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Comment by Groxx | Hacker News Reader

Interesting. I can see how it would be appealing to long-time alcoholics (the "endless optimism" would get pretty sickening).

Not entirely sure what my stance is on it, though - it's essentially long-term non-profit euthanasia. It's what they want, but it's also what they want because they're addicted and it's re-wired their brain so drastically they'll do just about anything to keep feeding it.

On the flip side, rehabilitating someone who doesn't want to be rehabilitated to some degree is essentially throwing enormous sums of money down the drain, and drags that time of their life far lower than it was before. Instead, this offers them companionship and fewer insults (and keeps them in line) until they die, and that seems to be what many people want - what they have for shorter instead of something else which may or may not be better for longer.

If nothing else, it has jogged my thinker; I'll probably debate with myself for a while on this :)

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long-term non-profit euthanasia

Not really. Euthanising long-term alcoholics would mean taking a syringe full of paralytics, potassium, versed and morphine and pushing as a lethal injection.

Hospice is realizing they are dying from their disease and providing for them while the disease runs its course.

If someone is dying from a disease you have cures for (it's simple, but hard: stop drinking), but they're not taking them, so you instead support that disease, how far from euthanasia is that really? It's absolutely hospice care in the approach, but they are literally helping them die more quickly. More happily, but more quickly. And euthanasia has nothing to do with absolute speed, only relative; a less-painful death at the expense of a shorter life. It's a trade-off everyone makes, but at what point does it switch from normal life / hospice care to occurring "too early"?

As compared to not taking care of them, and having them freeze to death?

If someone is dying from a disease you have cures for (it's simple, but hard: stop drinking), but they're not taking them, so you instead support that disease, how far from euthanasia is that really?

The difference is that people have the right to choose what treatment they take or don't take. Forcing a treatment on someone (antibiotics, chemotherapy, sewing a laceration) when they don't want it is legally called medical battery, and it's against the law.

This is particularly poignant in the case of diseases like alcoholism or drug addiction. I often have conversations with alcoholics along the lines of "Your alcohol level was 5 times the legal limit. If you keep drinking at this level, in a couple of years, your liver will be shot, and you're going to die of liver failure. Liver failure is one of the worst ways to die, because you die looking like a swollen yellow gourd."

Most don't care, and keep on drinking. Same thing with smoking. I smoked for 10 years while I was a Critical Care nurse. It was my choice and my addiction. It took trying to quit 15 times before I did it successfully. Some people aren't able to quit, or don't want to quit, and it kills them.

Should we deny people with lung cancer hospice because their disease was self inflicted? Should we deny people with heart disease hospice because they didn't manage their cholesterol properly? Should we deny people with type 2 diabetes hospice because they didn't manage their diet appropriately, exercise or lose weight?

I should point out that I do enjoy playing Devil's Advocate. But I'm not just trying to be contrary, these are essentially things running through my mind.

I largely agree with what you're saying (how could I not?), but I'm having difficulty finding testable definitions in it. Something hard-edged and consistent that can serve as a basis.

One of the problems with respecting the person's choices in cases of addiction is that there's room for arguing that they're not capable of making decisions for themselves due to the addiction. This comes up all the time in legal and medical situations - otherwise, we'd have no insanity clause, no forced rehab, no insane asylums (not that I think those are fantastic places, of course). I have no idea where the legal line lies in most situations, but would be interested if anyone does know it.

At what point do we decide whether it's the person or the disease that's talking? Alcohol in particular has a far longer history than the newer, "harder" drugs that our society has drawn clear distinctions for, and it's going to be much harder to find or make or convince others where the line for it lies.

I have no idea where the legal line lies in most situations, but would be interested if anyone does know it.

Sure, I deal with this on a nightly basis, when I'm at work. Most state laws stipulate that the only reason a hospital can hold someone against their will, is if they are a danger to themselves (in imminent danger of committing suicide), a danger to others (in imminent danger of committing homicide.) or gravely disabled ( e.g. walking around quacking like a duck and drinking from puddles).

And, even then, an ER can only place someone on a 72 hour hold. Then it has to go to court to hold someone against their will on a 10 day paper.

Getting someone committed to rehab for alcoholism is generally a court driven exercise that happens after a person has multiple DUI's or instances of committing crimes that are drug use related.

The law takes committing someone to drug, alcohol or psychiatric treatment against their will very, very seriously and only does so in extreme circumstances. And, frankly, providing a wet house for people to continue to choose to drink themselves to death is probably the path of least resistance, it's cheaper and in my opinion is the most humane of all the bad options.

>Then it has to go to court to hold someone against their will on a 10 day paper.

I don't quite follow that sentence... is that to get a 10 day period enforcement, or to go over 10 days? Or something else?

All in all, pretty clear, thanks! That sounds like a pretty rational set of rules. My main difficulties lie in that people seem to only care about things when they become imminent and obvious, while ignoring steady trends that are just as dangerous (or more). Legally, imminent is a nice, clean line to choose, because it's pretty clear most times. It's a line that can be protected, which is hugely important.

Ethically, I don't know, and any actions would be at odds with their free will... unless you view addictions as violations of their free will to begin with. A loss of free will that they chose, but that decision doesn't hold up against extremes like suicide. Is suicide somehow worse when it's immediate rather than over the course of, say, a year? What if they planned it for a year, and you only interrupted it at the crucial moment?

It seems like a very pragmatic solution for now.

I think it could be taken a step further by providing an alternative to going out onto the street to try to get alcohol in various forms (including mouthwash).

While I'm certainly no expert on psychology, my experience has shown me that sometimes the best way to get some tiny bit of purchase on a group of people is to offer a minimally reasonable alternative.

For example, if scrapers are constantly inundating your website one solution is to publically offer an API. Obtaining the data is easier through the API and reduces the automated hits to the human readable part of your website. You can require API users uniquely identify themselves and you are then able to throttle and better track how your data is dispensed.

Following this line of thinking: Why not put in a alcohol vending machine that dispenses variable percentage alcohol based on BAC of the user and frequency of use? It could also adjust the alcohol content up or down based on other factors, like recent civil service or run-ins with the police.

I could think of hundreds of ways this could be improved. Since you are likely getting BAC readings on a regular basis you have a measure of how successful your dispensing profile is. With enough machines you could even split test different percentages, etc... If the machine is not getting any use at first the alcohol level could be stepped up.

I want to know if someone actually stops drinking being in there. I mean if they viscerally feel death and don't actually wish it...

That'd be an interesting thing to check out. They do get to see first-hand what it's doing to others around them, over a period of time. It'd be a unique incentive to quit.

Also, when the constant pressure is taken off and their basic needs are taken care of, maybe some of them can reflect and take a less forced decision to quit. But maybe I'm underestimating alcohol's hold.

I seem to recall a story about this place, or a similar one, where a couple residents decided to sober up after "living the dream" (free booze for life!) and still not finding happiness. Many more tho drank themselves to death there.

Even as something of a liberal, this makes me feel conflicted. It doesn't quite feel like harm reduction - just cost-reduction for the agencies. It's very bleak.

But if you can't really reduce the harm (or not much), but you can significantly reduce the cost... is bleak bad?

America is on a huge "everyone should be happy" kick - smile all the time, buck up and be cheerful, if you're not happy take this pill - but that has its own problems, and masks problems like these people are having, making them worse. It also trivializes pain / unhappiness - everyone can have it! Why don't you? Try this pill, go to a meeting, look everyone can do it! - and given the amount of depression occurring can it even be said to be working? For some, sure - there are outliers in any system of people..

There's also that it can cause things to get even worse - if everyone really can / should be happy, and I can't, clearly something's wrong with me. You'll find a lot of depressed people in that line of thinking, and it crops up in suicides pretty often too.

Not really disagreeing, just debating with myself / you / the Internets.

Oh hey, someone who mocks the use of antidepressants. I suffer from congenital depression. Zoloft helps me to be a functioning, productive member of society. It has prevented many deaths from suicide. People like you prevent people from seeking help because they buy into the "just harden up" bullshit.

Should people with diabetes just kick the insulin habit? Please.

Where the hell are you getting that from? Read what's written, not what you want to see. I said America is on a happy kick, not that such drugs don't work or that they're unnecessary. There's an obsession with appearing happy that hides and / or causes a lot of problems, including depression.

I've applied a simple stereotype. Everyone I've ever seen saying "America / society / the world are on a mandatory happy kick" usually segues into a rant about the pharmaceuticals themselves, written in a disparaging tone.

You fit the profile, and it's a profile I find repugnant and dangerous to the mental health of depressed people everywhere.

There is an important difference between unhappiness due to life events and clinical depression. One may trigger the other; but the fact is that depression is a neurochemical disorder that is, in most cases, directly and immediately treatable with cheap, safe, effective pharmaceuticals with a minimum of fuss.

I've had the deep dark nights of despair. The black nights of the soul. I spent years trying to stare down the black dog. It is exhausting and I gained nothing by it. It has borne me no fruit whatsoever.

If that's your standard response to such an apparently-vague profile, without them actually stating such things, you're going to be jumping the gun a lot and probably win more enemies than successes. Do you also leap at people who think we're over-medicating?

You're right that I jumped the gun. I'd apologise, but it would be disingenuous as I still can't shake you out of the profile I put you in at first.

It's not fair, and it's not rational, but if there's anything I've learnt from taking zoloft it's that dualism is rubbish. We are illusions of ourselves, running on a largely hacked-together substrate made of meat.

I used to put the position that the drugs are over-prescribed, that it's a societal problem etc. But I don't feel that way any more, because thinking like that was another reason that I did not seek treatment. I basically lost my 20s to this disease, I don't want others to suffer as I did.

If that means erroneously attacking a few false positives on HN, so be it.

Would anecdotes help? My sister is bipolar, and medication has helped her immensely. My wife had a pretty bad bout of anxiety / depression that pretty much tanked two years until I convinced her to try some medication - a year of it helped get her over the edge, and she's off and doing much better.

Now I'll proceed to shoot somewhere near my foot, maybe hitting it :) I'd rather be understood and disagreed with than misunderstood and have fake happiness. And I would honestly be curious what your take is on this, I obviously haven't experienced everything there is in the world. There's no hard feelings here, I've seen that stance before, and I hate it too. It does indeed prevent people from getting help.

My main view with anything that tweaks your brain is that your brain is enormously flexible. Barring issues where you're not making enough / too much of a certain chemical (ie, largely genetic), you quite literally did this to yourself (as bad as that sounds). Your life habits have caused you to get stuck in the loop of depression / anxiety, and it builds on itself, pretty frequently until it controls you unless you are lucky enough to find a way to break out before then. Or someone drags you out. Drugs help get you out of that loop, but if your habits don't change you'll train your brain to go back to where it was in spite of the drugs (and this happens, it's not just dualism / zomg-natural-only. That's part of what causes psychological addictions, and depression is highly addictive). Again, unless there's a more permanent biological problem - then you're using drugs to reach normalcy, which is where your body / brain wants to be anyway. But enforced normalcy while you keep pulling yourself away from it is doomed to failure and high costs.

There are plenty of cases of, say, insufficient dopamine production due to genetics. And cases where depression / anxiety have caused chemical imbalances (ie: nearly all, especially severe cases). And the existence of medications to help that is utterly wonderful. But using drugs to ignore a problem isn't a solution. To solve a problem, yes, but that's not how many (possibly most) people use them, in part because of how quickly these medications are leapt at. Can't focus? Try hyperactivity drugs. Can't sleep? Try sleep aids. Can't be happy? Try antidepressants. Therapy, on the other hand, gets nowhere near as much medical support, despite similar success rates and often longer-term solutions. It has plenty of failures as well, everyone's different and there are plenty of bad therapists out there; I'm merely saying that it gets far less support than drugs do.

OK, we're getting dangerously nuanced now, which breaks all the rules of the Internet.

I think you're conflating the illusion of consciousness with the brain itself. It is possible to take actions to intervene in my own neurochemistry -- I am a self-observing system. I can avoid situations that upset me, I can spend more time with friends and family, and so on.

But my personal experience of depression is that it removes the will to be cured. Yes, you can seek therapy, spend time with friends, take up meditation and these will help. But when you are depressed even the thought of getting help is ... exhausting. A cause for dismay, even. It is a particularly invidious disease.

Each of us has different systemic set points for our internal processes -- dynamic equilibria which our systems drift to over time. Most of these are necessary and useful, they keep us alive. But some of us have set points with unpleasant side-effects. Some people have trouble regulating blood sugar, and they use exogenous insulin to do it manually. I have trouble regulating serotonin, and I use sertraline hydrochloride to influence it manually.

High doses broke the back of a depressive episode that lasted 5 years. Low doses have kept me functioning since then.

Is it perfect? No. I could do without the side-effects, but I expect that as time goes on these drugs will become more specific and effective. Or someone will come up with a gene therapy. Who knows?

I do not regard what I experience as fake happiness. It is as real as anybody else's.

I like breaking rules :)

I'm not claiming it's fake happiness. You've clearly made it work for you. I'm merely saying that many people expect drug X to solve all their problems, because it makes them feel better, and do nothing to solve the root problems (which will come back in time). Maybe not most, but even a small percentage means hundreds of thousands of people, and tons of kids who have no choice in the matter.

>it removes the will to be cured

Absolutely, that's why it's such a hard thing to fix. And drugs are a fantastic way to crack your way out of it, to break that relentless loop. And our current culture sneers at anyone (particularly men) seeking help to solve personal problems. That needs to change. It is, slightly, thankfully, but there's a very long way to go.

I take no issue with medicating. Only over-medicating. And neurochemical-manipulating drugs have been crammed down America's collective throat for a while now, without long-term trials, frequently with barely-detectable improvements over sugar pills (and later studies showing none or worse), and without really understanding what they're doing or their ramifications.

Not that I think that's surprising. It's a powerful, successful-enough new line of treatment that's helping a lot of people, and exposing a lot of existing problems that are now getting treated. Of course such a thing would be used before long-term trials were run. People would take it voluntarily - the immediate almost always out-weighs the long-term in any creature, but it's entirely founded when the immediate threatens your life.

The problem I find with the current everyone-must-be-happy trend (as nice as it would be to achieve) is that a) it adds more weight against those who are unhappy to conceal their problems rather than publicly seek help, as everyone else is clearly happy (ignoring the truth) and they don't want to cause unhappiness, and b) it has lead to over-prescribing short-term (in that they work quickly, not that they don't continue to work - that's debatable and essentially unknown currently) solutions, when the causes are the real demons that must be exorcised. It is masking the problems because people quit dealing with them because a fast way out is a doctor's visit and a complaint away. Which is their fault for being lazy, but that's human (and efficient), and it shouldn't be that readily handed out or advertised as a magic bullet.

It also doesn't help that hyperactivity drugs have been pushed by elementary schools (or individual teachers) for unruly kids when it's far more likely that they are bored or weren't raised properly. But that's a rant about our education system, which (especially at elementary levels) I feel is fundamentally, enormously flawed and contributing to a lot of problems. I won't go further on that.

What needs to be done is to treat the imminent danger, and then immediately work with people to solve the causes. But that's cross-discipline - medication and (essentially) psychotherapy - thus rare in a single person, and because the initial danger is gone people quit trying. It appears to be a solution, without actually being one, and long-term / long-term-use side-effects are very real and very dangerous, and largely unknown. One of which I do feel is that it teaches people to medicate their problems instead of dealing with them directly. It's encouraging people to take fast exits.

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Anecdote time! I had a couple years of depression a while back, and didn't take anything for it. I was lucky enough to find a way out of it before I got wholly stuck, and I'm incredibly aware of how close I was to getting stuck and how powerful the loop is - that realization is what shocked me out of it. I'm a minority in that, and I know I was lucky, not strong-willed or somehow better.

Once I got out of the loop, I knew it was just a matter of time before I was back to normal, so I just kept doing what was working. Drugs could likely have shortened it, but I'm leery of drugging my brain after trying various sleeping aids left me hung over and brain-dead for good chunks of that year. It's not entirely rational, and I fully admit it, but I think I made the right choice for me. The process of fixing it has improved me, as I work at fixing things much sooner now.

And if that's rambly, apologies! I'm sort of rambly-feeling right now, and this touches on a lot of areas so it's hard to make cohesive.

Only if you don't believe the people quoted in the article:

"This is about meeting people where they are and loving them. It's not rocket science," she said. "They still grieve, love and hurt. They still need food and shelter. They are you and I."

Dr. Steven Miles, professor of medicine and bioethics at the University of Minnesota, agreed.

The reason to support St. Anthony is not the money saved but the kindness extended to the residents. "It is the humanity of it, just like humanity drives the hospice system," he said.

The article paints a bleak picture, but it's essentially a homeless shelter for alcoholics who have long since given up on treatment.

It's not really direct "harm reduction" in the same sense as needle exchange clinics. More a way to make a few people's lives slightly less miserable; I find it difficult to object to that.

I think there's still many homeless who still have hope, and they are more deserving of the shelter and medical attention. But that's no reason to say that the guys who are lucky enough to get shelter don't deserve it.

We have treatment programs in place, most of the people in this article had given up on them. Given that this happens, and alcoholics do end up dying alone and cold on the streets... This seems to be the only rational thing to do.

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