Astral Codex Ten Podcast

The best thing about personalized medicine is that it's obviously right. The worst thing is we mostly have no idea how to do it. We know that different people respond to different treatments. But outside a few special cases like cancer, we don't know how to predict which treatment will work for which person. Some psychiatric researchers claim they can do this at a high level; I think they're wrong. For most treatments and most conditions, there's no way to figure out whether a given sometimes-effective treatment will work on a given individual besides trying it and seeing. This suggests that some chronic conditions might do best with a model centered around a controlled process of guess-and-check. When it's safe and possible, we should be maximizing throughput – finding out how to test as many medications as we can in the short time before we exhaust our patients' patience, and how to best assess the effects of each. The process of treating each individual should mirror the process of medicine in general, balancing the need to run controlled trials and gather more evidence with the need to move quickly. I don't know how seriously to take this idea, but I would like to try it.

There's some literature suggesting that people are more careful when they think in probabilities. If you ask them for a definite answer, they might give it and sound very confident, but if you encourage them to think probabilistically they might admit there's more uncertainty. I wanted to look into this in the context of the recent Supreme Court confirmation hearings, so I asked readers to estimate their probability that Judge Kavanaugh was guilty of sexually assaulting Dr. Ford. I got 2,350 responses (thank you, you are great). Here was the overall distribution of probabilities. Horizontal axis is percent chance he did it; vertical axis is number of people who responded with that percent: This looks weird because people were most likely to give numbers rounded off the the nearest ten. I separated responses into bins from 0 – 9%, 10 – 19%, and so on to 90 – 100%. Keep in mind that the last bin is slightly larger than the others, so it might make it unfairly look like more people gave extreme high answers than extreme low answers. I also switched the vertical axis to percent of responses in each bin. Smoothed out, it looks like this: This looks pretty balanced, and it is: the average probability is 52.64%. This is probably a fake balance based on all the different demographic skews involved cancelling out: 2.5x as many Democrats as Republicans answered the survey, but 9x as many men as women did.

Thanks to the 129 people who tried altering their nighttime carbon dioxide levels after my post on this, and who reported back to me. There was no difference between people who pre-registered for the study and people who didn't, on any variable, so I ignored pre-registration. 126 people reported one intervention they performed. The most common was sleeping with a window open: People generally reported slight but positive changes: When asked to rate the magnitude of improvement to well-being on a 0 to 5 scale, they averaged 1.4: I mentioned in the post that succulents could help in theory, but you needed to get the right kind of succulents and you needed at least ten of them. I was skeptical that anyone really got ten succulents in their room, so I wondered whether that might work as a crypto-placebo group. If so, the intervention failed to separate from placebo. Succulent users had an average improvement of 1.29, compared to about 1.50 for people who did other things. The difference wasn't significant, although admittedly the sample size was low. Looking at the various groups, the most striking difference was actually people who left a window open (1.57) vs. people who did one of the other named options (1.31). A few people who left windows open mentioned this made their room cooler, which seemed to help with sleep. But this is very post hoc, and this difference wasn't significant either.

[Content note: attempt to consider real people's real problems using angel-on-pinhead impractical reasoning and ideas] I. Imagine the state of nature, except for some reason there are cities. Some people in these cities play the drums all night and keep everyone else awake. The sleep-deprived people get together and agree this is unacceptable. They embark on a long journey to the wilderness where they found their own community of Nodrumia. They form a company, the Nodrumia Corporation, which owns all the property in the area. The corporation distributes usage rights via a legal instrument that looks suspiciously like private property: people who own usage rights keep them forever, can do whatever they want with the land, and can freely transfer and sell them to others. The only difference is that the usage rights have a big asterisk on them saying "contract is null and void if you break the rules of the Nodrumia Corporation". These rules are set by a board chosen democratically by the inhabitants, and are all things like "You can't play drums at night", and "You can't sell property to people who will play the drums at night", and "Anyone who plays the drums at night shall be exiled". One day a Nodrumian wants to move out, so he puts his house up for sale. The highest bidder is a drummer who wants to use the property as a studio so he can play the drums at night. The Corporation steps in and bans the sale. The property owner protests, saying that he is being oppressed. According to libertarian philosophy, who is in the right? The argument against the drummer: the land is basically the private property of the Nodrumia Corporation, and libertarians believe that private landowners should be able to determine what happens on their property. And more fundamentally, the people there have a strong preference against living near drummers, and that preference seems fundamentally satisfiable if their property rights are respected, and it seems stupid to legislate a world where people are forever forbidden from satisfying a fundamentally satisfiable preference and have to be unhappy all the time.

Quixote writes: It's odd to me how bad San Francisco is, when other large cities like New York or Paris are basically utopias. But just a few comments down, Lasagna says: I despise (I'm choosing that word carefully) [New York City]. I still commute there every day, and I can't stand it – the broken infrastructure, the horrible smells, the $14 for a yogurt and coffee in the morning, the massive crowds of unpleasant people (how could we NOT be? We're walking through an open sewer). There's a litany of other things that keep me permanently angry and depressed (just the thought of how much earlier I would have started a family if I didn't live there….) I find it decadent, selfish, shallow – pick your bad adjective. I'll stop now. Where I live now is nice. We have a town we can walk to, a lawn for the kids to play on and me to mow, we cook at home, we have enough room for our family to live and the kids to get exercise, even indoors. There's no WAY I'm giving that up so I can live in an apartment again, all so NYC can squeeze MORE people into its area. If I had my way, we'd be much further away from the metro area than we are now, in a bigger, cheaper home with more land. But that isn't possible; NYC is where my job is, and that's that. Fine. But let's not make things worse, and make NYC (and San Francisco, and DC, and Boston) even MORE indispensable generators of jobs. And please don't think for a second that there aren't sizable numbers of people like me, and like you, who do not want these things for our families […] Thanks for letting me rant. You should have seen the first draft of this thing. Twice as long, Scott. A litany of woes and anger. This would be fascinating if it weren't so predictable. One person describes NYC as "basically utopia", and another person can't stop ranting about how much he hates it and is glad to have escaped it. In the same vein, from Cerastes: "I think neurotypical people usually underestimate how bad cities are for people with noise sensitivities, anxiety, purity intuitions, or just a need for nature and green things in their environment, …" THIS!!! A MILLION TIMES THIS!! The concept of living somewhere that isn't green is literally nauseating to me, and the idea of a place that isn't teeming with wild animals feels like suffocating. My house is in as wild a place as possible given my commute, budget, and region, and almost every room has a fully planted vivarium with an animal (as well as my office). The amount of urbanist triumphalist crap drives me up the wall, as if these people cannot see why someone would not want to live in conditions far inferior to even low-quality zoos, or why someone might need to balance a job in a city with such desires. Being 100% honest, I actually feel like there's something genuinely wrong with people who don't feel the need to spend time in nature, especially if they also lack pets. They're like sterile androids in some sort of weird dystopia, utterly cut off from life.

[Epistemic status: very unsure. I sympathize with many YIMBY ideas and might support them on net; this post is me exaggerating the NIMBY parts of my brain to a degree I'm not sure I honestly support. This focuses on San Francisco to make it easier, but other cities exist too. Thanks to Nintil for some of the bright-line argument in part four. Conflict of interest notice: I live in a lower-density part of Oakland] Everyone I know is a YIMBY – ie "Yes In My Back Yard" – ie somebody who wants cities (usually San Francisco dominates the discussion) to build more and denser housing. This is a reasonable position, and is held by apparently-reasonable people – centrists, rationalists, economists, self-proclaimed neoliberals. Since everyone involved holds reason and civility as an important value, I would expect the discourse around housing to be unusually reasonable and civil. I have a weird habit of encountering the best parts of some movements and the worst parts of other movements, in a way that doesn't match other people's experiences. And certainly I know many YIMBYs who are amazing people who I love. But as for the movement as a whole, I feel like apparently-reasonable people have dropped the ball on this one. Sorry for having to say this, but YIMBYism is one of the most tribal, most emotional, most closed-minded movements I have ever seen this side of a college campus. So much so that even though I agree with much of what it says, I cannot resist writing a 5,000 word steelman of their enemies just to piss them off. So here are some YIMBY claims and why I cannot be entirely on board with them.

Grand Prize ($1000): Does The Education System Adequately Serve Advanced Students? Editor's Choice ($500): Should Transgender Children Transition? Honorable Mentions ($250): Should Childhood Vaccination Be Mandatory?, Are Islam And Liberal Democracy Compatible? I'm sorry for jerking the number and value of the prizes around so many times, but I wanted to balance my preferences, the contestants' preferences, and readers' preferences – and this was the best way I could think of to do it. Nobody has gotten less money than they expected, although some prize categories have gotten more money than I originally said. In the end I could not in good conscience let any of these escape without getting a prize. Thanks to this blog's Patreon supporters for making this possible. All winners should email me with their preferred form of payment (I can do Paypal, Bitcoin, or donations to a charity of their choice). The overwhelming winner of the popular vote was the collaboration on education. I agree this one was excellent. It cited a lot of research, analyzed it very well, and mostly came to conclusions. Its only flaw from my perspective was a lack of focus; it discussed many different educational interventions, some of which were similar enough that it was hard for me to keep track of what was going on. I chose the collaboration on transgender children. I thought it did an exceptional job of addressing a specific hot-button issue many people are concerned about, presenting all the evidence on both sides, and mostly coming to conclusions. My strongest complaint was that it ignored some of the potential side effects of puberty blockers which commenters pointed out, and sort of trivialized bone problems that are not trivial; given that the side effects of puberty blockers was a major crux of this question, I found that to be a major weakness. I was still very impressed with the piece's ability to break down and navigate such a controversial question.

A neglected gem from Less Wrong: Why The Tails Come Apart, by commenter Thrasymachus. It explains why even when two variables are strongly correlated, the most extreme value of one will rarely be the most extreme value of the other. Take these graphs of grip strength vs. arm strength and reading score vs. writing score: In a pinch, the second graph can also serve as a rough map of Afghanistan Grip strength is strongly correlated with arm strength. But the person with the strongest arm doesn't have the strongest grip. He's up there, but a couple of people clearly beat him. Reading and writing scores are even less correlated, and some of the people with the best reading scores aren't even close to being best at writing. Thrasymachus gives an intuitive geometric explanation of why this should be; I can't beat it, so I'll just copy it outright: I thought about this last week when I read this article on happiness research. The summary: if you ask people to "value their lives today on a 0 to 10 scale, with the worst possible life as a 0 and the best possible life as a 10", you will find that Scandinavian countries are the happiest in the world. But if you ask people "how much positive emotion do you experience?", you will find that Latin American countries are the happiest in the world. If you check where people are the least depressed, you will find Australia starts looking very good. And if you ask "how meaningful would you rate your life?" you find that African countries are the happiest in the world. It's tempting to completely dismiss "happiness" as a concept at all, but that's not right either. Who's happier: a millionaire with a loving family who lives in a beautiful mansion in the forest and spends all his time hiking and surfing and playing with his kids? Or a prisoner in a maximum security jail with chronic pain? If we can all agree on the millionaire – and who wouldn't? – happiness has to at least sort of be a real concept. The solution is to understand words as hidden inferences – they refer to a multidimensional correlation rather than to a single cohesive property. So for example, we have the word "strength", which combines grip strength and arm strength (and many other things). These variables really are heavily correlated (see the graph above), so it's almost always worthwhile to just refer to people as being strong or weak. I can say "Mike Tyson is stronger than an 80 year old woman", and this is better than having to say "Mike Tyson has higher grip strength, arm strength, leg strength, torso strength, and ten other different kinds of strength than an 80 year old woman." This is necessary to communicate anything at all and given how nicely all forms of strength correlate there's no reason not to do it.

A prodrome is an early stage of a condition that might have different symptoms than the full-blown version. In psychiatry, the prodrome of schizophrenia is the few-months-to-few-years period when a person is just starting to develop schizophrenia and is acting a little bit strange while still having some insight into their condition. There's a big push to treat schizophrenia prodrome as a critical period for intervention. Multiple studies have suggested that even though schizophrenia itself is a permanent condition which can be controlled but never cured, treating the prodrome aggressively enough can prevent full schizophrenia from ever developing at all. Advocates of this view compare it to detecting early-stage cancers, or getting prompt treatment for a developing stroke, or any of the million other examples from medicine of how you can get much better results by catching a disease very early before it has time to do damage. These models conceptualize psychosis as "toxic" – not just unpleasant in and of itself, but damaging the brain while it's happening. They focus on a statistic called Duration of Untreated Psychosis. The longer the DUP, the more chance psychosis has had to damage the patient before the fire gets put out and further damage is prevented. Under this model it's vitally important to put people who seem to be getting a little bit schizophrenic on medications as soon as possible. There has been a lot of work on this theory, but not a lot of light has been shed. Observational studies testing whether duration of untreated psychosis correlates with poor outcome mostly find it does a little bit, but there's a lot of potential confounding – maybe lower-class uneducated people take longer to see a psychiatrist, or maybe people who are especially psychotic are especially bad at recognizing they are psychotic. The relevant studies try their hardest to control for these factors, but remember that this is harder than you think. The randomized controlled trials of what happens if you intervene earlier in psychosis tend to do very badly and rarely show any benefit, but randomly intervening earlier in psychosis is hard, especially if you also need an ethics board's permission to keep a control group of other people who you are not going to intervene early on. Overall I could go either way on this.

I. Writing a review of The Black Swan is a nerve-wracking experience. First, because it forces me to reveal I am about ten years behind the times in my reading habits. But second, because its author Nassim Nicholas Taleb is infamous for angry Twitter rants against people who misunderstand his work. Much better men than I have read and reviewed Black Swan, messed it up, and ended up the victim of Taleb's acerbic tongue. One might ask: what's the worst that could happen? A famous intellectual yells at me on Twitter for a few minutes? Isn't that normal these days? Sure, occasionally Taleb will go further and write an entire enraged Medium article about some particularly egregious flub, but only occasionally. And even that isn't so bad, is it? But such an argument betrays the following underlying view: It assumes that events can always be mapped onto a bell curve, with a peak at the average and dropping off quickly as one moves towards extremes. Most reviews of Black Swan will get an angry Twitter rant. A few will get only a snarky Facebook post or an entire enraged Medium article. By the time we get to real extremes in either directions – a mere passive-aggressive Reddit comment, or a dramatic violent assault – the probabilities are so low that they can safely be ignored. Some distributions really do follow a bell curve. The classic example is height. The average person is about 5'7. The likelihood of anyone being a different height drops off dramatically with distance from the mean. Only about one in a million people should be taller than 7 feet; only one in a billion should be as tall as 7'5. Nobody is order-of-magnitude differences in height from anyone else. Taleb calls the world of bell curves and minor differences Mediocristan. If Taleb's reaction to bad reviews dwells alongside height in Mediocristan, I am safe; nothing an order-of-magnitude difference from an angry Twitter rant is likely to happen in entire lifetimes of misinterpreting his work. But other distributions are nothing like a bell curve. Taleb cites power-law distributions as an example, and calls their world Extremistan. Wealth inequality lives in Extremistan. If wealth followed a bell curve around the median household income of $57,000, and a standard deviation scaled the same way as height, then a rich person earning $70,000 would be as remarkable as a tall person hitting 7 feet. Someone who earned $76,000 would be the same kind of prodigy of nature as the 7'6 Yao Ming. Instead, people earning $70,000 are dirt-common, some people earn millions, and the occasional tycoon can make hundreds of millions of dollars per year. In Mediocristan, the extremes don't matter; in Extremistan, sometimes only the extremes matter. If you have a room full of 99 average-height people plus Yao Ming, Yao only has 1.3% of the total height in the room. If you have a room full of 99 average-income people plus Jeff Bezos, Bezos has 99.99% of the total wealth.