Throwaway05
1d ago
Yeah you can absolutely get some things done faster by heading over to the U.S. but keep in mind that the times where it's really useful (ex: cancer workup, need a new knee) it will become cost prohibitive and unreliable very quickly.
I assume the reality of the situation is Canada is not as bad as some of the stories would make it seem but those stories are still quite alarming.
It's also worth noting that while US care is expensive EMTALA and others things ensure you will get care for most types of maladies even if you become bankrupt afterwards. Many countries don't ensure this this outside the affluent west.
Throwaway05
1d ago
They are better than the USA, which is the key benchmark. Canada is much more similar than Western Europe and also has historically out-performed the USA, although our healthcare system is getting fucked on pretty hard right now so idk how the stats match up post-COVID.
Don't fall for the propaganda here, the U.S. has worse outcomes on many metrics but a population that is more unhealthy and those worse metrics are driven by a social goal (you have the freedom to accept lifestyle diseases). When you get sick you are better off here than everywhere else in every way except the pay check. You'll get faster care if it's outpatient, and better across the board. You might have worse outcomes because you eat too many Big Macs but that is a public health and cultural problem instead of a medical care one. The expense is higher is really the only problem.
(And note well: those lifestyle disease worsen outcomes on everything, example diabetes fucks with wound healing and metabolic process of all kinds, obesity makes surgery impossible, etc.)
I'm torn on this, if the USA also captures most of the world's pharma profits than this is a net gain no? No idea how the math works out there though.
I don't know either but good thinking.
This is true but hilarious. Americans are violently against "taxes to pay for healthcare" but are completely fine with "employer subsidized insurance premiums that mean they get less cash in hand in exchange for access to healthcare" which is functionally just taxes but with more middlemen??!!?! And poor people I guess get less services versus single-payer, but then everyone subsidizes them anyway via higher medical bills to offset all the non-payments from the aforementioned poor people.
This manifests in all kinds of ways. Don't want to take vaccines and want to accept the bad outcomes? American individualism. Clearly dying grandma with 95% 30 day mortality rate? Spend EVERYTHING. Etc.
Are death panels real anywhere? I also feel like prices/medical bankruptcy (66% of all USA bankruptcy filings) are kind of analogous? If you can't afford chemo you sell everything you have until you run out of money to pay for it and die. Also you absolutely do have rationing, it's just in the form of prices versus bureaucratic limits. It can be debated which type of rationing is better, but the human demand for healthcare is infinite, supply never will be.
The usual way this shows up in real life is in other countries under spending on end of life care (which is super expensive and with where I am in my life now.....yes I'd want that for me) and delay of care. Canada is notorious for this. I need major hip or knee surgery in the US and I can get it within the week, but Canada though? Months. People also die from cancer and other diseases or have worse morbidity because it takes awhile to be seen and treated.
U.S. has a lot of profit motive and well payed people so they get to both care about patients and actually hustle when it's necessary and the system allows it because $$$.
Also, since I don't really get to talk about my favorite medical topic here but now is a perfect time - Trauma!
No better place in the world to get fucking shot (at least in a civilian context)!
Throwaway05
1d ago
Their are two problems with this line of thinking:
- Are those systems actually that good?
- Can we make that happen here?
The U.S. is fundamentally a different place than Western Europe - we spend a lot of money on illegal immigrants, have a maximal amount of cost disease, we are more unhealthy (and importantly as other countries catch up they look more like us), we subsidize the rest of the world's medical research (maybe not fair, but we are the wealthiest country and nobody else will pick up the slack if we go away), we are more independently minded (people don't want to be forced onto insurance or into making certain decisions), medical malpractice is a huge drain, we don't have death panels and rationing, you can get care fast if you can afford it, etc. etc.
Fundamentally our healthcare system doesn't resemble anyone else's in both bad and good ways (don't believe the reddit left - the best care is in the USA).
Even putting aside those things good luck changing our system to resemble other's once reality comes into play (for instance forcing people onto plans).
Throwaway05
1d ago
The whole situation is a mess, I like to think of healthcare economics like communism - yes you can absolutely up end the system and make it way better than what we have now, but when has that ever happened successfully?
The thing that probably gets the most complaints over in doctor land is that changes to the current medicaid structure is likely going to result in a further decline in safety net and rural hospitals. This trend has been ongoing for some time but loss of medicaid dollars will probably accelerate it greatly and people are expecting to see that with the current wave of budget cuts.
Two specific things off the top of my head that you'd have to watch for:
-It is very easy for the hospital to help you by signing you up for medicaid. Private insurance would likely find ways to block this. Hospitals rely heavily on this.
-Medicare and Medicaid are much lower overhead on the clinical side of things and less paperwork. Private insurance is a lot more work (although Medicare is trying to change that! Yay). Don't expect a reduction in medicaid to reduce bureaucratic costs and middleman costs.
Throwaway05
7d ago
To add to these examples, in later rounds of the US physician licensing examination (USMLE Step 3) they will sometimes ask questions which are designed to be novel - no way you know this specific fact or have seen it in a board prep resource. You are then asked to determine what would be the most likely answer based off of your understanding of the underlying biology and so on.
These are hard to do so you don't see too many of them, but it is possible.
Throwaway05
7d ago
The process is somewhat individual and adversarial. In NJ the way it works is more or less this - somebody has to be concerned about the patient (usually a family member, a concerned bystander, cops walking by) the patient is then taking an ED or Crisis Center on a temporary hold, at which point a social worker has to see them and think they need to be committed at which point they are seen by two physicians who have to feel it is appropriate. Individuals involved can be sued, fined, lose their license for abuse and so on. Then afterwards there is an expungement process. If the patient is held for an extended period of time without discharge then they have a formal court hearing that can and will result in release from the psychiatric hospital.
Obviously there is some abuse and laziness in the process, most typically the second physician would be like "eh I wasn't there, I'll assume the first doc was correct."
Ultimately this involves multiple trained professionals with skin in the game to make the determination that someone needs to be committed and they can always go through a court process afterwards.
I think some of the value here is that most people who end up committed don't have the functional status to do much of anything. If you make it opt-in most wouldn't, and wouldn't be able to get expunged. I'm fine with a more robust way of people getting their rights back but it has to be done in away that isn't too egregiously expensive and defaults to no because of how dangerous a small subsection of these people are, which is hard to convey if you've never seen them.
Crisis centers do occasionally catch people who will explicitly say that they are interested in killing people (in a sociopathic way) and loading them down with rights restrictions before they get started in an unalloyed good.
Hope all of that makes sense, typed fast.
Some other stuff: -While most doctors aren't anti-gun they aren't committing people purely to get them away from their guns unless the doc has concerns for threat and its therefore appropriate. This is because these settings are overworked, their aren't enough beds for those who really need them, and the hospital doesn't get paid if the insurance company doesn't think the patient actually needs to be committed and that rolls onto the doctor's head. In the worse case scenario no psychiatric hospital will take the committed patient because they clearly don't need psychiatric care and then the ED comes over and stabs the psychiatrists 80 million times for taking up a bed while someone is bleeding to death in chairs.
-Average disorganized street homeless person is harmless other than the inability to care for themselves even if they are vaguely threatening, so they tend not to get taken in unless they are actively harassing someone or committing some other crime like trespassing.
Throwaway05
7d ago
It actually doesn't, as in the case I know where someone took a prescribed drug which caused psychotic symptoms. But even if that were so, a lot of things do. Showing some level of poor judgement and insight and lack of responsibility is not per se grounds for revoking a fundamental right.
I don't think we are going to get on the same page about this, but as a fact matter - if your friend was psychotic under the influence of a substance at that time he had poor judgement and insight, if they were committed involuntary (the correct response to oh holy shit the walls are talking to me is to you know, get help).
One of the challenges of managing society in general is what to do with people who are "fine" most of the time but dangerous while in a certain state (like decompensated mental illness, tripping balls, or just pissed off).
Throwaway05
8d ago
Would you feel more comfortable with this process if we were able to produce date that illustrates that patients admitted with homicidal ideation are equally or more likely to kill someone as felons?
Fundamentally we need to establish what level of problematic behavior disqualifies from gun use. Some amount is clearly appropriate there are people dumb or crazy enough to say "if you let me have a gun I'm going to kill X." Clearly they shouldn't be allowed to. Felons? Stickier not every felon is likely to kill someone but it's a good broad category. You could attack this laterally by making assault on healthcare workers a felony and charging it 100% of the time, but that would be even more overkill - it happens a lot and we try and let it go because a good number of people who do this aren't likely to cause trouble or are likely to cause a minimum of trouble.
While my co-workers (of most non-surgical specialties) are certainly politically motivated at times, and are unlikely to write a letter in support of someone owning guns because they don't believe in that for political reasons....and at the same time they aren't going to abuse the commitment process for political reasons. I could say its because of historical abuses leading to lots of ethic changes on this, I could say its because of the increased lawsuit risk, but realistically a large chunk of it is just because it's so infrequently anything other than intensely obvious (at least outside suicide, suicide risk gets a bit stickier).
Patients who are sick tend to be really fucking sick and unless you've seen it it's hard to understand. Your usual crazy schizophrenic homeless person wandering around on the street was deemed safe to go home. How bad do you think the ones who get dragged in are?
Throwaway05
8d ago
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Our judicial system is predicated on people not actually going to trial these days. Are you willing to accept the increased cost in taxes to do this, or more likely - a coercive structure that would necessitate a "plea deal equivalent." If so how much financial drain on society is acceptable to you?
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What is special about jury trials over other processes? If someone does a bench trial is that acceptable? If a judge rubber stamps a psychiatrists recommendation (the likely outcome of a push for a trial process) is that acceptable? How do you want this to actually happen? This is not a simple logistical thing you are suggesting.
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Being involuntarily committed requires some level of poor judgement and insight and lack of responsibility. Sometimes it is obviously disqualifying "I'm going to kill my neighbor doc" sometimes it is debatably disqualifying "I'm going to kill myself doc" (as feelings on suicide are complicated, even if our society has staked a view on this topic) sometimes it is something more like "I need you to calm down so I can help discharge you" "fuck you bitch cunt go fuck yourself" (in the setting of clear threat to self or others). A pro-2A MAXIMALIST might have no problem with someone who is overtly dangerous, foul tempered, and irresponsible owning a gun. Fine.
BUT.
You need a plan for individuals who are extremely likely to commit violence. Some patients are likely (where likely could means something like 30-70, not a baseline 2% risk of committing a murder) to commit violence. An example is ongoing escalatory stalking and harassment behavior. Seizing their guns and/or preventing them from buying guns gives the victim options while other social processes (like moving away, a restraining order and violations of the same leading to jail time) come into play.
What do you want to do to prevent Nybbler killing man from killing you. He gets discharged by the judge from the Psych hospital because he hasn't attacked anyone in the hospital. The Psychiatrist has a duty to warn by law to tell you hey I think this guy is at high risk of killing you. Guy goes home, everyone knows he is going to go kill you, how do you stop him? If you call the police they'll say "has he done anything yet?" or maybe "file a restraining order." That's shitty.
This is not theoretical. I've seen patient situations similar to this where the whole hospital goes "shit that guy is going to kill someone" but we can't do anything about it. Then we read about it on the news or treat the victim.
That's with the current state. It gets worse with guns involved.
This is a common sense restriction.
I suspect your issue is of the cathedral and woke politics - you don't trust Psychiatrists to appropriately judge if someone is really in need of an involuntary commitment. I'm sure they get it wrong sometimes just like felony convictions, but:
Can you produce any evidence that people getting guns being taken away from them because of involuntary commitment inappropriately is occurring with any degree of frequency?
Throwaway05
9d ago
Frequently (by no means all the time but often enough) that's grossly insufficient.
-Some patients remain essentially untreated. You don't need to take medication (there is however a slow process for forcing patients who are sufficiently dangerous). Nybbler murder patient may in fact want to murder no-one other than Nybbler, and behave more or less while in the hospital while refusing treatment. After the initial period further involuntary commitment involves a judge - the judge may say "well he hasn't done anything bad since he got here, maybe he won't murder Nybbler?" and off he goes. Walks out of the hospital, buys the gun, murder goes. This is not theoretical, it happens (sometimes even with mass shooting events but does also show up in the local news when the death count is low). Solution: force people to get treatment without their consent. Or force them to stay in the hospital until they consent. Both are significantly more rights destroying.
-Some patients are only dangerous when they use drugs. While intoxicated and for a while after they are a psychiatric problem but outside that the health care system has no control over them. People who keep smoking PCP and want to murder people while on PCP should probably not be allowed to own guns. This should be fixed by arresting people who use and sell PCP but society isn't really electing to do this these days. Solution: reengage the war on drugs. Not a popular option.
-Much more common and much trickier is that it is common for people to be committed, accept treatment, temporarily get better, and then relapse. They then become a threat again. Sometimes quite quickly. Much more quickly than any court process would go. Charitably (and in truth pretty commonly) this happens because medication works well at reducing things like hallucination and aggression but not the negative symptoms lack apathy and avolition. When your symptom is that you can't be motivated to take medication and you don't care if the other symptoms come back, well then it is hard to stay on medication. And then the risk comes back.
Making a public and credible threat to murder someone for reasons that are universally not given as acceptable (ex: for no reason at all or for reasons of delusion) should be exclusionary to owning guns. We aren't talking for political reasons or because the neighbor slept with your wife, we are talking because you are convinced the neighbor is Proxima Centauri.
Nybbler's issue seems to be (although he won't clarify it) that it didn't go through a legal proceeding. But opening up legal proceedings is a huge can of worms.
Let's say someone (police, healthcare worker, concerned person, whatever) can open a complaint about someone's safety to own weapons. That's time consuming, expensive, might involve temporarily seizing guns or the person, will involve litigating if expression of political beliefs counts... way more abusable than present state.
The fact of the matter is that the vast vast majority of people who are involuntarily committed* really should not be allowed to own guns. Failures are rare. Should you find one (for instance someone who did a shit ton of PCP for ten years and then spent 50 years not using PCP and wants some guns) the expungement process works pretty well.
The modal involuntary patient isn't actually suicidal or homicidal, instead they are something like a schizophrenic who is so severe they just can't feed or care for themselves. Someone that disorganized isn't safe to own anything remotely dangerous, and if they had the financial ability to own a car (most don't) they probably shouldn't.
*assuming you agree with the suicide end of things, that's a bit trickier.
Throwaway05
9d ago
I see Tchaikovsky come up on /r/Fantasy and /r/PrintSF quite a bit, but almost nobody ever mentions Shadows of the Apt, which I still feel is his best work.
Throwaway05
9d ago
So you want to pay the taxes required to run a criminal grade trial on everyone who is involuntary committed so that they can have their guns taken away by a jury of their peers. This would be expensive in a pure trial sense and because it would be slow people would be held unnecessarily - if you can go home after 4 days because the medication worked but you need to stay in the hospital (or be dispo'ed to jail/prison) for ....however many weeks to months it takes to hold an actual trial.... isn't that a worse violation of your rights?
Throwaway05
10d ago
Absolutely, and while overt delusional beliefs are what pop to non-medical people seeing or hearing about these patients, the real problem is the negative symptoms of schizophrenia (often manifesting as a total inability to care for oneself in a functional way). That is much less exciting but more important for commitment purposes a good chunk of the time.
I think a lot of the doubters here would be way more comfortable if they had a chance to stay in a city crisis center for five minutes.
Throwaway05
10d ago
That sounds like a plan. That sounds like you want this to be adjudicated in court instead. Explore that! Examine the consequences! Thank about it! Is it better? Worse?
I haven't seen good faith engagement from you in ages in this conversation. You clearly imply that some infringements on the right to bear arms is reasonable but you don't want to admit what that is then you later try and imply that you don't. Those are incompatible and you must pick.
Throwaway05
10d ago
That is not a plan.
Throwaway05
10d ago
What is your proposal.
Throwaway05
10d ago
Okay but the problem is that psychotically violent is a transient state - at present we hold them away from others while psychotically violent and then release them when they aren't.
A good number of people have one episode of violence or violent potential and then stop.
Likewise the mental health system is somewhat optimized for trying to predict violent potential in advance and head it off. Do you count the people who have committed that "pre crime" or not?
Throwaway05
10d ago
To be clear: you want the state to summarily execute between 5-10 percent of the population because of the presence of severe mental illness?
Throwaway05
10d ago
Bipolar + Schizophrenia + Schizoaffective disorder add up to something like 5% of the population. Not all of these people commit violence. Not all of these people end up with an involuntary commitment. Saying "you murdered someone during a manic episode I no longer feel comfortable with you living in the community" is one thing "the severity of your illness is so bad that someone thought you were going to hurt people but you didn't end up doing that, however I'm not sure I feel comfortable with you having guns even if you don't need to be in the hospital 100% of the time is another."
Plenty of people end up transiently psychotic because of things like medical illness, substance use (even caffeine!), sleep deprivation, stress, trauma and so on. Most of these do not go on to kill people. A fraction who do end up with an involuntary commitment are significantly more dangerous and risky.
Throwaway05
10d ago
I think a good thought experiment here is to look at traffic tickets.
Do you think cops should have flexibility in giving a ticket or not?
Choosing not to is also abomination of due process, it is inconsistent and potentially abusable and corrupt. It's also flexible and can work out well.
The system works better for most people overall when have some flexibility in the system. Some people are screwed over by that flexibility however in my experience it's usually for good reason (in this case: guy is likely an asshole).
If you want to remove the slack and flexibility in the system you can certainly advocate for that but you'll find it probably isn't what you want in practice.
With respect to this guy specifically, I got the impression that it seemed like he had more involvement with mental health care that he was letting on and was trying to minimize which is not a good sign.
Throwaway05
10d ago
Lets list some of the categories of patients this kinda thing applies to.
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Someone has a brief psychotic episode, has interest in killing someone but doesn't manage to do so. They have a 30% chance of not progressing into having any further episodes of psychosis.
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Someone uses drugs or alcohol. While under the influence of drugs or alcohol they become homicidal or suicidal.
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Someone has a medical problem like a brain tumor, dementia, or more reversible things like autoimmune encephalitis or hyperthyroidism. While medically unwell they become psychiatrically unwell.
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A totally normal person has a first time manic episode with threatened or actual HI/SI. Outside the manic episode they are totally normal. They take their medication but still have a risk of problems. Maybe they have a kid and end up with sleep deprivation. Maybe the run a 5k and become dehydrated and their lithium metabolism is altered.
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Schizophrenic guy who knows he is schizophrenic, takes a long acting injectable medication to make sure he doesn't forget. Symptoms are well controlled. Sometime over the course of his life his metabolism of the medicine changes and he ends up sick again (and dangerous).
You really want to lock up all of these people indefinitely?
Medicine and the legal system don't know with surety who will offend and who will be dangerous. So we try and be judicious in how much we violate rights. Summarily executing someone for being diagnosed with schizophrenia is a bit of an overshot. Locking people up indefinitely (especially when they have periods of healthy functioning that might even last decades) is also likely overshooting it.
It's also hideously expensive and drains resources that could be best used elsewhere.
They won't have guns anyway while locked up.
Why not start with less restrictive measures?
If individual autonomy isn't important to you (it certainly is to Nybbler) then the expense should certainly factor into it. How much extra in taxes do you want to pay to do this?
Throwaway05
10d ago
It's an argument about giving crazy people guns.
We make an effort to restrict people's rights to the minimum we can, even if it results in bad outcomes sometimes. Locking away someone indefinitely (or like, killing them) is extremely restrictive.
Giving them some rope with which to metaphorically hang themselves but not too much preserves autonomy as much as we can.
Throwaway05
10d ago
I mean this is the point, their exists a class of people in society who are not safe to themselves or others due to a mental illness (this is different from the class of people who are this way due to personality structure, life experience, genetics, racism, whatever - we call these criminals).
For many mental illnesses denial of the mental illness, denial of symptoms, denial of need for medications - all these things are frequent parts of the pathology (sniff test to make it make sense: if you are delusional of course you are going to think you don't have delusions).
People who acknowledge they have problems end up with a voluntary admission not an involuntary one "man you nearly killed yourself dude, you think being in the hospital for a few days would be good for you?"
In any case you come in, take meds, stabilize, get discharged. Then you go home and forget to take your beds, have medical stuff that happens that makes the meds don't work, decide not to take them "because it went away" whatever. Then you get sick again and dangerous.
Rights restriction (such involuntary outpatient commitment, forced medications, jail time, indefinite hospital stays) is usually the way - harm reduction approaches such as banning firearm access are both cheaper and much less disruptive to the patient.
This is why I want Nybbler to come up with an alternative plan because realistically the problem is often "jail and no guns" or "no jail and no guns" (even if it is just fancy jail with extra steps).
Throwaway05
10d ago
So I continue to hold him in the hospital against his will even though he is no longer a threat to himself or others? (he is only a threat after he goes home and stops taking his medicine).
That seems more rights destroying than preventing gun access, no?
Furthermore - who pays for this? Indefinite hospital stay is expensive as hell. What about the other people who need that bed?
Doubt on this front, the Western standard is for when things go wrong, which is rare - but if you get something like a T&A done in your 20s in a major academic hospital in the U.S. and have a major complication, you will likely be fine. In Mexico? No dice.
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