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The team I leave behind

I am leaving Ottawa in two weeks.

I don’t have that many feelings about it. It’s a city. I grew up here. It has houses and schools and public transit and public swimming pools, all the things I needed as a kid. No better than most cities, no worse. I’m not sentimental. But the city isn’t what’s hard to leave behind.

I am leaving behind some of my closest friends–but we’ll still be friends, I hope, even across the distance. Hell, I’ve been doing long-distance friendship with people all over the world for years.

The hardest thing to leave is the one that I can’t replace, or take with me in any form. Cities are cities, interchangeable for my purposes. Friends are still friends, even when it’s over Skype and gchat. But the place where I first learned what it was like to be really, truly, part of a team… I can’t take that with me, because I can’t take the team with me.

Nursing is hard, and relentless, and grinds you down. It’s an endless Man-Against-Nature war. Starting out as a new RN, it often felt like I was fighting that war alone. But in the last six months or so, something changed.

There’s always something magical that happens, on those days when someone’s patient is crashing and it doesn’t matter whose patient, because it’s everyone’s problem, and everyone steps in, helps, does what they can. And there’s something else that happens, equally magical, when a group of nurses work together and fall into a pattern where they know each other, and joke amongst themselves, and first and foremost trust each other almost completely.

A morning, in the ICU. I haven’t charted yet, but people are shinier. Hey, do you need help with anything? A reposition. Okay. We turn your intubated patient onto his other side. Do you need help with anything? An epi drip, please, make sure it’s quadruple strength, no, really. The IV pump ringing in someone’s room; the propofol bottle is empty. I fetch a new one, make a mental note to sign for it later. Do you need help with anything? I’ll fetch you a clean sheet, sure. New admission’s here. Isolation; I’ll gown up. In the room; does the patient need a catheter? I’ll put one in, I’m here anyway. Bring my patient down the hall’s vital signs up on the monitor. Hey, my patient’s BP is low, I think his norepinephrine drip is empty, can you go change the bag while I’m stuck in here? Thanks. Do you need help with anything? A bag of phenylephrine, okay. Patient is ringing the call bell. I answer. They want a drink of water. I check the chart, because the patient’s nurse is on break; they’ve got diet as tolerated ordered. I bring them water. The patient in the corner room needs to be suctioned; I do it without a second thought.

My team. We know each other like a walk down a familiar hallway. Cynthia: small, dark-haired, bright-eyed. Used to work in the ER. Smart as anything, warm with a ready ‘thank you’ always on her lips, occasionally philosophical, but practical on a moment’s notice. Joanna: wears her hair in a bun, with elegant Polish beauty. Conscientious, careful, sometimes anxious and too eager to please, but generally 100% on top of her shit. Alyssa: tiny, blonde, bubbly. Ran a marathon last year. Calls her patients adorable, like I do; we bond over bathing unconscious, intubated patients together. Chantal: big blonde bun of hair, wears the amazing mascara that she sells to all of us. Big personality, sarcastic sense of humour, cracks me up every time. She’s great with confused patients; they’re like little babies, she says, they get squirmy when they’re uncomfortable, just turn them and they settle. Mia: tall, with a nose piercing that she carefully tucks in and hides at work. She worked in pediatrics for ten years, and she’s great, but underconfident, so used to being 100% in control that she finds the new ICU environment overwhelming.

On a civilized day, we laugh together. We help turn each other’s patients, and share jokes at the nursing station. We retell the antics of various patients, and fellow staff. Humour is a necessity, a survival skill.

On a busy day, we support each other. Hey, do you need help? We prepare bags of meds for each other. Bring forgotten supplies to isolation rooms. Program each other’s bloodwork. Hey, I can’t get an IV, can you try?

On a really busy day, it’s like we’re one mind, a superorganism with a dozen hands and feet and half a dozen voices. Afterwards, sometimes it’s hard to remember who did what; we only register the fact that it was done. Patient arrives. You’re admitting this patient? Stay out, take your report, we’ll put her in the bed. Place the patient on the monitor. BP’s low? Page the doctor? I’m on it. Hey, can you prepare me a phenyl drip? I’m on it. Need IVs. On it. Bloodwork. On it. Transcribe the admission orders. Prepare antibiotics. I’m on it. I’ll need meds for intubation. The doctor’s giving verbal orders. I’ll give meds, but someone needs to chart. All right, I will. Can you just grab me the stuff for a NG tube? Thanks. You can call for the chest X-ray now.

On one of the days that are so awful they make you cry afterwards– I’m standing in the hallway. Cyn, I need help. Cynthia’s busy–but you never ask for help unless you need it, she says. What do you need? Set up a dialysis circuit. Stat. Okay, help me connect it? Done. Thirty minutes later, and my patient’s lost her pulse. I haven’t eaten all day, I’m ready to rip my hair out, but the others are there. Charting. Placing meds into my hands. Taking turns on CPR. I need a central line tray. Okay, done. I’ll prime you a line for an epi drip. What do you need? I don’t know. I don’t even know. My room is a mess and I can’t think. Okay. Sit down. Do your charting. I’ll tidy up for you. Afterwards, when the new shift has arrived and we’re all half-collapsed in corners, trying to pick up the pieces in the right order and chart half-remembered things that happened thirteen hours earlier, vital signs scribbled on scraps of napkin and taped to the inside of a window… Hey, are you okay? Need to talk about it? Thanks. Later, maybe.

Sometimes we’re frustrated–another thing goes wrong, and we roll our eyes. Seriously? This is really happening? We’re tired, we haven’t eaten and we need to pee, but we deal with it, and afterwards it takes forever for us to finish charting and go home, because we keep stopping to rant, one-upping each other for most ridiculous story.

 Sometimes we’re scattered, and we drop some of the pieces, but they get picked up. Anyone remember what time we intubated her? Uh, I’m gonna guess 16:30. Did someone prepare the vancomycin? No. On it now. Why hasn’t Xray come yet? I’ll call them again, I guess. Hey, whose bloodwork is this on the counter? Oops, mine. I’ll send it. Your bag of insulin is empty. Oops, uh, do you have time to make me a new one while I’m stuck in this isolation room? I had vital signs written on a bit of paper, I put it down somewhere, has anyone seen it? Oh, here it is.

Sometimes the exhaustion, the caffeine, the resignation to being behind on everything, and the adrenaline rush balance each other perfectly, for a kind of crystal-clear alertness and bottomless willpower that I swear I will never experience anywhere else, ever. This patient is trying to die, guys, but we won’t let her. We’re all in the room, or just outside it. We look around at each other, and none of us are quite smiling, but we’re all feeling alive, the most alive that we’ll ever be.

I have a deep-running desire to be useful. And, in Anna Salamon‘s words, to be used like a human. My job at the hospital is the first place where that ever felt close to fulfilled–where I felt like I was working to my capacity, using my brain for everything it could do, often things I hadn’t really believed I could ever do. It took my drive to serve and help others, and hit that button over and over and over again. Starting out, I worked way too much overtime, because a part of me never wanted to leave the hospital.

Nursing probably isn’t the place where I can be the most useful, in terms of positive effects on the world. Maybe it’s the place where I can feel the most useful, where all my sidekick buttons are pressed all the time, where I can fit seamlessly like a brick in a solid and unbreakable wall. Or maybe it isn’t. I will find other ways to be even more useful, and hopefully even more fulfilled. I will move on.

But I hope I will take some of what I learned with me: the way a team feels, and the ingredients you need to make it happen. Roughly compatible personalities, hard-won trust in one another, and a worthwhile problem to solve. This is what it feels like, to serve others joyfully. Rationalists, complaining that your kind can’t cooperate– This is what is possible. I can’t take this team with me, but I can take what I learned, and maybe build up something like it around me, someday, somewhere.

I am Samwise

Mindspace is wide and deep. “People are different” is a truism, but even knowing this, it’s still easy to underestimate.

I spent much of my initial engagement with the rationality community feeling weird and different. I appreciated the principle and project of rationality as things that were deeply important to me; I was pretty pro-self improvement, and kept tsuyoku naritai as my motto for several years. But the rationality community, the people who shared this interest of mine, often seemed baffled by my values and desires. I wasn’t ambitious, and had a hard time wanting to be. I had a hard time wanting to be anything other than a nurse.

It wasn’t until this August that I convinced myself that this wasn’t a failure in my rationality, but rather a difference in my basic drives. It’s around then, in the aftermath of the 2014 CFAR alumni reunion, that I wrote the following post.

I don’t believe in life-changing insights (that happen to me), but I think I’ve had one–it’s been two weeks and I’m still thinking about it, thus it seems fairly safe to say I did.

At a CFAR Monday test session, Anna was talking about the idea of having an “aura of destiny”–it’s hard to fully convey what she meant and I’m not sure I get it fully, but something like seeing yourself as you’ll be in 25 years once you’ve saved the world and accomplished a ton of awesome things. She added that your aura of destiny had to be in line with your sense of personal aesthetic, to feel “you.”

I mentioned to Kenzi that I felt stuck on this because I was pretty sure that the combination of ambition and being the locus of control that “aura of destiny” conveyed to me was against my sense of personal aesthetic.

Kenzi said, approximately [I don’t remember her exact words]: “What if your aura of destiny didn’t have to be those things? What if you could be like…Samwise, from Lord of the Rings? You’re competent, but most importantly, you’re *loyal* to Frodo. You’re the reason that the hero succeeds.”

I guess this isn’t true for most people–Kenzi said she didn’t want to keep thinking of other characters who were like this because she would get so insulted if someone kept comparing her to people’s sidekicks–but it feels like now I know what I am.

So. I’m Samwise. If you earn my loyalty, by convincing me that what you’re working on is valuable and that you’re the person who should be doing it, I’ll stick by you whatever it takes, and I’ll *make sure* you succeed. I don’t have a Frodo right now. But I’m looking for one.

It then turned out that quite a lot of other people recognized this, so I shifted from “this is a weird thing about me” to “this is one basic personality type, out of many.” Notably, Brienne wrote the following comment:

Sidekick” doesn’t *quite* fit my aesthetic, but it’s extremely close, and I feel it in certain moods. Most of the time, I think of myself more as what TV tropes would call a “dragon”. Like the Witch-king of Angmar, if we’re sticking of LOTR. Or Bellatrix Black. Or Darth Vader. (It’s not my fault people aren’t willing to give the good guys dragons in literature.)

For me, finding someone who shared my values, who was smart and rational enough for me to trust him, and who was in a much better position to actually accomplish what I most cared about than I imagined myself ever being, was the best thing that could have happened to me.

She also gave me what’s maybe one of the best and most moving compliments I’ve ever received.

In Australia, something about the way you interacted with people suggested to me that you help people in a completely free way, joyfully, because it fulfills you to serve those you care about, and not because you want something from them… I was able to relax around you, and ask for your support when I needed it while I worked on my classes. It was really lovely… The other surprising thing was that you seemed to act that way with everyone. You weren’t “on” all the time, but when you were, everybody around you got the benefit. I’d never recognized in anyone I’d met a more diffuse service impulse, like the whole human race might be your master. So I suddenly felt like I understood nurses and other people in similar service roles for the first time.

Sarah Constantin, who according to a mutual friend is one of the most loyal people who exists, chimed in with some nuance to the Frodo/Samwise dynamic: “Sam isn’t blindly loyal to Frodo. He makes sure the mission succeeds even when Frodo is fucking it up. He stands up to Frodo. And that’s important too.”

Kate Donovan, who also seems to share this basic psychological makeup, added “I have a strong preference for making the lives of the lead heroes better, and very little interest in ever being one.”

Meanwhile, there were doubts from others who didn’t feel this way. The “we need heroes, the world needs heroes” narrative is especially strong in the rationalist community. And typical mind fallacy abounds. It seems easy to assume that if someone wants to be a support character, it’s because they’re insecure–that really, if they believed in themselves, they would aim for protagonist.

I don’t think this is true. As Kenzi pointed out: “The other thing I felt like was important about Samwise is that his self-efficacy around his particular mission wasn’t a detriment to his aura of destiny – he did have insecurities around his ability to do this thing – to stand by Frodo – but even if he’d somehow not had them, he still would have been Samwise – like that kind of self-efficacy would have made his essence *more* distilled, not less.”

Brienne added: “Becoming the hero would be a personal tragedy, even though it would be a triumph for the world if it happened because I surpassed him, or discovered he was fundamentally wrong.”

Why write this post?

Usually, “this is a true and interesting thing about humans” is enough of a reason for me to write something. But I’ve got a lot of other reasons, this time.

I suspect that the rationality community, with its “hero” focus, drives away many people who are like me in this sense. I’ve thought about walking away from it, for basically that reason. I could stay in Ottawa and be a nurse for forty years; it would fulfil all my most basic emotional needs, and no one would try to change me. Because oh boy, have people tried to do that. It’s really hard to be someone who just wants to please others, and to be told, basically, that you’re not good enough–and that you owe it to the world to turn yourself ambitious, strategic, Slytherin.

Firstly, this is mean regardless. Secondly, it’s not true.

Samwise was important. So was Frodo, of course. But Frodo needed Samwise. Heroes need sidekicks. They can function without them, but function a lot better with them. Maybe it’s true that there aren’t enough heroes trying to save the world. But there sure as hell aren’t enough sidekicks trying to help them. And there especially aren’t enough talented, competent, awesome sidekicks.

If you’re reading this post, and it resonates with you… Especially if you’re someone who has felt unappreciated and alienated for being different… I have something to tell you. You count. You. Fucking. Count. You’re needed, even if the heroes don’t realize it yet. (Seriously, heroes, you should be more strategic about looking for awesome sidekicks. AFAIK only Nick Bostrom is doing it.) CFAR has tasked me with finding ten of you.

I’d like, someday, to live in a culture that doesn’t shame this way of being. As Brienne points out, “Society likes *selfless* people, who help everybody equally, sure. It’s socially acceptable to be a nurse, for example. Complete loyalty and devotion to “the hero”, though, makes people think of brainwashing, and I’m not sure what else exactly but bad things.” (And not all subsets of society even accept nursing as a Valid Life Choice.) I’d like to live in a world where an aspiring Samwise can find role models; where he sees awesome, successful people and can say, “yes, I want to grow up to be that.”

Maybe I can’t have that world right away. But at least I know what I’m reaching for. I have a name for it. And I have a Frodo–Ruby and I are going to be working together from here on out. I have a reason not to walk away.

Fears about personal growth

There was a talk at the CFAR alumni reunion, back in August, about “Core Skills Growth.” I don’t actually remember all the content of the talk; the notes that I took were all about my squick reactions, the things that seemed wrong or bad or scary about rapid personal growth and change. (Note: I’m going to use the phrase ‘personal growth’, but I mean a specific kind of rationality-community-cluster personal growth, which probably isn’t the same thing as the mainstream meaning. If you’re not familiar with this usage, it might be confusing, but I’m too tired to try to attempt a full definition now.)

I think this might be one of those “mindspace is wide and deep” areas; a place where humans vary drastically, and my fears might seem completely alien to other people. But they’re real to me and I take them seriously. And pretty much every time I’ve had the thought “I’m probably weird and broken and no one else is like me”, it’s turned out that a bunch of other people were like me but hadn’t been writing about it.

These were the fears on my list:

  • 1) Becoming arrogant
  • 2) Becoming prone to existential angst
  • 3) Moving ahead of friends and then leaving them behind.
  • 4) Not being replaceable anymore.
  • 5) Not being able to hang out with supervillains


  1. Becoming Arrogant

I think I might hold this as a Bad Thing on a basic, virtue-ethics level. People have certainly made the argument to me that a measure of arrogance is a good thing. My response tends to be “okay, so it’s a good thing for you. I still don’t want to be arrogant!” This feels similar to the way in which, even though loyalty has its downsides, I still want to be loyal. One of the consequences of having a brain that runs on virtue ethics is that I have an idea of what character I want to have, and some things just conflict with that.

There might be an area of personal growth that would require me to be more okay with arrogance, or at least some aspects of it. (A fully unpacked definition of it would be useful, but I’m not actually 100% sure what rationality-community-cluster people mean.) I think if I could convince myself that ‘not being arrogant’ was an instrumental value that supported other values, like other humans being happy, but that actually ‘being more arrogant’ supported those values better, I’d be okay with it.


  1. Existential angst

I think I used to feel a little bit smugly superior for not suffering from this thing that so many people on LW apparently suffered from. I know people who are desperately afraid of death, and others who have conquered their fear of it. I don’t remember ever fearing death much in the first place. I’ve never gone through a religious deconversion, painful or otherwise. I’ve never agonized about the meaning of life. I’ve agonized about plenty of things, but they tend to be personal, even petty.

Growing up, I think acceptance/resignation was the easiest attitude for me to adopt. I am a thing made out of atoms in a horrifyingly neutral universe. The best I can do is survive. At least I can be good at it.

But a lot of personal growth relies on anti-acceptance–on staring reality in the face and saying “no, not okay.” And acceptance relies, at least partly, on thinking of yourself as small and unimportant.

I’m not sure how much a person’s tendency to existential angst is due to beliefs about the world (in which case it seems likely to change), or basic personality traits (less likely). But it does seem like having the tendency would make me less productive, and is thus worth worrying about.


  1. Moving ahead

A specific example comes to mind here. I have a friend who I’ve known since we were both twelve years old–the only non-family person I’ve been in contact with that long. In high school and early university, she was often the only person I felt able to be vulnerable with. I could tell her anything, even the humiliating things. I became the godmother of her son; we lived together for a year and a half. In a different version of my life, we could have been lifelong best friends.

The problem is that I have changed, in the past ten years, and she hasn’t–not enough. I don’t know how to connect to her anymore, and I don’t know how to not feel like a terrible human being for wanting to pull away.

I’m afraid of this happening to other people in my life–like my sister, my parents. I haven’t even done that much self-modification in the past ten years, and hardly any of it deliberate. I’m afraid that the five-years-from-now me might look back and find my parents’ values as alien as I find my friend’s now. (This seems unlikely. My parents are really freaking cool. But it still scares me.)


4) Not being replaceable

This one is kind of hard to explain. I think I find a lot of security in thinking of myself as a gamepiece interchangeable with others. I’m a nurse. I do valuable, important work…but if I get sick, if I get depressed, if I die, nothing bad happens to the world. There are other nurses.

(It’s hard to explain because other people seem to find this really alien. I know people aren’t fungible, and I know I’m not replaceable to my friends or my parents–but I kind of wish I was? It’s comforting to see my friends having other friends and know that the system is robust even if you take my part out.)

It might be possible to grow a lot and accomplish a lot without changing this, but it seems like thinking of oneself as important (and thus irreplaceable) helps for personal growth.


5) Not being able to hang out with supervillains

This is a catchphrase for a complicated idea/feeling that I’m not sure I can convey, but I’ll try. Basically…my current “self”, as a cluster of values, seems pretty robust, pretty stable. No one’s going to be able to convince me that I ought to be more selfish; I doubt even reading Ayn Rand in my teens would’ve done this. (Anna Salamon’s alternate-world-prediction is that it would have caused me to rebel and be less selfish.) No one, by force of argument, can touch the things that I really care about.

That means it’s safe to talk to anyone. I can hang out with neoreactionaries, or social justice people, or the weirdest parts of Less Wrong, or anything in between, and never worry that my values will get hijacked. I don’t get upset about arguments on the Internet because they don’t really touch me. This means that I can be purely curious about the world, and learn all sorts of interesting things and marvel at what a surreal age I live in.

The price of stability? Two years, and I’ve made only a little headway on convincing myself that ambition isn’t always a bad thing. Superficial values aren’t that hard; I was easily coaxed away from ‘saving all your money and never buying things is virtuous’ to ‘making the best use of your resources in all currencies including money, time, and attention is virtuous.’ To the part of my brain that manages virtues, those are the same thing, a value reacting to empirically different world-states.

If I’m going to try to change my values on purpose, it will require being vulnerable in a way I’ve never been before–and I’m not sure it would allow me to shield my core values in the same way. I would have to adopt a kind of epistemic hygiene, avoiding reading and interacting with ‘supervillains’, i.e. people whose values I don’t want to accidentally incorporate into my own.

I’m not sure why that’s so bad, except that it seems really really bad.


I don’t have a better solution to most of these, other than ‘plow ahead anyway.’ I might think of some solutions in the next few months or years. If I do, I’ll probably write about them.

Hufflepuff Tradeoffs

I’m really Hufflepuff. Enough for it to be blindingly obvious to most people I know.

And yet… Once in a while I get the very un-Hufflepuff thought that “wait, I could’ve been a physicist. That would’ve been easier.” (If I’d had programming on my radar at age 15, I might have thought of that too–it fulfills my other criteria of being a steady, dependable career better.)

I think anyone who knew me in high school would’ve pegged me as a Ravenclaw. I read books really fast. I was frequently bored in class. I remember reading ‘The Selfish Gene’ under my desk in biology class; it was technically biology, just more interesting. I’m still Ravenclaw enough to excitedly read Up-To-Date articles on my patients’ conditions, and sort of try to hang out around the nursing station when the staff doctor is quizzing medical students and then try really hard not to interrupt when I know the answer.

In high school, it’s not like math was easy. But it was straightforwardly hard. People were hard hard.

People are still hard.

I’m not amazingly good at nursing. It might (gasp) take me more than five years to get really good at it. Right now I’m okay. My patients often remember and like me–that feels good. I get excited about things, which helps me to eventually get good at them. I’m still pretty rubbish at putting in IVs. I’ve almost entirely gotten over the anxiety involved in making and answering phone calls at work. On a good day, I’m probably a pretty good person to work with–on a bad day, I want to hide in a corner and not talk to humans and I really just want to have intubated patients because my social-anxiety-module has decided they don’t count as humans…but I can generally still provide my patients with safe and competent care.

There are parts that aren’t natural to me and probably never will be. Time management was hard. My younger self lived in Maker time, and learning to deal with interruptions and time pressures and more interruptions and nothing going as planned ever was really hard. (And I think I’ve permanently lost some of my Maker-time ability–writing, at least the sitting-down-and-focusing part, is a lot harder than it used to be. I could also attribute that to the existence of Facebook.)

Even the attention to detail required is hard for me. One of the things other nurses still complain about concerning me is that my patients’ rooms aren’t tidy enough at the end of a shift. They are obviously perfectly fine for me, and other people’s mess has never bothered me. By default, I don’t see it. I’ve had to slowly, painstakingly learn how to see it, and obviously I’m still not succeeding completely, since I’m actually at a loss as to what exactly I should do to make the other nurses happy.

When I was 15, my parents had a friend, a mycologist at a university. He was your stereotypical absentminded professor–brilliant, messy, eccentric, happy as a pig in mud all alone in his lab. My mom said I’d make the perfect academic, like him.

Needless to say, that isn’t the person I grew up to be.

When I started to become more involved with the CFAR community, one of the first characteristics people attached to me was good at logistics. If I’d gone back in time and told my 12-year-old self that was going to happen, she would’ve have believed me. Not because it sounded bad, but because it was so implausible. Me, good at a thing that requires attention to detail, organization, and having to talk to lots of people on the phone?

Being a programmer might have been easier. I could have sat in my little bubble and banged my brain against problems that were straightforwardly hard. I might even have been an above-average programmer, in a way that I’m not an above-average nurse. Danny Reeves said I seemed to pick things up quickly. I’ve probably got an IQ a couple of standard deviations above the average, and that’s more helpful for programming than for nursing, where as far as I can tell it’s not helpful at all.

Every once in a while, the part of my brain that doesn’t like hard things will stage a minor internal hissy fit over how now I’m stuck being the person who’s good at logistics and has to answer phones forever, and that’s not fair why can’t I just be a programmer and always get to sit in a corner?

But there’s a reason why that isn’t the life I picked. There’s a reason why, when I was reading Tilda Shalof’s A Nurse’s Story, it resonated so hard as the life I wanted to have. (Note: if you find it hard to understand why I became a nurse, you should read this book.)

I didn’t start out with Hufflepuff skills–I wasn’t initially any good at being the person I wanted to be in. I’m still not especially good at it. I guess I didn’t start out with many skills period–no one does. At age fifteen I was above average at writing (which is no great praise when you’re comparing yourself to other 15-year-olds) and I had a good memory for stuff I’d read in books.

But I still knew what person I wanted to be.

So I guess I’m “stuck” doing the thing that’s hard for me, forever, and gets frustrated when other people pick it up faster, and when I have to keep doing the thing day in and day out and it’s still hard, every time, it never stops being hard. Being around people when you’re introverted–more than that, learning how to model social dynamics and play status games when it makes about as much sense to you as monkey being insane all the time. Having to keep your Attention to Detail turned on when your native state is wrapped up in the plot of a novel that you’re writing in your head. Lapsing back into that state the moment I get home, and thus living in even more of a pigsty than I would otherwise. (I haven’t done dishes in a week.)

But even so, I chose this and I’m still choosing it, every day, and I’m pretty damn proud of the progress I’ve made. You’ve got to be pretty Hufflepuff, to do that.

Consent in a society of mind

I hold consent as something pretty close to a Fundamental Good Thing. I absorbed it first from nursing culture, along with a few other deontological, maybe-incoherent principles like ‘Autonomy’ and ‘Dignity.’ (I’m not sure how to define dignity, except that my brain screams at me when it sees an example of it being violated). Then I absorbed consent as a Fundamental Good Thing from the social justice community, too.

And it is a good thing. There’s no doubt about that. So many of the ways in which humans hurt one another are because consent isn’t taken seriously, and taking it seriously does make a difference. This is one of the things that it’s great to have a word for.

It’s also kind of complicated.

A few months ago, I had my first PAP smear. I’m sure these aren’t fun for anyone, but as someone with pretty severe vaginismus, I’d been putting it off, and dreading it, for years. As a nurse, though, I can appreciate the importance of public health screening measures. No one likes prostate exams, either, but they’re Recommended.

I called my doctor’s office, booked the appointment, and went in of my own free will–I gave my consent for the procedure, explicitly and implicitly. I told my family doctor, who I like and trust, to keep going even if I was screaming, which I probably would be, because I really wanted to just get it over with.

It still felt really fucking awful, and I was actually mad at her, afterwards. I’d been screaming in pain and she hadn’t stopped. The part of me that was mad didn’t care that I’d asked her not to.

“Personhood” and unitary selves

At first glance, my PAP-smear reaction doesn’t make any sense. The explaining factor is that I don’t speak for all of myself. Having a unitary ‘self’ at all is an abstraction, a simplification over the various drives and desires and inconsistent preferences that make up a human being.

As Melting Asphalt writes:

A person (as such) is a social fiction: an abstraction specifying the contract for an idealized interaction partner. Most of our institutions, even whole civilizations, are built to this interface — but fundamentally we are human beings, i.e., mere creatures. …Even the most ironclad person among us will find herself the occasional subject of an outburst or breakdown that reveals what a leaky abstraction her personhood really is.

I have mixed feelings about this article, but I think it says something important. Society–including laws and norms about consent–runs on the assumption that humans have unitary selves, singular agency. A lot of the time, that model works. And the medical field’s laws and norms about consent also have a way to handle humans who don’t and can’t hold up their end of the “personhood contract” and aren’t able to offer their informed consent; young children, psychotic patients, comatose patients, suicidal patients. Thus: power of attorney, substitute decision makers, “Form One” and forced hospitalization, “assumed consent” to treatment for anyone found unconscious. And there are new norms in the making for general society, like the norm that intoxicated people can’t consent to sex.

Ultimately, though, those are exceptions, special cases. Medicine, and society as a whole, assume that there exists a baseline population who can give their informed consent, who can speak for themselves as unitary agents.

But no one is a unitary agent. We are all societies of mind–more or less coherent, more or less unified.

I don’t want to die of cervical cancer that was diagnosed too late. I’m pretty clear on that, and I’m also pretty sure that five minutes of pain once every several years is worth it. I can do the math–or, at least, the ‘I’ that speaks for me understands math. But I can’t bring all the parts of myself on board with this. The part of me that doesn’t want anything or anyone anywhere near my vagina is…well, not convinced by math, probably not capable of math, and also doesn’t give a shit about reasonable explanations.

Grey areas in consent

I take care of a lot of patients whose “personhood” is somewhat broken down. There’s a continuum here. On the bottom end, I’ve got my intubated, sedated, critically ill patients, who basically can’t communicate any preferences at all, aside from squirming or making faces or trying to pull tubes out. Taking care of them is a bit like having an infant. I don’t feel bad about tying their hands down. I don’t ask them if/when they want to be turned or cleaned or suctioned. I do my best to explain what’s going on.

Midway up the scale, I’ve got patients who are awake and able to talk to me, but might be forgetful or confused or delirious. I hate tying awake patients’ hands, because BASIC HUMAN DIGNITY!!!, but if they’ve pulled out their feeding tube more than twice, or if they really need their oxygen but keep taking it off, I am going to do it. I try to listen to their preferences in other ways, and give them choices, like ‘which side do you want to turn on?’, but ultimately it’s kind of a token effort–I do it to try to comfort them, to make the loss of autonomy slightly less bad.

There’s a converse to this. I don’t hold my patients to the same standard that I would a coworker. If they’ve pulled their feeding tube out for the third time, I do my very, very best not to show any frustration or annoyance. In some sense, ‘it’s not their fault.’ When delirious patients yell swearwords at me, I politely tell them to please stop, but I’m not upset.

After my PAP-smear experience, I went back to work and felt like I was seeing things for the first time. In my doctor’s office, on the exam table, my illusion of singular agency broke down. I left feeling violated and traumatized, even though it was five minutes of discomfort that I’d undertaken voluntarily for a benefit that I thought was worth it.

Most of my patients consented to treatment at some point, unless they came into the ER unconscious with no previous directives. We’re pretty good about, for example, respecting patients’ decisions not to be intubated, not to receive CPR, not to receive dialysis or blood transfusions etc etc etc.

But even for the patients who, at the beginning, consented to “take all reasonable measures to keep me alive”…at some point, a couple of days down the road, they’re loopy on drugs and have a tube down their throat and their hands tied to the bedrails – and when this happens, the part of them that can do math is probably on vacation and the rest of them is screaming.

Ozy writes:

Our culture is really really bad about dealing with sex that you gave permission for but that is still experienced as violating or even traumatizing. Sex where you dissociate to get through it; sex that makes you feel like an object, an orifice being used, rather than a participant; sex where you feel gross and cry afterward and scrub yourself because you don’t want to have had it.

Sex might not be a special case. I kind of feel like our society is bad at dealing with all experiences that were consented to but still traumatizing–that were consented to, but not with all the parts of the mind. Maybe because a society is, basically, a charade where humans put on their “person”-faces and do their best to present as singular agents.

And then what?

If there’s a solution to this, it’s probably a complicated and many-faceted one.

Anecdote: I had a patient recently who refused to be turned. She had an infected bedsore, and it was important that we turn her, but she was afraid of falling out of bed. I think she knew it wasn’t a rational fear; she was a bit self-deprecating about it. But she flat-out refused. She was all there, “alert and oriented” in medical-speak, and so I wasn’t going to do it against her will.

But I did ask her if she thought that, if I asked the doctor to order more medications to control her anxiety, and they were effective, whether maybe then she would agree to turn. She said “maybe, I think so.”

(I ended up turning her at 4 am after I’d given her Gravol for nausea, which made her very drowsy. I felt a little bit bad about that–it was sneaky–but she wasn’t panicking while I did it, at least.)

I had strongly considered asking my family doctor if she could do my PAP smear under conscious sedation. I ended up not asking because it would be inconvenient–I wouldn’t be able to bike home unaccompanied afterwards. But it would have appeased the part of me that was upset about it.

Sometimes, changing societal norms will make there be fewer conflicts. Ozy writes about the societal norm of ‘compulsory sexuality'; changing this, making it more acceptable and normal and okay not to want sex, might take off some of the pressure to consent to it. There are societal norms that would make my job easier, too–I’ve had my fair share of patients who wanted to be tough and thus wouldn’t ever say when they were in pain, or who were ashamed of all their bodily functions.

Sometimes, the only option is to very carefully try to listen to and address all of the parts, whether you’re doing it for yourself or for another person.



You can’t save them all

[Content note: it’s 2:00 am and I’m on a plane and I have had a total of three hours of sleep in the last 36 hours and outside view says I am probably not coherent.]

I went out for breakfast with a colleague after my last night shift (one of the silly decisions that led to the three hours of sleep). It had been an awful night for her–struggling just to keep her patient alive till the morning, the new and inexperienced resident scared shitless, basically every nurse on the unit hanging around the room staring at the monitor. Once you’ve been an ICU nurse long enough, there’s something fascinating about a blood pressure of 60/40 and sats of 81%, and it becomes hard to stop watching it.


The patient died at 7:45 am, and she finished the obligatory charting, and we went out and ate a huge greasy diner breakfast and drank endless decaf coffee, and we told all the most horrific stories of our respective work experiences, and we laughed. We weren’t as loud and disruptive as a group of five nurses post night shift will inevitably be, but we laughed, and then we noticed we were laughing about horrible things, and felt bad. But it’s a coping mechanism, an absolutely necessary one, and probably a healthier one than alcohol or even diner breakfasts.


It got me thinking about coping mechanisms in general, and how I try to take the things I see at work and somehow, some way integrate them into my past, somehow accept them and gain strength from them without having to pull away.


And yeah, the things I’ve seen at work have sometimes been awful, and probably more awful for someone with my personality. Ruby says that I don’t have a dark side–I’m not 100% sure what this means, but I don’t seem to have that harder facet of myself that I can rotate into place to survive the things that would otherwise hurt too much. I don’t do indifference, but I also don’t do anger or outrage or hatred, which seem to be the emotions that, although negative, can bring strength. When something bad happens, I feel sad, I feel helpless, I feel guilty…and the feelings demand expression, catharsis, whatever you might call it. I want to feel sad for the person who just died, who was someone’s mother, someone’s sister, someone’s friend. I want to grieve, even if she wasn’t my family, even if I knew next to nothing aside from her name and age.


Since university, I’ve accumulated an extensive list of songs, movie clips, and bits of books and blog posts that can make me cry. Often these are songs that I liked but didn’t find all that sad back in high school.


Wish I could reassure you/Wish I could talk to you and tell you how I feel

I’ve been very careless/ This I don’t deny

But could we start again please
You surely know I love you/ But something in me stands aside and lets you slip away

Perhaps that’s what you wanted/ Perhaps I want that too
But could we start again please


Oh. My. God. Could there possibly exist a sadder song? Something in me stands aside, and lets you slip away… We stood outside the patient’s room at 7:45 am, exhausted after 12 hours, and watched her heart rate drop into the 50s, then the 30s, then just an occasional ventricular beat here or there. Watched the blood pressure go down to 30/10, which at that point is not really a blood pressure anymore, before we lost it entirely. She was DNR and was already maxed on every vasopressor and we were running epinephrine at 20 mcg/min, which was 5x the highest dose on our perfusion table, and we knew there was no winning this one–we had known it for days, really. You can’t save them all.


I don’t remember all of my patients, by any stretch of the imagination. The COPD exacerbations and pneumonias and urosepsis cases all kind of blur together after a while. But I remember the patients we lost.


I had a lady once for five 12-hour shifts. It was a week of ridiculous assignments: I had two intubated patients every day except the last. She had chronic lung disease, was back in the ICU for the second time that year, on a ventilator, sedated. She was on home oxygen at her residence and probably wasn’t that functional, but she had a friend in the residence who came to see her every day in the hospital, and sat by her bedside to talk to her, and asked me if I knew when she’d be coming back so he could get the room ready. It was one of the sweetest things I had ever seen.


She was my ‘boring’ patient that week. I turned her every two hours, sometimes every three or four hours because we were short staffed. I strained my back trying to turn her alone, when I was already late and didn’t feel like trying to track down someone else to help. I put dressings on her inevitable bedsores. I wiped her poop, and splooged crushed-up dissolved medications down her feeding tube, and cleaned her mouth despite her best attempts to bite me, and did the sort of really, really quick assessments that you get good at after a while. I tread the fine balance between ‘way too sedated’ and ‘wide awake and obviously terrified’, and tried to make sure she wasn’t in pain.


Maybe three weeks later, after several more four-day blocks of shifts, I had two other patients and was run off my feet and stopped midafternoon at the nursing station to print an ECG strip, and I saw that her heart rate was 30. I glanced over and saw the nurse and RT in the room, and knew immediately that she was palliative, that they were going to take her off the ventilator and switch her to comfort care only.


I didn’t have time to watch; she wasn’t my patient. But I did anyway, stood outside the room where she was alone, and watched her heart stop, and I wanted to say, I’m sorry. I’m sorry I called you my boring patient. I’m sorry I didn’t love you more, Fellow human, I want you to know that I know this is wrong, even though it’s the least wrong option. That for the last ten years you were slowly losing your strength, more and more constrained to your long term care room, tethered to your oxygen, and that the last three weeks of your life were spent helpless in a bed, surrounded by machines that beeped constantly, and that now there’s nothing more we can offer you except for a death without pain… None of that is right. We gave you our best, every step of the way, but that doesn’t make it right. I’m sorry that humans still have to get old and die. I’m sorry that I didn’t have the courage to go into the room with you and hold your hand, because you weren’t my patient and it would’ve looked weird and I didn’t have time.


…I wrote that, and cried the whole time, which is vaguely embarrassing because I’m on a plane surrounded by strangers. It feels right, though, to cry for a thing that really is sad and wrong and terrible. And the grief I felt, for a woman who wasn’t my mother or sister or friend, wasn’t just about her. It was about the dozens of other deaths I’ve witnessed. It was about all the times I’ve imagined death in all its worst forms coming to my friends and family–and by imagine, I mean really imagine, my brain knows what death looks like and thinks that providing vivid images is helpful. I cry like a baby every time I read Scott’s post Who By Very Slow Decay and it’s mostly because I’m imagining Scott as one of my patients, dying and trying desperately to communicate that he wants to go outside.


And yeah, that probably seems really weird to anyone who isn’t in the medical profession. It seems to be one coping strategy among others, similar to the ‘listen to sad songs’ strategy–lean into the sadness, experience it like it deserves to be experienced, and then move forward. Until the next one.


(A lot of people have asked me if I’m scared of death. Interestingly, I’m not, at least not for myself. It takes away a lot from the emotional appeal of cryonics…I tell myself “you could die!” and my brain is like “yeah, duh, I know that, hell, I’ve imagined about fifty different deaths I could have and the ripple effect it would have on my family and community, it’s not a nice thought and I don’t want to die but it’s not scary.”)

The Virtue of Abnegation and the Ideal Nurse

“I will be my undoing If I become my obsession.
I will forget the ones I love If I do not serve them.
I will war with others If I refuse to see them.
Therefore I choose to turn away from my reflection,
To rely not on myself
But on my brothers and sisters,
To project always outward
Until I disappear.”

-Abnegation Manifesto

I only saw Divergent recently, and I didn’t even notice this quote at first–the movie is so focused on Dauntless, they’re not trying to make you notice Abnegation. But when I actually read the quote, it resonated with me maybe more than anything else has ever.

My brain runs on virtue ethics. Given this, it’s not surprising that, in my training as a nurse, I tried to figure out what the Ideal Nurse’s virtues were and then emulate them as closely as possible.

As a nurse, you don’t interact with patients as a fellow human being. Yes, you show them compassion and empathy, but you do so as part of a role. And the roles are not equal. The patient is allowed to scream at you, they’re allowed to shit in the bed, they’re allowed to refuse to eat anything all day and then ask for pudding at 4 am. As a nurse, you learn to focus on the needs of others, and keep your own needs outside of the situation.

…I think it hit me, after I read the Abnegation manifesto, how much of my younger self’s conception of virtue was “the Ideal Nurse doesn’t have needs, therefore neither will I.”

I did a lot of not-very-strategic self-modification as a teenager. Making myself useful was one of the common threads (ability to react under pressure, etc) and being as flexible and non-needy as possible was a lot of the rest. I had a mantra, “be like water”, which I think meant something like “absorb any inconveniences yourself.”

This is all well and good–I still think that Abnegation, in moderation, is a good thing to be able to have. I would even like to be better at it than I am now. The problem was when I started building it into my self-identity, started to model myself as someone who didn’t have needs. Because then, when part of me did need something, I couldn’t endorse it–obviously, those voices weren’t really me.

I think this is maybe 80% why I had regular sex for six months, even though I knew I didn’t want it–because I couldn’t let it be about what I wanted, that would be admitting I wanted things.

To a lesser extent, I think this has caused problems with my introspection/luminosity. Even if I thought Abnegation was the be-all and end-all of virtues, it isn’t an accurate model of my mind. I do have needs and wants. I can override some of them some of the time, but I can’t override all of them indefinitely…and if I had to, pretending they didn’t exist probably wouldn’t be the best way.

Fundamentally, the movie portrayal of Abnegation comes across as sort of incompatible with Dauntless (my friend was startled when I claimed to identify with both), and at the very least anti-self improvement. To improve yourself, you need to turn inwards, to look in the mirror; you need to care about your reflection, and want it to be better.

And to really help other people, you need self-improvement; you need to be the strongest possible version of yourself, and that means knowing your needs and desires and meeting all of them in the cheapest ways that hurt others the least.

The Ideal Nurse is a mode, a role. The person playing that role has needs, desires, etc; she just isn’t trying to meet them in her interactions with patients, because she already met them on her own time–and that’s not selfish.

Belated National Coming Out Day post: Why having words for things matters

Almost exactly a year ago, I came out as asexual on Facebook.

I’m asexual, or possibly some degree of greysexual/demisexual; so far it’s hard to tell. Because I do experience romantic desires, I didn’t know this until fairly recently.

I have it easy because at least I appear heterosexual. And it does look to me like sexual desire is a massive distraction and productivity-drain in other people’s lives, so if someone offered me the chance to add that neural wiring, I’m not sure I’d take it.

The hard part comes with being in a relationship, or wanting to be in one, and having the realization that most other people out there have a totally different conception of what a “relationship” means. The hard part is living with the cultural expectation that, as someone’s girlfriend, you owe them physical and sexual intimacy. The assumption that not wanting sex means that you don’t actually love or desire someone; worse, the idea that you can’t just get into bed with a significant other three times a week, as the tradeoff for getting all the awesome parts of the relationship like hours-long conversations, cooking together, and having kids someday. If you’re not “into it”, it doesn’t count.

So if you’re a guy and you’ve been the recipient of my confusing romantic signals in the past, I apologize. I probably did like you. I could have fallen in love with you, even. But that’s a pretty scary leap when you become an emotional wreck a week into dating anyone and have no idea why.

If you’re one of the people who’s been incredibly kind and understanding about this, and helped me try to sort through my feelings in a way that felt safe, you know who you are, and thank you.


I don’t think it took long after this before it became general knowledge to most of my friends in the CFAR/LW community. I don’t remember exactly what was on my mind when I made that post, but I do remember that I didn’t think anyone would care much, and I doubted it would change anything.

A year later, it feels like it’s changed everything.


On “baggage”

Miranda!2013 had what my mother would call ‘baggage’ around relationships: a mixture of strong aversions, mistaken intuitions, conflicted feelings, et cetera. It wasn’t like I hadn’t noticed this, either. I knew pretty well that it made no sense how rapidly I could flip from having a crush on someone and being excited about seeing them, to wanting to avoid speaking to them forever. I had been working on it.

In fact, I’d been working on it quite deliberately since 2011, when I made a New Years Eve resolution to have a serious relationship. Yes, really. There were moments that were wonderful. I remember standing in my boyfriend’s kitchen, him behind me with his arms around my waist, rocking from side to side as we cuddled…and how I could remember my mother and father standing in that position, and it felt so adult and right.

But then there was the kissing, the making out, the clothes coming off, and the sleepovers where I lay awake all night…and worst of all, the suffocating feeling of knowing that I was loved by someone who I didn’t and couldn’t love back, not in the way he wanted. I remember being afraid of how much he wanted me, afraid that he would rape me. I thought that quiet voice in my head was being stupid, because obviously my boyfriend wasn’t going to pin me down against my will. He loved me; he was gentle and caring and kind.

But we had sex anyway, six months later. I spent a year and four months throwing all of my ingenuity into making that relationship work, into not letting my ‘baggage’ hold me back.

And every time we had sex, it felt a little bit like rape, even though I was technically consenting, even initiating. The little voice screamed that it was wrong, wrong, wrong, and I pushed that voice down until I barely noticed it–until I could look at our relationship and see a victory, a triumph of self-modification.

In the process, I created an enormous stack of baggage, which made it really fucking difficult to have any kind of relationship at all for the next several years.

Miranda!2011 had the usual inhibitions and insecurities of someone who had grown up nerdy and somewhat of a loner, and a misbehaving vagina, but that was about it. Miranda!2013 had a desperate roller coaster relationship with intimacy of any kind. I wanted to be needed, but I was terrified of being wanted. Sometimes it was too scary even thinking about future relationships, and I would resolve to be celibate forever and go to a sperm bank when I hit 25. Even as I started groping towards the think I thought I might want, I only felt safe in long-distance relationships, or seeing poly people who already had primaries, or preferably long distance relationships with poly people who already had primaries. The amount of travelling I was doing in 2013 made this more feasible.

In May 2013, I turned down sex with someone I really, really liked, who liked me back. It was a tentative step in a direction I didn’t even have a name for yet. At this point I’d managed to convince myself that I didn’t like commitment. Commitment, the thing I’d found most beautiful about my parents’ marriage, but poisoned by association.

In the fall of 2013 I started seeing Alex and Ania, a poly couple. It was one of the most healing experiences I could have had, and I will never be able to thank them enough for respecting my boundaries even when I was completely confused about what that meant. At that point, even getting frequent texts from someone I was dating was scary; it implied interest, which implied desire, which would surely lead to one part of me guilt tripping the rest of me into having sex. Instead of arguing with that, Alex and Ania respected it perfectly. I saw them when I wanted to, and no more.

I still spent the rest of that winter convinced that what I really, truly desired in a relationship was to see my partner no more than once a week, and not be expected to even feel like cuddling, and to be free not to talk to them all week if I liked, even then I would have days, or weeks, when I didn’t want to even think about it.

I met Ruby (in person) in February 2014, and things are completely different and a lot better than 2013!Miranda could have imagined–if anything, I am in exactly the relationship I have always wanted–but it took a lot of difficult communication, of digging through baggage and figuring out what the hell it meant.


The Moral

It didn’t happen all at once, but the thing that made me feel safe loving someone, and being loved in return, and letting myself want what I really actually wanted and not just what was least scary, was coming out as asexual–more specifically, the community response to my coming out as asexual. People paid attention, and remembered it about me, and brought it up in conversation, and were curious about it, in a way that was incredibly validating. It turned out there were online forums full of people talking about being asexual. Sometime in early 2014, there was a gradual but massive shift where I stopped thinking of myself as a weird broken monkey with missing neural circuitry, and started being okay with asexuality as part of my identity, and then even started being happy about it.

There’s another half to that–one of the foundations of my current relationship is that Ruby knew, before he even met me in person, that I was asexual and what that meant. Starting a new relationship is always going to be confusing and hard, but having a public label took a lot of the ambiguity out–and so far, my being asexual has been a complete non-issue, not even interesting. Ruby is a pretty wonderful person, but it would have been a lot harder for him to find that out a few months in.

I really wish 2011!Miranda could have had that, before she managed to convince herself that she hated commitment and really only wanted casual long distance relationships with people who already had primaries–even though those are nice.

And 2011!Miranda almost had that. I attended my high school’s Gay Straight Alliance, and knew what it looked like to be gay or lesbian or trans. If my college dating experience had consisted of unsatisfactory dates and make-outs with boys, and confusing but thrilling feelings about the girls on swim team with me, or if I’d noticed that I felt wrong in my body and being referred to as ‘she’ made me feel sick, I would have recognized that. (Which wouldn’t make things easy, necessarily–having a word and a name for what you’re feeling doesn’t protect you from discrimination by family, friends, and society.)

But I had no model for “I really like this guy and want to live with him and cook for him and talk about economics until four am and maybe have babies someday, but ohgod if he touches me one more time I am going to run away to the corner and cry.” My mother was supportive and understanding, and her way of being supportive was to buy me chocolate once I managed to have sex.

I’m hopeful, and I’ve got a lot of resources to work on it, but I’m not sure if I’ll ever shed the baggage I amassed in two years of trying really hard to make ‘normal’ relationships work.

That’s why having words for things matters.



Where Heroic Responsibility Fails

“You could call it heroic responsibility, maybe,” Harry Potter said. “Not like the usual sort. It means that whatever happens, no matter what, it’s always your fault. Even if you tell Professor McGonagall, she’s not responsible for what happens, you are. Following the school rules isn’t an excuse, someone else being in charge isn’t an excuse, even trying your best isn’t an excuse. There just aren’t any excuses, you’ve got to get the job done no matter what.” Harry’s face tightened. “That’s why I say you’re not thinking responsibly, Hermione. Thinking that your job is done when you tell Professor McGonagall—that isn’t heroine thinking. Like Hannah being beat up is okay then, because it isn’t your fault anymore. Being a heroine means your job isn’t finished until you’ve done whatever it takes to protect the other girls, permanently.” In Harry’s voice was a touch of the steel he had acquired since the day Fawkes had been on his shoulder. “You can’t think as if just following the rules means you’ve done your duty.”

-Harry Potter and the Methods of Rationality, Chapter 75

I like this concept. I think it counters a particular, common failure mode, and that it’s an amazingly useful thing for a lot of people to hear. I even think it was a useful thing for me to hear a year ago.

But… I’m not sure about this yet, and my thoughts about it are probably confused, but I think that there’s an opposite failure mode, and that maybe it’s not that easy to avoid.


Something Impossible

I dealt with a situation at work a while back–May 2014 according to my journal. I had a patient for five consecutive days, and each day his condition was a little bit worse. Every day, I registered with the staff doctor my feeling that the current treatment was Not Working, and that maybe we ought to try something else. There were lots of complicated medical reasons why his decisions were constrained, and why ‘let’s wait and see’ was maybe the best decision, statistically speaking–that in a majority of possible worlds, waiting it out would lead to better outcomes than one of the potential more aggressive treatments, which came with side effects. And he wasn’t actually ignoring me; he would listen patiently to all my concerns. Nevertheless, he wasn’t the one watching the guy writhe around in bed, uncomfortable and delirious, for eight or twelve hours every day, and I felt ignored, and I was pretty frustrated.

On day three or four, I was listening to Raemon’s Solstice album on my break, and the song ‘Something Impossible’ came up.

Bold attempts aren’t enough, roads can’t be paved with intentions…

You probably don’t even got what it takes,

But you better try anyway, for everyone’s sake

And you won’t find the answer until you escape from the

Labyrinth of your conventions.

It’s time to just shut up, and do the impossible.

Can’t walk away…

Gotta break off those shackles, and shake off those chains

Gotta make something impossible happen today…

It hit me like a load of bricks–this whole thing was stupid and rationalists should win. So I spent my entire break talking on Gchat with one of my CFAR friends, trying to see if he could help me come up with a suggestion that the doctor would agree was good. This wasn’t something either of us were trained in, and the one creative solution I came up with was worse than the status quo for several obvious reasons.

I went home on day four feeling totally drained and having asked to please have a different patient in the morning. I came in to find that the patient had nearly died in the middle of the night. (He was now intubated and sedated, which wasn’t great for him but made my life a hell of a lot easier.) We eventually transferred him to another hospital, and I spent a while feeling like I’d personally failed.

I’m not sure whether or not this was a no-win scenario even in theory. I do think that I was a perfectly good nurse, who fulfilled my responsibilities to my patient. Nurses have a lot of responsibilities to their patients, well specified in my years of schooling and in various documents published by the College of Nurses of Ontario. Nurses also have responsibility to the abstract higher authority of “the nursing profession”; we are expected to hold ourselves accountable for our mistakes, to improve continuously, to propagate certain virtues. But nurses aren’t expected or supposed to take heroic responsibility for these things, and it doesn’t make things better when they do.

And, when I consider it, I don’t actually think that’s a problem. In fact, it seems like a better situation than the converse.


The Well-Functioning Gear

I feel like maybe the hospital is an emergent system that has the property of patient-healing, but I’d be surprised if any one part of it does.

Suppose I see an unusual result on my patient. I don’t know what it means, so I mention it to a specialist. The specialist, who doesn’t know anything about the patient beyond what I’ve told him, says to order a technetium scan. He has no idea what a technetium scan is or how it is performed, except that it’s the proper thing to do in this situation. A nurse is called to bring the patient to the scanner, but has no idea why. The scanning technician, who has only a vague idea why the scan is being done, does the scan and spits out a number, which ends up with me. I bring it to the specialist, who gives me a diagnosis and tells me to ask another specialist what the right medicine for that is. I ask the other specialist – who has only the sketchiest idea of the events leading up to the diagnosis – about the correct medicine, and she gives me a name and tells me to ask the pharmacist how to dose it. The pharmacist – who has only the vague outline of an idea who the patient is, what test he got, or what the diagnosis is – doses the medication. Then a nurse, who has no idea about any of this, gives the medication to the patient. Somehow, the system works and the patient improves.

Part of being an intern is adjusting to all of this, losing some of your delusions of heroism, getting used to the fact that you’re not going to be Dr. House, that you are at best going to be a very well-functioning gear in a vast machine that does often tedious but always valuable work.

Scott Alexander, Slate Star Codex

The medical system doesn’t run on exceptional people–it runs on average people, with predictably average levels of skill, slots in working memory, ability to notice things, etc. And it doesn’t run under optimal conditions; it runs under average conditions. Which means tired staff working at four in the morning.

Sure, there are problems with the machine. The machine is inefficient. The machine doesn’t have all the correct incentives lined up. The machine does need fixing–but I would argue that from within the machine, as one of its parts, taking heroic responsibility for your own sphere of control isn’t the way to go about fixing the system.

Taking heroic responsibility for your patient would mean…well, optimizing for them. In the most extreme case, it might mean killing the itinerant stranger to obtain a compatible kidney. In the less extreme case, you spend all your time giving your patient great care, instead of helping the nurse in the room over, whose patient is much sicker. And then sometimes your patient will die, and there will be literally nothing you can do about it, their death was causally set in stone twenty-four hours before they came to the hospital.



Someone’s going to be the Minister of Health for Canada, and they’re likely to be in a position where taking heroic responsibility for the Canadian health care system makes things better. They’ll be able to look at the machine, and say “this part isn’t working well” or “this process is inefficient,” and bring in experts, and do whatever it takes to win. And probably the current Minister of Health isn’t being strategic, isn’t taking the level of responsibility that they could, and the concept of heroic responsibility would be the best thing for them to encounter.

I think that many people in the rationalist community imagine themselves in a similar position the the Minister of Health. And some of them are. And maybe a lot more of them ought to be. It might, in fact, be a morally right action for me to leave nursing and choose something higher-impact, somewhere where my heroic responsibility will matter.

But not everyone is going to be the Minister of Health, and I kind of predict that the results of installing heroic responsibility as a virtue, among average humans under average conditions, would be a) everyone stepping on everyone else’s toes, and b) 99% of them quitting a year later.

And I suspect that many people who read Less Wrong and HPMOR are working as parts in a huge machine that does “tedious but always valuable” work, and maybe, like I did, feeling terrible that they couldn’t “win”, and that seems wrong.

Trickle-down effects of asexuality, or why I’m a bitch sometimes

More specifically, I’m talking about “effects from having been asexual and trying to have relationships before I knew asexuality was a thing.” If I’d read a book at age 15 with an asexual main character and immediately recognized myself, or something, I suspect I would interact with relationships very differently in the present.

Relationships are awfully Guess Culture. And this means that there are things that are communicated without being said–or even communicated when you’re saying the opposite out loud.

I think that up until age nineteen, my emotional development was pretty close to median, for an introverted, nerdy girl who didn’t think of herself as attractive. I had unrequited crushes, which is a close-to-universal human experience. I watched romantic comedies, and although they weren’t very interesting, they seemed realistic and plausible.

Then I had my first serious long-term relationship­–the first time any person had really really cared how I felt about them, how I treated them, how I acted around them. And I probably cared less, but I cared enough to have a stake in it, and I cared about my own ability to play the right role, too.

We talked a lot. I thought we had great communication, at the time. I was saying how I felt, he was saying how he felt, and we were overcoming obstacles and making things work like pros. Except that there was a subtext that I hadn’t even really noticed until now. The subtext was about what was normal, and therefore correct and right and good. The desires he expressed–for more affection, more attention, more making out, and of course sex–were ‘normal’ and ‘healthy’. And the desires I expressed–to be touched less, to have more time to myself, and most of all not to have sex–were wrong and broken. I was the problem, and I needed fixing–hell, it was for my sake that we ought to ‘work on it’, because of course I would be happier if I were normal.


As a result of this, the conclusion of nearly every ‘we need to talk’ was for me to change and mould myself to be able to provide the thing he wanted. And of course a lot of this was my personality, the same framework of motivations-desires-values that makes me love nursing. Relationship meta seemed like a cooperative endeavour, and I thought it was win-win; but in actual fact, I lost.


I think that this is why I hate having “relationship talks”, and why I sometimes get all avoid-y when I feel like someone cares too much about me, and why I’m basically only comfortable dating people who already have primary partners or people who live in other countries who I’ll only see occasionally, and why I catch myself always trying not to care that much. Because if my stakes are lower, and if their stakes are lower, then I can’t lose as badly. And I’ve treated some people kind of terribly, according to what I knew they wanted, which is a much better standard than “what society thinks girlfriends owe their partners.”


I don’t think that this is anything fundamental about who I am; I think it was an adaptive mechanism that is now pretty broken and maladaptive, because things are different now that basically the entire rationality community knows I’m asexual, and so does everyone I’m friends with on Facebook.


First of all, Ask/Tell Culture. People in this community and related communities don’t think it’s weird to try to be specific about how your brain works. Secondly, different incentives for social validation by my friends; if I’m dating someone and we’re having problems and I go to a mutual friend, and all of our friend group knows that I’m asexual, I’m much less likely to hear things like “well, of course they want sex, that’s normal, you’re being unreasonable about it.”


So I’d like it if all these aversions and habits and learned patterns of behaviour just kind of went away, but brains don’t work like that. So it’s likely to be a slow process of feeling safer, and letting go of the habits that used to protect me, and letting myself care more and open up more of myself. And of course being more luminous and actually listening and being curious about my sub-agents that are screaming incoherent things at me.


In the meantime… If you catch me doing something bitchy, please do tell me in the gentlest way possible.