I have very mixed feelings about ECT. Although I've seen it help many patients, I've also seen it induce near-catatonic states and mood swings in more patients than I would like. There is also limited research on the long-term effects of ECT and whether or not ECT actually provides enough long-term relief from symptoms to be worth the discomfort and physical and psychological risk.

Ketamine and Propofol have, in my opinion, a better cost-benefit ratio, and I like that they don't induce a seizure-like response in the brain. Recent research on consciousness would seem to suggest that altering the structure of the brain under anesthesia, when the consciousness is not able to access it, may be very disorienting and uncomfortable for the consciousness.

Furthermore, advances in consciousness research have allowed development of techniques like Transcranial Magnetic Stimulation, which are much less invasive, although in my opinion inducing an electromagnetic current in the brain by any form is like using a hammer to adjust your rearview mirror.

I think unusual conscious experiences and fresh ways of looking at the world allow the consciousness to participate in positive reorganization of neural networks, which is one of the reasons I think psychotherapy and introspection are such important parts of psychiatric treatment. Medication and other physical treatments can correct the wiring, but if you repair a computer and then only download viruses all day, the computer won't last long. Retraining patterns of thought is just as important as reorganizing neural pathways.

These are just my opinions, and have nothing to do with the particulars of my job or the policies of my hospital.

Don't burn out! You're too important ❤️

I feel I can empathize with your last sentence there. At the psych hospital where I work, in the US, I care for many patients who have been involuntarily committed. Although I have deep ethical concerns about many practices in American psychiatry, and the American Mental Health Court system, people only become committed to the hospital's care after they have fallen through every safety net and crack in society, of which there are desperately few to begin with. This is the best we have, at the moment, but I see a large part of my life's work as the fight toward a better, more ethical, more compassionate system.

Australia had an issue with one of our public trusts (which can take over financial custodianship when no alternative is available)... They were, in my opinion, unethically billing them which one might interpret as theft...

Mental capacity is a huge issue even before multiple personalities enter the fray. If I had better answers I might try to complain louder.

Along these lines: it's not uncommon to see people who are floridly psychotic or display a serious inability to care for themself be legally committed to the care of the hospital involuntarily, or to have guardianship assigned to a relative or other legal guardian. In these cases, a simple question raises grave concerns: what if the person with legal guardianship secretly but potently hates the person for whom they are enabled to make medical decisions?

The biggest thing that strikes me here is the problem of serving multiple masters.

There are two identities in the hermit and the giant and it's morally complex to try and serve both, especially if those interests are competing...

A similar debate occurs in treatments where the interests of a mother and unborn baby don't align, and are probably similar again for multiple personalities...

Another fascinating one is that psychiatrists can serve the interests of the state/community (harm prevention) or the interests of the patient...

As far as I know any legal principles in this domain, where there is a physical codependency, are at best grey. Does consent need to be unanimous or is majority rule ok? Can some entities be disenfranchised through mental fitness, are these thresholds different from a single entity? If the principle of integration of multiple personalities within one physical entity is seen as morally sound does that have implications for the treatment chosen for a person (or parts of a person) given they need to integrate with society writ large?

Another area I haven't looked at but would have some bearing is conjoined twins, especially situations where separation is impossible (physically, ethically, or both)?

If a healer chooses to bear guilt beyond what society asks they do I think it's a personal decision, if they've fulfilled their duties to the best of their ability, and society has deemed them capable of executing those duties based on a reasonable burden of information what more can we ask for?

Is governments choosing to put children in schools not a deliberate and artificial improvement? So it's certainly possible, because it's been done.

Turns out, in the real world, nobody cares about philosophical debates, they don't wait, they go with their gut feeling or weird preconceived cultural notions about what's "improvement", and sometimes it even works out.

Also, what is a "viable belief"? Something being false is different from something being unpopular, and "unpopular" is different from "unpopular in the West".

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Curious what your thoughts are about ECT, ketamine and propofol?

Ketamine and propofol have both been shown to offer some benefit to patients suffering from depression independent of inducing seizures...

But I'm yet to run into a study that tries to isolate the medical benefit of inducing seizures relative to the anaesthetic alone, and the fact that it hasn't been systematically analysed scares the crap out of me.

If you don't want to comment for professional reasons I understand.

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I find it surprising that IVF and other fertility treatment procedures are excluded from the eugenics issue. In the US, two percent of children born are conceived using this method. A decade earlier, it was half that. The rate increase is sure to continue upward due to societal factors including advanced age, single parenting, and same sex couple parenting.

Absolutely you can

Thanks...your reply speaks to me, too. Gives me a little hope, for the long path we travelers often take.

I, um, have seen you on another sub that I (very occasionally) lurk in, but is it okay if I talk to you about that in PM? I totally consider you "my people", no worries :)

Scientist here.

1. It's always been like this. Always. You can see great good, fantastic good, exemplars of true humanity--but science has only relatively recently had eugenics become publicly unacceptable. Privately, it's still in, VERY much so. Is any of it rational? Does any of it make the slightest degree of sense? Nope.

2. No one is at the helm. Maybe the people who give the money, to a degree. But there's no one here to turn this ship around.

Genetic success is essentially tautological: successful genes are passed down, and they are passed down because they are successful. What does this mean for our post-Malthusian industrial landscape, when our choices for reproduction come down to aesthetics instead pragmatism (are they different? is there overlap? to what degree)? This is probably the ultimate stated-preference vs revealed-preference issue a person can face. This article about choice of sperm donor is insightful:

https://secondnexus.com/brazil-sperm-donations-caucasian-features

I mean wouldn't the take away here be that withholding treatment to a degree is reasonable? While it may be cruel to do so taking intermediate measures to observe the patient/moloch would I imagine greatly alter the treatment and dialogue needed. And, even after doing so if the physician fails I would argue a change in methodology would be prompted to be better following the example if a better disguised giant came not fully trusting the patient.

Moloch/Hermit were unreliable narrators of their own condition and like all other medicine should take their opinions in stride not disregarded or ignoring them but exploring and verifying. Disregarding the giant killing him and bringing out the hermit is wrong for it will crush him in their lack of empathy for something different, as for pure compassion well we see how it played out.

I do believe the Healer was wrong in his methodology, however feeling guilt/quitting would only prevent helping someone else and shouldn't need to, mistakes happen it is up to them to grow and learn from it.

If a perfect giant came and you tried to explore what was wrong with them but couldn't trust your conclusions then its by your digression by risk assessment. How will the treatment help? Will it kill them? Is it permanent? The healer may have informed the giant of the risks but he himself wasn't sure of the outcome for a giant or if the risks were correctly portrayed due to his unfamiliarity which was overall bad practice of wanting to help and doing more harm then good.

Ultimately blind compassion and a distrust of the patient are the wrong answers and finding a fine line between them seems right to me. rant over ggs

How do I do that?

No matter how well we understand neuroscience, I imagine conscious inner privacy will remain an ethical issue for a very long time. I cannot directly access another person’s consciousness, I cannot know for myself what the experience they are having feels like to have. I can only infer things about their experience from various sources of data. If some quantum-informational theories of consciousness are correct, inner privacy may be a fundamental law of information in the universe, so I think this issue will remain salient for quite a while.

I think you raise a great point. A patient who feels at war within themselves will not achieve peace by killing some part of themselves, and so often the course we take in psychiatry is exactly what you suggest, integrating things rather than trying to kill or remove them. For example, some patients on inpatient units I have worked on find the experience of being physically or chemically restrained to be enjoyable for some reason or another, and have learned how to create situations in which there is sufficient danger to the patient or others that hospital policy requires restraints. The clinical course for these patients involves 1) attempting to limit situations where an escalation to restrain is possible, and 2) attempting to understand and modify the motivations of this behavior, in order to allow the patient to obtain the emotional gratification they get from restraint, from other sources. If this desire for restraint is not acknowledged as part of the problem, however, the patient will continue to behave dangerously in order to be repeatedly restrained.

1. Play stupid games, win stupid prizes -hannibal did an experiment, it could've gone worse, like the towns people rioting, he is lucky that they want to help

2. Fuck around, find out

• this where i salute hannibal, he fucked around, and stuck to finding out, even if it meant his death

3. Asymmetric information (a lot of unknowns) -awen was presented with the giant, not knowing hannibal is the puppeteer, the giant told a narrative, and that narrative is what awen has to work with. I think he did his doctor duties and gave moloch/hannibal dignity and agency in choosing the treatment

4. God's point of view -compared to tge olden times, our current tech is like God's eyes, CT scan, MRI, Ultrasound, even bloodwork can reveal a lot -so if awen did see moloch as a puppet and hannibal as the puppeteer, i think they will address hannibal instead of moloch, disregarding moloch as a "mask"/puppet

This hits close to home, is well written, and from my perspective asks questions other philosophical ideals haven’t or aren’t able to answer.

My most pressing questions regarding the issues presented relate to the identity of the mind as a whole: is it entirely the conscious, subconscious, or unconscious; or a blend of the three? With the latter most likely being the case, is Hannibal essential to Moloch, and is Moloch essential to Hannibal? If the conscious motivates action in one direction, but the subconscious motivates action in the opposite, is the individual as a whole responsible, or are others responsible for making a decision towards one or the other? In summation, how many different entities lie within one mind, and whose mind has the right or responsibility to determine which entities get preference?

In regard to the idea of having a novel framework and understanding the experience of mental illness before ethical action, is waiting unethical, even if the experience isn’t understood? I would argue that our society has said yes, treatment of some kind is better than no treatment, even if one harms more than the other unknowingly.

Like the start, nice writing.

There’s a book called The Mask of Sanity by Harvey M. Cleckley which was one of the first to compare the appearance of psychopathy between different psychopaths. The book is from 1941 and so obviously quite outdated, but Cleckley’s metaphor of a mask remains quite relevant. Many ASPD patients I’ve worked with have described feeling as though they are constantly wearing a mask, or as though they are a mask with nothing behind it. I.E. if the constructed character they present to the world were removed, they would have no internal frame of reference at all. It follows, then, to ask ask to whom the suffering belongs: the psychopath, or the mask?

Thanks for the insightful comment. I think you’ve summed up my experience working in psych as well. Because it would be totally wrong to assume patients are lying from the get-go, the provider simply has to do the best they can, providing informed consent and prompting self-reflection where possible, and allow the patient to assume some responsibility for giving the information they give and requesting the treatment they do. There are of course some conditions, such as munchausen’s, in which self-report of symptoms is intentionally deceptive, and in my experience the medical system is still pretty unprepared to detect and diagnose these types of issues, and it was around these types of problems that I designed the thought experiment. I really don’t have a specific clinical course I’m arguing for, because I think we simply need to learn more about the mind before our diagnostic tools will improve to a significant degree.

Do you really think we will ever be able to truly understand the complexities of the human mind in a way that we can honestly withhold certain treatment in an ethical way? Even if the client appears to have the capacity to understand the risks?

I work in psychiatry and I also have 10 years experience working in a SICU. There should be no personal guilt involved in the health Practitioner when they provided informed consent (including potential risks, benefits, etc) and offered the current best practice to resolve an ailment. We often look back in time and cringe at the medical procedures that used to be performed, but those interventions were developed based on past experience. We only got where we are today due to the medical interventions performed in the past. We learn through past experience. Hannibal seemed to be of sound mind when he made the decision to undergo the procedures. Awen did well, and if he uses this experience to improve his practice then he will continue to do well. I don't always know if my psych patients are malingering or have alternative motives when they provide me their symptoms (I work in child psychiatry and there are times it seems my patients are trying to avoid school or home), however, I need to trust them because there is no other choice. If I choose to not believe my patient then I am risking the possibility that I will provide poor treatment to someone who truly needs it.

Edit: I didn't spell Awen's name correctly.