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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.

 

Conclusion

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.