• Sean II

    The strongest argument in play here is the one that says “if we let people opt out of treatments that work,we should let them opt into treatments that might work.”

    Problem: one could avoid this inconsistency simply by backing out of the premise. It’s not hard to do.

    Nearly all patients who refuse treatment are wrong to do so. At this point in the history of medicine – and all the more so in its emerging future – nearly everyone is better off just following medical advice.

    As rights go, “informed consent” has a track record so wretched it should wake the inner utilitarian in anybody who can count. Nearly everyone who exercises this right is made worse off as a result. Nearly everyone who waives it is made better.

    It’s actually difficult to name a less felicitous and more self destructive right. Even things like “the right to ride motorcycles without a helmet” or “the right to eat Tide pods” are less harmful than the right to refuse medical treatment.

    Only the right to suicide stands comparison here. Because if your doctor is arguing hard enough that you need to invoke the right of refusal, you probably are committing suicide.

    In which case, why don’t we just call it that: a right to self harm.

    Sure, it’ll sell fewer copies. But at least we won’t compromise ourselves by engaging in fraud.

    • JVC

      “The strongest argument in play here is the one that says ‘if we let people opt out of treatments that work, we should let them opt into treatments that might work’.”

      What about the arguments that regulators tend to be overly cautious in approving new medicines and that people would be able to access drugs more cheaply and conveniently if there were fewer regulations. Those seem like much better arguments.

      ‘Nearly everyone is better off just following medical advice’

      True. Wouldn’t most people continue to do that under a less regulated system? Or would they?

      ‘It’s actually difficult to name a less felicitous and more self destructive right. Even things like “the right to ride motorcycles without a helmet” or “the right to eat Tide pods” are less harmful than the right to refuse medical treatment.’

      Those other rights have very few countervailing benefits. In this case the losses to those who would use their newfound pharmaceutical freedom unwisely might be offset by the benefits I allude to above.

      Aside from the efficiency gains in terms of cost for the same treatment to those who continue to follow the rules, and the fact that available treatments might be significantly better if those rules were determined by private rather than governmental oversight, consider that some people who might under the current system not seek treatment at all until it’s too late might be induced to do so if, say, they could arrange a quick skype-call with their doctor and then order some drugs off amazon.

      Also there are many non-medicinal or quasi-medicinal uses of drugs which are denied to people by current drug laws. In some cases facilitating those would be on the net beneficial, and in others not.

      It seems that the costs and benefits of significant drug deregulation are very difficult to quantify here given the state of the available emperical evidence.

    • JVC

      “The strongest argument in play here is the one that says ‘if we let people opt out of treatments that work, we should let them opt into treatments that might work”.

      What about the arguments that say ‘pharmaceutical companies tend to take too long approve new medicines’, or ‘drugs would be be availably more cheaply and conveniently if there were fewer regulations’. Those seem like much better arguments.

      ‘Nearly everyone is better off just following medical advice’

      True. Wouldn’t most people continue to do so if that advice were certified privately rather than governmentally?

      “It’s actually difficult to name a less felicitous and more self destructive right. Even things like ‘the right to ride motorcycles without a helmet’ or ‘the right to eat Tide pods’ are less harmful than the right to refuse medical treatment”

      Those rights have few benefits. In this case the gains I allude to above might offset the lossess to those who would use their newfound pharmaceutical freedom unwisely.

      Aside from the fact that any given treatment would be cheaper, and that range of available treatments might be better if the rules governing prescription were privately determined, consider that a person who might otherwise have delayed seeking treatment until it was too under late under the current system might be induced to so in a more timely manner if, say, they could arrange a quick Skype call with their doctor and then order some drugs of Amazon.

      Also, there are many non-medicinal and quasi-medicinal uses of drugs which are denied to people under current drug laws. In some cases facilitating those uses would be on the net benefficial, and in others not.

      It seems that the cost and benefits of drug deregulation are very difficult to quantify given the available empirical evidence.

    • Rob Gressis

      I was under the impression that deaths from healthcare is the third leading cause of death in the USA. If true (it’s probably not), it seems relevant.

      • Sean II

        Best answer: medical errors are not made less, but rather more likely by increasing the decision making power of the least medically trained player in the game: patients.

        Extended answer: 3rd leading is an absurd figure cooked up by well intentioned but economically illiterate QI crusaders. The definition of “medical error” you have to use to get that is so broad as to make nonsense of the term. You get stuff like:

        A 73 year old functionally illiterate male with type II, high blood pressure, and COPD is found down. They bring him in and do a head CT. It’s negative. So they work him up for urinary tract. It’s not that so they consider pneumonia. It’s not that but meanwhile his urine comes back positive for benzos, cocaine, and marijuana. Also looks like he’s been taken his roomate’s Viagra. “Oooh, the Cuervo Gold…” New theory is maybe drug overdose, benzos plus booze. So it makes sense to the resident when, early one morning, he’s observed to be shaking a bit in his sleep. Next day a new crew comes in and someone notices the old guy ain’t moving. It’s a stroke. Which would explain the twitching. Eventually some relative appears to reveal this man had a long history of seizure. Not charted because he lied in order to keep driving or something.

        Now senior attendings are a tiny bit nervous. So the resident gets asked “why didn’t you order a head CT”. She says “because he just had one and we were working a differential for overdose”. Which is a perfect explanation and they know it. But she’s a resident and every culture has its rites of passage, so this goes in for an error report.

        But you tell me: what did this man actually die of?

        And would he have died sooner or later if he’d been more in charge of his medical decisions?

        • Rob Gressis

          I agree that some cases are hard, but there are surprising cases of medical error. When my dad was dying in hospice, one group of nurses gave him solid food despite the fact that he had had a feeding tube put in. No patient error there. And that was not the only such error with him. And that was at a good hospice.

          I wouldn’t be shocked if the left hand didn’t know what the right hand was doing at a lot of medical care facilities, especially ones that are in poor areas.

          You’re not denying that such things happen, of course. Nor are you denying that they happen very often. You’re just denying that they’re *that* common. OK. But how common do you think they are?

          (I take it you’ve read Goldhill? https://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/307617/)

          • Sean II

            That reminds me of an old Robert Klein joke:

            “I got a real grudge against the state of Florida for the murder of my parents. I moved two perfectly healthy 75 year olds down there, and ten years later THEY’RE DEAD!”

            Goldhill’s dad was 83. He was sick enough to be in the ICU for five weeks. He was there because his immune system had already died.

            The real failure of doctoring here is that no one took that guy by the shoulders and said: “It was his time. If not this way, some other.”

            The first thing to understand about medical error is: cases like that should not count. There aren’t enough life years at risk. And most of the patient’s body has already stopped cooperating with the project of survival.

            If you restrict the set properly, to people who could be healthy again, who have real time at risk, and who suffer bad outcome that could genuinely have been avoided if only someone paid a reasonable amount (but not a Greg House amount) of attention, medical error doesn’t break the top 20.

          • Rob Gressis

            Don’t forget, my family and I are really smart too. We caught the error, despite being under a lot of stress.

            That said, I would bet you’re being too dismissive of the incidence of medical error. A 2002 study I saw put the number at 100,000 people per year. A CDC study in 2016 put it at 250,000. I would bet these researchers take at least some care to take super high risk people out of the data.

            As for it being the 83 year old’s time: not necessarily. Some people live to be 90. It’s possible Goldhill’s dad would have been one of them. From what I recall, Goldhill’s dad went in for a fairly routine procedure.

            Goldhill wrote Catastrophic Care (I think that’s the title) where he makes his case in much greater detail.

          • Sean II

            1) “Don’t forget, my family and I are really smart too. We caught the error, despite being under a lot of stress.”

            You say that like intelligence runs in families or something. Madness.

            In any case I was referring to the workers, not the patients. Should have said “smart staff covers a multitude of sins”.

            2) “I would bet these researchers take at least some care to take super high risk people out of the data.”

            I would hope, but not bet on that. I’ve never seen a “medical error = high number” study that wasn’t compromised by failure to control for patient population, baseline, etc.

            It’s a widespread problem. Just as American education looks dismal until you control for demography, and then suddenly we look like Finland…so does American health care look very different once you take out people whose primary affliction is low human capital.

            And by the way: time preference is probably even more important than intellect here.

            A lot of the sickest people in our society got that way (and fail to get better) by chronically choosing some short term reward at the expense of their long term well being.

            3) “As for it being the 83 year old’s time: not necessarily. Some people live to be 90. It’s possible Goldhill’s dad would have been one of them. From what I recall, Goldhill’s dad went in for a fairly routine procedure.”

            I’m afraid you’re mistaken on that point. Goldhill’s dad came in with “the old man’s friend”, pneumonia. Why did he have it? Because his immune system gave out. Why did he then pick up every pathogen the hospital had to offer? Same reason.

            One of the key phrases in health care is “in immunocompetent persons…”. If you’re on the right side of that disclaimer, things tend to work. If you’re on the wrong side, better not pre-pay for an vacations.

            It’s actually pretty simple when you get down to it. In order to have specialization and technology in health care, you have to have centers – i.e. hospitals. By definition these will be places where sick people and their pathogens concentrate. (Maybe in some future Star Trek world with no scarcity, we can have an isolation pod for every patient. But this world isn’t that.)

            As long as we gather our sick people together in places, the ones with wholly non-cooperative immune systems will get sicker. Which they would have done on the outside anyway, but do a bit faster this way.

            If you know any doctors, you can test this wisdom. Prime them only by saying: “I’d like to get your opinion on a case of medical error so egregious it inspired a crusade. Patient was an 83 year old white male who presented with pneumonia. Once in hospital he acquired an infection…”

            Most likely you get an eye-roll right there.

            I know, because I’ve done that experiment several times this past week. Talking with you about it made me curious to know how widely shared my opinion is. So far I’ve run that story by: a pulm crit care fellow, a medicine chief, an ID attending, four senior residents, and a old ward nurse with 40 years on the job. Same response every time.

            Nurse had the funniest line: “Honey, that’s not MRSA, that’s mercy.”

    • Sean II

      There was another reply here, but when I went to answer it the page refreshed and it vanished.

      My apologies to whoever posted that. Must be some disqus glitch.

      • JVC

        I posted the following comment which was marked as spam for some reason. I’ll try again.

        “The strongest argument in play here is the one that says ‘if we let people opt out of treatments that work, we should let them opt into treatments that might work”.

        What about the arguments that say ‘pharmaceutical companies tend to take too long approve new medicines’, or ‘drugs would be available more cheaply and conveniently if there were fewer regulations’. Those seem like much better arguments.

        ‘Nearly everyone is better off just following medical advice’

        True. Wouldn’t most people continue to do so if that advice were certified privately rather than governmentally?

        “It’s actually difficult to name a less felicitous and more self destructive right. Even things like ‘the right to ride motorcycles without a helmet’ or ‘the right to eat Tide pods’ are less harmful than the right to refuse medical treatment”

        Those rights have few benefits. In this case the gains I allude to above might offset the losses to those who would use their newfound pharmaceutical freedom unwisely. Aside from the fact that any given treatment would be cheaper, and that the range of available treatments might be better if the rules governing prescription were privately determined, consider that a person who might otherwise have delayed seeking treatment until it was too under late under the current system might be induced to so in a more timely manner if, say, they could arrange a quick Skype call with their doctor and then order some drugs from Amazon. Also, there are many non-medicinal and quasi-medicinal uses of drugs which are denied to people under current drug laws. In some cases facilitating those uses would be on the net beneficial, and in others not.

        It seems that the cost and benefits of drug deregulation are very difficult to quantify given the available empirical evidence.

      • JVC

        Ok, I think I’ve figured out what the cause of the glitch was (it doesn’t like it when it when I edit my mistakes after posting). So here’s the comment again:

        “The strongest argument in play here is the one that says ‘if we let people opt out of treatments that work, we should let them opt into treatments that might work”.

        What about the arguments that say ‘government regulators tend to be overly cautious in approving new medicines’, or ‘drugs would be available more cheaply and conveniently if there were fewer regulations’. Those seem like much better arguments.

        ‘Nearly everyone is better off just following medical advice’

        True. Wouldn’t most people continue to do so if that advice were certified privately rather than governmentally?

        “It’s actually difficult to name a less felicitous and more self destructive right. Even things like ‘the right to ride motorcycles without a helmet’ or ‘the right to eat Tide pods’ are less harmful than the right to refuse medical treatment”

        Those rights have few benefits. In this case the gains I allude to above might offset the losses to those who would use their newfound pharmaceutical freedom unwisely. Aside from the fact that any given treatment would be cheaper, and that the range of available treatments might be better if the rules governing prescription were privately determined, consider that a person who might otherwise have delayed seeking treatment until it was too under late under the current system might be induced to do so in a more timely manner if, say, they could arrange a quick Skype call with their doctor and then order some drugs from Amazon. Also, there are many non-medicinal and quasi-medicinal uses of drugs which are denied to people under current drug laws. In some cases facilitating those uses would be on the net beneficial, and in others not.

        It seems that the cost and benefits of drug deregulation are very difficult to quantify given the available empirical evidence.

        • Sean II

          1) “What about the arguments that say ‘government regulators tend to be overly cautious in approving new medicines’, or ‘drugs would be available more cheaply and conveniently if there were fewer regulations’. Those seem like much better arguments.”

          Those are good arguments, but they don’t get you to an individual right to self-experiment.

          They just suggest a different regulatory regime.

          2) “Wouldn’t most people continue to [just follow medical advice] if that advice were certified privately rather than governmentally?

          Almost certainly.

          3) “Those rights have few benefits. In this case the gains I allude to above might offset the losses to those who would use their newfound pharmaceutical freedom unwisely.”

          No, in the general population idiots outnumber smart rational people by a wide margin. As Penn Jillette says: you can measure the amount of freedom by the amount of stupid.

          We should be honest and up front about this.

          The vast majority of people who try to medically innovate with their own body for a lab will end of hurting themselves.

          4) “…the current system might be induced to do so in a more timely manner if, say, they could arrange a quick Skype call with their doctor and then order some drugs from Amazon.”

          Okay, but that only path to that is massive liability reform. It’s not the greed of doctors that makes them afraid to prescribe a measly 800 of motrin without first having you visit the office.

          It’s the lawyers gave us that.

          5) “Also, there are many non-medicinal and quasi-medicinal uses of drugs which are denied to people under current drug laws. In some cases facilitating those uses would be on the net beneficial, and in others not.”

          Sure, off-labelling is a decent work around. And since we will never get rid of the FDA, we could maybe corrupt it over time by getting more drugs approved for bullshit reasons and then off-labelling them into something useful.

          That at least sounds like the sort of civic compromise that could actually happen under our system of government. Because lord knows nothing is ever going to get outright abolished.

          6) “It seems that the cost and benefits of drug deregulation are very difficult to quantify given the available empirical evidence.”

          Yeah, pretty much. If we could do that trick, we’d probably be able to make central planning work. But of course we can’t.

          • JVC

            You clearly know much more about this topic than I do, so I’ll just respond to a few of your points.

            ‘Those are good arguments, but they don’t get you to an individual right to self-experiment.’

            It seems to me like there are some significant efficiencies which could only be achieved by allowing a right to self-experiment. In order to enforce the absence of such a right we need to officially licences doctors, prevent anyone else from prescribing medicines, and stop people from selling medicines to people who don’t have a prescription. All of those processes will make medicines and medical services cost more and make the process of obtaining them more cumbersome.

            Also, it’s struck me that people sort of already have the right to self-experiment at the moment. It’s called ‘alternative medicine’.
            Maybe extending that right towards more substances would mainly just shift the business models of the swindlers who sell those kinds of products towards providing things that science says might work (but perhaps are more dangerous), in place of things that science says almost certainly don’t work.

            ‘No, [the losses to unwise drug users would not be offset by various efficiency gains]. In the general population idiots outnumber smart rational people by a wide margin. As Penn Jillette says: you can measure the amount of freedom by the amount of stupid’.

            I’m a little confused by your reasoning process here.
            Doesn’t your response to (2) imply a concession that these ‘idiots’ who would make bad choices would be a relatively small number of people.

            And it’s not clear how the proportion of ‘idiots’ in a population helps to predict the consequence of more pharmaceutical freedom. We need empirical evidence about the various determinants, including intelligence or whatever else ‘idiot’ captures, of whatever dumb behaviours might ensue in response. ‘Idiots’ are probably disproportionately likely to get too stoned and resultantly crash their cars, but that doesn’t imply that more legal weed will create a car crash epidemic.

            A major determinant of how people might respond to increasing drug accessibility would likely be the evolution of social norms which would occur as a result. Many people, smart and dumb alike, avoid alcoholism not because they think carefully every night about the costs and benefits of chugging a bottle whiskey and conclude against it, but because it would never even occur to them to have a drink outside of socially sanctioned occasions for drinking.

            ‘Yeah, pretty much. If we could do that trick, we’d probably be able to make central planning work. But of course we can’t.’

            At the risk of being pedantic, I think not. To the extent that central planning indeed does not work it’s also because even when the best policy is reasonably clear in some broad sense, as sometimes is the case, political actors are often neither smart enough to see why it’s the best policy, nor appropriately incentivised to go about trying to discover that it is, nor incentivized to implement it if they did know.

        • Sean II

          Hey, I think it happened again. I saw a reply from you to my latest comment but when it came back to answer it was gone.

          Any chance you saved a copy to re-post?

          • JVC

            Conveniently enough, my comment history saves them for me. So here’s the comment again:

            You clearly know much more about this topic than I do, so I’ll just respond to a few of your points.

            ‘Those are good arguments, but they don’t get you to an individual right to self-experiment.’

            It seems to me that there are some significant efficiencies which could only be achieved by allowing a right to self-experiment. In order to enforce the absence of such a right we need to officially licence doctors, prevent anyone else from prescribing medicines, and stop people from selling medicines to people who don’t have a prescription. All of those processes will make medicines and medical services cost more and make the process of obtaining them more cumbersome.

            Also, it’s struck me that people sort of already have the right to self-experiment at the moment. It’s called ‘alternative medicine’.
            Maybe extending that right towards more substances would mainly just shift the business models of the swindlers who sell those kinds of products towards providing things that science says might work (but perhaps are more dangerous), in place of things that science says almost certainly don’t work.

            ‘No, [the losses to unwise drug users would not be offset by various efficiency gains]. In the general population idiots outnumber smart rational people by a wide margin. As Penn Jillette says: you can measure the amount of freedom by the amount of stupid’.

            I’m a little confused by your reasoning process here.

            Doesn’t your response to (2) imply a concession that these ‘idiots’ who would make bad choices would be a relatively small number of people?

            And it’s not clear how the proportion of ‘idiots’ in a population helps to predict the consequence of more pharmaceutical freedom. We need empirical evidence about the various determinants, including intelligence or whatever else ‘idiot’ captures, of whatever dumb behaviours might ensue in response. ‘Idiots’ are probably disproportionately likely to get too stoned and resultantly crash their cars, but that doesn’t imply that more legal weed will create a car crash epidemic.

            A major determinant of how people might respond to increasing drug accessibility, would likely be the evolution of social norms which would occur as a result. Many people, smart and dumb alike, avoid alcoholism not because they think carefully every night about the costs and benefits of chugging a bottle whiskey and conclude against it, but because it would never even occur to them to have a drink outside of socially sanctioned occasions for drinking.

          • JVC

            Disqus, f**ck off please. This comment is not spam:

            You clearly know much more about this topic than I do, so I’ll just respond to a few of your points.

            ‘Those are good arguments, but they don’t get you to an individual right to self-experiment.’

            It seems to me that there are some significant efficiencies which could only be achieved by allowing a right to self-experiment. In order to enforce the absence of such a right we need to officially licence doctors, prevent anyone else from prescribing medicines, and stop people from selling medicines to people who don’t have a prescription. All of those processes will make medicines and medical services cost more and make the process of obtaining them more cumbersome.

            Also, it’s struck me that people sort of already have the right to self-experiment at the moment. It’s called ‘alternative medicine’.
            Maybe extending that right towards more substances would mainly just shift the business models of the swindlers who sell those kinds of products towards providing things that science says might work (but perhaps are more dangerous), in place of things that science says almost certainly don’t work.

            ‘No, [the losses to unwise drug users would not be offset by various efficiency gains]. In the general population idiots outnumber smart rational people by a wide margin. As Penn Jillette says: you can measure the amount of freedom by the amount of stupid’.

            I’m a little confused by your reasoning process here. Doesn’t your response to (2) imply a concession that these ‘idiots’ who would make bad choices would be a relatively small number of people?

            And it’s not clear how the proportion of ‘idiots’ in a population helps to predict the consequence of more pharmaceutical freedom. We need empirical evidence about the various determinants, including intelligence or whatever else ‘idiot’ captures, of whatever dumb behaviours might ensue in response. ‘Idiots’ are probably disproportionately likely to get too stoned and resultantly crash their cars, but that doesn’t imply that more legal weed will create a car crash epidemic.

            A major determinant of how people might respond to increasing drug accessibility, would likely be the evolution of social norms which would occur as a result. Many people, smart and dumb alike, avoid alcoholism not because they think carefully every night about the costs and benefits of chugging a bottle whiskey and conclude against it, but because it would never even occur to them to have a drink outside of socially sanctioned occasions for drinking.