning abilities, but that need not always be, thanks to forthcoming technological interventions, too numerous to list. True, this may not be coming soon. What was that about caring for the long-term?

As per, pessimism is sensible. In the zeroth approximation, bet on China. Beyond that, don’t bother. This is where we are at.

The Harmless Psychopaths

Psychopathy probably does not exist in the way most people think of it.

Any psychological trait that varies between individuals is distributed on a continuum whose limits are defined by the trait’s fitness benefit. This is why the personality disorders are considered dubious by some: how much sense does it make to cordon off a particular quartile, decile, centile of the distribution and declare it an illness?

Antisocial personality disorder, which most people still call psychopathy or sociopathy, is characterised by a suite of “extreme” traits, and is identified through behavioural indicators. Those are the cases that go to prison and the ones that show up in the media. But if these people’s predilections were that abnormal, they would not exist – thanks to selection pressure. The heritability of APD is no lower than the general heritability of personality, suggesting that this concatenation of traits is a (mal)adaptation.

Estimates of the prevalence of APD are on the order of 1-3%. It is not the case that 1-3% of people are violent criminals, nor that everyone in prison has the diagnosis, so it is neither necessary nor sufficient for most crime. A good chunk of diagnoses must occur because of repetitious criminal behaviour. What of the rest?

It is news to no one, of course, that most psychopaths are not criminals. The question is: what separates the criminal from the law-abiding variety?

This is a moment of revelation for some, when they have their heads scanned and realise that their neurology is “consistent” with that of a Jeffrey Dahmer. But they are not Jeffrey Dahmer. So much for the notion that it is impossible to be unaware that you have this psychological profile. Thus, they turn to parenting and other things that do not matter as an explanation to assuage the headfuck.

One hypothesis, and a testable one, is that the difference is made by IQ. One begins to sounds like a broken record, but the link between IQ and crime is well established, and given that 1 US adult in 7 is unable to perform mental operations more complex than finding the expiration date on a driving licence, it is not hard to imagine what this does when combined with a temperamental disposition towards narcissism. Not only do they feel social norms “don’t apply” to them; they are too stupid to understand the consequences of violating them.

High-IQ individuals with Dark Triad traits often go undetected or are even wildly successful. You probably know a few, and it probably isn’t worth giving them a second thought. The proto-criminal types are easier to spot, but no one wants his or her child to be branded “high-risk” before any criminal wrongdoing is committed. Nor are they prepared to confront the fact that there is essentially nothing they can do to “fix” the problem, and so nothing (useful) is done. Isn’t that just too fucking bad?

Educational Formality and Its Abundance

Obsession with provisioning and protecting children is a trend in the norms of WEIRD societies. In a certain type of person this often leads to an array of strange, inconsistent beliefs. Some complain non-stop about the adult abdication of grown-up responsibilities and simultaneously claim that a 16-year-old engaged in active sexual pursuit of an adult is by definition a victim of child molestation. Others bleat on about the dangers of what they call helicopter parenting while asserting that a mother’s decision to leave her child in a daycare for 8 hours of the 24 in a day is tantamount to a form of child abuse. One may see the concrescence of these stupidities in a recent New York Times article about the harassment of so-called neglectful mothers by public busybodies.

Kidnapping and child molestation are and always have been rare, so this obsession is new albeit no one knows when it began exactly. Likewise, genetics has long since set the record straight on the relevance of parenting to adult behaviour: it barely leaves a dent except in cases of extreme abuse or neglect. Dote on your children or not; they are who they are. Thus, the discourse on how to treat children ought not to focus on how it affects them, but rather what we know to be pragmatic and efficient for both parents and children.

Bryan Caplan argues that education is primarily about job-market signalling, hence the phenomenon of credential inflation and repeated efforts to pour more money into teaching even though it is well known to have weak long-term effects. This means that almost no one remembers much of what they are allegedly learning, and what they do remember is of little use to them in their work lives. Formal education is in actual fact useless to anyone but the mid-witted. Geniuses tend to be self-taught and already know a thousand times more than their classmates by the time they get to school, meanwhile the borderline intellectual functioning struggle through it all and come out at the end with very little signalling currency (i.e. grades).

Formal education before the age of 10 need not exist. It is glorified babysitting. I do not recall learning anything substantive in school for that period of my life, and I know no one who reports otherwise. Child care need not even exist unless the child is very young. Why not just let the kids run free? If this sounds alien and horrifying to you, please note that there are already places on this planet where children as young as 7 may perform most of the functions of daily life with no adult supervision and commute around gigantic megalopolises either alone or in troupes with other children. It requires an intelligent, high-social-capital society where crime is freakishly rare, which can be facilitated by homogeneity, embryonic selection for IQ (since IQ is linked to all things good), and deliciously brutal punishments for the disruption of public order and safety.

Another reason for the alleged necessity of early education is that a child must be socialised, which is to say interact with other children, and this speaks to the age-segregation trend of the First World. It hits high-IQ children the hardest: “He needs to learn to be with people his own age!” No one ever asks why, because no one actually knows why. Children who are adept at talking to adults are probably doing so out of frustration or boredom with other children, especially if they are bright, and it is not as if this “skill” is something they will carry with them for long – once they become adults, they (especially males) will be forbidden from socialising with children lest they be accused of child molestation.

In the days before institutional education was widespread, children socialised with other children, and adults, in their locale with no school, state, or bureaucracy sticking its nose in. Given the aforesaid prerequisites of high social capital, this is achievable to an even greater degree today. Smartphone addiction in children ought to be encouraged; it is the way of the True Aristocrat. Especially, encourage them to use it to get in touch with other children near them, on the same street or what have you, and then get on with their fun and games – no adult oversight needed. A nursery or daycare where I am from is often no more than a repurposed house in a residential area, much less fun than the setup I have described. This will make for less miserable childhoods and fewer put-upon and harassed parents, which, I think we should all agree, are good things.

The Accidental Eugenicists

This article is about 1) how a taboo against incestuous reproduction could be used to make the political mainstream comfortable with (explicit) eugenics, and 2) other ethical considerations surrounding human genetic enhancement – in that order.

One must differentiate what I call implicit and explicit eugenics. The implicit version encompasses those things which all people do in the interest of “good genes” but without actually thinking of it in those terms, such as mate selection.

An explicit, or more explicit, example is the outlawing of incest. The case for doing so is easy to make. Incest can lead to inbred children, and this is probably, in part, responsible for the neuroses that afflict the Islamic world, for theirs is a hyper-consanguineous culture. In recent times, I have come to think that the only chapter in the history of the European Church that one can praise without a dozen or more extensive caveats was their prohibition of inbreeding. As HBD Chick has discussed, this was instrumental in the evolutionary trajectory of (especially north-western) Europeans and the development of uniquely European traits such as individualism.

But how much difference do anti-incest laws make now? I would wager not much. Consanguineous breeding among Europeans is a highly marginal phenomenon even in places where it is legal, and I do not see how criminalising it could be any more effective than anti-drug laws. But Westerners have negative reactions to both incest and explicit eugenics. This could be seized upon, in theory: allow the consensually incestuous adults to have children, but make it mandatory for them to go through screening of the embryo’s genome first once the technology is widespread. The procedure could then be extended to, for example, mothers of advanced age, and then beyond.

The word eugenics is also a problem. Trying to revive it is pointless. A far better strategy would be to adopt a term which is descriptively accurate but with none of the nasty connotations, such as “directed evolution”. Saying “eugenics” purely to inflame people is childish.

I am sceptical of the reflexive libertarian position on human enhancement with respect to traits such as IQ, neuroticism, and all diseases with a genetic basis. Note: abortion-related concerns are moot since this is mostly about pre-implantation embryo selection. I do not see how refusing to use this technology when it is available is morally superior to child abuse. “You may allow a car to be built with a sub-optimal design, but you may not damage it once it is built” seems like the position of people who would condemn the latter but endorse the former of these. Allowing nature to take its course is now a choice, not an inevitability. Why should people be free to make that choice? Again, this is specifically with respect to the traits I mentioned.

Many mainstream leftists who balk at these possibilities are happy to accept that vaccinating one’s children be mandatory. So am I. So why not: increasing children’s genotypic IQ above a certain threshold (whatever it may be), or reducing their genetic propensity to experience negative emotion? Again this is a morally inconsistent position: “You are allowed to improve your car once it is built, but you may not just make better cars or, heaven forbid, mandate that better cars be built.” These mainstream leftists should just accept the moral salience of willfully increasing potential for future harm to their children by either refusing to have them vaccinated or refusing to genetically enhance them.

People will make excuses for why the analogy with vaccination is not a comparable situation, but people only come up with these post hoc. It is like when libertarians whine about the government’s taking away all their money but have no problem with huge global corporations’ outsourcing jobs to foreigners, either home or abroad. The net result is the same: fewer job opportunities – and therefore less money.

Neuroticism and low IQ are things that we happen to not give disease-like names to, up to a point. Where and why is that point set? Well, with neuroticism it is where you are continuously anxious about everything and nothing (generalised anxiety disorder), because this impedes daily functioning. With IQ it is 70, because a person with an IQ below 70 seldom if ever has the wherewithal to perform basic tasks. That threshold will go up, however, when society is technologically complex enough that even those of us between 100 and 135 are rendered useless. As for neuroticism, people are shit-scared of jumping out of planes even though skydiving is, statistically, probably less dangerous than a whole lot of other things they do without a second thought, such as driving. People’s brains are not equipped to assess risk in a technified society such as ours, and neuroticism is strongly anti-correlated with about a thousand negative life outcomes. Some people argue that there is a trade-off to be made with it for “creativity”, but one does not need an anxiety disorder to be creative, and I doubt that whatever difference it makes is worth it in QALYs.

“Everything is allowed unless it is explicitly forbidden. Something is only explicitly forbidden if it can be shown empirically to be harmful.” I do not literally think of those words every time I am pondering solutions to some social problem, but if you reverse-engineer my ideas about society, you will end up with some formula similar to this. I believe this is quite close to the mentality of the typical libertarian, except the primary difference is that most self-identified libertarians would never countenance forbidding inaction, e.g. not vaccinating one’s children. Luckily, I am not so arrogant as to assume the point of view of the universe. Not everyone agrees with me about what should or should not be mandatory. That is fine. They should not have to live around me, nor I them.