A technical expert might hear “there should be less pollution” and have dozens of questions. Do you just want to do common-sense things, like lower the detection threshold for hexamethyldecawhatever? Or do you want to ban tetraethylpentawhatever, which is vital for the baby formula food chain and would cause millions of babies to die if you banned it?
And yet ordinary people should be able to say “I want to stop choking on yellow smoke every time I go outside” without having to learn the difference between hexamethyldecawhatever and tetraethylpentawhatever.
I think you’re supposed to imagine the environmentalists’ experts and the industries’ experts meeting policy-makers and hammering out a compromise, then moving one direction or another along the Pareto frontier based on how loudly normal people protest pollution.
But if you’ve been demanding an end to pollution for years, and nothing has happened, then it might be time to hit the books, learn about hexamethyldecawhatever, and make sure that what you’re demanding is possible, coherent, and doesn’t have so many tradeoffs that experts inevitably recoil as soon as they have to think about the specifics.
II.
I’m not a pollution expert, but I’m a psychiatrist, and I’ve been involved in the involuntary commitment process. So when people say “we should do something about mentally ill homeless people”, I naturally tend towards thinking this is meaningless unless you specify what you want to do - something most of these people never get to.
Let’s start with a summary of the current process for dealing with disruptive mentally ill homeless people:
Okay, then can you just make it a crime to be mentally ill, and throw everyone in prison? According to NIMH, 22.7% of Americans have a mental illness, so that’s a lot of prisoners. “You know what I mean, psychotic homeless people in tents!” Okay, fine, can you make homelessness a crime? As of last month, yes you can! But before doing this, consider:
In practice, the government tries some combination of these things, each of which works a little. Sometimes they fiddle with the law around inpatient commitment around the edges. Sometimes they give people free houses. Sometimes they threaten them with Involuntary Outpatient Commitment orders. Sometimes they throw them in prison. Most of these things work a little. Some of them could work better with more funding.
Nobody thinks the current system is perfect. I respect people who want to change it. But you’ve got to propose a specific change! Don’t just write yet another article saying “the damn liberals are soft on the mentally ill”.
The damn liberals are soft because some of them are the people who have to develop an alternative plan, and they can’t think of a good one. If you’re going to write yet another article like this, and you want to change minds, you should skip the one hundred paragraphs about the damn liberals, and go straight to the part where you explain how you plan to do better.
I think you’re supposed to imagine the environmentalists’ experts and the industries’ experts meeting policy-makers and hammering out a compromise, then moving one direction or another along the Pareto frontier based on how loudly normal people protest pollution.
But if you’ve been demanding an end to pollution for years, and nothing has happened, then it might be time to hit the books, learn about hexamethyldecawhatever, and make sure that what you’re demanding is possible, coherent, and doesn’t have so many tradeoffs that experts inevitably recoil as soon as they have to think about the specifics.
II.
I’m not a pollution expert, but I’m a psychiatrist, and I’ve been involved in the involuntary commitment process. So when people say “we should do something about mentally ill homeless people”, I naturally tend towards thinking this is meaningless unless you specify what you want to do - something most of these people never get to.
Let’s start with a summary of the current process for dealing with disruptive mentally ill homeless people:
- A police officer sees a mentally ill homeless person and assesses them as disruptive. Technically the officer should assess whether the person is “a danger to themselves or others”, but in practice it’s all vibes. They bring this person to the ER of a hospital with a psychiatric ward.
- In the ER, psychiatrists evaluate the person. If some number of doctors, psychiatrists, and others (it varies on a state-by-state basis, and most people defer to the first psychiatrist anyway) agree the person is a “danger to themselves or others”, they can involuntarily commit them. Psychiatrists know lots of tricks for getting the evaluation result they want. For example, wasn’t the person brought in by the cops? Aren’t cops infamous for shooting mentally ill people? Sounds like whatever they did to attract the cops’ attention put them at risk of getting shot, which makes them a “danger to themselves or others”. Again, in reality this is all vibes.
- The patient gets committed to the hospital. The hospital makes an appointment with a judge to legally evaluate the commitment order. But realistically the appointment is 4-14 days out (depending on the state), and by then the patient may well be gone anyway, in which case the hearing can be cancelled. If it does go to trial, the judge will always defer to the psychiatrists, because they’re experts trying to do a tough and socially important job, and the defendant is represented by an overworked public defender who has devoted 0.01 minutes of thought to this case. This is part of why everyone feels comfortable making commitment decisions on vibes.
- If the patient seems psychotic, the doctors start them on antipsychotic drugs. These take about 2-4 weeks to make people less psychotic. But one of their side effects is sedation, that side effect kicks in right away, and heavily-sedated people seem less psychotic. So realistically the person will stop seeming psychotic right away.
- After a few days, the hospital declares victory and discharges the patient with a prescription for antipsychotics and an appointment with an outpatient psychiatrist who can continue their treatment.
- The patient stops taking the antipsychotics almost immediately. Sometimes this is because they’re having side effects. Other times it’s because they’re still psychotic and making irrational decisions. But most of the time, it’s because some trivial hiccup comes up in getting the prescription refilled, or in getting to the doctor’s appointment. Nobody likes dealing with healthcare bureaucracy, but semi-psychotic homeless people are even worse at this than usual. Social services can sometimes help here, but other times they’re just another bureaucracy that it’s hard to deal with, and it usually doesn’t take long for something to slip through the cracks.
- Repeat steps 1-6 forever.
Okay, then can you just make it a crime to be mentally ill, and throw everyone in prison? According to NIMH, 22.7% of Americans have a mental illness, so that’s a lot of prisoners. “You know what I mean, psychotic homeless people in tents!” Okay, fine, can you make homelessness a crime? As of last month, yes you can! But before doing this, consider:
- In San Francisco, the average wait time for a homeless shelter bed is 826 days. So people mostly don’t have the option to go to a homeless shelter. If you criminalize unsheltered homelessness, you’re criminalizing homelessness full stop; if someone can’t afford an apartment or hotel, they go to jail.
- Most (?) homeless people are only homeless for a few weeks, and 80% of homeless people are homeless for less than a year. If someone was going to be homeless for a week, and instead you imprison them for a year, you’re not doing them or society any favors.
- How long should prison sentences for homelessness be? Theft is a year, so if homelessness is more than that, it becomes rational for people to steal in order to make rent. And realistically it will take police years to arrest all of the tens of thousands of homeless people, so if a sentence is less than a year, then most homeless people will be on the street (and not in prison) most of the time, and you won’t get much homelessness reduction.
- What’s your plan for when homeless people finish their prison sentence? Release them back onto the street, then immediately arrest them again (since there’s no way they can suddenly generate a house while in prison)? Connect them to social services in some magical way such that the social service will give them a house within 24 hours of them getting out of prison? If such magical social services exist, wouldn’t it be cheaper and more humane to invoke them before putting someone in prison?
In practice, the government tries some combination of these things, each of which works a little. Sometimes they fiddle with the law around inpatient commitment around the edges. Sometimes they give people free houses. Sometimes they threaten them with Involuntary Outpatient Commitment orders. Sometimes they throw them in prison. Most of these things work a little. Some of them could work better with more funding.
Nobody thinks the current system is perfect. I respect people who want to change it. But you’ve got to propose a specific change! Don’t just write yet another article saying “the damn liberals are soft on the mentally ill”.
The damn liberals are soft because some of them are the people who have to develop an alternative plan, and they can’t think of a good one. If you’re going to write yet another article like this, and you want to change minds, you should skip the one hundred paragraphs about the damn liberals, and go straight to the part where you explain how you plan to do better.
by Scott Alexander, Astral Codex Ten | Read more:
Image: Luis Sinco/Los Angeles Times via Getty Images via
