Ever since the "marginal revolution", economists have sought to "think on the margin". Health care people buy for themselves is our starting point, and then granting them free health insurance causes them to consume additional healthcare, making that marginal healthcare. You could also reverse that if there were some kind of tax on healthcare imposed on people, then the healthcare they previously consumed but now forego could be considered marginal.
Actually, you need to re-read too perhaps. The first paragraph in this article contains: """It would be easy to round Hanson’s position off to something weaker, like “extra health care isn’t valuable on the margin”. This is how most people interpret the studies he cites. Still, I think his current, actual position is that medicine doesn’t work. """
"Let us now summarize and interpret these results. Medicine is composed of a great many specific activities. Presumably some of these activities help patients, some hurt patients, and some are neutral. (Don’t believe medicine can hurt? Consider the high rate of medical errors, and see the Fisher & Welch Journal of American Medical Association 1999 theory article.)
We have observed many kinds of disturbances which change the distribution of medical activities, such as variations in local medical culture, local wealth levels, medical prices, and so on. Taken at face value, our inability to see much health impact from the disturbances we have observed suggests that such disturbances increase or decrease helpful and harmful medicine in roughly equal amounts.
This in turn suggests that if we were to reduce medical spending via a disturbance similar in character to the types of disturbances we have observed, such a spending reduction would also reduce helpful and harmful medicine in roughly equal amounts. The claim is not that there would be no harmful health effects of such a policy, but rather that harmful effects would be roughly balanced by helpful effects. And the claim is not that harmful and helpful effects would exactly balance, but rather that any net health harm will be small compared to the health gains possible by spending the savings on other health influences, and to the utility gains possible from spending the savings in other ways.
How much could we cut? For the U.S. it seems reasonable to project the 30% cut in the RAND results to a 50% cut, since the U.S. spends so much more than other nations without obvious extra health gains. I thus claim: we could cut U.S. medical spending in half without substantial net health costs. This would give us the equivalent of an 8% pay raise."
Scott also says that the reason he responded is because he learned Bryan Caplan takes Hanson seriously on the topic. This is what Byan actually wrote:
"The idea that the quality of health care has improved is already almost universally accepted. Economists who argue that healthcare expenditures are wasteful are self-consciously challenging this standard view, highlighting surprisingly strong evidence that marginal medicine fails to improve health. See Robin Hanson’s “Cut Medicine in Half” for details."
Years ago in the Atlantic there was a cover story about healthcare as a percentage of GDP, and how money might be spent on other things a society might value. If that is all Hanson is saying it’s not terribly contrarian? Although someone like Tyler Cowen with his Candide-like complacency would assume we spend exactly the amount we like to spend and are signaling our enjoyment of healthcare.
But the trio’s rhetorical default is provocation without regard for absurdity.
Behavioural change often works very well but is REALLY HARD to implement both individually but especially on a societal level. Medical interventions provide often much more realistic a solution (cases in point: obesity, blood pressure, psychosocial correlates of much psychiatric stuff) if not ideal.
I am skeptical whether Hanson really believes what he's saying with real confidence.
If he has a significant bacterial infection, would he not take antibiotics? If he develops a treatable cancer, will he reject modern medicine? I sincerely doubt that would be the case. Revealed preference would be telling in that situation.
His stated idea is that he would be buying the socially approved experience of feeling cared for by a high status person, and acting out the cultural script about what he is supposed to do in the case of an illness, and that the whole belief about effectiveness is just a screen to justify the real reason he is doing these things.
So the revealed preference of his behavior is wholly consistent with his model that medical purchases are about getting something different than better health.
Having said that, I'm pretty confident he would actually want the antibiotics because he thinks they actually kill the bacteria, and he would actually want the chemo because he thought it worked if the clinical studies seemed to robustly claim that it worked -- my model of Hanson also does do what I would do, and actually read the clinical studies at some point before getting injected with the drugs.
"His stated idea is that he would be buying the socially approved experience of feeling cared for by a high status person, and acting out the cultural script about what he is supposed to do in the case of an illness, and that the whole belief about effectiveness is just a screen to justify the real reason he is doing these things."
Okay, then I'm sure we can source a witchdoctor for the next time he has the megrims.
Even so, having *some* kind of painkiller is better than nothing. Undergoing severe pain with no relief at all is not doing any good to anyone. There are problems we don't have the answer to yet, but that is not to say that medicine doesn't work.
I get the feeling Hanson may be arguing something completely different - does having health insurance make a population healthier or not? - but he can't resist making a big (dumb) argument; this is the guy with the "gentle rape" thought experiment, after all:
"Regular docs are mostly in it for the money, and are also hard to evaluate. If we on average get near zero health from our last units of medicine, we are better off replacing those units with anything cheaper, at least if it also gives near zero net health effect and similar non-health benefits. Faith healing seems to fit this bill"
This is a completely self-defeating argument since he can't claim to a) understand the irrational unconscious forces that drive his behaviors and b) still be subject to them. At some level anyone who expects to be taken seriously has to present themselves as a self-consistent rational actor (at least on the subject they're talking about), otherwise they can be dismissed on the theory that their argument isn't actually the result of their honest beliefs but is the result of subconsciously adhering to the socially approved experience of being a contrarian public intellectual.
If you take the "everything is signaling" argument to its logical conclusions then the very prospect of rational debate collapses in a cloud of nihilism. Either accept that people CAN, on some level, respond rationally to the propositional content of an argument, or live the reality of rejecting it by shutting the hell up and doing whatever it is that stimulus-response automatons do. Sorry, but it's not elephants all the way down.
> he can't claim to a) understand the irrational unconscious forces that drive his behaviors and b) still be subject to them
Why? That's like saying you shouldn't be affected by gravity if you know how it works. Sure, you can do things to alleviate its affects, but it obviously still exists. And if you're only going to take people who are "self-consistent rational actors" seriously, then you can't take ANYONE seriously, because there is no human on Earth that could fulfill that description. Everyone sure as hell pretends, but their actions (in)consistently prove otherwise.
And yes, "rational debate" is somewhat of an oxymoron, but that doesn't mean there isn't truth to be found. Truth leads to understanding of the world, and that leads to power. And power is indisputable.
Is it really that important if humans are "rational" creatures are not? These "stimulus-response automatons," as you would call them, live, work, fight, and die, all while accumulating more and more power despite not even being able to directly observe reality. I personally find that beautiful. Don't you?
Perhaps a more precise way of stating it would be that he can't a) claim that his economic behaviors are dictated by social pressures but b) that his expressed opinions are not. And if his opinions are just an avatar of some socially-mediated subconscious consensus then there's no reason for me to listen to him at all - or anyone else for that matter.
>that doesn't mean there isn't truth to be found
Yes it does. If all behavior is social signaling then the only truth that can be discovered are truths about the structure of social signals. Sorry, but I'm only interested in the propositional content of arguments, not the subtextual implications that they may or may not imply.
"Either accept that people CAN, on some level, respond rationally to the propositional content of an argument, or live the reality of rejecting it by shutting the hell up and doing whatever it is that stimulus-response automatons do."
False dichotomy. Hobbies don't have to be useful, they just have to be fun. Debate is a fun hobby for a lot of people. This is only nihilism if I accept your world view, where you think the Marketplace of Ideas is drives human behavior and not vice versa. I have a different world view so trivializing rationality and debate isn't nihilistic in the slightest. My deepest held biases against pedophilia, incest, murder, slavery, monarchism...these principles aren't subject to rational debate, so they are invulnerable. Whereas the true believer in Rational Debate could hypothetically be talked out of one of these taboos by a better debater. So which side is more vulnerable to nihilism?
I think his point is not that all medicines do not work but rather some help and some hurt and they mostly cancel out. If that’s the case, “medicine” as a system is net zero EV but a drug or treatment can be very positive.
I am trying to reconcile this skepticism with his proposal to infect volunteers with low doses of covid before we had vaccines.
On one hand we have willingness to engage in radical medical intervention on positive EV suspicions supported by some but by no means iron clad evidence.
On the other hand wants to dismiss all medical literature because of p hacking. How does he decide what evidence he is willing to consider?
It feels like the anti-evolution people separating out 'micro evolution' (white moth to black moth) vs macro evolution (fish to monkey).
Sure, if we separate medicine into ones with large immediate effects, and those with marginal long term effects, the second group doesn't look as dramatically helpful. Not sure that says anything at all, and leads to his silly conclusion.
I think there’s something potentially meaningful here. If antibiotics and vaccination worked, but literally everything else medicine did was useless, then there would be some reasonable sense in which you could say “medicine basically doesn’t work”. Similarly, if someone owns stock worth billions and billions of dollars, but has literally no other financial assets (no house, no car, no income, no savings), then if there’s some reason they couldn’t sell their stock, there would be a meaningful sense in which they are poor. Theres a concept of being “house rich, cash poor”, where someone takes on too big a mortgage and has to pile all of their earnings into the monthly payments, and although their net worth goes up (particularly if there’s a boom in the housing market), they can’t actually access most of that wealth unless they move.
If nothing in medicine works besides antibiotics and vaccines, that seems like a surprising and notable result that people should talk about. Quibbling about the exact words used to describe this result doesn't seem super beneficial.
I don't think that only antibiotics and vaccines work. But I do think that it's pretty uncertain to point to any random medicine and say, "This definitely works."
"No True Scotsman" is always a matter of degree. If someone keeps finding a new reason to reject every proposed counterexample, and there's no particular pattern to those reasons, then it's suggestive that their general principle isn't really very general.
But conversely, there's also the "exception that proves the rule" phenomenon. If I propose that all Scotsmen do X, and the only counterexamples you find are Scotsmen who moved to Paris at age 10 and lived there for 20 years before moving back, or Scotsmen who have been obsessed with anime their whole lives and visit Japan for a month every year, then it's suggestive that there's something meaningful here connected to nationality and attachment to the nation, even if it's not quite universal.
I personally think that Hanson is more on the "No True Scotsman" side, but it's always useful to have someone arguing the contrarian null hypothesis, just to push people to be more clear about measuring the real signal.
Then what *is* he arguing against? Blood pressure medication? Metformin? Anti-cancer chemotherapy? Gall bladder surgery? Removal of kidney stones? Obstetrics? Appendectomies?
Antibiotics were first used in medicine in the 1940s, and Insulin in 1922. The "Medical Nihilism" view is antibiotics, insulin, painkillers, and trauma care are valuable and substantive, but the valuable part of medicine is at most 20% of the medicine purchased. And Scott's pretty charts are all about the "benefits" and don't show the costs. No, I would not be impressed by his chart that blood pressure medication would lower my chance of dying by 1% in the next five years. That is a meaningless aggregate figure. There are a 100 other more important personal variables that effect my survival outcome, and anyway I would not trade sexual potency and other well-being factors for a 1% less chance of dying in the next five years.
The bailey is suggesting alternatives with even weaker evidence, since they don’t have medicine’s institutional baggage.
I’m not sure the latter describes Hanson, who does address the difference between “core” and “extra” care. He doesn’t appear to be grifting with an acupressure company or something, either. I still think it makes for bad epistemology.
Also, conditions that used to be routinely fatal, for which we have diverse novel interventions: appendicitis, type I diabetes, and end-stage renal disease leap to mind. Iatrogenic harm could conceivably balance these out, but is that the argument Hanson is making? It would also be odd if we had a smattering of high-quality, routinely life-saving interventions sprinkled amongst a bunch of neutral or harmful trash, produced by the same institutions using similar methods of discovery and evaluation and the same biological knowledge base. I think the prima facie conclusion to draw from the obviously life-preserving interventions is that less obviously life-preserving interventions which have the mentioned continuities are probably also mostly helpful.
Okay, now if THIS were what Hanson is arguing against, I'm inclined to agree with him: I DO think the situation you describe as "odd" is pretty much true. Terms like "smattering" and "sprinkled" might be a bit of an exaggeration, but I think there IS plenty of neutral or harmful trash produced by the same institutions that produce the good actually-life-saving stuff.
Agreed, much in the way that drug companies benefit from a few blockbuster drugs supporting a vast sea of unprofitable drugs, it's not unreasonable to suspect that the goodwill of modern medicine is propped up by a few blockbuster therapies supporting a sea of modestly effective/ineffective treatments (e.g. migraines)
More than just antibiotics and (many) vaccines, I'd say painkillers, insulin, many (most?) surgeries, most cancer treatments, some cardiac stuff (blood thinner, defebrillators, that kind of thing), are also good.
The "20% of GDP" is just rent-seeking enabled by the FDA/DEA and the doctors' cartel. It is possible to get much better quality medical care for much cheaper.
Yeah. My kid developed some horrific abscess in his finger while we were on a trip. Overnight he developed a fever. We took him to urgent care the next morning for abx and to drain it. They charged $175 but were concerned he'd need IV anti-biotics so they refused to do anything and sent us to the ER. We thought that was not really necessary but took him to the ER anyway since the one doctor within 100 miles wasn't going to help us.
Thankfully, the ER agreed he did not need IV abx and gave us oral abx. They also drained his finger. He was there 2 1/2 hours total, mostly waiting. They've billed us... $4500 for this with a straight face.
Has Robin ever talked to a doctor or been ill? I need someone to explain to me why this isn't the stupidest thing anyone has ever said. Myself and my girlfriend have both had simple surgeries for life threatening problems, we'd both be dead without medicine.
I think his claim is that while medicine probably has some clear victories, it also probably kills some people through side effects, so it's hard to say whether it's on net good or bad, and we can't easily distinguish the good parts from the bad parts. See the casino quote early in the article.
That's still kind of absurd. Yes, there are some treatments of ambiguous value, but there are tons of examples of conditions with roughly 100% mortality rates when untreated and nearly 0% when treated promptly: type 1 diabetes, ruptured appendix, adrenal crisis, ectopic pregnancy, HIV infection...the idea that one somehow can't tell that medicine works to treat these conditions, or that one can't distinguish treatments like insulin and appendectomies from the pool of treatments with more complex cost-benefit equations, is silly.
These are not good examples to criticize a study of insurance over for the obvious reason that they'll get treated regardless of whether the patient is insured.
For the same reason, they do not provide much of an argument for expanding insurance coverage.
Hanson doesn't make that argument. Scott provides a long quote from Hanson. Here's what he says about the seventeenth century:
> Europeans in 1600 likely prided themselves on the ways in which their “modern” medicine was superior to what “primitives” had to accept. But we today aren’t so sure: seventeenth century medical theory was based on the four humors, and bloodletting was a common treatment. When we look back at those doctors, we think they may well have done more harm than good.
Here's what he says about the modern day:
> When we look at our own medical practices, however, we tend to be confident we are in good hands, and that the money that goes to buying medical care – in 2020, it was 19.7% of our G.D.P. – is well spent.
> We believe in medicine, and this faith has comforted us during the pandemic. But likewise the patients of the seventeenth century; they could probably also have named a relative cured by bloodletting. Yet health outcomes are typically too random for the experience of one family to justify medical confidence. How do we know our belief is justified?
> This might seem like a silly question: in Europe of the seventeenth century, the average lifespan was in the low 30s. Now it’s the low 80s. Isn’t that difference due to medicine? In fact, the consensus is now that historical lifespan gains are better explained by nutrition, sanitation, and wealth.
> surely modern science must have some reliable way to study the aggregate value of medicine? Yes, we do. The key is to keep a study so simple, pre-announced, and well-examined that there isn’t much room for authors to “cheat” by data-dredging, p-hacking, etc. Large trials where we randomly induce some people to consume more medicine overall, and then track how their health differs from a control population
The seventeenth century is characterized by medicine doing "more harm than good". The modern day is characterized by the money spent on medicine "being well spent". That point is in dispute, and Hanson is pretty clearly correct to disagree with it.
You don't need to rely on Scott's weird interpretation of Hanson's argument when Scott leads off by quoting Hanson.
Hanson is making a mistake when he refers to "inducing some people to consume more medicine" as a way to study the aggregate value of medicine. It's a way to study the marginal value of medicine. Given a study that allows people to boost medicine consumption from low to normal levels, though, it does tell you a lot about the aggregate value of normal levels of consumption.
I'm not sure long-term diabetes care or HIV care will be given regardless of insurance status and/or that it will be the same effective care you'd get with insurance, compared to how you'll definitely get an appendectomy.
Once I tried to find info about outcomes on untreated appendicitis, and didn't find any good. I think it could be as well closer to 50% than 100%. If one gets perforated appendix, then it manages to heal, doctors could claim as well it was never perforated to start with and also doctors often handwaive conditions which just decrease QoL.
"so it's hard to say whether it's on net good or bad, and we can't easily distinguish the good parts from the bad parts"
Okay, so I can't swear on here, but I'll tell Robin how we figure out "is medical care on net good or bad?" and we look at what happens when people don't get medical care.
They die.
Siblings of my mother died young because of lack of medical care. Is cosmetic surgery to give you zeppelin sized breasts on net good or bad? I'd say bad, but if we're talking about "gee, is chemotherapy for cancer good or bad?" then fuck yeah, Robin, if the cancer is found in time. Yeah, chemotherapy and radiotherapy are terribly hard on the patient, but if the cancer is too far advanced for these procedures to help, then the end is not a happy one and it's damn easy to see "is it on net good or bad to have this done?"
Well, had my mother's cancer been found before it was too goddamn late to do anything about it, maybe she wouldn't have died within four months of diagnosis. Even if she only got a few extra years of life, my family would have considered it worth it.
Looking at the linked post, I'm going to disagree here:
"All tumors start in a target organ (breast, lung or colon). The first grow slowly and are unlikely to shed cells elsewhere. These are not going to kill you in your natural life. You might feel them with your hand someday and cut them out, but even if you didn’t, you have nothing to worry about.
The second are those that spread microscopic cells very early on. Even if you find them when small, they have seeded other organs. There is almost nothing you can do to avoid dying by this cancer short of removing all your organs prophylactically— but then you have other issues. If you find this tumor and cut it out and take chemo— you still die of that cancer— but with a few more surgeries and more time on chemo than had you found it later.
The third type of tumor is the tumor that starts in the target organ, and was going to spread, and going to kill you, but because you find it and cut it out, you live much longer than you otherwise would. This is what we want to find!
Now consider that all three are indistinguishable under the microscope. All get the same treatment— surgery, radiation, and chemotherapy.
The problem is that finding tumors #1 and #2 is not good for you. You are subject to surgery, radiation and chemotherapy that you don’t need. These interventions can improve survival when done appropriately, but when done on people who don’t need them, result in a net loss of survival. Your life is shorter and worse off if you got these treatments when you can’t benefit."
Absolutely had my mother's fatal lung cancer been Tumour Number Two, it would have been worth it. She would have grabbed at any extra months of life, because she was terrified of dying. It's easy to go "theoretically in a hypothetical case, you might as well just forego the chemo and die naturally" but not when it's happening to *you*.
Things like whole body MRI probably are overkill and not worth it, but that's a different case. That's "I have enough money to spend on worrying about my health, without having anything seriously wrong" and having hospitals out there willing to do such procedures because it generates profit.
How about polygenic selection of embryos:? Is that going too far to try and prevent possible cancers? What about having mastectomies in case you later develop the breast cancer that is prevalent in your family? One person's 'overdiagnosed' is another person's 'vital preventative intervention'.
His trichotomy of tumors isn't even accurate. Both my cousin and uncle have had cancers where the tumors have spread to multiple places: too many to cut out, especially of sensitive areas like the heart. It was the radiation and chemo that saved them both.
This analysis is nowhere near sophisticated enough to be convincing to Robin; you need to not just identify the effects on one side of the scales but clearly be balancing it against the effects on the other side of the scales, to see which is larger.
If we count influential nutritionist scientists changing how we eat by publishing flawed or fraudulent work (Nicholai Anichkov and Ansel Keyes, for two - without mentioning 'smoking is healthy') they're killing us in droves (and only sometimes surgically delay the deaths they cause).
The casino quote doesn't make this clear at all, and in fact suggests a different situation altogether. If casinos had some games that were winners over time and others (like slots) that were obvious losers, it would be a better analogy for a mixed bag of excellent, neutral, and harmful interventions. Casino winners don't pick good games--possibly excepting a handful of expert card players, they just get lucky.
Eyeballing things Hanson has written, that seems to be the case - the contrarian portion of his position isn't that he thinks no modern medicine works; it's that he has an unusually high estimate of how much modern medicine is actively harmful.
This is a little weird, because it means that medicine, by this argument, is effective in some countries with much lower GDP - where the money is spent on the "easy wins" like antibiotics, vaccines, insulin, removing cancerous tumours, etc. Medicine is only ineffective when it's 20% of GDP.
Depending on your own lifestyle and a little luck, I can see how some people can get the idea that medicine is useless. If you're broadly healthy and take very few physical risks, there is just no good reason to visit a doctor. For myself, I literally don't remember the last time I visited one; It's probably half a decade ago or so? Most medication I get from the pharmacist is QoL-improving and I take it quite rarely, but the headache I'm suppressing is not going to kill me without it anyway. Among acquaintances, I know several older people who got treatment for something non-life-threatening, and then died in a way that is likely related to the treatment (knee and hip surgeries -> infection mostly). For these reasons, I actually agree with a version that says roughly, if your life isn't threatened or otherwise seriously compromised, don't go to the doctor, they're almost as likely to make it worse than they are to make it better.
But nevertheless, I agree that looking at medicine comprehensively it's hard to conclude that it is net-neutral. Surgeries for serious physical injuries, tumor removal and similar is certainly a big one. Antibiotics is another. Vaccinations as well.
> Depending on your own lifestyle and a little luck, I can see how some people can get the idea that medicine is useless. If you're broadly healthy and take very few physical risks, there is just no good reason to visit a doctor.
Well, do such people not have any older relatives?
Did you not read the second part of that paragraph? Questionable treatments are common enough among older people so that if you're not paying much attention or do deliberate statistics, you can get away with the impression that it's hurting as much as helping. Especially if your older relatives, like you, are disproportionally healthy as well (which is quite likely, bc this tends to run in the family, be it through nature or nurture).
To give another example, my late grandma was quite healthy for most of her life and never really visited a doctor. She got a serious fungal infection in old age that probably would have killed her pretty fast, but at least we have modern medicine! Except instead she got stuck in the hospital afterwards and slowly withered away over months. Not only was this very expensive, but she also was barely aware of anything, and complained about pain when she was. It's hard to say that this was preferably to dying quickly, let alone a good use of money in cost-adjusted QALY. And these aren't just cherry-picked, these are as common, if not more common, than medical success stories among my acquaintances and family.
I think some of these arguments separate surgery from medicine. Which should be the default assumption because if someone says "I'm going to take some medicine tomorrow" you would be extremely surprised if it turned out they meant "I'm going to hospital to have surgery".
I'm still not fully convinced Hanson's original post isn't actually a satire about expensive, poorly done studies on medical effectiveness rather than a genuine argument against medicine -- in the spirit of the famous BMJ study that showed that parachutes were not effective in preventing injuries when jumping from a plane https://www.bmj.com/content/363/bmj.k5094. When he writes "It seems we have three options: we can stick our head in the sand and ignore this unwelcome news, we can accept the difficult truth that medicine just isn’t that useful, or we can hope there’s some mistake here and check again. A mere 0.1% of U.S. annual medical spending, or $4.2 billion, could fund a far larger experiment, and hopefully settle the matter. What do you choose?" That isn't really intended to provoke a response of "oh yes, this op-ed has totally convinced me that we should spend $4.2 billion on a study of medical effectiveness, otherwise I just can't be sure if it's not a waste of money to vaccinate babies," is it?
This is easily resolvable by viewing life saving surgery as an extremely small fraction of medicine. Most medicine is people who feel somewhat under the weather being prescribed antibiotics, or fat people being prescribed to not be fat. These things largely shouldn’t be grouped together in analysis.
So I see your point but I do not think you meaningfully interact with what Hanson is saying - in fact it seems like what he brings forward does not effect how you respond to him at all. Even if we can grant that the maximum application of his thesis is just obviously incorrect by no other metric than the successful eradication of certain infectious diseases or things like soft-tissue repair, that does not invalidate everything he has said. That being said, if you are charitable with the person you are responding to, then certainly you should be given pause that for all the praise of modern medicine there are massive problems.
The chemical-imbalance theory of clinical depression has always been controversial and now that the theory is losing support you can only look out into the aftermath of prescribing people so many of these different anti-depressants to see the problems.
How many people were potentially harmed by following the tau theory in Alzheimer's?
How many women have been harmed by the overuse of C-sections for routine pregnancies?
How much medicine has been developed to treat diseases brought about by poor lifestyle choices like obesity or malnourishment from eating processed foods with no nutrients?
Medicine in America is run like a business, and that has some major problematic implications so your response comes off as being dangerously defensive of what may in fact be indefensible.
I think you are doing a mood affiliation thing where you say there are some things you don't like about medicine, and therefore all anti-medicine claims are correct regardless of their literal content.
Except my post didn't say anything close to that at all - there is no need to be defensive if someone points out that you are being uncharitable to someone making a point about something by only attacking the maximal and almost absurd interpretation of what they are saying. In fact based on how quickly you replied I question if you actually read my response or just quickly skimmed over it and made some unfortunate assumptions.
Also this is not at all an attack on your content that you links (and thank you for that) but aren't posts from 9 years ago somewhat dated? Do you think they accurately reflect what is being discussed in regards to the chemical imbalance theory in the current moment?
I haven't seen any change in the argument in the past nine years that has led me to update that post. Part of the issue with how people present this is that they always talk about "we've learned it's not chemical imbalance!" as some kind of new discovery or crumbling orthodoxy, whereas in fact people have been talking about the ways "chemical imbalance" does vs. doesn't describe the territory for as long as anyone has used the term, usually with approximately the same arguments.
Are arguments data? Because certainly in 9 years (ages in some sciences) the data has been updated. Also by your statement in those posts you were new to the field - are you telling me in 9 years you have gained or seen nothing new?
You're talking about the chemical imbalance argument, which is a mostly philosophical argument about how to think about depression and its treatments given the facts we know. I hope those two articles will explain what I mean by that.
Do you have an actual argument or are you just going to vaguely hint at stuff? If you think that modern medicine is indefensible then just say so and support it with facts.
(Also the irony of you accusing Scott of being defensive given your later posts here.)
>Even if we can grant that the maximum application of his thesis is just obviously incorrect ... that does not invalidate everything he has said.
No-one has ever claimed that. It seems like you clicked on an article called "Contra Hanson On Medical Effectiveness" and expected it to be about your own hobbyhorses instead of about a counterargument to Hanson. It's rather weird.
Ok I will assume this is an honest question unlike some of the other commenters here: I am disagreeing with how Scott addresses the issues brought up by Robin in this post. Dr. Alexander's was completely uncharitable with the points raised by Robin and seems to be attacking an argument that is not being credibly made so that those points do not have to be addressed - even if Hanson is ultimately wrong, it is hard to discern that when the engagement is not honest or charitable.
It was indeed an honest question. You sort of answered it, but only vaguely. "attacking an argument that is not being made" ... I understand what claim he is attacking (medicine is, on net, not useful.) Are you saying Robin makes no such claim? But Scott quoted him extensively here, so you can't say the quotes are out of context, right? And he seems to be saying that. So where is the lack of charity? It seems he went through Robin's claims one at a time and for each explained "here's why I'm not convinced". What am I missing?
What opinion are you suggesting that people change? Are you just saying that people overestimate how well doctors and researches understand physiology (a claim I agree with), or is there more to your argument that I'm not seeing?
The only way in which people have been harmed by following perhaps-wrong theories of Alzheimer's is the opportunity cost of pursuing other theories which could lead to effective interventions, an argument which concedes the effectiveness of medicine.
That is not the only way people are and were harmed - both Tau and AB have produced therapies that failed in various stages of trials and in some cases accelerated neurodegenerate decline or produced medically significant side-effects. What made you argue this point which is not close to true at all?
Yes, it is not literally true that this is the only way that people have been harmed in the process of researching drugs that didn't pan out. Because you highlighted the harm in the context of following a particular theory, as opposed to the harms of doing clinical research in general, I assumed you meant the harms /differentially/ caused by following a particular theory that has yet to pan out, and weren't just gesturing at the fact that clinical research can cause harm. Is there something else going on the case of research into tau in ALZ that makes the case worth pointing out?
Honest question, I thought tau theory was more popular now, and amyloid fibril theory was wrong? As for the damage caused by amyloid plaque theory, Aducanumab was pretty worthless but not very harmful and not many took it.
Unnecessary C-sections suck, but they cause serious harm to very few people. Necessary C-sections prevent many infant/maternal deaths. If the best you have against medicine is Aducanumab and some C-sections, that's a weak case.
Finally, I eat junk food because it tastes good, not because statins have been invented. I expect the same is true for pretty much everyone else who eats junk food. Notably poor people with the least healthcare access eat the most junk food, suggesting that medicine is not the cause of people eating bad stuff.
The Tau theory is certainly most interesting now that Amyloid-Beta seems to have faced intense scrutiny, but it is also old (nearly 40 years) hypothesis that has had its own string of therapeutic failures so going back to Tau Theory is not necessarily an advancement of treating the disease but certainly there is nothing wrong with further research.
Unnecessary C-sections cause massive harm to large numbers of women - what are you even talking about?! It seems to me like you are just giving your opinions - which is fine ultimately - but not stating that they are in fact just your opinions on the matter.
There is an FDA-approved drug that targets amyloid (lecanemab). The idea is that previous amyloid antibodies failed because they didn't target the right conformation of the amyloid protein, and lecanemab does. There was controversy over its initial approval since that approval was based on a surrogate endpoint. They have since completed a study on cognitive decline in early Alzheimers patients patients and found that it decreased cognitive decline significantly.
There are maybe some open questions that bigger trials and future drugs can answer, but calling the amyloid theory "wrong" seems like a stretch, or at least needs some qualifications.
> How much medicine has been developed to treat diseases brought about by poor lifestyle choices like obesity or malnourishment from eating processed foods with no nutrients?
Isn’t this more evidence that medicine works and has positive health outcomes, making up for negative health outcomes caused by changes in nutrition?
To seriously answer your question: no it does not, it in fact makes health outcomes worse as therapeutically treating symptoms of chronic disease brought about by lifestyle choices does not address the cause of those symptoms in the first place, and puts you down a path of every increasingly worse outcomes.
"puts you down a path of every increasingly worse outcomes."
How does it do this? If the cause isn't medical (because it's just the simple cheap abundance of calories), why would medical amelioration (or more, a medical solution, as Ozempic may be for some) make things worse overall? Are you saying we shouldn't do any sort of medical intervention on obesity related health issues?
"Are you saying we shouldn't do any sort of medical intervention on obesity related health issues?" See this is what I mean about being disingenuous or uncharitable - the only person who said anything close to this is you, but for some reason you feel the need to question me on if I am saying that when clearly I did not. In fact I said that the problem was not addressing the root cause by instead addressing the chronic symptoms themselves - so obviously I believe there needs to be a medical intervention with obesity and reading anything else to me, comes off as completely dishonest.
To answer your question generally, treating the symptoms at best prevents further damage from those particular symptoms, but does not ameliorate the condition because the condition (in this case obesity) is not being treated, just the symptoms caused by it.
Using a simple analogy: imagine you have been driving on a tire that has lost most of its tread (a lifestyle choice), so you experience the symptoms of uneven turning, uneven driving, a loss of traction, and a loss of effective braking. Further, you run the risk of air pressure loss as the treads further wear into the steel banding and eventually a catastrophic accident while driving (analogous to a cardiac event of some kind.
In this instance you can either address the root cause (the bald tire), or go along a therapeutic route of driving more diligently, buying more powerful brakes, and putting chains around the bald tire to shore up the traction. Further, if you experience air pressure loss through leaks or through a small puncture in the tire you can use rubberized aerosol sprays to repair any damage and prevent further leaking.
All of those things address the symptoms and can address them to a degree that you are practically 'cured' of those symptoms even though the condition (balding tire you choose to drive on and further wear) remains and is worsening over time- just as remaining obese will worsen your health outcomes over time even if you address all of the symptoms successfully.
Rubberized aerosol (fix a flat) will successfully treat your more severe symptoms, and in keeping with your question regarding how this leads to worse outcomes despite successful therapy of symptoms, even severe ones - the fix a flat adds solid mass within the tire and the more you add (even it is always successfully prevents air loss) the more wear you put on the axel that now has to deal with the effects of this added mass, which is also going to increase vibrations which will damage other components of the vehicle even though they are not related to your balding tire whatsoever.
The therapy is also not making the tire any less bald - it is allowing you to ignore the balding tire, which means at some point you are increasing your risk of catastrophic failure of the tire while driving.
When all of this could have been prevented by addressing the bald tire and not therapeutically addressing the symptoms even if in doing so you are 100% successful in treating those symptoms.
In regards to obesity, not addressing the fat directly - and by necessity the life style changes that caused it, is going to worsen your outcomes over time in much the same way.
It's not disingenuous or uncharitable to ask for clarification in the form of mentioning one possible logical consequence of an underdetermined argument. The fact that so many people, by your lights, are acting disingenuous might suggest to you that you are not articulating something very well.
In this particular case, you've just set up a false dichotomy between effectively treating the non-medical root cause and treating the symptoms. Doctors treat the symptoms of obesity because, until Ozempic et al. at least, treating the root cause medically was ineffective. You can tell a patient to diet and exercise until you're blue in the face, but it's largely going to go unheeded. There hasn't been a very good medical intervention until Ozempic (and in some cases gastric bypass) that does lead to drastically lowered calorie consumption. It's just doesn't seem to be the case that, given a patient's failure to diet and exercise, treating symptoms puts a patient "down a path of every increasingly worse outcomes."
How does not treating the cause make things worse? I would think that since you at least treat the symptoms you make things better. It’s true that if you find a way to mitigate some of the harms from something that people like to do, then they often do more of that thing and thus experience more total harms. But you’re still helping them achieve a better overall value of life than they could achieve without this mitigation.
"How much medicine has been developed to treat diseases brought about by poor lifestyle choices like obesity or malnourishment from eating processed foods with no nutrients?"
A lot, and thanks God for it! How is this an argument against medicine? Also the way you sneak this in after listing two sides effects of medical procedures directly is deeply dishonest. In which ways did doctor make people obese? People make themselves obese (or start smoking, or pick up drugs, or do dangerous sports) and medicine does its best (which is quite better than nothing) to keep them alive anyway.
Cancer is a poor place to look for effects - and especially for a $ per QALY metric which a rough steelmanning of Hanson. Which obviously is orthogonal to a “medicine doesn’t work” argument but might support a “we spend too much money to help the elderly live a few more poor years” generalized argument.
Much better places to look are 1) antibiotics 2) emergency medicine 3) pre-natal and maternity care 4) general surgery, for starters - both on a mortality basis and a QALY basis.
If Hanson wanted to make a $ per QALY argument, I would argue against it (or maybe not, I don't really obejct to that). I really do want to stress that his real argument is "maybe medicine doesn't work at all".
Very fine post! Having read quite a lot of Hanson, I am not sure, this really is "his real argument" - though I admit your interpretation is legit. His "motte" seemed more along: 1. Naive claims that 'univ. h. care insurance are great' - are: naive / 2. the 20% of GDP thrown at the medicinal-regulatory-complex bring no justifiable added health value compared to spending, say, half of that (I'd guess: a quarter) / 3. if there were real added value it should turn up more in those studies (when all treatable health issues together should show up, even if each specific issue might not). - I assume Hanson can re-do the math better than me - and I am looking forward to his response. (Caplan will find a way to "prove" he was never wrong no matter what, I guess; btw: me BIG fan of all of you.)
ALL the studies quoted suffer from being too "short-term", imho. Here in Germany we had generations to adjust to "free care", and now we visit doctors on average 10 times a year (2018; Korea 17, Japan 12, Sweden: three). A change in my diet would improve my health much more than any medical intervention could. Got to go, wife called: 'lunch is ready!' Yummy.
Think about the Laffer curve: as you increase the marginal tax rate, eventually people start hiding economic activity (or moving it elsewhere) and so the amount of tax you collect actually decreases.
If someone said "our tax rate is too high, it's causing us to collect too little money", I don't think that's a claim that all taxes ever decrease government revenues. I think Robin is mostly saying that we're spending too much on medicine, such that we buy a lot of quackery that doesn't help on net (and quite possibly hurts). I have seen a bunch of cancer screening recommendations shift backwards in my lifetime, as doctors were over-treating patients; you've got to count that sort of thing in your net effect of our current level of medical spending.
I think this is pretty different from "maybe medicine doesn't work at all"!
>This is a strong claim. It would be easy to round Hanson’s position off to something weaker, like “extra health care isn’t valuable on the margin”. This is how most people interpret the studies he cites. Still, I think his current, actual position is that medicine doesn’t work. For example, he writes:
>> [Multiple examples of Hanson claiming that medicin doesn't work at all]
As Scott says: it's fine if you want to make some other argument, but Hanson's actual position seems to be that medicine doesn't work.
I get that; I read the article. I also read all of Hanson's articles, and some of the original literature, and I think Scott is misunderstanding him / not adequately counting the health costs of the medical system. I, following Scott in Who By Very Slow Decay ( https://slatestarcodex.com/2013/07/17/who-by-very-slow-decay/ ), view the medical system as giving people _negative_ QALYs. When you subtract those from the positive QALYs it gives people, what is the result? (And then also the infections received in hospitals, the medications and treatments that turn out to be not worth it, and--)
But still, I think the Laffer Curve point is a better estimate of Hanson's true beliefs than "medicin doesn't work at all", as you put it. To state it another way, suppose medicine's contribution to expanded lifespans was 10% of the total effect. (See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827626/ as a source that answers a different question with roughly that number.) Is that more like 0% or 100%?
Hanson sees people describing it as tho it was 100%, and is trying to flip that on its head to be closer to the truth. People argue passionately about expanding access to health insurance, which, if you buy the estimate of 0 effect from those studies, is all wasted passion.
[I think Hanson should update more on the Obamacare study, and also I think the medical system is steadily improving--but I think Hanson is right that the way in which the system is improving is pretty slow and not actually very reliable. I buy his guess that cutting medical spending in half would probably not materially worsen outcomes, especially given what we could do with the resources freed up.]
Sorry, I was unclear in the beginning; I mean giving "some" people negative QALYs, by prolonging lives they would rather not be living; obviously this doesn't happen to everyone.
You seem to be going in circles. Scott say "I will write about Hansons opinion strong-X". You respond "But you should write about weak-X". And I respond "But he was writing about strong-X". And you respond again "But he should write about weak-X!".
Just accept that this post was about strong-X. Scott has written plenty about weak-X, see eg the posts on Amish healthcare costs.
If Scott were to say "strong-X is wrong", well, sure, we can have that conversation. But he writes instead "Hanson believes strong-X, which is wrong," to which I think it is fair to respond "no, Hanson believes weak-X." Like, I think this is a reading comprehension fail on Scott's part.
Bit of a tangent here, but I have something to say about the Laffer Curve. The point at which people start hiding economic activity can be moved by using more brutal enforcement methods. Said brutal enforcement methods can be made palatable to the public by pairing them with populist measures. Price controls are a perfect example of this. Robespierre maintained support for his abhorrent Reign of Terror by linking it with populist price controls. (Conversely, you can actually make price controls work if you just brutally stamp out the black market. It's doable. If consumer choice and nonessential goods availability plummet, that's a small price to pay for equitable prices.)
I hate the way this discussion is framed. Robin says "medicine doesn't work." Scott says "medicine does work." Why is the relevant object "medicine?" How does that make any sense? There isn't some one big, monolithic thing called "medicine." There are many different, heterogeneous pathologies, and many different, heterogeneous treatments. My null hypothesis would be some of these are great, and some of them suck (even worse than doing nothing). And having read the entire post, I still think that's exactly the case.
It's easy to believe that modern antibiotics are excellent for treating many bacteria infections. And that some forms surgery, perhaps spinal fusion surgery for degenerative disks, can be worse than doing nothing. And that medicine is a big mixed bag containing everything in between. There's no paradox or puzzle here, and it's just dumb to frame this as a fight between "medicine works" and "medicine doesn't work."
I think different levels of generality are appropriate in different contexts. We can get more and more fine grained into infinity - there's no one big monolithic thing called "cancer", there's no one big monolithic thing called "malnutrition", etc, etc. And that level of specificity is appropriate if you want to argue that the way we treat non-Hodgkin's Lymphoma is suboptimal or something.
But if for example you want to argue that the libertarian utopia doesn't need a state apparatus to raise taxes and pay for healthcare for those who can't afford it because medicine is fake and gay, you're going to be arguing at a higher level of generality.
An appropriate and useful level of generality requires prudential judgment and will differ by context, as you say. My point is that, in my judgment, both Robin and Scott have adopted too high a level of generality for their analyses to be useful.
I think of my father, who for reasons too complicated to go into, could never be told anything by a doctor (“diabetic” launched its own frenzy of confused starvation interspersed with binging, making mother’s life difficult about cooking, while away from home he would drop his new hobby and eat whatever he wanted; testing was a fun thing to do many times a day and there was lots to spend $ on) without going whole hog for treatment (in the same way he *had to* compulsively spend money on other things - he has no moderating judgment, and is probably bipolar, though alcoholism threw us off realizing that, had we known the word in those decades). So when he was told he had prostate cancer in his 60s, he didn’t consider forgoing treatment though I have no reason to believe he had other than the usual old man prostate cancer. He excitedly did something called proton therapy. I don’t understand why but when prostate cancer recurred some years later, the former meant he couldn’t do radiation. He had various surgeries and got a device for eliminating.
In time that failed or something and he got a catheter. Now he has two. He has enough sense, or maybe has been told, to realize that some over-doctoring got him into this position. I believe he *might* have died from prostate cancer, though I never heard any numbers - but on the other hand, I think it might have just grown slowly and he would not for years have required round the clock care from my mother and others; how much a round course of harsh chemo a couple years ago that so weakened him we and he assumed he was dying, has prolonged life I don’t know. (But having him down to a 100 pounds or so and still thinking he needed to pound Diet Coke and so forth was a little aggravating.)
But the health problems connected with a catheter are chronic and so hard to deal with … He is brave about pain, I’ll give him that; takes nothing more than Tylenol. And he has terrible pain now - though no doctor has ever said why, only that everything in his abdomen is messed up, which we can all see from a cat scan.
It has made me rather negative about catheters.
Just the sheer amount of stuff, changes, changes that didn’t work, ER visits because it didn’t work and he couldn’t go; constant abdominal infections and UTIs … I have wondered if diapers would be preferable and safer. He must wear them anyway, all the time, with boosters, because the catheter doesn’t carry everything away. So it seems like you get the inconvenience of both …
Some of this may be a rant about doctors not exercising judgment on behalf of patients who lack the capacity for understanding choices and odds.
Medicine, when practiced well, relies heavily on good judgment, taking into account the overall course of life. The Hippocratic dictum "first, do no harm," is not some abstract ethical principle. It is a very practical principle, stemming from the fact that, even within the range of standard treatments, there are many ways to do harm.
I think both authors are running a motte and bailey here.
Hanson is saying "medicine doesn't work" and making arguments about doctor visits. Alexander is saying "medicine does work" and making arguments about antibiotics.
I think you're right that "medicine" is an enormous bag of stuff. Some of it works quite well, other parts don't. There's another author who quoted an executive saying "At best only half of marketing works, but I don't know which half does."
I think Scott would argue that he's not using a motte and bailey, but rather engaging in legitimate "rounding" to a valid summary conclusion.
My argument is that, no, "medicine" is too big and heterogeneous for that rounding to be helpful. You simply have to decompose "medicine" a level or two to say anything helpful.
I love the motte and bailey framing and have found it useful...but they are kind of in the eye of the beholder. Or more cynically, if you start looking for them, it's mottes and baileys all the way down...
> I think if Robin wants to do something with these insurance study results, he should follow other economists, including the study authors, and argue about whether the marginal unit of insurance is cost-effective - not about whether medication works at all.
As far as I can recall, Robin Hanson generally talks about the marginal unit of healthcare, rather than whether medication works "at all". For example, in his long paper on medical behavior, he talked about "A near-zero marginal health-value of medical care" rather than whether medical care had any value "at all" (see https://mason.gmu.edu/~rhanson/showcare.pdf). I also recall him being clear to say that he's only talking about marginal effectiveness of medicine in his book The Elephant in the Brain.
I agree that the way he talks about this topic can be confusing. But ultimately I suspect that, if Hanson ends up replying to this post, he will say that you misunderstood his views on medicine.
I recall that, many years ago, Hanson published a piece in a libertarian website arguing that the US government should cut its medical spending to half its current levels. This supports the interpretation that he is talking about the marginal value of medicine, since otherwise why not cut the budget to zero? On the other hand, some of the quotes Scott provides support the opposite interpretation. My sense is that Hanson has not stated his views about the value of medicine sufficiently clearly.
I agree, I've been following Hanson for close to 15 years, read both Age of EMs and Elephant in the Brain, tend to agree he is misread very often and think basically all of his "I said this and people misread me"s are correct and I *still* thought his view was closer to "most medicine save antibiotics, bone setting and diabetes" does close to zero, rather than "the marginal rate is negative".
Why did I think this? He opens his chapter on Medicine in Elephant in the Brain with a detailed story about obviously fake treatments on a long where age is essentially tortured as a cure, and asks how this could all happen if the treatments didn't work and Medicine was about medicine. He repeatedly emphasizes the status of doctors, and how the status distorts treatment incentives. He probably said somewhere that he mostly thinks about the margin, I don't deny that! But when lots of points are stated like "here's why we wouldn't expect this to work all" instead of "here's why this works less better than it could", forgive a brother for misremembering.
Saying treatments have no effect and saying that they don't have any net effect are two different positions.
If you take antibiotics as an example, it's possible that a society uses antibiotics in a way where they are on net harmful because they destroy benefitial bacteria as well as harmful bacteria.
For ear infections, bronchitis, sinusitis, and sore throats Hanson even makes that point explictely "Patients with ear infections are more likely to be harmed by antibiotics than helped. [...] The same is true for bronchitis, sinusitis, and sore throats." (https://www.overcomingbias.com/p/medical-ideologyhtml)
Antibiotics are not special in Hanson's view. In general, just because a drug was benefitial in an RCT in a population that was carefully selected to benefit from the drug does not mean that the average way doctors use the drug is net benefitial to patients.
Hanson has now replied to Scott, and makes exactly the same point I did above:
> There’s also my 2007 article Cut Medicine in Half where I say:
>> In the aggregate, variations in medical spending usually show no statistically significant medical effect on health. … the tiny effect of medicine found in large studies is in striking contrast to the large apparent effects we find even in small studies of other influences.
> Obviously, if I thought medicine was useless at all margins, I’d have said to cut it all, not just cut it in half.
None of this meaningfully disproves Hanson. Hanson's (correctly!) credits spontaneously occuring secular trends with the increase in life expectancy. Others did so before him and there are a bunch of other studies basically coming to the same conclusion, i.e. finding small to irrelevant effects for medical care. This is not new and not surprising, and anybody practicing medicine with open eyes has noticed that the presentations of new cases of practically all diseases seem to ameliorate over time and the clinically large/evident presentations of the past are practically absent in todays practice.
The error here is the same with all the other evidence that has been dragged in to refute this, in that people do not understand that incidence rules health, that comparably large increases in survival in lethal disease will not appreciably change the population's life expectancy when incidence is low, and that incidence has always been low even for those supposedly common deadly diseases of history. Adjuncts to these errors are the failure to understand that most chronic diseases of aging do not result in death or disability if left alone, most treatment fails to meaningfully alter the course of the disease it pretends to treat and the failure to understand lead-time- and length-time-biases, as demonstrated by the diatribe on cancer survival.
I understand the need to believe in medicine when you are working as a physician, but this is sloppy reasoning.
He also said I was 'doing some mood affiliation thing' which has nothing to do with the content of my reply at all and in fact ignored me when I objected to his radical misreading of what I said, then links me to some 2015 posts because it is 'mostly philosophy that hasnt changed in 9 years" - I do not think Dr. Alexander is being charitable at all.
You've contributed very little actual content to this comments area and the blog host was perfectly reasonable to you. You don't really get to ask things like this.
And instead of responding to any of the actual content in those posts, you simply said they were old and declined to elaborate further. I don't see anything worth being charitable to.
That is obviously not what I said as I asked questions and Dr. Alexander provided further links which I am reading. Way to read hostility into something that did not require it.
Reading the comment in question, I also think you were doing a mood affiliation thing. It's the only way I can make sense of citing three examples of mistakes in medical science/practice in support of the position that medicine literally does not work. They're completely unrelated questions, linked only by a general distrust of medicine- hence the mood affiliation accusation.
But actually you didn't think that, because the entire 'diagnosis' was made up and give you nothing to make that assertion in a credible way. I in fact used those as examples of Dr. Alexander not charitably engaging with Hanson and his points. You should read Hanson for yourself understand his arguments before bandwagoning something you do not understand on Substack.
On the contrary, prevention is the most useless part of contemporary medical practice. No current intervention seems to appreciably change mortality on the overall population level.
I have been sick plenty of times and so have family members. Neither myself nor them were helped by medical treatment in any appreciable way. I cannot say the same for my patients, I take credit for saving a few lives each year, but that is because I work in a very niche field of medicine, and if you were to quantify the impact my specialty has on population health, it would be not detectable.
This is mostly what makes the Hanson argument commensurable with the fact that some medicine surprisingly does work: most does not, and the bits that do are far too rare to make any quantifiable difference to the population as a whole.
Nah - the secular trends do not seem to have really been caused by prevention. Sanitation and nutrition are not what this is about (they are probably responsible) - but even there you would be hard pressed to find an effect from fluoride on mortality for instance (might decrease cavities by a bit, bu so what? dentists are a thing). BTW: Europe does not do half the things on your list, and ife expectancy is higher there than in the US.
Which half of those are you claiming that Europe doesn't do? 'cause as far as I know, having lived in Europe all my life, all of those things are done here.
I'm sorry you and your family members were not helped by modern medicine, and I hope you guys are all OK! Please don't generalise to the literally billions of people who have been helped, however
If each individual intervention appreciably changed mortality rates at the population level, we'd all be living to the maximum human lifespan unless hit by trucks. Scott addressed statistical problems with evaluating individual interventions this way in the post.
But jokes apart, I think this is key. You don't appreciate how much modern medicine has make the world so safe that with a bit of luck (yes, you and your family were lucky) you can avoid "visible" medicine.
I never got to be helped by iron lungs bc polio is extinct, thanks to vaccines.
I never got to be helped by treatments for tetanus, despite a childhood spent playing with rusty stuff, bc I'm vaxxed.
Thanks to Ozempic, my chances to avail myself of a cardiac bypass or similia are much lower.
What is the NNT for avoiding cardiac bypass from Ozempic? Were you ever even told or did you look it up? Diabetes meds are probably the poster child for the Hanson argument: marginal gains, ubiquitous harms, overall effect for population health likely near zero, gargantuan costs.
I really don't get this argument. You do an RCT and find significant effects. In that case you are comparing the "just leave it alone and see what happens" (what you are talking about) to intervention. Intervention helps. So the treatment meaningfully alters the course of disease.
If you got a treatable cancer, would you reject treatment?
Most RCTs these days are not comparing against "no treatment", because we usually have an existing treatment. It's not moral to not give people treatment, so they compare the new one with the existing one.
And then at some point in the trial they often find that the new treatment is doing better, so it's not moral to continue not to treat people with the one that works better. So they switch to the new one, and try to write the paper afterwards.
This is not the point - the point is that most RCTs find in fact tiny effects on mortality (PCI famously improves survival by an absolute 2% IIRC) and if the indications are rare (to stay with this example, OMI is very rare indeed these days) this will not make an appreciable difference in life expectancy.
A secondary point is that there have been large declines in mortality from most diseases without any appreciable influence of specific medical interventions. Most of these declines started before the medical improvements were even conceptualised (i.e. there is a decline in heart disease mortality that started in the sixties, where medicine was famously useless at treating OMI that has pretty much stayed constant regardless of the interventions medicine offered).
Of course you go for indicated treatment that has proven benefit. But that does not change very much the statement that the effect medicine has at the margins does not account for the bulk of the gains in life expectancy since approx. 1850.
So you're saying that polio would have gone away by itself after some time or the effects would have reduced over time to the point where they aren't important any more and therefore spending the time / money / effort on the polio vaccine was pointless?
Okay... maybe... but we can be pretty sure that would have taken longer than the vaccine that effectively eradicated polio. So your argument is that the very large amount of patients that would have gotten polio, if not for the vaccine, would have been acceptable as the vaccine creation and distribution cost was not worth it?
It you look at how polio became such a big deal in the middle of last century, the story gets more complicated.
1. Before sanitation efforts, polio was ubiquitous. Babies were exposed, some died, the others pulled through.
2. Then sanitation meant that people were exposed later in life. One of the odd things about polio is that as far as I know the effects tend to be worse, the older you are on first exposure. At this point it became necessary to develop a vaccine, as people weren't going to stop the sanitation efforts.
3. So now we have polio vaccines, and sanitation is so good we pretty much have to import our polio cases.
Thank you for making my argument against Hanson stronger!
If Hanson's argument is that sanitation did most of the work and not medicine, then the case of polio specifically points out something that was made worse by sanitation and then fixed by mecidine! Go Medicine!
Polio was already in decline before the introduction of the vaccine, yes. Whether this trend woudl have continued we do not really know. But the Sabin vaccine has left no real signature in the mortality of children in some countries, so the effect on overall health is not at all that clear.
Is you argument that, since death isn't common, that means that interventions to prevent death can't, even in principle, be useful? I think most people would disagree with your definition of useful. The number needed to treat to prevent death over one year of a magical pill that completely prevented death would be quite high in most populations. Where's your line between that pill and useless interventions? I'll give concrete examples, because I think they'd be helpful in elucidating what you mean (in practice, access is a barrier, but that's irrelevant to whether healthcare works). I'd be interested in your take on these individually: GLP-1s; blood pressure drugs; imatinib.
Your magical pill would have to have zero harm associated with it, and that is not what we find for todays drugs or surgeries. But yeah, the NNT would be horrendous.
Re your examples: antidiabetic and blood pressure drugs have poor effects on survival. Imatinib is pretty rad, but CML was and is rare and the loss of life from it was approx. 10 years prior to imatinib. So that kinda proves the point that medicine works at the margins and the margins are not at all contributing to the bulk of improvement in life expectancy.
It sounds like you're saying that Hanson is right to claim that medicine is not the cause of increases in life expectancy, and the "large increases in survival of disease" exist but don't explain the life expectancy gains.
In that case you already agree with Scott over Hanson. Because as Scott took care to establish at the beginning of the post, Hanson is making the much stronger claim that medicine does not have a consistently positive effect on survival of disease (or any other health outcome).
But what SA doesn't get is that these positions are largely equivalent if you factor in medical harm. When marginal gains get eaten up by rare but devastating harm, you end up with no or negative effects on survival.
> Imagine someone claimed that casinos produce, not just entertainment, but also money. I would reply that while some people have indeed walked away from casinos with more money than they arrived with, it is very rare for anyone to be able to reasonably expect this result. There may well be a few such people, but there are severe barriers to creating regular social practices wherein large groups of people can reasonably expect to make money from casinos. We have data suggesting such barriers exist, and we have reasonable theories of what could cause such barriers. Regarding medicine (the stuff doctors do), my claims are similar.
This sounds pretty clear to me. “There are severe barriers to regular social practices wherein large groups can expect to see benefits from healthcare.” That’s not a marginal argument, but a structural one!
The incidence of heart disease is not low and the treatments for it are in fact very effective relative to pre-medicine baselines of doing nothing. Critical care units, pacemakers, stents, cardiac surgery, statins, imaging to detect cardiovascular disease, EKGs and echo and cardiac MRI to detect and differentiate diff types of heart disease, anticoagulants, etc.
You can see this in RCTs, you can see this with broad epi data finding cause specific mortality going down, you can even just grok this by reading biographies from different time periods 1900, 1940, 1980, 2010 and realize heart disease became increasingly better understood, better treated, much less of a death sentence, etc.
Nope, unfortunately not. The decline in heart disease mortality started in the 1960s, when treatment for OMI and vasoocclusive disease was useless/probably harmful.
I'm having trouble reconciling "The error here is the same with all the other evidence that has been dragged in to refute this, in that people do not understand that incidence rules health, that comparably large increases in survival in lethal disease will not appreciably change the population's life expectancy when incidence is low, and that incidence has always been low even for those supposedly common deadly diseases of history" and "I understand the need to believe in medicine when you are working as a physician, but this is sloppy reasoning." Surely in the former you're arguing that medicine can work for individual people, but will not meaningfully change population outcomes because very few people get those diseases, yet in the latter you seem to be saying that medicine doesn't work at all. Could you unpack that a bit? What proposition exactly are you or Hanson arguing in favor of?
I have no clue what Hanson argues for deep down since I am not him. But I read his argument as that a) most medicine does not appreciably change life expectancy b) the bit of medicine that does is too rare to make a difference on the population level. Both of these statements I woudl get behind. What I meant by that last statement ist that these two realisations are hurting doctors' pride and sense of purpose and are thus fought tooth and nail when the data point sadly to exactly this conclusion.
I'm really curious what Robin would say to all the progress on cancer. One might argue that it's a poor use of money, but some of the new cancer treatments have huge effect sizes that would swamp his complaints for high noise.
"I’ve spent fifteen years not responding to this argument, because I worry it would be harsh and annoying to use my platform to beat up on one contrarian who nobody else listens to."
Admittedly I don't have as big of a platform as you do, but one solution I often use for this is to first argue with the contrarian about it behind the scenes, and then only publish the rebuttal if they don't self-correct.
The problem with not getting it corrected at all is that "who nobody else listens to" is wrong. E.g. for a period of time, I found it plausible that Robin Hanson was right, because I assumed he and others had done their basic statistics to check the validity of the claims (especially because I saw e.g. Eliezer Yudkowsky reference the results too). It's only after getting a better mindset for the statistics (many of the problems you mention here show up in *a lot* of studies) that I started disbelieving.
Agreed with this, and I particularly like seeing the improvement in mortality for specific conditions over time like this, it strikes me as a really strong argument for the effectiveness of medicine.
What I do think remains a valid sort-of anti-medicine point is that treatment is vastly less cost-effective than prevention, I recall hearing it being about 50 times less so, and so clearly vast savings could be made through government disease-prevention programs such as dissuasion campaigns against and fees on the externalities of risk factors for disease and especially the broad category of "ingested substances" whether food or recreational drugs and even air pollution; the feeing of externalities ("pigovian taxation") is of course the least econonomically burdensome and indeed in theory if we could properly calculate the value of the externalities it would be economically optimal, since it doesn't require making any government expenditure and to the contrary actually constitutes a source of income for the government and can substitute for an equal amount of economically harmful taxation, so that's what seems to me the most obvious major policy to help reduce healthcare costs, though frustratingly it's foolishly opposed by many and ironically generally the most so by the "taxation is theft" crowd.
Since I haven't actually read Robin on the matter, and have come across a few comments retorting that Robin isn't actually stating that medicine doesn't work at all (which would indeed be odd) and rather that medicine isn't clearly strongly net-beneficial, I feel compelled to clarify that at the very least it does appear that certain medical interventions probably have too little net benefit to justify their practice, and that there should be a greater effort to identify them and eliminate them from standard practice.
And I agree with others that actually the cancer survival data is skewed by increase in diagnosis, so I partly take back my support for that being a strong argument; however we do know that certain cancers (and other conditions eg bacterial infections and emergency conditions as has been mentioned by others) now do have a much more favorable outcome thanks to specific treatments that have been developed, to the extent that it seems very unlikely that there not be a net positive effect, and so if there are indeed many wasteful interventions, eliminating them should make the positive effect of these beneficial interventions become more apparent at the population level.
The prevention>treatment case is much more complicated than people think. The USPTF has a bunch of recommendations for prevention with strong evidence. They're quite bare bones - much less than people might think. Why? Because it's a lot trickier than people think to 1) tell if your prevention intervention is net good 2) if it's net good, it's cost effective
Like I replied to others, my first comment was rather unthinking and failed to specify that I was mostly thinking of lifestyle factors. Definitely something like screening is trickier since it can be quite expensive and can lead to excessive treatment causing even worth health outcomes through adverse effects, which would constitute an argument in favor of Robin's notion that medicine isn't helpful overall, though thankfully the screening that does get done usually precisely follows the guidelines which itself is based on quite rigorous evidence in favor of its efficacy - at least if we only look at health outcomes; admittedly another issue is that an intervention that does on average lead to improved health might still not be cost-effective. Ultimately the main conclusion is that there needs to be a good determination of the cost-effectiveness of interventions and resources should be allocated only to cost-effective ones and preferentially towards the most cost-effective ones. (Edit:typo)
>What I do think remains a valid sort-of anti-medicine point is that treatment is vastly less cost-effective than prevention, I recall hearing it being about 50 times less so
Whered you get that from? My impression was that its the opposite. Or are you taking about the "live a healthy lifestyle" sort of prevention thats cheap on paper but noone actually does?
>the "live a healthy lifestyle" sort of prevention thats cheap on paper but noone actually does?
<mild grumble>
The e.g. "eat healthy and exercise" advice is financially cheap on paper but not cheap in time and effort (exercise) nor cheap in foregone pleasure (pizza!).
Vague memory from med school, and yes I mean the live a healthy lifestyle kind of prevention, and the point is that people do in fact do it to some extent if they are nudged, and what I recall is that the saved medical costs downstream far outweigh the cost of that nudging, though admittedly I haven't researched the matter further; anyway like I said if we actually do externality pricing (eg slapping an extra fee on junk food) which is a form of nudging too then the cost is actually negative ie it's a source of revenue for the government.
Ok, that sounds more realistic. Still I imagine it really depends on the details. For example I vaguely remember that smokers are cheaper, because they die before needing expensive old-people things. That might still be consistent with what you heard, but your first comment sounds a bit too general.
I agree that subsidised healthcare logically goes with health paternalism like these taxes, but a lot of the steps in that direction actually taken do not inspire confidence.
Yes I agree that it's too general and thus kind of meaningless at best, I'm going to search for some studies on the matter.
Regarding smokers dying earlier, yes in a sense it makes them cheaper, but seen like that the most economical thing to do would be make humans extinct as soon as possible.
And pigovian taxation isn't just health paternalism but also simply economically optimal policy at least in theory, and it has already long been successfully used for ethanol and tobacco though typically not explicitly as such, and I am not aware of major problems with it there, though I do recall reading that for cannabis in California this didn't work well because it favored the perpetuation of an illegal market, and the author's recommendation which seems sound to me was to first have no such tax so that the legal producers outcompetes the illegal ones and only then once there is little illegal production left do you implement the tax at which point it will be difficult for illegal production to reconstitute itself.
>seen like that the most economical thing to do would be make humans extinct as soon as possible.
But then they wouldnt pay taxes. To be fair, the average person is net negative currently, but we dont expect government deficits to continue forever. And besides, if you dont like that perspective then you shouldnt take pigouvian taxes having negative cost to the government as a positive.
>it has already long been successfully used for ethanol and tobacco
I agree that those examples are successful. But there have been plenty of times when they picked the wrong horse too, especially on the diet-related topics.
I'm all for pigouvian taxation, but I think that the prevention vs cure debate is hopelessly muddled by semantical jerrymandering. Most cures for something are also prevention for the comorbidities of that something. To add, there are several layers of prevention to anything.
Case in point: somebody with a dog in the debate could have just waited to see whether Ozempic worked. Had it been useless, they could have grandstanded about yet another useless cure for obesity, and the need for more prevention (exercise, better nutrition, etc.). Now that it turns out it works, well, it's a startling victory for prevention! Saving so many QALYs and $s by making people thinner earlier rather than saving them from strokes later!
It's not *wrong*, but it's not particularly *fruitful*
Yes agreed, I was mostly thinking of lifestyle factors and in the context of primary prevention, I should have been more specific though there were already hints that that's what I had in mind.
Like of course the evidence is less clear-cut when you look at life-expectancy as a whole rather than specific diseases. You throw away a bunch of signal and then the snr gets worse. Surprised pikachu face.
Well yes, but in defense of the (at least alleged) Hanson position, if it indeed appears that medicine doesn't particularly improve overall life expectancy or quality of life, then it's true that it would be better to just not do any medicine rather than to pursue medicine as currently practiced, since it would mean there appears to be no net benefit from the latter, and meanwhile it incurs a lot of expense, though of course I would want much more robust evidence that medicine indeed fails in these metrics; obviously in practice we know that some interventions are particularly beneficial so it would be silly to eliminate them, at least if we don't take the position that prolonging life is actually typically detrimental due to increasing age-related diseases thereby increasing total healthcare costs.
If it "appears" that medicine doesn't improve life expectancy or quality of life, where are you looking that has a control group that doesn't get any medicine?
*Less* medicine, doesn't cut it unless you're making an argument at the margin.
Randomized controlled trials aren't the only way of determining things like this. Scott's original post covers Robin's arguments about why at least in his eyes it appears that medicine is ineffective and they are at least superificially sound; notably if overall mean lifespan doesn't increase significantly despite large improvements in medicine and without a worsening of other factors that could counterbalance these improvements, that makes medicine as a whole seem quite useless.
Of course in the United States the reason for the lack of increase in lifespan is a worsening of societal problems, and in other already-wealthy countries that have not experienced this, lifespan has in fact continued to increase, albeit more slowly since we are getting closer and closer to the limit imposed by aging, so actually there is no phenomenon of unexplained lack of improvement of lifespan despite advances in medicine, rendering that argument moot.
So to look on the positive side, as a physician, I feel like I now understand better the perspective of police officers now in response to the Defund the Police movement.
What, Turtle, you don't think the Doctor's Office to Morgue pipeline can't be disrupted by getting a social worker to do your job instead? 😁 De-escalate!
Lol, the way things are going, in a few years people will be protesting in doctors' offices with photos of minorities who have been harmed by medical mistakes. End Medical Racism Now! Did you know the American Heart Association recently removed race as a risk factor for cardiovascular disease? Another shining example of the triumph of What's Right over pesky biology or truth.
I think basically that argument - racism is the real cause of any observed difference in rates of heart disease. Similar to the anti-criminal justice system argument of “racism is the real cause of disproportionate violent crime in the Black community.” Strikes me as profoundly disempowering for actual Black people.
In the case of medicine, sadly for the wokies, claims that there are no biological differences between races are easily falsified. Even beyond the obvious differences in Sun sensitivity with different levels of skin melanin, there are clear differences in the frequency of sarcoidosis, cystic fibrosis, haemochromatosis, sickle cell anaemia, and numerous other diseases between people of European and African ancestry. Here in Australia we know that Indigenous Australians have higher rates of diabetes and chronic kidney disease, and we use that information to help them, by instituting screening for these diseases earlier and more frequently.
This strikes me as the real problem with policies and practices that aim to elevate ideology above truth - they end up hurting precisely the vulnerable groups that you’re trying to help.
Wow, I wish people would either stop using generic generalizations or read the semantic literature on the variety of incompatible interpretations people make of generics. There is nothing scientifically respectable about summarizing a claim as a generic generalization.
Follow-up... the semantics literature gets technical very quickly but the reader's digest version is that generics are generalizations that are tolerant of exceptions, but how many exceptions they tolerate is not coherent. In turns out it is highly dependent on highly psychologized features like how much a subject is afraid of something or whether the generalization is about animals or artifacts or social categories or other such things.
Antibiotics starting with penicillin and moving forward ever since.
Insulin.
Primary PCI for STEMI.
There are many explicit examples where medicine “works”. And when a guy is willing to say a P value of 0.01 is “noise”, there’s really not much point engaging with the guy.
I agree with your distinction btw secondary prevention and primary prevention. Although I think the fundamental difference is in effect size (and NNT).
I think maybe where he “might” have a point (and this is the part that bothers me daily) is in the lack of precision medicine. When a certain treatment has an NNT of 10….that’s a blockbuster….yet in 9 of those people the therapy will provide no benefit, and we have no a priori way of knowing who that 1 lucky person (out of 10) is.
p<0.01 can be noise if the researcher (or the entire medical research profession, seen collectively) ran 100 experiments and only published the experiment in which p<0.01.
Of course, such a result will not be reproducible and other researchers will have a clear incentive to show it nonreproducible, so it seems unlikely that too many results of that sort will enter established medical practice.
This was the odd thing about the discussion of the three different studies Scott spent so much time analyzing. "Outcome A showed improvement from study X but not Y and Z, outcome B showed improvement from study Y but not study X and Z ..."
>Come on! Thousands of clinical RCTs show that medicine has an effect. Robin wants to ignore these in favor of insurance experiments that are underpowered to find effects even when they’re there. Then when someone finally does an insurance experiment big and powerful enough to find effects, and it finds the same thing as all the thousands of clinical RCTs, p = 0.01, Robin says maybe we should dismiss it, because p = 0.01 findings are sometimes just “noise”. Aaargh!
You may want to steelman him here. When analyzing large, complex quasi-experimental data, there are many, many analytic choices to make. The more choices to make, the more opportunity to p-hack. As such, an apparent p value of 0.01 is not necessarily an honest p value of 0.01 because there are many ways to turn large than 0.01 values into apparent 0.01. How do we know the authors didn't cheat here? We don't know that. Would need a specification curve analysis or something like that.
Um... I think the more relevant question is, how did you come to the conclusion that this statistically significant result also represents a meaningful real-life effect? "We sent a letter to 4.5M people, then found the difference in frequency of an outcome between populations was <2%. We suspect this resulted in a downstream change in mortality of <<1%. But since there are enough people in the sample, we lucked out with a low p-value."
Why should I care about this? In Scott's words, "Come on!" The intervention is so far removed from the outcome as to be meaningless. Doesn't have insurance > gets a letter > gets insurance because of the letter > uses more health care services > actually takes treatments > treatments affect health > less likely to die. And Scott is mad at Hanson for being insufficiently skeptical of this? Can we PLEASE not settle for bad experimental results just because they support our priors? How about we just say, "yeah the arrow pointed the direction I agree with, but it's not meaningful," and then wait for the meaningful experiments to be done. Accepting bad study results just encourages this kind of behavior.
Please address the substance of my argument. They had a large enough sample to detect a difference of 6 in 10,000 people. The argument of the study, then, is that 6 of every 10,000 people who got a letter changed their mind about getting insurance. The assumption is that as a result of getting the letter, they signed up for insurance, used healthcare resources they otherwise would not have gotten, those healthcare resources prevented deadly disease, and the people lived longer than those who did not get the letter and did not make this choice.
Yes, I'm saying this is a meaningless result. A p-value of <0.000001 would not change that. Results have to be meaningful, not just statistically significant. Larger sample size doesn't fix that problem.
Why is this meaningless? 6/10000 is not small you just don't realize how many people there are. An effect that size would save 210,000 Americans, more than have been killed by a number of ills we spend a great deal of effort and ink on.
If you want to argue the price was too high you can, but show your work. But it's definitely not small.
This was a natural experiment, not an RCT. Nobody sat down and said "We think that sending out letters to people telling them to buy health insurance is a powerful way to improve health care outcomes, so we're going to test that" they simply noticed that they had accidentally done an experiment on a very large sample size and decided to gather what evidence they could from it.
A small effect size would be meaningless if you were actually proposing it as a treatment worth investing in, but that doesn't make it meaningless for the question of "does more health insurance improve outcomes?"
Hanson's argument really is just absurd. I cannot imagine that he really believes it. Surely this must be the adoption of an extreme position in order to get attention.
It is possible for it to be simultaneously true that specific medical interventions are beneficial, while the entirety of modern medicine to have no effect, which I believe is closer to Hanson's position than "No medicine works at all".
Bloodletting gets a terrible rap, but we still practice it! It's the standard treatment for hemochromatosis. (Note: If you have hemochromatosis, and you go to a hospital for this treatment, you're both charged for the treatment, and also the blood is generally discarded, at least as of the last time I looked which granted was a few years ago. You can get your treatment for free (or, in some places, get paid for your treatment) by donating blood.)
This, I think, may be a good analogy for Hanson's position: We have a bunch of really effective treatments which are beneficial - and also a lot of treatments that are, on net, negative. If you're just looking into, specifically, blood pressure - you may be looking specifically at the treatments that are beneficial and neglecting the treatments that are harmful.
It's even possible for treatments that are strictly beneficial to be, on net, negative - I think a common example/argument in this direction is that you are more likely to contract a disease if you go to a hospital (as you're more likely to be in proximity to individuals with infectious diseases). Taking that example as a given, there is some level of beneficial hospital treatment where the benefit is precisely offset by that additional risk. This may be particularly obvious or intuitive during a pandemic, when the risk of going to a hospital may be sufficiently high that even very beneficial treatments can be, on net, negative.
Pointing out that individual interventions are beneficial doesn't really argue against the thrust of the claims being made, which necessarily requires extremely large trials like RAND - because the claim isn't that medicine is never beneficial, but rather that the average effect of medicine is not beneficial.
This is an argument one can make but none of the insurance studies Hanson cites are evidence for it. Simply because they are not powered enough to measure mortality. The only studies that are powered enough to test this are not really randomized but do generally show positive effects.
Bloodletting is also used for some benign proliferative hematologic disorders, and, interestingly, will work in a pinch for a large subset of cases of acutely decompensating congestive heart failure. My guess is that that last one drove meaningful success rates in the ages before dialysis.
> If you're just looking into, specifically, blood pressure - you may be looking specifically at the treatments that are beneficial and neglecting the treatments that are harmful.
I've looked into the science behind blood pressure before. It was disturbingly unconvincing. The pro-healthcare argument sort of slides around that, defining blood pressure as itself a health outcome but it's not. We only care about blood pressure because it's (claimed to be) associated with other more objective outcomes like heart attacks or strokes.
For example, and please don't ask me to cite this because I didn't bookmark it, but there was a study done where lots of people were prescribed anti-hypertensive drugs. The drugs definitely worked because incidents of fainting went up a lot, but the number of strokes etc didn't shift. Implying that the underlying theory may be wrong. It was nonetheless described as a success because the drugs lowered blood pressure. I think this is the sort of thing that drives people like Hanson to become "medicine deniers".
I think the literature on BP and controlling HTN is pretty strong for high-risk groups - especially men with a history of MI. The problem with BP is that it has been rolled out to the rest of the population writ large, then assumed to be some general factor for health. There's not much good evidence that a 35yo woman with no previous history of cardiac events is well served by hitting specific BP targets, yet we'll dutifully report it as some major health advance.
I strongly agree with the point that surrogate endpoints are way over-reported as 'health benefits'. That's not what anyone cares about. Scott spends way too much of the essay arguing that one surrogate endpoint or another equates to better health care outcomes. Those arguments are not valid.
There are two different questions: 1. Does medicine improve health while alive? 2. Does medicine reduce mortality? I believe the second can be shown to be true statistically, but the first one must be examined carefully.
I cannot convince you of otherwise, but very least cancer patients tend to get treatments that reduce mortality but at the cost of health. There ALSO patients who live their average-lifespan entire lives with a condition that would otherwise in Wordline B get medicated; if they get medicated, their health improves, but we will not know if they had lived help (it does not help most people who get diagnosized also get medicated). There are ALSO many treatments that improve health but do not least significantly reduce mortality such the drops you put into your nose when its stuck, many skin care products, and hair care products. Vaccination to a lethal and fast-killing enough disease that your health does not noticeably with side effect that disable 1% will also look weird on a plot of mortality reduction and health effects over time. There's very likely much more but I am not getting paid to write this.
Years ago, I read a study that surveyed oncologists on their use of cancer treatment. These oncologists were as likely to get first line treatments, but much less likely to get each subsequent line of treatment as early therapies failed. I've seen cancer patients fight tooth and nail for maybe an extra month of terrible side effects. I can understand an oncologist not signing up for that kind of torture just to eek out a few extra weeks of life. At least in oncology, 1 and 2 are sometimes inversely correlated.
>You may have read the excellent article How Doctors Die. If you haven’t, do it now. It says that most doctors, knowing everything I’ve just mentioned above, choose to die quickly and with very limited engagement with the health system.
>I (and the doctors in my family whom I’ve asked) am pretty much like the doctors in the article. If I get a terminal disease, I want to wring what I can out of the few months of life I have left and totally avoid any surgery, chemotherapy, amputations, ventilators, and the like. It would be a clean death. It would be okay.
Thanks for linking! That may be what I was thinking about (it's been a long time). I do think it's a personal decision about priorities and not a binary one at that.
A few years back at a conference, we had a physician talk about her ongoing decision-making process with her oncologist about priorities. After adjuvant chemo failed, her discussion with her doctor was about how to survive until her youngest child graduated from high school and left the house. She survived, but then the goals of treatment shifted to minimizing side effects of therapy so she could do a road trip to her daughter's college. Quality of life versus quantity is, unfortunately, a major consideration in oncology therapy.
This would probably at least partially depend on whether we adopt the old, more externally-assessed ("absence of disease") or new, more subjectively determined ("general wellbeing") concept of health.
Big chunk of modern medicine is well being/quality of life related, and provides essentially symptomatic treatments. Pure anecdata here, but in middle age I get three treatments, all three little to do with mortality: while ultimately having my GERD treated might conceivably reduce esophagus cancer risk, at this stage in my life it's pretty much "making my life less miserable intervention". Painkillers for arthritis are fully symptomatic. HRT, same.
Reproductive health care: mostly same (tho it's possible my first child would have not survived without the c/s, and subsequent IV antibiotics for GBS, and I'd say perinatal care looks like a good candidate for medicine that works overall, even as it's ridiculously over applied probably causing some harms too).
So essentially -- no. Many things that disable, especially in a minor way, won't kill at scale, or might only contribute to slightly earlier death at the life end where gains are marginal anyway.
No, I think the easiest example of this would be Anabolic steroids, and Growth hormone, they very clearly improve health while alive and also very clearly *increase* mortality.
I think point 1 is even more obviously true than point 2. E.g. I had gallstones and they were extremely painful, and then the doctors took out my gall bladder and I feel way better.
Fap over weak studies all you want - My seizures are very well controlled by medication, and if I go off of meds they will come back like clockwork. It is rather easy to come up with many examples of medical issues and interventions like this.
I think "health" is a bit of a frail concept when used outside of formal contexts with a clear operationalization.
Still, I'd say the opposite: there are many painful and debilitating conditions that, assuming some sort of support, do not result in death. Eg leaving gout untreated would probably not significantly move life expectancy, but it would make life worse for many. To be morbid, people with missing limbs could survive to old age, obviously it was a less dignified life than having a prothesis.
So if you wanna account for health in general and not only survival, I don't really see how medicine comes out worse than nothing on net
Can we Aumann agree that the potentoal debate(s) should be *structured* this way? IE instead of "medicine works / does not", two distinguished debates: "medicine works for improving health / medicine does not work for improving health" & "medicine works for not dying / medicine does not work for not dying."
You have have the patience of Job. Hanson’s claims are so transcendently wrong I could barely read your debunking. I could certainly never even attempt that myself.
To what extent should this lead me to downweight the opinions of Hanson, Caplan, and a bunch of other "nuh-uh things aren't the way you think it is, just look at this one study" contrarians?
It's already reminding me strongly of Caplan's "Case Against Education" -- thing that everyone thinks is important turns out not to look unimportant when measured in some particular way and is therefore useless.
Well, this depends on how much weight you were already giving them. Clearly some contrarian ideas are true, because the mainstream doesn't even perfectly agree on everything, let alone being infallible, but the outside view odds for any particular contrarian idea being true should be pretty low.
I find "Case Against Education" more plausible because it kind of forces us to confront not just mechanistic questions like "Does teaching Civil War history cause someone to know more Civil War history?" (and consider that even this is complicated; most 40 years olds don't remember much of the Civil War history they learned in school, and might learn it elsewhere anyway, so it's not obvious that teaching Civil War history at age 10 causes you to know more of it at 40) but also social questions like "Does teaching Civil War history at age 10 increase some kind of good outcome later?"
How do you know which people will be interested in Civil War history unless you expose them to it? Some may go on to be Civil War History professors. Others may take it as an impetus to interest in other aspects of war, or sociology, or even horses, if that is the aspect that catches their interest.
You don't need 1000 hours of Civil War history at age 10, but some hours seem worthwhile as introductory material, a set of common knowledge with which all adults would be expected to have some familiarity. Five hours each of 200 different subjects sounds like a more useful time spend.
But you're looking at it from the point of view of the student.
The case for public finance of education is that it makes for better citizens - able to do more things, think up better ways of doing things, etc. That case has been proved pretty thoroughly for literacy and numeracy.
The case for history would I think come under "civics", i.e. it is taught using public money so the student will know the background of how the government works and why it's that way.
It gets a lot muddier when you get to tertiary education levels of investment.
Not saying don't have it - universities have been around for at least seven hundred years.
Should the public be paying for large portions of the cost, for what is now (if I remember correctly) roughly a quarter of the population? That's much less clear.
"Does teaching Civil War history at age 10 increase some kind of good outcome later?"
I mean, the standard, banal, small-l liberal answer is that you should know your country's history so that you can understand why your country got to be the way it is, and can make better decisions about the future (decisions that influence how you vote/which politicians you support). That's how it's supposed to work, anyway. "Those who forget their history are doomed to repeat it." Whether it actually does work is a separate question.
Ah well the US Civil War is a special example. You don't teach the US Civil War to kids because you want them to understand the US Civil War, you teach it to kids because you want your side to gain a political leg-up in the present day. And it's a culture war topic so you can't stop hearing about it as an adult. I'm sure I never learned anything about the US CIvil War in school but I learned it from Bugs Bunny cartoons (seriously I think that's where I was first exposed to the concept) and I haven't stopped hearing about it ever since, to the exclusion of much more interesting Civil Wars like the English Civil War.
I come to whine about methodology of measuring quality of cancer treatment and nothing else.
We check if someone survived cancer by checking if they were alive 5 years after we diagnosed them with cancer. We also scan more and better for cancer (ignoring even scanning younger people which would limit deaths from other causes), meaning we discover cancers earlier on in their development.
That's of course good for various reasons, but it also means that the same person with the same cancer could be considered a survivor today, but not 50 years ago, even if their cancer progressed and lead to their death in the exact same way, simply because we put 'start' indicator earlier in its development.
It can be corrected for, but you don't indicate you checked for it in any way, so here I am.
That's exactly the kind of complicated fragile argument that is subject to p-hacking that you said you would avoid in this post. If you want to talk specifically about cancer, it's good to write it out as an individual post (although I find it utterly unconvincing), but as part of this post I think it is net negative. Just stick to heart attacks and strokes.
Look up the 5-year survival for early-stage versus metastatic disease in … almost any tumor, but check out cervical cancer, or head and neck, to see the difference most clearly. There *are* cancers where early diagnosis probably amounts to overdiagnosis and/or overtreatment for a few patients at the margin (ductal carcinoma in situ in the breast comes to mind) but it’s not a central scenario.
Like you, I also came to whine about that. I confess I read past Scott's caveat.
But I am also unconvinced that that plot is a good indication of the claim. A plot measuring the five year survival rate given a fixed stage of cancer would be more convincing.
I guess that for some forms of cancer, you do not need extensive diagnostics. Looking at a weird-looking piece of your skin and thinking "I better ask a doctor if this is a melanoma" is something you could do just as well in 1970. (Still, it is certainly possible that people were less likely to do so in a rural area in 1970 where the nearest GP was presumably further away on average.)
On the other hand, for other forms of cancer, I would imagine that the modern apparatus of diagnostics (CT, MRI, ultrasound, biomarkers) are way more effective and less invasive than they were 1970, when you had the feeling in the fingertips of the doctor and (contrast) x-ray. (Handheld ultrasound was commercialized in 1963. Given how humans work, I find it unlikely that most licensed physicians had an ultrasound by '70. If the practitioner was 50 in '63, the probability of them being an early adopter who spends a lot of time getting the training to use and interpret it correctly plus the money to buy an ultrasound seems low. More likely that progress worked one funeral at a time, as so often.) Can you even diagnose a small brain tumor on contrast x-ray? Or would you depend on letting your doctor take a peek into your skull?
Also, Going from 50% 5-year survival to 67% does not feel much, but if you assume that survival follows an exponential decay (which is an oversimplification), then 50% correspond to an expected life time of 7.2 years and 67% correspond to 12.5 years.
Of course, share Scott's opinion that cancer treatment has made good progress (even I my understanding is certainly more shallow).
Another good example of medical progress is child birth. Here we do not have to rely on comparing outcomes over the chasm of time (with all the other general progress factors as confounders) because some people heroically take it upon them to be part of the control group and try to give birth at home instead of in a hospital. (As they are not randomly selected, this will probably add other confounders though.)
I think that it is hard to dispute that some medical interventions clearly work. If you have a broken arm, you are better off going to the hospital instead of just trying to keep it still until it stops hurting. Of course, that does not mean that every intervention works, and especially not that marginal interventions are cost-effective.
I have basically no doubt about medicine being useful, including cancer treatment. My issue is (was? I didn't go through text Scott linked yet) with using this specific measure in presence of what I'm point at.
So, I think the particular claim being made -- the concept that past-few-decades innovations are fairly unimpressive and medicine is miscredited for general improvements -- is probably true in some fields, but trivially disprovable for all-medicine by one example:
Neonatology.
Neonatal intensive care units are places where reality breaks. A baby can be far sicker and far more premature than you think possible, and be carried out of an NICU by their parents weeks later. In the early 1970s, the leading pediatric textbook wrote that the limit of viability must be about 28 weeks -- the tiniest preemies that could survive. Today, about half of 23-weekers get to grow up. A normal pregnancy is 40 weeks.
There's a measure called the "Apgar scale" routinely used to assess the health of newborns. It's scored from 0 to 10, with 0-2 points available in five different areas (activity, pulse, grimace, appearance, respiration). A score of 0 in one area means nothing -- a baby that doesn't move, or doesn't cry, or doesn't breathe. A baby with a total Apgar score of 0 is in any conventional sense dead.
There are articles with titles like "The long-term outcome in surviving infants with Apgar zero at 10 minutes" and "Improving infant outcome with a 10 min Apgar of 0". These exist because there are so many babies that are born dead, stay dead for ten minutes, and *come back to life*. Extrapolate from there to babies with Apgar 0 at 1 or 5 minutes, which are the usual times when scores are taken. The prognosis for Apgar 0 babies is...not fantastic, but it is not 100% mortality, which it would be by any natural physiological measure. There is at least one baby reported in the medical literature with an Apgar score of 0 at *twenty* minutes who, in a childhood follow-up, was alive and had absolutely no developmental problems of any kind.
This isn't a tradeoff of "they're alive but profoundly disabled", either. Developmental issues are more common in NICU survivors than the general population, but don't track cleanly to such a framework. The definition of "neurodevelopmental impairment" in follow-up studies is rather broad -- amongst other things, it includes literally any level of cerebral palsy, despite the supermajority of people with the commonly-caused-by-prematurity forms of cerebral palsy being able to walk without assistance. The rates of "any 'NDI' including imperceptibly mild cerebral palsy" amongst extreme preemies consistently go down with the death rates; "unimpaired survival" is a metric that improves just as "survival" is. Truly profound disabilities are pretty rare in this population -- a lot of studies and practitioners use the term "severe disability" in ways that don't actually match what parents think of (a recent large study, https://dranniejanvier.com/wp-content/uploads/2023/05/tchildren-10-0088.pdf, found that clinical vignettes of the most common outcomes called "severe NDI" in follow-up studies are rarely considered significant problems by parents).
There's no way neonatology can be called an improvement in non-medicine. 23-weekers -- hell, 22-weekers -- and babies with 10-minute Apgar scores of 0 aren't surviving because sanitation got better. They're surviving because people have pushed up against the limits of reality.
Infant mortality as a whole is a big win, but a lot of it is nutrition-sanitation-etc. A lot of the remaining improvement past that is vaccines and antibiotics, which seem to be carved-out exceptions from Hanson's claim. Neonatology can't be carved out like this -- a baby born at 26 weeks had *absolutely no chance* of survival in any time before a few decades ago, and today will probably survive without serious disability. NICUs are intense places precisely because these babies don't survive by accident.
Thank you; I came here to write the same thing. There's no plausible universe in which my very premature baby would have survived (and is now a thriving child) without modern medicine. There's no room for ambiguity here in neonatology, as you say.
Yes, and I'd extend this to perinatal care generally. Not just neonatalogy but maternal mortality, where some gains are to do with sanitation, but much is medicine (infection control, antibiotics, surgery).
Not to mention a society-changing medical advance which is genuine, highly reliable and practically doable contraception possible without celibacy.
Exactly right. If my daughter had been born in 1980 or earlier she would 100% without a doubt have died within a week of birth due to a congenital heart condition. Today she's alive and well thanks to ob-gyns with the technology to spot the defect long before birth and surgeons who were able to intervene shortly after birth. These days someone with her condition has an 80% chance of surviving to age 30, compared to the 0% chance of surviving to one month without treatment. She's alive because medical interventions can work, and because we've spent the last forty years inventing new techniques, technologies, and surgeries that improve on what we had before.
We have an 8 month old with an Absent Pulmonary Valve and Intact Ventricular Septum. He had a BT Shunt at 5 days old and a Glenn procedure just after Thanksgiving.
Like your daughter, just a decade or more ago he would have died in the first few days or weeks of life without the medical care and surgeries he has had. I wish great things for your daughter and my heart goes out to you and your family.
Tricuspid atresia: her right ventricle never developed. She had a BT shunt put in three days after birth, and she's had a Glenn too. We're actually getting ready for her (knock on wood) final surgery, a Norwood, a few years after the Glenn.
I don't know much about APV with IVS, but I know how hard it is to see your newborn go through open heart surgery. I want you to know that my daughter has grown and thrived into a sweet little girl, and she lives a normal life (with the exception of having to take heart meds every day, but she doesn't even know that's unusual at this point). I wish you the same for your child.
As I mention below, my son has a congenital heart defect and would be dead were it not for advances in medicine over the past few years.
I think for most people they interact with medicine almost exclusively when they or someone they love is at the end of their life. They see suffering, decay, and death highly correlated with medicine.
When you have the contrary experience - huge medical interventions at the beginning of life - you see flourishing, growth, and life. It is so clear, for these children, that medicine works.
The quotation from the Goldin, Lurie, and McCubbin paper seems to have some strange formatting that causes the "f"s to drop out of "effect". There are three instances of "eect" in the block quotation.
Hanson closes with "A mere 0.1% of U.S. annual medical spending, or $4.2 billion, could fund a far larger experiment, and hopefully settle the matter."
It is a call to reflect on the questions to ask and then separate wheat from chaff.
Yet most of you seem to strawman. "Look at all that wheat".
All three studies only look for the effect of insurance. None of them actively blocked access to medical treatment. An interesting third way would be "health credit". If the non-insured are so good at choosing the right subset of treatments, we can use that to drop two unfavorable cases:
* the patient judges a particular treatment to be beneficial, but cannot afford it right now
* the patient is of indifferent opinion to a particular treatment. But since cost is covered by insurance, he does the doctor a favor and gives in.
I see!!! He is, essentially, a medicine communist. "Capitalism has all these flaws and is inefficient, so we should kick it to the curb and try something else." Thank you for helping to clear that up. \S
Thats fine but then why have the first three paragraphs of his piece which imply modern medicine is falling for the same fallacies as 17th century medicine?
Reading the whole thing left me with one update for my(!) world model: There might be low (lower than i previously thought) hanging fruit to better tell two categories of medical treatment apart. That of treatments we should apply more often, and those we should apply less often. (will not elaborate on it in this reply).
Now the actual reply to your post:
since i value the piece for giving me that interesting pointer i(!) am willing to mark everything else there as the "hook story". If i find a golden nugget in a lake of mud, i pick the nugget and don't bother for the quality of the lake.
Rereading my post, i acknowledge i could have expressed myself better.
So here my update:
I don't bother whether Hanson is in total right/wrong good/bad.
I even don't bother whether a particular essay is right in every detail.
From reading this one i did not extend my basket of beliefs.
But i now have another question to carry around and pick up evidence where i see it in future. For that i value Hanson's essay.
Second update (thanks to your reply):
I am now more open to other ppl to react in a different way to it.
I just don't accept the distinction between sanitation and medicine. I understand that we can see sanitation as preventive, and medicine and reactive. But it's the same science that generates both.
And even if he has a point about the benefits to lots of treatments being small on a statistical level, I think that's clearly a different kind of failure mode from blood-letting. Blood-letting literally didn't work; it did nothing to treat (mitigate or cure) the diseases it was used for. Modern drugs have all been checked to see if they do that. It's possible that a subtle health thing is happening, as he suggests, e.g. the overall effect of many modern drugs includes a bunch of side effects that mean the drug is basically a wash, and the apparent gains to life as they are being used are in fact due to a bunch of other factors, like doctors keeping cleaner hospitals... But if all that's true, it's still a qualitatively different kind of failure.
Blood-letting *sort* of worked; for example, if you have dangerously high blood pressure, then losing some volume of blood will temporarily relieve it (we achieve the same result today with diuretics to cause greater urine output and reduction of fluid volume).
Or excess iron in the blood, where we still use blood-letting (but call it by a different name) today:
"Haemochromatosis is an inherited condition where iron levels in the body slowly build up over many years.
This build-up of iron, known as iron overload, can cause unpleasant symptoms. If it is not treated, this can damage parts of the body such as the liver, joints, pancreas and heart.
Haemochromatosis most often affects people of white northern European background and is particularly common in countries where lots of people have a Celtic background, such as Ireland, Scotland and Wales.
There are 2 main treatments.
- venesection (phlebotomy) – a procedure to remove some of your blood; this may need to be done every week at first and can continue to be needed 2 to 4 times a year for the rest of your life
- chelation therapy – where you take medicine to reduce the amount of iron in your body; this is only used if it's not easy to regularly remove some of your blood".
So blood-letting was a procedure that could be observed to be helpful in some cases, and like all cures, it was then subject to "if it works for X, could it work for Y? let's try it!"
I don't believe that it was first observed to work for people with haemochromatosis and then spread to others. Just as treating the weapon rather than the wound didn't begin with a case where it actually worked https://occludedsun.wordpress.com/2009/08/19/treating-the-weapon/
I didn't mean it that way, I meant "this procedure was used for a reason, and it was observed to be effective in some cases, which then reinforced the idea that it was useful".
We know *now* why it worked in some cases but was not the effective cure they believed, but that's blaming people for not knowing things they couldn't know. If we were still in the stage of performing blood-letting for a general cure-all, then yes, go ahead and criticise modern medicine. But while it may be correct that there are current treatments that in future will turn out to be the modern equivalent of blood-letting, we can't know until we know. So just shrugging and saying "We can't tell, so we won't do anything" is not a solution, either.
Look at the guy on here with cancer who is desperately trying to get on to all sorts of clinical trials in the hopes that something, some experimental drug, some novel therapy, will extend his life for a bit longer. You could say to him "Just give up, you can't know what will work, why put yourself through all this suffering when it's inevitable you will die?" but that's not the advice he or his wife want.
I still don't believe "this procedure was used for a reason". I don't believe actual usefulness was noticed. I think it was like other useless treatments at the time, where it is basically just by random chance we now believe there are any conditions it helps.
I will blame the past (broadly speaking) for not doing any control trials, and thus for not discovering regression to the mean in health. It doesn't actually require advanced mathematics or anything, it's just something people didn't bother to do. Medicine could have started making actual progress long ago, but instead it was on-net harmful for an extraordinary length time time, worse than doing nothing.
A diagnosis was performed, and current medical analysis proposed a treatment, which may or may not have worked successfully. If it did not, does that mean the analysis was faulty? Not necessarily. If the diagnosis and analysis were both sound, then it is reasonable to try the treatment again in similar circumstances.
Scientific treatments must be judged in light of the evidence. Experiments must be repeatable to able to be shown correct, but confounding factors mean not every such experiment will give the same result.
The "analysis" which led Paracelsus to believe that treating the weapon would be effective was obviously faulty. The problem is that the experimental method didn't even exist, so people were not improving the stock of knowledge by discarding treatments that didn't work.
"It doesn't actually require advanced mathematics or anything, it's just something people didn't bother to do"
You're blaming people for not discovering methods earlier than they were discovered, which is a dangerous game to play. *You* have the benefit of hindsight, being born into the era of "this is how we do science today". Drop you four hundred years into the past with no experience or knowledge of same, how obvious would it be to you to do such a thing? We've had the same arguments about "but why couldn't people simply believe the obvious truth Galileo stated about the earth orbiting the sun?" Well, because it *wasn't* obvious, any more than "regression to the mean" or "double blind control trials" was obvious in the 2nd century BC.
Anyway, an interesting article on "Therapeutic bloodletting in Ireland from the medieval period to modern times", and indeed that it was the 17th century when 'modern medicine' began to be established:
"As Standish O’Grady’s description of Gaelic physicians as ‘staunch Arabians’ indicates, they adhered to the classical medicine of Hippocrates and Galen. But by the sixteenth and early seventeenth centuries traditional medicine was changing. The publications of Andreas Vesalius’(1514–64) De humani fabrica corporis, Ambrose Paré’s (1510–90) La Méthod de traicter les playes faites par les arquebuses et aultres bastons à feu, and William Harvey’s (1578–1657) Exercitatio anatomica de motu cordis et sanguinis in animalibus challenged medieval ideas about anatomy, surgery and physiology, and laid the foundations for modern medicine. The whole tradition of Galenic medicine was attacked by Paracelsus (1493–1541) who espoused iatrochemistry, a fusion of alchemy, chemistry and medicine. He advocated chemical treatments for disease including the use of a combination of mercury, zinc and opium which he called laudanum. Later the Belgian physician Jean Baptiste van Helmont (1580–1644) believed that each disease had a vital principle of its own that could be countered by chemical treatments. Bloodletting had no part in this philosophy and van Helmont, who was familiar with medical practice in Gaelic Ireland, disapproved of it altogether. He made the very modern suggestion that a randomised trial of the treatment of fever with and without bloodletting be conducted using the patients’ funerals as the end point of the study.
...At the beginning of the eighteenth century, Henry Cope, twice president of the Royal College of Physicians of Ireland articulated the established medical view on bleeding in his book Medicina Vindicata. He stated that ‘bleeding, vomiting and purging are the chief operations in physic, by which diseases are cured and health preserved’; all accepted this philosophy ‘excepting a few enthusiastic chemists, who…boasted that all…diseases might be eradicated by one medicine’. While physicians recommended bleeding it was the surgeons and apothecaries who performed the procedure. Very often non-physician practitioners and others proceeded to ‘bleeding, vomiting and purging’ on their own initiative, eliciting a robust response from the physicians; in 1725 they petitioned the Irish House of Commons for a bill ‘to prevent abuses in the practice of physic’. In response Humphry Markwell argued that the physicians were motivated by avarice and pointed out that they had been unable ‘to convince the hundredth part of this city that they can cure folks better than their neighbours’. The bill did not pass, but the century was dominated by rivalry between the various medical professionals, eventually resolved by the emergence of separate regulatory bodies for physicians, surgeons and apothecaries.
...By contrast, in a very detailed report from the Waterford Fever Hospital, Dr John King Bracken said that in 1817 he never used bloodletting ‘by any mode, in any case’. In 1818 he did resort to bleeding and reported a small observational study of fifteen of his patients: ‘six completely or very much relieved, three moderately relieved, in four the relief was partial, temporary or uncertain, and two not relieved at all’. He commented that bloodletting might be used safely in the management of fever but ‘to do no injury is one thing and to relieve is another’. Dr John Murray from Cavan was also unimpressed by bloodletting: ‘bleeding did not form a part of our general practice and I verily believe that none of our patients died for the want of it’.
...Although bloodletting continued to be described in medical textbooks, it no longer had a place in the management of infection. It was used for treating heart failure, hypertension and cerebral haemorrhage. On 12 August 1922, Arthur Griffith, president of Dáil Eireann collapsed from a stroke at a nursing home in Dublin. The surgeon Oliver St John Gogarty found him lying dead at the top of a stairs:
His left arm was outstretched and bloody. A long incision of four inches gaped where his pulse was. It was not bleeding, though the artery had been severed by Mr Meade, who was on the spot, the only attempt that could be made to counteract cerebral haemorrhage."
As to why people continued to engage in practices like blood-letting, despite evidence it did little good and indeed caused death? Because sometimes it worked for fevers/inflammations (see ending of excerpt below about availability of iron), and until people knew what really caused disease, you go with pragmatism:
"Bloodletting in Ireland has a very long history. Based on the humoral medical tradition traceable to Hippocrates and Galen it was used to maintain health and treat disease. It is possible that Irish physicians of the early medieval period were aware of the classical theories and bled patients, but the evidence is scant. Bloodletting probably came to Ireland in the twelfth century and was practised thereafter by both the Anglo-Norman and Gaelic communities. Although challenged by new medical knowledge in the late sixteenth and early seventeenth centuries, bleeding continued to be pursued as a treatment for illness until the latter half of the nineteenth century. A variety of practitioners performed bleeding by opening a vein or an artery, or by the application of leeches. Cupping with or without scarification was also used. The discovery of microorganisms and the development of the germ theory of disease in the late nineteenth century finally put an end to bleeding as a therapeutic option for most conditions, but it continued to be recommended for problems such as heart failure and stroke. Venesection is still used today in medicine to deplete iron stores in haemochromatosis and leeches are used following some plastic surgery procedures. Complementary and alternative medical therapists also use cupping either on its own (dry cupping) or with bleeding (wet cupping) for several conditions, especially the relief of pain. Iron is an essential element for metabolism in all living cells. Reduced bioavailability of iron in a host deprives an invading organism of this vital nutrient thereby inhibiting its virulence. While modern medicine considers bloodletting an example of early therapeutic ignorance, it is just possible that as part of a health maintenance regimen bleeding may have provided some protection against infection to people in Ireland in the past."
Some of the empiricists were *for* blood-letting, as against the 'theoreticians' with what was becoming modern science:
"At the Edinburgh School of Medicine Dr William Alison (1790–1859) and Dr Hughes Bennett (1812–1875) were a study in contrasts. The former was a dignified old-timer and strong believer in bloodletting, while the latter was an arrogant newcomer and resolute debunker of bloodletting. Whereas Dr Alison followed the old tradition of clinical experience and empirical observation, Dr Bennett believed in the new methods of pathology and physiology supported by the microscope and the stethoscope.
Central to their debate was the observation that the improved outcome of patients with pneumonia paralleled the decreased usage of bloodletting. While Dr Alison ascribed this to a “change in type” of illness which had gone from sthenic (strong) to asthenic (weak), Dr Bennett believed it due to diminished use of a dangerous therapy.
Both were implacable in their point of view, thereby underlining the significant gap between their beliefs in empirical observation versus scientific verification. Dr Bennett had the advantage of the latest techniques and “grounded his rejection of bloodletting on pathologic concepts of inflammation and pneumonia derived from microscopic studies of inflamed tissues.”
No, Galileo was not obviously correct. Heliocentrism would not be confirmed until much more accurate measurements (particularly those from Tycho Brahe) were available than previously, finally enabling Kepler to come up with a more accurate model (Copernicus' was less accurate and featured more epicycles to boot, but it also incorrectly consisted of perfect circles which is why Copernicus himself believed it). And Paracelsus does not refute my point about the pseudoscientific nature of medicine back then, since he's the one who came up with the "treating the weapon" theory that I've been pointing to as obvious pseudoscience that nobody should have ever believed.
I think he separates sanitation out because we don't have doctors do sanitation (or even nurses in many cases - those are often done by people without those designations).
What are surgeons doing when they scrub up before surgery if not practicing sanitation? To us, sanitation seems separate from medicine because sanitation is not new to us, but when Semmelweis proposed that maybe doctors were killing their patients by not washing their hands, that was a new, revolutionary thing!
Not to mention Semmelweis was a physician - a doctor "doing" sanitation.
I think we're now in "lumpers vs. splitters" territory.
In a government budget "medical" is generally separate from "public health" and "public works". Often because the first has insurance providers (either public or private) involved, but not generally in the others.
What I think of as "sanitation" tends to include more of the latter two than the first.
The origin of the idea of pollution is religious. not scientific. If you think of sanitation as "pollution control and removal", then it's pre- our idea of medicine anyway.
Agree. Is "midwives washing hands before sticking them up the birth canal" sanitation or medicine? Much infection control straddles domains but it's driven by MEDICAL knowledge.
Honestly this just strikes me as a disingenuous take by Hanson from the top. He uses medicine. I strongly suspect Caplan also uses medicine. Medicine is manifestly and obviously useful for treating major injuries and curing directly treatable illnesses through a cause-and-effect mechanism: We can repair broken bones, we can destroy once-fatal illnesses with antibiotics, trauma surgeons save the lives of people who are shot or in car wrecks. All of this is indisputable so it's far more reasonable to conclude "our ways of measuring medical outcomes miss something" than to argue "medicine doesn't work."
"Europeans in 1600 likely prided themselves on the ways in which their “modern” medicine was superior to what “primitives” had to accept. But we today aren’t so sure: seventeenth century medical theory was based on the four humors, and bloodletting was a common treatment. When we look back at those doctors, we think they may well have done more harm than good."
Hanson seems to conflate medieval medical theory and practice. From a historian:
TL;DR: There was a total disconnect between medical theory and practice. Those who practiced medicine on actual patients didn't write about it, and the people who wrote about the centuries-old theory (e.g. the four humors) didn't ever practice. Modern medical theory being bad because the "four humors" theory was bad (as we would understand it today) does not follow.
Some quotes from the article:
"[We] have a doubly difficult time understanding what medieval medicine was, because the people who practiced didn’t write about it, and the people who wrote about medicine thought practice was beneath them."
"This [archeological evidence from leper colony burials] suggests that medieval understanding of these diseases in practice was a lot more sophisticated than theoretical writings suggest."
"There’s only one thing left: leeches and bloodletting, real or no? Real, but not what you think. Bloodletting, leeches, cupping, and cautery were all popular methods of balancing humors, but they were only practiced by the elite. Cupping has been making a comeback in recent years, and leeches never really went away. None of these were done frequently."
I can't really speak to Hanson's other arguments, but drawing parallels to pre-modern medical theory does not help his case.
Telling “just so” stories based on wrong history seems to be a common vice among economists. See also the famous, and false, story that teams of Chinese workers would hire someone to whip them to prevent individual incentives to slack off.
Yes, the elite could afford to hire doctors while they poor couldn't. That's why they had higher maternal mortality once doctors started displacing midwives (while they were also handlling infectious corpses).
You quoted some of the caveats in that last study, but I think it's worth emphasizing that their numbers are kind of sketchy. They say
> we estimate that the average per-month effect of the coverage induced by the intervention on two-year mortality was approximately -0.17 percentage points.
But this would give you -4 percentage points over the whole two years, or -2 percentage points in a single year. That's implausibly huge - life expectancy in the US is more than 1/0.02, so a 2 percentage point risk of death is more than your entire annual mortality risk! You could salvage this if the insurance signups were concentrated in really old people, but mostly I just don't buy it. In fact the authors don't buy it either:
> We view the effects at the lower-magnitude end of our confidence interval as most plausible, given the treatment effect magnitudes reported in prior research
They also note that extending the month-level effects linearly might be a bad idea:
> We also present suggestive evidence that the steady-state effect of annual coverage on mortality is less than 12 times our estimated per-month effect due to concavity in the relationship between coverage and mortality
I haven't dived into the statistics for this study enough to independently have opinions about their analysis, but "we found an implausibly huge effect, but our confidence interval extends to the effect size being 6 times smaller than observed, which wouldn't be as implausible, but luckily the confidence interval still misses zero" is not the kind of epistemic state where I feel _great_ about the conclusions.
Scott mentions the leukemia drug imatinib and the lymphoma drug rituximab, both of which I was able to be on (a more powerful successor of imatinib called dasatinib, actually, which I still take daily) and which were the main crux of the regimen which saved my life when I was diagnosed with acute lymphoblastic leukemia in my mid twenties.
My leukemia is driven by a mutation called Philadelphia chromosome only present in a small minority of A.L.L. cases. It was, fun fact, the first cancer mutation ever identified, since it is visible under a powerful microscope by causing some *very* wonky stuff with the 22nd chromosome - they first saw it in 1959.
Previously, leukemias had proven treatable in many cases with the advent of bone marrow transplants: leukemia is bone marrow cancer, so we use intense radiation and chemotherapy to fry your bone marrow into oblivion and then replace it with someone else's who is similar enough to you that you can get by.
But, it didn't really help people with Philadelphia chromosome, which for some reason was much more resistant to treatment. Even a couple of decades ago, other kinds of A.L.L. were seeing 5 year survival rates around 50-60% while diagnosis of Philadelphia chromosome was a death knell; survival rates hovered below 10%. Treatment could usually induce a remission but it almost always came back stronger within weeks or months.
And then, in the early 2000s, a miracle; the development of the first mutation-targeted medication for a cancer, in a weird twist of fate for the first kind of cancer whose mutation was ever identified. Imatinib is a tyrosine kinase inhibitor - a tyrosine kinase being, to my understanding, a kind of enzyme that signals cellular reproduction and which Philadelphia chromosome causes its cells to make a broken version of which is always on, always signaling for reproduction. TKIs find cells that have the broken enzyme and cause cell death. (And also to some amount of regular blood cells too I'm pretty sure since mine makes me continuously anemic and immunocompromised, but I'm not going to look a gift horse in the mouth here, it hits the mark most of the time)
This finally gave patients with Philadelphia positive A.L.L. some hope, as well as patients with chronic leukemias, a much higher proportion of which have Philadelphia mutation origins. People began living longer, and some even began being cured and remain alive today.
There are now two successor generations of TKIs, generation two is dozens of times more powerful than imatinib and generation three is hundreds of times more powerful. Two years ago when I was diagnosed, my doctor gave me a prognosis of not just a 70% chance of 5 year survival, but a 60% chance of reaching a cure - and unlike Philadelphia-negative A.L.L., without even a bone marrow transplant. Outcomes for ph+ and ph- A.L.L. are now more or less similar and it seems possible that in the future, ph+ leukemia could actually be regarded as a favorable mutation for prognosis.
Also part of my treatment regimen (which included more medications than I can count on my hands) was rituximab, because my leukemia also came with the C.D. marker rituximab is able to treat. I'm not too sure on exactly what a C.D. marker is and it seems like neither are most non-hematologist doctors I've asked, but I'm thankful for it, and it improved my chances considerably.
Anyways, cheers to modern medicine! I literally could not get by without it. My leukemia isn't cured - yet, growth mindset - but it's controlled to an extent that it's undetectable on tests most of the time, and if it ever decides to come back I still have several lines of treatment and more powerful TKIs left available to me, even more than I had when I started out.
Minor point but I wouldn’t waste much time with the “patients are just diagnosed younger and therefore do better” line wrt cancer. In many common tumors the cancers typically found in younger people are biologically and clinically different, and often much worse (faster-progressing with a shorter prognosis), than those typically found in older people.
(Breast and lung especially should really be thought of as multiple disparate diseases at this point and imo it makes this kind of broad conversation difficult to illustrate with them, let alone with “cancer” writ large; much better if feasible to zero in on a specific, coherently characterizable tumor type that fits your specific example needs. But I do get that this is a lot to ask in a thirty-thousand-foot-view essay about Medicine Y/N lol.)
The problem is, Robin makes a specific claim I think is false, and if I don't refute it, then other people start thinking it's true and repeating the claim. It's not a straw man argument if it's the literal position a lot of people are making! I can refute that argument without necessarily refuting some other argument that other people on vaguely the same side should have made.
Because that has two straightforward interpretations, and you've chosen the less charitable interpretation, which happens to fail to be consistent with the dozen+ posts he has written on the subject, to argue against.
I am not sure I agree with Robert here, but I see a few gaps in your arguments.
1. Survival rates. These are heavily dependent on detection timing. Imagine a world where we cannot treat cancer at all, but suddenly discover a technology to detect all cancers 6y earlier. Then the correct comparison would be between 5y survival rates pre-discovery and 11y survival rates post discovery. The cancers we observe post-discovery are much less deadly, on average, than the ones we observed pre-discovery. 5y survival rate would get to a very high level, but it is not clear what the benefit would be as we would be still unable to treat any cancers. Thus, your comparisons of survival rates are biased by better and earlier diagnosis.
2. Bayesian chaining. It is not obvious to me that a claim "medicine does not work" applies only to step 4 of your causal chain. Step 4 corresponds to the "medicines/medication do not work" claim. I think Robert is arguing about "medicine", not "medication", so it is not very nice to switch the goal to "medication" as do in your conclusions.
It is possible that there is a breakdown at steps 2 or 3 in our healthcare as a system that renders it useless while some medicines do work when used properly. I think it is fair to call these step 2 and 3 breakdowns "medicine does not work". For example., imagine a world where doctors make diagnoses completely at random irrespective of the underlying conditions. Then step 2 would be badly broken, and we would not observe good outcomes for the group with greater access to doctors. I think it would be fair to describe this situation as "medicine does not work". (And, yes, I am aware that this hypothetical is not compatible with perfect detection hypothetical in 1)
2. I think it depends what you want to prove. If you want to prove that society shouldn't spend money on doctors (because people will never go to them anyway), you care about step 1. If you want to know if you personally should take medication a doctor prescribed you, you should care about step 4. So it matters a lot which of these steps fails!
(also, my position is that none of them fail, you just lose statistical significance at them)
1. Thank you, I read that 2018 post now. It argues that most of cancer survival rate improvement is not due to a shift in detection stage. However, it makes this argument by referring to several published papers. This is a perfectly respectable argument, except that in today's post you seem to accept to play the game of assuming that we do not trust a single published paper on treatment efficiency. If the argument "medicine works because this published scientific article confirms it in this particular case" is allowed, Hanson point is clearly untenable.
2. You quote Hanson to claim that "medicine does not work" so it would make sense to build an argument to disprove that premise and not a related one.
There is detecting weaker heart attacks however. Things that a prototypical farmer might have shruged off and died of the n-th time propably go to the ER more often now.
And don't forget preventative public health measures! These are part of medicine too. Better to not have cholera or dysentery or polio or HBP or excessive LDL (name your condition) in the first place, than to seek treatment after these conditions become a problem. Preventative measures are generally a good thing, and have been driven by biomedical research. Medicine is not only treatment for a preexisting condition: it's also about preventing the problem arise in the first place: and often the interventions are cheap pharmaceuticals. Sun block, statins, polio vaccine, clean water, etc. The counterfactuals here are weird: should we just close all our primary treatment centres and not bother putting in tents, repairing compound fractures, or whatever?
> And don't forget preventative public health measures! These are part of medicine too.
I think this is controversial but semantic. (That is, I don't think Hanson considers them to be part of medicine.) At issue is whether "patient-facing medicine" is net helpful / how well we can estimate it, which we should be able to account for separately from public health improvements.
>Even Robin admits this is a real effect; he just classifies it as more physics than medicine.
Does he have the same opinion about really obvious surgery? Clearly everything that ever works is physics in the end, even if we can't discern all the intermediate steps in most cases.
I was raised in Christian Science, a faith-healing cult that avoids all medical intervention (this is an excellent comprehensive documentary on the topic: https://www.youtube.com/watch?v=E7RT4wNhiYQ).
My grandmother died slowly and horribly and pointlessly of a skin cancer which would have been trivially easy to treat (it has a 99% survival rate).
I, and every single surviving family member also raised in Christian Science, now have varying degrees of permanent damage from benign medical neglect.
Had Robin Hanson looked into Christian Science, he would not have formed these conclusions.
You know what, fair enough. Many of Christian Science's mandates indeed optimize for health - teetotaling, abstinence from tobacco, daily deep meditative prayer - and then of course medical malpractice is difficult to experience if you don't have medical attention.
When I'm in the mood to explain why Christian Science got a foothold, I like to say, "It REALLY works until it doesn't."
Nassim Taleb argued that religion was selected for in the past because it kept you away from doctors (who were harmful). I don't think that applies as well to sects other than Christian Science.
>I, and every single surviving family member also raised in Christian Science, now have varying degrees of permanent damage from benign medical neglect.
Could you give some examples? Its hard to tell what sort of thing youre talking about if you only have experience with normally medicine-using people.
Yeah, my brother dislocated his shoulder while attending a Christian Science boarding school and the adults in charge didn't have him medically treated. He has some permanent pain and weakness now, 25+ years later. He had it seen later as an adult, and the doctor said that because it wasn't properly reset and I-don't-know-what-else, it never properly healed and it's dubious if an attempt to correct it now would be successful.
My mother was effectively crippled by arthritis, especially in her hips - the surgeon who eventually performed her hip replacement said the imaging was "ten out of ten bad," some of the worst he's ever seen. She's now had both hips replaced and is *much* better, but has some knock-on effects in her knees and etc from not having had the hip replacement 20-25 years ago and compensating by hobbling around instead. She also had a shoulder injury from tennis about 30 years ago which was never seen and prevents her from being able to lift her arm above her shoulder - doctors say it would be unwise to do the surgery now (I gather. I wasn't in any of these rooms).
My uncle has a potential prostate cancer thing which he's decided to treat with diet and fasting. He is also divorced from a Christian Science practitioner who was diagnosed with BPD during the incredibly contentious divorce - while not technically physical injuries, she deeply and very likely permanently damaged him with (what turned out to be demonstrably false) accusations and totally alienating their son from him - he hasn't spoken to him in at least a decade and even had to hire a private investigator to find him to distribute inheritance (when my grandmother died horribly).
(If the alienation thing seems implausible, let me assure you, my uncle's ex is the most powerfully charismatic person I've ever met, she 100% could have started the kind of cult which would end up in a Netflix documentary, but she put all that charismatic and influence into her son instead.)
I got out of Christian Science earlier in my life than my various family members and maybe I can't claim the same kind of "permanent" injury, but untreated PCOS starting in puberty led to a hormone imbalance which caused a perfect absence of sexual desire. I eventually read about this "totally normal" orientation called "asexuality" and embraced the identity - only to have it accidentally 100% reversed in my 30s.
(I have Many Thoughts about the profound effect of hormones on perception, motivation, and personality. )
Was missing out on 15-20 prime years of sex and romantic relationships a "permanent injury?" I'd argue yes, especially if you consider that I was blocked from the opportunity to partner with someone and consider having children in the proper window of opportunity for those things.
And then there was my grandmother, who did indeed die extremely slowly and horribly. And because I was the most lost-cause atheist in the family at the time, quite a bit of the end-of-life daily medical care fell to me, because she didn't want anyone else's faith shook by the reality of cleaning an infected tumor the side of my palm.
I never understood why some dying people would tell their loved ones, "Don't come to my deathbed, I don't want you to remember me like that," but now I do. The sheer gruesome absurd horror of the last three months of her life became my most vivid and primary memories of her, despite her being a third parental figure most of my life. I don't think I'll ever be able to disassociate them from her full and awesome life.
And for Christian Scientists, my family was actually relatively lucky!
I have now subscribed to your Substack on the hopes that you will at some point share your Many Thoughts about the profound effect of hormones on perception, motivation, and personality. I too have Many Thoughts about this and how it interacts with identity, self, control, etc. and based on your writing here today I believe I would enjoy reading your Many Thoughts.
I didn't even think about the cancellable aspect, in spite of living with someone on hormones from a group of people that people get quite defensive about. Sorry about that!
I was more of thinking about how hormones interact with people not from any specific subgroup, and also actions that can cause or stop hormones, and thinking about if that's a kind of mind control... also, who is the person, the person "without" hormones, the person under the influence of a "normal" set of hormones, etc....
Thanks for responding. Many thoughts about this. Firstly, most of those sound surprisingly normal. Grandmas untreated cancer is weird, and the hip issues might be depending on the age they happened, but everything else sounds like it could happen to normal people the same way. By contrast, where my relatives were saved (when younger) by medicine its very clear-cut, like one was hours from his appendix bursting for example.
Secondly, this extrapolates to large numbers of working-age people with disabilities in e.g. the middle ages. That seems weird but I really have no idea if its true.
Id also love to hear how you felt/feel about getting a sex drive.
I know that some "normal" people avoid doctors either because they just don't like seeking medical care or they can't afford it, but I should underline that my mother and brother suffered excruciating pain from their injuries in these examples. Not only did they not seek formal medical care for their very obvious injuries, but they didn't take *anything* to treat the pain - not even acetaminophen. My mother's hip replacements were 15 years later than a normal person would have had them, because a normal person would have refused to tolerate the kind of pain and infirmity my mother suffered if medical care was a viable alternative.
Likewise, grandmother concealed the excruciating pain from her tumor for a couple of years, until it was so debilitating that she was half-dragged to urgent care and after that into medical care in general. You didn't know her, so you can't understand how much pain it would take for my grandmother to concede defeat in Christian Science, but let me assure you, it was a truly awesome amount of pain, the kind a normal person would find unthinkable. I was present for several different doctors' appointments and home care visits and watched all of the medical staff blanche, universally unable to conceal their shock and sympathy.
My family happened to have the good luck to not have life-threatening events like appendicitis, so I can't say for sure what would have happened if we had. My father, who is not a Christian Scientist, later said he would have over-ridden my mother and grandmother and gotten us medical care had we kids ever appeared to be seriously injured or dangerously ill, but I have to imagine that would have been a very late intervention indeed, much later than a normal family's.
And yes, while bad divorces are common, Christian Science's insistence on *very literally* denying the existence of negative things (sin, sickness, malice, etc) made my uncle far more tolerant of his ex-wife's destructive behavior than I think most normal people would have been. Of course, plenty of normal people are human doormats, but in this case, the religion strongly guided my uncle to deny/ignore the problem instead of addressing it.
>I know that some "normal" people avoid doctors either because they just don't like seeking medical care or they can't afford it
Thats not what I meant. Dislocated shoulders not fully healing is common even with medical attention, I even knew a guy whose just kept popping out for years despite many doctors visits. PCOS is easily missed even for medicine-positive people. I dont think I would have seen it in a medical light if I had never developed a sex drive, theres no one clearly pathological symptom in general - doctors understandably dont notice often. Unmanaged mental illness is mostly down to side effects and bad decision making resulting from said mental illness, less often to attitudes about medicine. Benign prostate tumors are recommended to monitor only in some places, though propably not the US. Those things I had in mind.
Thanks for your personal story. Sorry for what happened to you and I wish you lots of fun now.
Yeah, Christian scientists have lower life expectancies than other groups nowadays (they used to have comparable/superior, since their teetotalling stuff helps with health and medicine used to be a game of Russian roulette). They make for a pretty good natural experiment on the overall impact of medicine.
I'm surprised the argument centers narrowly on survival. Medicine is also good for improving bodily function and alleviating symptoms.
For example, anti-epileptic medications might be life-saving (I don't know the data), but they certainly help people to live more normal lives. Opioids and benzodiazepines have made the dying process for many people less horrific. Trauma surgery means broken bones can be fixed and a once disabling injury now is only a temporary set-back. There's durable symptomatic control of many chronic diseases with medication (e.g., rheumatoid arthritis, inflammatory bowel disease, SLE, COPD).
I think it's an inevitable epistemic challenge that there are things we don't know now that we'll know in fifty years about the interventions we're currently using - either there are unintended negative consequences or we thought some things were working when they really weren't (e.g., cancer drugs approved via the accelerated pathway end up showing no benefit when tested more rigorously). That's just the nature of how science evolves over time. In the face of this epistemic challenge, though, is it better to do nothing or something? I think that's the question best asked on a disease-by-disease, person-by-person basis. Will this intervention help this person right now? I spend a lot of my time in palliative care helping folks to navigate just those kinds of questions.
FYI Hanson & Caplan are not alone, this skeptical position is also the main point of Jacob Stegenga, Medical Nihilism (https://www.amazon.fr/Medical-Nihilism-Jacob-Stegenga/dp/0198747047) : "This book argues that if we consider the ubiquity of small effect sizes in medicine, the extent of misleading evidence in medical research, the thin theoretical basis of many interventions, and the malleability of empirical methods, and if we employ our best inductive framework, then our confidence in medical interventions ought to be low"
I do not agree Medicine is not effective, but I think his point is more about what dominates in terms of increasing lifespan and the sort of cost-benefit analysis. For example, it could be that all the cancer, cardiovascular etc medicine we have only increases lifespan on aggregate by like 2 years (because people who have these diseases are likely to die of some other affliction soon enough.) There was a paper arguing that curing *all* cancer would lead to an increase in lifespan of ~ 3 years. I think it's fair to ask: is it worth spending so much money for such small benefits or could this money be used better? I do not think these questions matter a lot because people will still prefer getting medicine, but it's a fair question and I do think we might overestimate the average add in lifespan from medicine beyond antibiotics and stuff like this.
That being said, to me this is the best argument to invest in ageing research.
actually, I was wrong, I do think these questions matter. Pondering just how little cancer treatments would add to lifespan was an important reason why I became interested in ageing.
Clearly reasoned (absence of evidence is not evidence of absence), but are you tilting at windmills? Hanson's perspective seems preposterous. Can we seriously question that diphtheria vaccine has no effect? that antibiotics for bacterial pneumonia are worthless? that insulin is useless for type 1 diabetics? that antihypertensives have no impact on malignant hypertension?
The other angle to do this is doing it bottom-up. Surely dialysis and kidney transplants work against diabetes? Surely getting your broken arm put in a cast works? Surely antibiotics work? Surely having surgeons treat that stab wound works? Surely having your infected appendix removed works? Surely the Covid vaccine worked? Surely antihistamines work? And so on and so on - once you've established that vast slews of medical interventions *obviously* work, then any odd statistics that claim they don't must surely have methodological errors.
As a MD and a researcher setting up clinical trials, I found Robin Hanson considerations absurd and obsolete. It is like discussing if the earth is flat or at the center of the solar system. I think there are far more relevant thought experiment to discuss such AI doctors, AI as a government to avoid needless wars, robot assisted society, space colonization etc.
The Scott Alexander answer is excellent. Vaccines, antibiotics, antidiabetics, antiarythmics, immunotherapy, robot surgery have demonstrated their clinical efficacy in terms of survival rates, quality of life, autonomy and mobility etc.
Okay, can anybody explain to me why Robin Hanson is taken seriously about anything? From my view, the one thing he's done is write some SF about emulated humans in a computer. But that seems to make him a Respected Big Thinker.
The guy comes out with "yeah I had my broken arm fixed, but are we *really* sure medicine is any good?"
Now, do we have contemporary theories that will eventually turn out to be like the four humours? Probably, but that will be due to the advancement of knowledge like everything else. Next time Hanson breaks his arm, do you think he'll stay at home and do some deep breathing, because medicine is still on the level of Galen, or will he head to the local hospital?
The only sense I can make out of all this is that he enjoys being a feckin' eejit, I mean contrarian, and taking the "if everyone jumped off a cliff, would you do it do? yes, mom, I would!" position. That's fun, but do it consistently and you don't come across as a gadfly, you seem to be a silly person.
What's next - "is food actually necessary? history shows primitive peoples believed you could acquire the characteristics of a creature by consuming its flesh, hence they would eat the heart of a lion to become brave, we know today this is nonsense, but Big Agriculture and Big Dietician Industry has convinced us we need to 'eat' to live, I propose instead that all you need is air".
EDIT: I admit, I rather admire this man for his sheer cheek, now *this* is the kind of fasting I can get behind! Though even I blanch at the idea of a double quarter pounder:
"Wiley Brooks (1936–2016) was the founder of the Breatharian Institute of America. He was first introduced to the public in 1980 when he appeared on the TV show That's Incredible! Brooks stopped teaching shortly before his death in 2016 to "devote 100% of his time on solving the problem as to why he needed to eat some type of food to keep his physical body alive and allow his light body to manifest completely". Brooks claims to have found "four major deterrents" which prevented him from living without food: "people pollution", "food pollution", "air pollution", and "electro pollution".
In 1983, he was reportedly observed leaving a Santa Cruz 7-Eleven with a Slurpee, a hot dog, and Twinkies. He told Colors magazine in 2003 that he periodically breaks his fasting with a cheeseburger and a cola, explaining that when he's surrounded by junk culture and junk food, consuming them adds balance.
Brooks later claimed that "All McDonalds are constructed on properties that are protected by 5th Dimensional high energy/spiritual portals", encouraging the consumption of Diet Coke and McDonald's Double-Quarter-Pounder/with cheese meal ("It is also acceptable to combine 2 quarter-pounder with cheese burgers to make one double-quarter pounder if you can't get the double-quarter-pounder with cheese where you live"), and discouraging the consumption of "water of any kind". The idea of separate but interconnected 5D and 3D worlds was a major part of Brooks' ideology, and Brooks encouraged his followers to only eat these special 5D foods, as well as to meditate on a set of magical 5D words."
I’m glad to see you pushing back on this claim as it may undermine the urgency for much more investment into medical research. I would like to see 10x the amount of medical research being done. And why not? There is a lot of room for improvement when it comes to reducing the suffering from physical and mental health problems.
You can increase medicine use with no effects on questionnaires or measured health outcomes. When I was younger, I was very allergic to tuna and salmon. I went and reintroduced them into my alimentation. It took a lot of time, probably shot me to the top 5% of medicine use for my age and country, but did not change a lot on how I would have responded or scored on most questionnaires. I was very good a avoiding my allergies, so I doubt my adverse event rate or death rate moved any direction. I was also not very stressed about the allergy or the procedure and would have not scored differently on mood or stress. You could build a case that nothing changed and that it was useless with the kind of metrics tracked by those studies. Except from the fact that I can eat tuna and salmon now, and that while it's probably not the most efficient use of medicine, it still works and I am happy with it.
How quickly we forget! Does he even know that the mid-thirties were once called "the heart attack years"? I saw a huge change in heart disease over my forty years in practice, partly due to less smoking, but also partly due to diet and statins. Another example: when I was diagnosed with CLL, I looked up the stats and they were dismal. Fortunately things have changed, with targeted treatments the outlook is vastly better, and I may even be cured by an HSCT.
I'm surprised to hear this about the mid-thirties - any source? I thought heart attacks were happening more often in young people now (because of obesity)
Thank you for writing this! I know you said no one takes Hanson and Caplan seriously, but I definitely take them seriously, even I do not always agree with them. I work in healthcare, and though intuitively I thought Hanson was wrong, I could not figure out exactly where his mistake was. This left me with a gnawing feeling that I might just be biased and everything I do for my job is pointless and doesn’t help anyone. This article reduces that feeling.
> This might seem like a silly question: in Europe of the seventeenth century, the average lifespan was in the low 30s. Now it’s the low 80s. Isn’t that difference due to medicine? In fact, the consensus is now that historical lifespan gains are better explained by nutrition, sanitation, and wealth.
Wow. Hanson is committing one of the best-known statistical errors here. First off, it doesn't pass the basic "smell test." (Does anyone *really* believe that 300 years ago we had a bunch of elderly people in their 30s running around?!?) I can't help but wonder, does Hanson not realize just how well-known of a mistake this specific claim is? It's practically a textbook example of wrongly grouping together unlike data.
"Historical lifespan gains" are virtually nonexistent. Modern conditions have improved things a little bit at the margin, but certainly not by decades! That "average" is explained almost entirely by throwing a whole bunch of 0s, 1s, and 2s into the data that skew the overall number far too far to the low side, and then we came up with vaccines and other treatments that did away with infant mortality almost entirely.
Once you separate infant mortality from adult mortality, a very different picture emerges: the ancient figure of 70-80 years for a human lifespan (Psalm 90:10) has remained almost completely unchanged for millennia, and we're just barely starting to improve on it today.
> That "average" is explained almost entirely by throwing a whole bunch of 0s, 1s, and 2s into the data that skew the overall number far too far to the low side, and then we came up with vaccines and other treatments that did away with infant mortality almost entirely.
Well, apart from medicine, irrigation, health, roads, cheese and education, baths and the Circus Maximus, what have the Romans ever done for us?
> the ancient figure of 70-80 years for a human lifespan (Psalm 90:10)
You appear to have missed the point entirely. I'm not saying there's anything bad about getting rid of infant mortality; I'm saying that it is statistically entirely different from, and unrelated to, adult lifespan, and mixing the two together is a well-understood error.
> I'm saying that it is statistically entirely different from, and unrelated to, adult lifespan, and mixing the two together is a well-understood
Okay, then I did misunderstand your point.
Yes, from what I know, average lifespans were a lot longer if you discount deaths in the first few years. However, there were plenty of opportunities to die before reaching 70: death from childbirth (practically solved today), death from bacterial infections (practically solved today), death from appendicitis (practically solved today), death from viral infections (much less serious today – keep in mind that the bubonic plague killed about 50% of Europe's population in the 14th century; COVID-19 killed something like 0.2-03%). And that doesn't even consider deaths that are prevented by medicine, like deaths from malnutrition or unsafe working conditions.
All this makes it very hard to imagine that the average lifespan (even discounting infant mortality) hasn't increased by at least 20 years.
> the ancient figure of 70-80 years for a human lifespan (Psalm 90:10)
Sorry, but I can't get myself to take demographic statistics picked from a Bible passage even remotely serious.
What’s to take seriously? He said it was the ancient figure. What other than ancient texts could we use to determine ancient people’s understanding of age ranges?
Of course the Bible is not a definitive source about how long people in that time lived. But the author(s) would be expected to use a figure that readers would have found plausible, just as “man is born to trouble as the sparks fly upward” relies on the reader knowing that sparks do indeed fly upward.
> What other than ancient texts could we use to determine ancient people’s understanding of age ranges?
Bob's claim wasn't about "people's understanding" of lifespan, but about actual lifespan. The former is irrelevant to this discussion, and the latter can't reliably be determined from a single passage in the Bible.
As for plausibility to the readers: A contemporary reader would say "Yeah, I know one or two geezers that look so wrinkly they might as well be 80, sounds about right for maximum human lifespan", and not take into account all those people in his village that died between the ages of 2 and 70. Because that reader wasn't a statistician meticulously collecting data across a large population.
And then there's the issue with translations and misinterpretations of ancient texts. Can we be sure that the author really meant "average life expectancy", which is what we're talking about here, or rather "maximum age"/"top percentile", which is a very different concept, and which is today much higher than "70 to 80".
>the bubonic plague killed about 50% of Europe's population in the 14th century; COVID-19 killed something like 0.2-03%).
Thats because they are substantially different viruses. If Covid had swept Europe in the middle ages, they wouldnt even write it down as a plague year. There has never been an airborne virus as dangerous as the bubonic plague, and thank god, that could very much still wreck us today.
I think saying “no” to “does modern medicine work?” encompasses multitudes, the possible answers being (strongest no to weakest, clickbaity no):
1. It’s all fake and pointless, all medicine may as well be sugar pills, surgery’s just a more drastic alternative to acupuncture.
2. A few bits and pieces work (eg antibiotics) but the same’s true of witch doctor potions and Chinese medicine; most of it’s pointless.
3. Quite a few of the pills work; most are overrated and some are rubbish. Doctors themselves are a pointless bureaucratic hurdle to pill-buying who add no value.
4. Modern medicine has some kind of paradigm/worldview which is better than chance but fundamentally wrong (a bit like Cartesian vertices).
6. Health insurance achieves nothing, in spite of the pills working.
7. Health insurance is overrated.
Hanson’s position seems to be 2, but his studies only get him to 6 at best. The study you’d need for 2 is a comparison of effect sizes (or a better measure of efficacy) against placebo for a panel of medicines weighted by how commonly they’re prescribed.
It might be too difficult, especially with easily available data, but maybe some extra stats could make a stronger case from a lot of these studies -- if the main problem is a largeish number of marginal results.
(I'm not sure how much further effort it's worth going to on this topic but I think the below is generally interesting and worth trying.)
Karnataka measured over 80 outcomes and there are various others.
Unlike published RCTs maybe we can hope they don't suffer from selection (publication) bias, after all they seem to have published a lot of non-results.
Hopefully they also published anything that looked like the medicine was harmful!
Case 1 (no real effect): We'd expect to see a range of results, with no particular bias towards positive outcomes and some marginal results in both directions.
Case 2 (beneficial effect of medicine): We'd expect to see a range of results but with a positive drift. It might be hard to produce well powered formal test, though there are some simple things one could do:
a. Plot effect estimates with CIs, maybe there's a visually obvious positive bias
b. A sign test: What fraction of findings suggest a positive effect vs. negative.
@Scott: If you have or know where the get the data relatively easily, I'm happy to poke around, make some plots and try some tests. Maybe with some kind of pre-registration of what to try, once the basic parameters of the data are clear?
Can the correct medical treatment work if administered properly? Yes, for many diseases the effect is massively positive.
Is going to the hospital and doing what the doctors tell you to likely to increase your health? This is where Robin has the chance to be correct. He identifies a huge gap between what we think medical intervention can do (massively increase our length and quality of life) and what it actually does in practice (very specific and often marginal improvements in a subset of the ailments humans have). This gap creates a huge mismatch in expectations which is extremely dangerous. Patients are massively biased towards intervention. They get frustrated with the modest gains of real medicine and will seek more and more intervention to try to get the increases in health they imagine medicine should be able to give them. Intervention is dangerous. Doctors are likewise frustrated with the mismatch between their very high social status and their very modest ability to heal. They will go along with or even encourage the unnecessary interventions. Every surgery has risk, every medication has side effects. If people seek intervention far out of proportion to real benefits, then the iatrogenic effects of treatment can cancel our the small positive effects of medicine. In this way, even if medical treatment is real, the total effect of the medical sector can plausibly be negative or within statistical error of zero.
I think your on expectations vs. reality is really onto something. I think there is an issue with spheres of control that is not sufficiently set out. Modern medicine is at its strongest dealing with visible, physical phenomena - broken bones, neurosurgery, repairing joints, etc. But that is also, in some ways, closest to the competency of pre-modern medicine. I think that if you had given a pre-modern surgeon access to modern imaging technology and anesthetic and scalpels (and forcibly washed his hands) he would have had a relatively short learning curve to accomplish many of these interventions. Egyptians were trepanning millennia ago - presumably not very successfully, but still.
Just at or below this tier is germ theory and antibiotics. Taking a tangible sickness caused by a microscopic (but observable) physical foreign organism and treating, not just its symptoms, but the underlying antigen. Vaccination falls here as well.
Below again are diseases caused by failing systems of the body. Interventions here are subject to many compounding factors and treatments range from quite effective to virtually useless to harmful. Cancer, chronic illness, etc.
Below even further is Scott's area of psychiatry and psychopharmacology. His own posts have noted the absolutely abysmal effectiveness rates of almost all anti-depressants, for example. Below even this are fields that are effectively pseudo-science the quality is so bad, nutrition being an example.
In essence, the simpler and more tangible an ailment's cause, the closer it is to the central sphere of control of medicine. The further out you go, the lower your expectations should be. I think many folks encounter medicine in a central context, then are disappointed when they try it for a less central ailment. For example, I knew a brain aneurysm patient who received quick and effective care, neurosurgery within 48 hours, and ICU care for several weeks. The doctors were able to control BP during that time like turning a thermostat dial, accurate within 2 points on either side. Intracranial pressure was monitored and corrected, and eventually a permanent shunt was placed. Following some therapy, full recovery was achieved. It was a triumph of interventional medicine. Shortly thereafter, another patient I knew was diagnosed with advanced pancreatic cancer. Care was perfunctory at best by doctors (probably due to expected futility) and side effects were severe; probably no intervention would have been a better choice. It was jarring, after watching body processes be manipulated with machine-like precision, to realize that medicine was basically helpless or actively harmful. But that was an expectations issue. Had I not recently seen the one, I would have been less surprised at the other.
What surprised me is that Scott, who practices on the bottom rung of medicine's effectiveness ladder / outermost sphere of control, doesn't recognize this effect. Of course most of what he does is poor quality medicine with minor effects. He's posted over and over about how nothing really works in mental health (or conversely everything works, but with low reliability). Internal medicine has similar hierarchy problems. The more complicated the system, the more useless medicine has become. Hanson basically accepts the low-hanging fruit of the inner spheres, and dismisses the rest. This is too simplistic, but it's fair to say that medicine in those outer spheres is useless IF your expectation for "useful" is set by the inner sphere.
I should clarify that I'm not at all saying Scott is a poor medical practitioner. I meant "poor quality medicine" only in the sense that it is in the most-complex and lowest-confidence area of medicine.
I'm not sure if the astonishing success medicine has had with infectious disease is "close to competence of premodern medicine". Before salvarsan (roughly) there was pretty much nothing.
As to psychiatry. I think we focus so much on the common maladies largely treated in outpatient care that we forget the ABSOLUTELY REVOLUTIONARY impact of antipsychotics (yes, including the first gen neuroleptics). I'm not a physician but I did a very comprehensive psych degree which included psychiatry, and neurology taught in hospital environment by medical doctors and while I'm not old enough to remember it, I'm old enough to have been taught by some people who remembered their advent as something borderline miraculous, notwithstanding the heavy side effects and that they were not by any means a cure, the development of drugs that could reduce or stop acute psychosis made a big difference.
Okay, to steelman the argument: without antibiotics and the advent of techniques such as x-rays, 21st century medicine would be as ineffective as 17th century medicine, where high mortality rates were due in part to deaths from infections that could not be treated either prophylactically, as with inoculations and vaccinations, or concurrent with the advent of the infection.
Lack of effective painkillers and anaesthesia was also contributory, as well as lack of knowledge about dietary requirements and deficiencies, basic hygiene theory, and knowledge of organ function.
Since they did not yet have advanced understanding, they propounded theories to explain illness and disease which we know now to be grossly mistaken. Similarly, in future, there may be theories which we today assume to be correct or at least to have explanatory power, but further advances will reveal to be mistaken.
That being the best I can say for Hanson's argument, even in the 17th century they did have *some* effective treatments. Medicine was based as much on a practical and pragmatic view as on theoretical; you might not know exactly how foxglove or willowbark worked to cure, but you could see that dosages of these were effective:
"Were any important discoveries made in the 17th century that helped improve doctors knowledge?
In the 1620s an Englishman named William Harvey, who had studied at the great Italian medical school in Padua, discovered that blood circulates around the body, the heart acting as a pump with valves to control the flow. King Charles I encouraged Harvey’s efforts after seeing his work. King Charles II, who came to the throne in 1660 after the death of Cromwell, was also interested in everything scientific, including medicine.
In 1661, a chemist called Robert Boyle published a book called The Sceptical Chemist, which described how the body takes in something from the air to breathe. Boyle also established that without this important gas, which we now know as oxygen, animals and birds would die. In 1662, Charles II granted a Royal Charter to the Royal Society and this encouraged scientists to attempt new experiments. However, despite such promising developments, many superstitions were still accepted as truths in the 17th century."
In the 17th century some effective medical techniques might have existed, but they were outweighed by the multitude of harmful treatments that doctors of the time thought were effective.
Yeah, but that was down to lack of knowledge. On the face of it, he's doing the equivalent of complaining that there was no Apollo program in the 17th century. Well, no, there wasn't and for very good reasons.
I don't think it's the equivalent at all. But if we tried to treat the science of space comparably, an imaginary version of Hanson (perhaps like Stephen Williamson's "Right-Wing Anti-Krugman") could say they took astrology seriously back then, and that means we should distrust astronomy now.
> after you’ve already gotten the cancer, so it’s hard to see how nutrition, sanitation, etc could explain this
If a person gets cancer or a heart attack, it seems like an obvious hypothesis that they might improve their nutrition, exercise, etc.
The fact that this hypothesis isn't even considered in this article is a great microcosm of the overconfidence of modern scientists.
And I'm guessing there isn't great data on it, but it's fascinating how biases rear their heads on all sides of an argument, and most people don't see it.
It seems to me that while so many people appeal to science, they use poor quality science to rationalize biases and intuitions, rather than saying, "Hey, the science here sucks. Let's bring everyone together from all sides and design a great study to evaluate." COVID is a perfect example: the world was ready to run RCTs on a massive scale and all we got was tiny, crappy ones and decisions mostly based on non-RCTs.
Exactly! Most of modern medical stats about health care outcomes will be dominated by the Big Three killers: heart disease, diabetes, and cancer. Yet we know that all three of these are much rarer in low-income countries and in the past. In other words, there's an inflection point somewhere between dying because you're "undernourished" and dying because you're "malnourished". One, you're not getting enough to eat and you can't fight off disease or outrun a predator or whatever. The other, you're overweight and never take a walk so your vital organs stop working right.
We know the way to prevent 90% of these chronic conditions is to be thin and fit. Medicine is a poor substitute for when people fail to achieve that aim, but it's also the *universal* substitute. I think you'd have fewer arguments like these from the likes of Hanson if good nutrition did its job and medicine could focus on its strengths, instead of fighting losing battles.
Maybe the whole reason we're here isn't because nutrition is so good, but rather the opposite. It's not clear to me that the last 50 years of 'advances' in nutrition have been a net positive. I know the standard line is that lifestyle and eating habits are getting worse and if people would just listen to the experts they'd get thin and healthy. What does it say about modern nutrition science that massive increases in every metric for nutrition advice have been directly proportional to increasingly widespread malnutrition?
Maybe the constant preaching has increased because the need increase (maybe it's a lagging indicator, not a causative one?). Okay, but it's hard to argue that it helped health get BETTER than it would have without the experts. I personally suspect a causal relationship (nutrition advice is on net bad for public health). Maybe if we went back to the era where people didn't count calories/monounsaturated fats/carbohydrates/riboflavin/whatever we'd be healthier. We at least know it's not a requirement for good health to track any of those things.
I determined, in about March 2020, from news saying COVID was an mRNA virus (thus prone to mutations) that a vaccine was about as likely as a vaccine against the common cold. About June of 2020, I looked at studies, from before 2020, about mask effectiveness, and determined masks may reduce susceptibility to the virus, but not significantly unless properly using an N95 (or better) mask.
It seems to me that people ignored the basic science of the pandemic for non-health reasons, such as to ensure the public that everything was under control, not to panic, and that everything would be fine if we all followed their guidance. I do not think COVID policy was science-based.
I believe that the workings of healthy bodies aren't studied nearly enough. Unless I've missed something, the result is treatments usually drugs) aimed at relieving symptoms, but the treatments have serious side effects, and sometimes weird side effects that aren't related to the ailment in any obvious way.
There are billions of people who don't have schizophrenia and don't have dry mouth, either. How does this work?
I realize it could be hard to get financing for what seems like abstract knowledge that isn't closely related to a specific illness or a cure for it, but abstract knowledge can end up being very important.
I have no strong opinion about how much of medicine as now practiced is worth it, though I would be on more than Hansen says and less than people who trust the whole system think.
A lot of basic research aims directly at the kind of healthy mechanistic understanding of human biology you describe. Ironically, often the best way to understand basic mechanisms is by either breaking the system or looking at a broken system and comparing it to healthy systems to see what's different. And not just in studying human disease. Early genetics research was literally this, where scientists would irradiate cells, look at what was different, then go back and check which gene(s) had mutated. If a fruit fly got covered in fungus when you knocked out Toll receptors, that probably meant the Toll receptors had something to do with fungal defense.
Actually, it's a lot harder to design a treatment for a specific disease than you'd think. Much easier to take something we already have, see what it works on, then go hunting for a disease that might be affected by that thing. There are ways to reverse this process with libraries of chemicals - and we do try to design specific therapies! - but if you're watching a commercial about restless leg syndrome or whatever, it's a good bet that therapy was a product of the research and not the other way around.
I'm sleepy, so I might just be being stupid, but this doesn't seem 100% coherent at first glance:
> "In Robin’s model, these extraordinary studies would have to be bias or chance, and totally coincidentally at the same time somehow better nutrition made leukemia patients (but not uterine cancer patients) twice as likely to survive."
If we grant that the study/medicine is somehow bullshit, then surely we're granting that the survival rates you're referencing here are bullshit data? Or maybe I'm misunderstanding the association between this data point and the research in question. Like I said, I'm sleepy.
Fwiw I’ve read a lot of what Hanson wrote about this, and my impression was always that his framing was “medicine doesn’t clearly work in aggregate”, instead of “no individual type of medicine works”. My understanding might be right or I might be implicitly taking a saner-but-wrong interpretation.
In any case, I think there is a very good question here: if we assume medicine really, obviously works, e.g. by using arguments in this article (and tbc I do), then why can’t we support this with population-wide sociological studies? We spend a very significant fraction of our total wealth on medicine, and it should distress us that we can’t (or simply don’t try hard to) find a high-level aggregate effect.
I think a stronger argument would be, "most medical spending doesn't work" as opposed to the blanket statement that "all medicine doesn't work". This is why Hanson's argument falls on deaf ears. People can see clearly effective medical interventions that nobody argues with and they dismiss the argument out of hand. Meanwhile, most of the money is spent on preventative care for chronic conditions, not because there's good evidence that those treatments make people better off over time or prevent early death, so much as because they create permanent patients who feed the industry forever.
Two things can be true: medicine can be really good at reactive treatments, and really bad at preventing low-frequency bad outcomes through preventative care.
(With some overlap both directions, such as bad some bad cancer treatments that don't do much more than let you die just as slowly but with bad side effects, or vaccines that prevent measles. The overlap probably just serves to confuse the problem, allowing people to overgeneralize in both directions.)
"Medicine never works" is sure catchier than "some medical interventions don't work very well," but it is only the latter than has a chance of being plausibly defended. When I was in my late 30s, I ruptured a disc in my back at L5-S1. This was excruciatingly painful, to the point that even sitting was close to impossible. I had to lie on the waiting room floor prior to surgery. I had a very successful laminectomy, without which I would be walking with a cane and taking opioids every day of my life. If this happens to Hanson, what's his plan? If he really believes medicine never works, then he might as well go to a witch doctor, or "traditional Chinese medicine," or do nothing at all. Get a cane and some oxycodones, I guess.
My impression is he would say "that's not *medicine*, that's *surgery* which is completely different!" He had surgery on his own broken arm, yet comes away with "still how can we know medicine net good or net bad?"
Surgery for a broken arm or appendectomy clearly works in a way that can be evaluated without a study. There are surgeries that don't seem to work reliably, off the top of my head I'm thinking of hernias and nasal passage repairs, but even these are basically auto mechanic work on the body, there's no great unknown here, they just weren't able to fix it for the same kind of reason that your mechanic wasn't able to fix your engine (skill deficiency, or an undetected flaw in a really complex part that made typical repair protocols fail.)
These all seem of a different kind to me than pharmaceuticals, where there's a host of unknowns and the replication crisis has given us real reason to wonder if we're in our own "leeches and humors" bubble of ignorance.
Without taking an overall position on the debate (yet), a couple of points:
"[This paper] finds that “plan effects on blood pressure” were three times higher for hypertensives for non-hypertensives; that is, unlike statistical flukes (which we would expect to affect everyone equally), the effect was concentrated in the people we would expect doctors to treat."
This seems mistaken to me -- conditional on the assumption that blood pressure is the 1 of 30 that coincidentally had positive effects, high effects on hypertensives specifically is something we should *expect* to find.
"Third, you need the diagnoses to result in more treatment (eg blood pressure medication)."
An additional factor that could be a separate step of the funnel or could be lumped into this third step is medication compliance, which we know is often poor.
Generally when I'm making the argument that medicine doesn't work, I look to country data. Time series life improvements don't really impress me when those same improvements show up everywhere in the world regardless of how much medical spending those countries are doing.
Spending a short amount of time looking up some numbers, the US spends some thirteen thousand dollars per capita on healthcare. Ecuador spends around five hundred dollars per capita. Life expectancy at 15 is 80 in both countries.
Nice, but lots of confounding factors between countries. For example, suicide rate in the US is twice that of Ecuador. We could control for that, plus violent crime, plus genetic differences, plus ...
Eventually we have to concede that cross-country analyses like these aren't any simpler than time series or other arguments.
My problem with using controls like that is, it's plausible that medicine causes suicides, and etc.
I would argue that once you're spending a fifth of your wealth on something, the benefits should be fairly obvious and should be visible without using a more complicated algorithm than a linear regression between healthcare and life expectancy at age two.
I find that simple standards tend to be best, because confirmation bias. The more specifically accurate you try to make your model, the more of your own assumptions you're feeding into it, the more your original worldview starts feeding into itself, and thence, the more circular your logic becomes.
Conversely, random factors shouldn't tend to favour one side or the other anyway, so it's not normally useful to control for that stuff anyway.
In sum, if our medicine is worth a fifth of our wealth, why can't the effect sizes eclipse such factors?
I agree that in theory there should be a huge difference. If the point you're trying to make is that we get diminishing returns for our money, or that there's a lot of wasteful, poorly allocated spending I'm right there with you.
But cross country analyses have a lot of assumptions built in, and the biggest of those is that there is some equivalent health baseline. Do you believe that? Would you drink the water in Ecuador without first looking it up? Would you vacation in Ecuador's countryside without first figuring out whether you need certain travel advised vaccinations?
Assuming a model is simple isn't the same as that model actually being simple. Comparing expected number of feet by averaging out all members of my household seems straightforward until I remember the dog.
I guess I've been burned too often by the seemingly simple approach to trust it like you do. I agree you shouldn't trust complex regression analyses, though. Natural population level differences are all suspect in my mind.
I should note, my argument is that, I'm sad that we have this whole argument about whether healthcare works at all without addressing what seems to me to be the obvious elephant in the room. Going a step further to what I actually believe, diminishing returns with lots of wasteful poorly allocated spending, isn't so far off from my position, though I could go further in that it does seem to me to be somewhat likely that healthcare is net negative to health.
I should note, in my definition of healthcare as used above, clean water is not healthcare.
So, getting to simplicity, I sense that there's a divide in our definitions, I'm more using simplicity as in, simple to define? Whilst you seem to be indicating towards, simple to operate? So, like, under my definitions, there's no assumption needed, the model just is simple. That doesn't mean it works for the problem at hand, just that the code needed to convert the input into the output takes fewer operations than some other model's code (simplicity is relative).
Regarding equivalent health baseline, I think your sense of scale is not being reasonable here? The confounders just aren't that significant. Ecuadoreans are not elves.
Of course, I wouldn't actually expect the confounders to favour America to begin with. If America had longer life expectancy than Ecuador, then perhaps that could be better healthcare, or it could be something else. But there's not as much room for America to have lower life expectancy than Ecuador and yet still have a working healthcare industry which consumes a fifth of our economy.
Right, we don't have an argument on "health care spending is a good bargain". We don't even disagree that some medical interventions are likely harmful - and more than just because they cost money. Look at the old PSA standards, or other screening tests that produced too many false negatives for the populations they were being applied to.
The biggest disagreement is that you don't think there's enough room in your quick and dirty analysis for "health care spending produces some net gain". I'm not sure this is knowable, since to accurately assess this we'd have to quantify:
1. All positive effects from healthcare treatments
2. All negative effects from healthcare treatments
And then net that number out. Now, before you get upset I do hear you that you believe your analysis moots the whole issue. But it's one thing to say, "on net there's no effect", a stipulation that requires more precision than saying, "20% GDP is getting what we paid for". The second statement isn't in dispute. It's the first one.
And no, you're not doing an assumption-free test. Any time you compare two things, you're implicitly assuming that those two things are comparable. I'm questioning to what precision your comparison is valid. That's standard practice, to question your assumptions.
Why does any of this matter? For me, there's a difference between saying, "All healthcare spending is good/bad", which suggests implicitly trusting/distrusting the system as a whole, versus saying, "On net it's probably beneficial. But given that the magnitude of the effect is difficult to parse, any individual intervention deserves scrutiny the efficacy of its claims."
Reducing the rate of mortality by 0.06% is implausibly high, at least if I'm understanding it right. Preventing 1 out of ~1,600 people from dying is a plausible result from providing those 1,600 health insurance, but that's not what happened. Only about 1% of people who were sent a letter actually got insurance, so that means that about 1 out of *16* people who got insurance had their life saved in the next two years as a result of getting insurance. I don't believe that in the slightest.
Yeah, much of that analysis seems flawed. Like, what's the probability that:
1. You get the health insurance
2. You get sick enough within the next two years to kill you
3. Your death is preventable by modern medicine
4. You wouldn't have gone in and gotten that medical treatment but for the insurance?
If you fall off a roof and are rushed to the hospital, you're not going to die because you didn't have insurance. Maybe you don't go in for medical screening, but that's a long-run effect. What's between, "if I don't go to the doctor I die today" and "if I don't go to the doctor I die in 5 years" that's frequent enough to show up in this 2-year statistic?
Something about this study smells wrong. The low p-value wouldn't compensate for that even if this were a direct intervention, let alone one that's at least twice removed from cause-effect.
I personally know intelligent, educated people who profess views similar to Robin's (so it's more than just two contrarians). Sometimes this is just a basic failure of reasoning: only sick people go to the doctor, so if you never go to the doctor, you'll never get sick. But often, I think it's some form of mood affiliation or virtue signaling: medicine is artificial, unnatural, "Western"; natural, "Eastern", or "native" solutions must be better.
Robin's own stated explanation for increased life expectancy contradicts his argument, anyway. Sanitation is good because unsanitary conditions make people sick. Improving sanitation is straightforwardly a form of preventative medicine.
I don't think that's contradictory at all. You are calling sanitation "medicine", but most people wouldn't. Elsewhere in this thread it was pointed out that trauma surgeons are better at treating victims of car crashes & bullet wounds. I think that's true. But seatbelts and kevlar vests are not considered "medicine", nor are roads designed to be safer.
For what it's worth, I don't view sanitation as 'medicine' per se as opposed to medical procedure. I would be surprised if most people viewed hand washing as medicine qua medicine.
> Robin’s argument (that medicine doesn’t work) assumes that the only possible failure is at step 4, and that the failure must be a true failure rather than one of statistical significance. But in fact there are failures at every step (although I kind of have to stretch it for step 3), and the authors of the papers tell us explicitly that these are most likely failures of statistical power.
Is that his argument? I think if doctors randomly assigned diagnoses to patients (i.e. complete failure at step 2), Robin's overall argument would be correct, since he's talking about the medical system as a whole, not just medicine.
I wish Hanson wouldn't insist on making the most insupportable version of the argument. It's a waste of everyone's time. If we were debating the medical and cost effectiveness of specific treatments, that would be great. We should do that. Let's not have the college dorm room stoner version of the debate.
Isn't healthcare very likely one of the main mechanisms wealth actually leads to better health (especially if we're already pulling out nutrition and sanitation as separate mechanisms)?
Maternal mortality would seem to be another line where one could argue that medicine works. Especially potent since it's one of the cases where medicine was very likely a net negative (in the 1700's and 1800's) and has now moved to be a definite positive.
Also traumatic injury, hasn't treatment of, for example gunshot victims, improved survivability enough that many of the contrarian folks (though perhaps not exactly these contrarian folks) have hypothesized that it messes some with the crime statistics?
AIDS medications? AIDS went from a death sentence to a manageable condition with targeted therapies. See also curing hepatitis-c.
Really medicine is such a broad category that, as others have noted, it seems just crazy to treat it as one thing. There are undoubtedly parts of it that 'work'. Treatment of infections diseases (vaccines, antibiotics, targeted anti-virals) and traumatic injury/event treatment would seem to be exceptionally clear cases. Of course there are parts that don't work or are even negative to health, and in some cases we have a pretty good idea what those are, in others it's less clear. And the claim for health insurance working is more nuanced (particularly for the marginal increase thereof, and the specific implementation may make substantial difference). And many parts scream out of better cost/benefit (and not just monetary, consider over screening and associated unnecessary treatment side-effects that are argued around, for ex. breast and prostate cancer). But just saying it doesn't work is nuts.
Feels that it is somewhat fair to say that the marginal expense side of medicine has lost efficiency. But, that is a banal statement that relies on how effective our groundwork of medical treatments even is today? Stated differently, I would expect that research dollars spent on medical treatments will not go as far today; because they first have to cover known advances that we are building upon.
Taking that to a stronger statement that medical treatments don't work is markedly absurd. Just look through a family tree going back a hundred years. Be sure to ask how many kids aren't included because they died before they were 5. Then pay attention to how many died of sepsis in the past.
I love Hanson. One of the amazing things about him is that, despite his self-identifying as not very good at social things, he appears to be a natural at some of the Dark Arts. This is a perfect example: by the time you're arguing about specific claims you've already lost. You might as well be arguing with the sportscar salesman about what kind of shirt you'll look coolest in driving this convertible. If medicine were as great as some think it, nobody would have to get down into the weeds to discuss at what ages people are getting cancer.
I mentioned in another comment that if we count 'nutritionists' as medical researchers, folks like Anichkov and Keyes ('saturated fat is bad for obligate herbivores like rabbits therefore it' s bad for you' and 'let me just hide the findings about saturated fat that don't agree with my conclusions) likely have contributed to more cancer than all the rest of the researchers have managed to cure.
Yeah obviously childhood vaccines and acute trauma care are effective, but anyone who has been in public somewhere that isn't rich and trendy can immediately see how sick everyone is. It's bad out there.
I think Robin would probably agree that a drug works. Not all of them but sure, they exist.
The real question is what is the outcome of all medical interventions as typically practiced by the system? If there’s a common drug that helps leukemia and a common surgery that kills more cvd patients then it helps, how do things actually net out? How could you possibly know?
Probably medical system helps but the big takeaway for me is do we really know? Put this in the category of other questions like Caplans do we know education helps kids?
I come away from this thinking A) at least some medicines and condition-screening "works", and B) providing free health care is a bad deal for taxpayers when the recipients are under 45. The rational health policy this would lead to is one where Medicaid expansion is limited to older people, and to the extent certain types of coverage are mandated for insurance carriers it would be heavily focused on things like annual screenings for cancer and hypertension.
While some of this is reflected in PPACA coverage minimums, it also forces insurance companies to provide care that the majority of "customers" will never use, notably substance abuse counseling, pharmaceutical interventions for addiction, expensive patented pre-exposure drugs for unmarried/promiscuous gay males to avoid HIV, and a range of birth control products. And as a result, we have deductibles that aren't far off from the $5K ones RAND considered "very bad" in the 70s, back when insurance was mostly seen as a way to cover accidents and emergencies rather than an overall care plan.
It also continues to baffle me that the people who seemed the most politically active in advocating for various "Medicare 4 All" style programs in the past decade were the younger Millenials in their 20s and 30s, statistically the people for whom increased access to care does demonstrably nothing and who are decades away from any of the mandatory screenings that have benefits. It leaves me to wonder whether these people are particularly neurotic and overuse health care access, particularly sickly, or whether their immediate concern was for older family members. The people most likely to agitate for student loan relief are people who owe a lot of student loans, but the people most likely to agitate for health care access are the people who don't need it?
...Wait what? Why would you want to give free medical access to the people with the least number of productive years left? If increased access to care for younger people does nothing, then that's an argument to get rid of nearly all public health spending.
Assuming Cjw's understanding of effectiveness is correct and assuming your value to optimize of ROI, then this can be reconciled as: "Giving healthcare to increase productivity of individuals at their most productive / highest earning time of their life. The longer we can keep them healthy, the longer they stay employed and out of retirement. In fact for high-earning individuals, not only are we providing free healthcare, but we're requiring regular screening and health checks in order for you keep your license (driver, professional, whatever it takes)."
Welcome to the DMV, check in for your appointment. Make sure you have a copy of your colonoscopy and cholesterol panel with you as well as a filled form C-1. If you do not have your C&C&C on hand, leave and get it immediately. Your appointment will not be held for you if your number is called and you do not have your documents.
>>providing free health care is a bad deal for taxpayers when the recipients are under 45.
No data, but I'd speculate that providing BASIC free healthcare for under 45yo is probably by far the most effective way to spend money because in this demographic we have the problems where medicine brings clear, obvious benefits to survival, reduces disability and (economically) improves productivity, including trauma care (not mental obvs, you'd never afford that with current self diagnosis rates ;), infectious disease (vaccination and treatment), fixing of some easy to fix congenital problems (eg cleft palates), basic reproductive health care (contraception, basic perinatal care for mothers and neonates), t1d.
It's in the late life that the more problematic situations start to dominate.
I've always understood Hanson's considered claim as "we have a huge overemphasis on medicine" not that "modern medicine doesn't work." That's why he suggested cutting medical spending by half, not entirely. This piece doesn't rebut that claim.
Yeah, if that's the argument, it's something to be engaged with. But Hanson can't resist being provocative, so he leads off with "modern medicine is as useless as 17th century medicine with its humours and leeches" and that's not so.
I get the sense that Robin Hanson is trolling people for the lolz.
When I was ten years old, I developed abdominal pain. My mom took me to the doctor, who palpated my abdomen and announced that my appendix was about to burst and I needed surgery immediately.
The post-op recovery sucked really badly, especially for a child (I couldn't laugh, because it hurt so much; I had to eat gross pureed carrot soup and wasn't allowed any fried foods or chocolate for months; I hate carrot soup to this day). But the surgery SAVED MY LIFE. Yes, yes, n = 1 anecdote blah blah, but this particular anecdote is MY LIFE. I'd like to see how Europeans in the 1600s, with their leeches and four humors, would have taken care of my appendix.
Robin Hanson can take his contrarianism and shove it where the sun don't shine.
Wait, I disagree with that. Seeing Scott start from the basics to support something all of us take for granted, and probably should take for granted, still exercises some intellectual muscle that I like having flexed. (Or maybe this is all elementary and I'm a big dum-dum who likes hearing wise tribe elder say smart thing).
In any case, I'd like it if this continued with stranger and stranger stances until we landed on "Contra Krugar the Skulltaker on Cannibalism Benefits" or "Contra the Desert Apostles on Global Warming Accelerationism".
"Contra Krugar the Skulltaker on Cannibalism Benefits"
You know I have to do it 😁
THE HIGHER UNITY
"The Rev. Isaiah Bunter has disappeared into the interior of the Solomon Islands, and it is feared that he may have been devoured by the natives, as there has been a considerable revival of religious customs among the Polynesians."
A real paragraph from a real Paper; only the names altered.
Ironically there's starting to be some push in medicine to cut back on appendectomies in appendicitis cases, instead opting for antibiotics, rest, and observation.
Not saying that in your case a modern, current-educated doctor wouldn't have chosen to take yours. Just thought it was ironic.
It seems like the dodge of attributing longer lifespans to “nutrition, sanitation, and wealth” is dumb? Wealth is the dumbest since it manifests as better nutrition and better sanitation (and access to medicine, but we can ignore that for now), so it’s redundant. But even nutrition and sanitation are sus since….aren’t those kind of medicine? Like I guess one could say medicine is only drugs, but is it? Why have nutrition and sanitation gotten better if not for “medical” research?
To me the explanation is obvious. The way insurance works, or is intended to work, is that people rarely need healthcare but would struggle to afford it when they are the rare person who needs it. If a particular condition affects 1/1,000 people and costs $1,000 dollars to fix, then insurance charges everyone $1 and pays for the people who need it. At least in theory and discounting administrative costs, etc.
There are some problems with this simplistic model. The chain of events mentioned in the article is the source of most of it. You can't get people treatment if you don't know they have the disease, which you can't know if they aren't getting to the doctor, which they can't do if they can't afford it/don't have insurance. So instead of 1/1,000 of the population getting treatment, you have a much much higher percentage getting checked for the condition, some proportion getting a more significant follow-up check to confirm, and then some final number getting treated. This final number is likely higher than 1/1,000 because it includes people who are mistakenly diagnosed or who fall below some threshold where treatment is necessary but still get the treatment anyway (which the patient will often demand and medical malpractice makes difficult to say no to).
So the costs that should be a certain figure are significantly higher, and most of the difference is not helping actual patient outcomes. You're still only benefitting 1/1,000 of the population, while spending resources on most of the population.
If he's taking the strong stance that all medicine is bunk, then I strongly disagree. If he's taking the weaker stance that a significant portion, likely an overwhelming majority, of our expense on healthcare is wasted/ineffective, I do agree with that. In fact, I think that explains why we get such small results over the population despite knowing that medical interventions *have* to be working in many cases.
Roughly speaking, I would guess that the first 1% of GDP put into healthcare is likely miraculous in results, the next few percent are very effective, the next few percent are actuarily measurable, the next few are a wash in a cost/benefit sense, and the last few are actually making things worse. Averaged out over the whole cost, we end up being unable to link spending with outcomes in a measurable way.
I think his claims totally make sense if you think about the almost 20% of GDP spent compared to how difficult it is to measure positive outcomes. The problem is not that medicine is worthless/ineffective, but that we spend a majority of our healthcare money on things that even in theory can't help people feel better (diagnostics, real estate, administration) to find the small minority of cases that we can help with relatively cheap medical care (relative to the total cost).
If you look at how the US is a *massive* outlier in many analyses of the relationship between healthcare expenditure and outcomes (at this short notice I can only supply this life expectancy chart, but even that is fairly striking:
... maybe the question of whether medicine works should be replaced by one of how come your healthcare system works SO BADLY. To the point that countries which spent between the fifth and tenth of what the US spends per capita achieve comparable life expectancies -- this would favour massively decreasing marginal returns hypothesis -- but also, countries that spend relatively higher amounts, still nowhere near as high as the US but more like half to three-quarters of the US spend (Switzerland, Norway, Canada - I'm ignoring Japan because of too much cultural difference) have life expectancies higher by a good few years. So, extra spending does make a difference, but seemingly not in the US?
Can't Baumol explain a lot of that spending difference? I know this chart is in international dollars, but US doctors make an average of $350k/year while Japanese doctors make an average of $100-150k/year in 2022 international dollars. I know doctors are only one part of the system, and the system is what contributes to doctors being paid so much (and we should almost certainly relax restrictions on supply), but the spending numbers wouldn't look so bad without the Baumol effect.
Right, but why do you think this effect would be so much stronger in the US than Japan or EU, for example?
Also that US average for ALL DOCTORS seems *astonishingly high*: average UK doctor earns a bit more than 2x average UK teacher, but in the US is a factor of 7x....
The US is richer. In Japan if the doctor had decided to be a programmer, what would they make vs if they if the opted to be a programmer in the US? (Lean 2 Code doctors!)
Or for a more similar skillset: opted to be a small business owner (which many doctors in the US effectively are).
Don't get me wrong, the hellish hazing they put doctors through definitely artificially restricts supply. But even accounting for PPP, many jobs (particularly high-end jobs) pay a lot more in the US than elsewhere.
The reason Robin interprets null results as negative results is that studies do not fall from the sky (except natural experiments). The RAND study was designed to detect a certain level of effect. Its failure to detect that effect is a statistically significant rejection of the hypothesis of effectiveness held by the designers. This is a dangerous line of thought, but also having a prior on a non-quantitative hypothesis like "medicine is real" is also a dangerous line of thought. The zero point isn't magic. Medicine has obvious health costs. If marginal medicine is designed to have a 10:1 health benefit to health cost and then it is discovered to only have 1/10th the benefit it was believed to, it is quite easy for it to be net negative.
Lots of problems with this analysis on both sides. Imagine a trial where you give out free aspirin to people and track how their headaches improve. The biggest finding is that people didn't have to go out and buy their own aspirin as much. Okay, so this study wasn't about whether people got aspirin (giving it away for free isn't the same as preventing people from getting it) so much as the financial benefit of having to pay for something or not.
I'm mostly NOT sympathetic to Hanson's point, but the decrease in depression and reduced financial burden might be correlated with "didn't have to pay for health insurance" in the Oregon study. Let's take a charitable middle ground argument and say that at least 15% of health care spending obviously works (especially a lot of interventional stuff people in the comments have mentioned; I'd also add cancer therapies with good overall survival benefits, like imatinib, but probably not most modern medicines).
On the other side, let's say at least 50% of health care spending is just ineffective cope for "your lifestyle choices made you unhealthy and we're going to pretend to fix all that". We'll set aside the other 35%, for now, as 'uncertain benefit'. If we cut health care spending from 20% of GDP to 10% of GDP, would people be better off?
(Would people be better off if we shifted 10% of GDP to helping people get fit instead? Probably not. Increased nutrition advice seems to be inversely correlated to people getting thin and fit. Either it doesn't work or it harms people. We need good evidence on this one before we roll it out widely.)
The assessments of whether health care make you better off or not are terrible. That increase in HTN meds? First, I would assume the most severe cases start off on the meds, so increasing HTN medication availability should yield diminishing returns. But what were those returns? Lower blood pressure. Really?! Who cares whether their BP is 140/90 vs. 137/87? Patients care about whether they get headaches, or SOB, or more importantly whether they're going to die of a heart attack. It's death and pain that people get hung up on.
Doc: Where does it hurt?
Patient: In the HbA1c.
Nobody does this. People don't care about their hemoglobin's post-translational modifications, the salinity of their urine, or how much triglycerides are in their blood. They care about living long, better lives. So the real question is: do people live better and/or longer with the intervention. Most of these studies don't measure that over the long term, and aren't designed to. Therefore we can't conclude one way or the other about efficacy.
The correct study is to look at either lifespan or overall survival over long time horizons. There's a reason nobody is doing this. That study is impractical and by the time you get the results it's been a half century and medicine has changed. There's no exception that says "bad data can be substituted for good data because it's impractical to do it right". The exception is, "if we can't do it right, then we just don't know."
>The exception is, "if we can't do it right, then we just don't know."
Yup. I must say, I tend to cringe at studies where the end result is a biomarker change... Even if the biomarker is a valid predictor in an unmodified population, once you start to modify the population, how sure is anyone that the biomarker is still a valid predictor?
I'd be interested in his analysis of addiction treatment. One argument would be that after a brief medical detox, treatment does nothing to increase the odds of sobriety. The other argument would be that people who want to remain sober need multiple interventions across many domains such as economic, housing, emotional, social, and legal.
I'm stopping near the beginning to comment. My spouse is a highly cited, known medical researcher of integrity, and he has been saying the exact. same. things. for years. Our educated friends dismiss him out of hand in spite of hard data and extreme expertise. He thinks statins made a difference in quality of life late in life, and they meet the criteria for validated research. He likes my hip replacement; surgery matters. Antibiotics in moderation matter.
But in general, much medicine and especially socialized medicine is an elaborate grift at the top, supported by well-meaning people who do not question simplistic, conventional narrative.
There are a some things in medicine that work. Vaccines. Anti-hypertensives. Statins. ACE inhibitors. Pap smears. Post-MI care. There are a million studies showing disease-specific as well as all-cause mortality benefits to those interventions. (And some studies that challenge those, but the preponderance of evidence is in favor of mortality reduction.) But there are a million devices, medicines, tests, and woowoo for which we either have no evidence or evidence of no, and which we let the medical system sell with impunity. Population health improvements have been striking. Covid barely made a dent in what we have been able to achieve over the past 200-300 years. Some of that is clearly nutrition, sanitation, etc. And some medical technologies clearly help spin the wheels underneath those mortality reductions but beyond the obvious suspects, we do not know what else is helping. Just some ballpark numbers: out of about 1 million devices, medicines, and tests, maybe 1000 are clearly effective. That's 0.1% with clear benefits. That's enough to account for the majority of the ~2-3mo improvement in life expectancy yearly. But it's also not enough for someone to claim with pretty good certainly that >99% of the stuff in medicine is probably nothing (and I include placebo in nothing).
I very much doubt effective treatments are only 0.1 percent of all medical interventions that are done. But accepting it for the sake of argument, it then reminds me of an old biology/ecology joke:
We have reason to believe that 99.9 percent of all species that have ever lived, are extinct.
Therefore, as a first approximation, we can assume that all species are extinct.
...perhaps this is the reasoning behind the "all medicine is bunk" assumption.
I largely agree with your conclusions. People are far too quick to assume that more expensive insurance leads to better treatment. Medical insurance is actually very disconnected from health outcomes, as you show in your funnel. That is why expanding health insurance yields tepid results.
I think the problem is not that modern medicine does not work. It is largely about diminishing returns per marginal dollar invested, and the fact that there are other factors that are far more closely liked to health outcomes.
Genetics and healthy habits do far more for long-term health than medical treatments and insurance.
It will save a lot of effort for readers of this blog to recall that Scott is not pedantic and therefore the phrase "claims that medicine does not work" is an extremely valid rhetorical description of the fact that Hanson is arguing that the marginal value of health care is literally zero - even dismissing the Obamacare study with significant statistical power
Furthermore if you do find the 'marginal health spending is not relatively valuable' argument to be persuasive and wish to defend it you should probably support the concept that the argument should be specifically made in a more defensible and persuasive manner!
I own the book and flipped to the relevant chapter, and the section about modern medicine opens with this sentence, "Medicine today is different in one crucial regard: it's often very effective."
I suspect he will just say that he doesn't believe that medicine doesn't work and that this is a strawman.
I don't have the book in PDF, so I'm going to great pains to write these quotes, but here's more.
"The big historical improvements in medical technology don't tell us much about the value of the marginal medicine we consume in developed countries. Remember we're not asking whether some medicine is better than no medicine, but whether spending $7000 in a year is better for our health than spending $5000. It's perfectly consistent to believe that modern medicine performs miracles and that we frequently overtreat ourselves."
So you're effectively saying that Scott's contra is arguing against a non-existing claim, and Hanson is making a borderline no-brainer claim about the highest spending countries?
Yes, that's basically it. The US spends a ton on healthcare and it's perfectly natural to assume there is a lot of waste. Scott takes issue with some studies that Hanson uses to make this point, but in terms of priors it's a sensible claim.
THIS claim seems sensible. It would be potentially sensible even if ALL treatments worked. It's an economics/budgetary claim -- if literally every treatment was net effective, provided they had very high unit costs and/or very high NNTs.
The claim Scott is arguing with is a claim that (charitably) *as a whole* medicine as a system doesn't work, anywhere in the world (more charitably: in the US but they include the Indian study), or (most preposterously) that while some medical treatments might be net effective, as a total they do nothing. Which isn't at all what your quotes suggest.
Given that higher aggregate health care spending is often seen as, roughly, a "good thing" by many people, it probably isn't accurate to call it a "no-brainer" claim.
Ok, fair. The notion of marginal costs and diminishing returns evokes distaste when applied to things like medicine, yet obviously all (or maybe not all, maybe only socialised ones) systems assign monetary values to DALYs or whatever other measure they use when allocating resources or approving treatments or devices.
True, not sure what we conclude from that though? Using cost/benefit measures for top-level funding decisions is a long way from the practice of medicine at the front line.
Do most people think that higher life expectancies are due to medicine treatments? I don't think most 70 year olds have had a life saving medical procedure during their lives.
A lot of money in medicine is spent doing stuff "just in case" (like unnecessary tests, MRI's, check ups) as well as making the experience more pleasant for the patient. You could design a maximally cheap health care system from the top down where patients can't choose their physician, can't see a specialist without fulfilling specific guidelines, don't get access to any examinations that aren't evidence based, where there are long waiting periods for everything that isn't urgent, -- and this would save a lot of money probably without statistical detriment to outcomes. Patients would hate it though. (This is what public health care is like in some countries.) A lot of people with enough money or private insurance would still spend a lot of money to get more "luxurious" care (like going to a specialist right away or getting an MRI even when there is no strict medical need.) The point is that only part of the money in medicine goes to medical outcomes, per se.
I mean, if European countries that spend about 10% of their GDP on health care get about the same outcomes as the United States that spends nearly 20% (and has a higher GDP per capita), it is pretty clear that theoretically the United States could save a lot on healthcare. You don't need to try to argue that "modern medicine doesn't work any better than blood letting".
In terms of life expectancy at least, better outcomes in many EU countries.
Even the UK, in comparable cultural/lifestyle universe, has a slightly higher LE than the US while spending about half the money (less than half in absolute terms, bit more than half as GDP %)
The average pay for a doctor in the UK is 94k in 2022 international dollars. In the US it is 350k. Physician pay isn't everything but the salaries of other roles in the system probably is similarly inflated. Nurse pay in the US is about twice UK in international dollars. How much of this is Baumol? Or is it all wealth extraction by a cartel?
I'm sure a lot is systemic in various Moloch-y ways. Even leaving aside medical professionals pay you have the fact that with socialised healthcare paying the vast majority of the drug costs, the price of drugs is negotiated (functionally: regulated) at a national level. I'm not sure if Medicare / Medicaid do that in the US. It wouldn't surprise me if much of the "excess spend" went directly on drugs and med professionals pay.
Feels more like some kind of cartel effect because from what I've read your teachers' salaries aren't all that wonderful and they should be subject to Baumol effects?
Same effect with teachers. I didn't Google too hard but the average pay for teachers in the UK was mostly expressed as ranges, but it looked like 24k-35k GBP which translates to 34k-50k international dollars, whereas in the USA it's 66k international dollars.
Of course that doesn't take into account total compensation package, don't know how generous retirement benefits are in the UK, but in the USA the retirement benefits are known to be a large part of compensation.
(No, I don't believe medicare/medicaid negotiates drug rates, in fact I think they are prevented from doing it.)
Of note, it doesn't look like overall median pay for all professions in the US is double that of the UK. 60k USA vs 48k UK. But if there's a significant premium for teachers and medical professionals, I'd be curious to know which professions are paid less in the US than in the UK.
> Do most people think that higher life expectancies are due to medicine treatments? I don't think most 70 year olds have had a life saving medical procedure during their lives.
Of course medical interventions affect life expectancy. Looking at ONE common condition, something like 6.7-8.6% of the population gets appendicitis at some point in their lives[1]. It has a 50% death rate untreated[2] and had a 26% death rate (with treatment) 50 years ago[3]. The current death rate is <1%. Treatment for that one condition probably adds at least several months to life expectancy.[4]
Obviously we're overpaying for that treatment in the US, but that's overpaying in the "seems like I could pay less for the same service" sense, not the "there is no consumer surplus, why bother?" sense.
"Human life expectancy is a statistical measure of the estimate of the average remaining years of life at a given age." (https://en.m.wikipedia.org/wiki/Life_expectancy) that is definitely affected by medicine keeping people alive.
Are you thinking of life span ("the maximum amount of time that a member of a given species could survive between birth and death, provided circumstances that are optimal to that member's longevity")? There are no treatments that I know of which have been shown to extend human life span, though some exist for worms and mice.
Trephination is still done occasionally today. When a person gets a concussion, the brain swells inside the cranium. Trephination relives the pressure and minimizes brain damage. No doubt there were many, many, head traumas in early human evolution, so it seems reasonable that the procedure was thought out and its usefulness deduced. I forgot to mention that trephination is known in early human history all over the world, so it's unlikely it was local religious myth of some sort. References available in my Fundamentals of Cognitive Science (Routledge).
The quote starting with "The rate of mortality among previously uninsured 45-64 year-olds" seems to have had some copy/paste errors, there are missing letters and extra spaces inserted.
I'm dying from recurrent / metastatic squamous cell carcinoma of the head and neck (R / M HNSCC_frustrating), so the sections about cancer in particular stand out to me. Regardless of the current state-of-the-art for cancer treatment, personalized and mRNA vaccines are likely on the verge of revolutionizing cancer treatment.
Take the HNSCC that's killing me: I got a partial glossectomy in Oct. 2022. Mine had some high-risk features, but I was assured that, with radiation therapy, it wouldn't recur In retrospect, I obviously should've done chemo and radiation, but at the time I was pleased to not need chemo, and I foolishly didn't look deeply into the data on recurrence, which is common for HNSCC, and I didn't seek second opinions.
Docs are reluctant to impose systemic chemo because of the side effects. But Transgene has a personalized vaccine that is supposed to prevent HNSCC recurrence: https://www.nec.com/en/press/202304/global_20230418_01.html: "In the head and neck cancer trial to date, all patients treated with TG4050 have remained disease-free, despite unfavorable systemic immunity and tumor micro-environment before treatment," And most of these personalized vaccines have essentially no side effects.
Moderna's mRNA-4157 platform also looks good: https://jakeseliger.com/2024/04/12/moderna-mrna-4157-v90-news-for-head-and-neck-cancer-patients-like-me/, not only in R / M HNSCC, but in melanoma and lung, too. Right now mRNA-4157 is only being tested in the recurrent / metastatic setting, as far as I know, but the logical time to use it is probably when initial surgeries are done: cut the cancer, sequence it, and then vaccine against it to prevent recurrence.
Right now, from a society-wide perspective, the healthcare I've been getting probably fails the cost-benefit test (apart from the fact that the data I'm generating for clinical trials helps move the state-of-the-art forward). My quality of life is low, and while treatment has been extending my life, it almost certainly won't lead to remission. And even if a clinical-trial drug somehow leads to complete remission, I'll never be able to sleep or speak normally again (https://jakeseliger.com/2023/08/27/on-being-ready-to-die-and-yet-also-now-being-able-to-swallow-slurries-including-ice-cream/). A few months ago my brother casually referred to me being disabled, and I was momentarily confused: Who was he talking about? But he was in fact right: I'm disabled and unlikely to ever be able to think or work in the way I did before losing my tongue.
But that should change! Part of the reason I'm so frustrated by the FDA is that mRNA-4157 and TG4050 should already be available for HNSCC. Instead, they're stuck in trial hell, while HNSCC patients like me suffer recurrences and then die.
I remember the 2008 Oregon experiment. I assume that the researchers had to throw something together very quickly if in order to take advantage of the opportunity to perform a controlled study with random assignment. That's why they ended up with self assessment questionaires that the researchers acknowledged might not reflect actual improvements in health, and measures of clinical results where the improvements were too small to be statistically significant
After the study was released, David Brooks claimed on the PBS New Hour that it showed that people didn't benefit from Medicaid--but I note that Brooks never announced that he was giving up <em>his</em> health insurance.
US health spending as a percentage of GDP has been just over 17% every single year since 2008 except for two specific years: 2020 and 2021. Those two years obviously were impacted by COVID on both sides of the ratio, and for 2022 the percentage settled right back down to 17.3%.
My point here is not about whether 17.3 compared to 19.7 (the 2020 peak pct) invalidates Hanson's argument. Rather it is that his cherry-picking of an obvious outlier year, and then rounding it up rhetorically to represent the norm ("we spend 20% of GDP on medicine"), is enough to me to conclude that he's not presenting any actual serious argument he's just internetting.
Scott concludes: "I think if Robin wants to do something with these insurance study results, he should follow other economists, including the study authors, and argue about whether the marginal unit of insurance is cost-effective"
...fair enough, but you seem to forget what the product insurance (all types of insurance) provides/is meant to provide.
The product is not better health, or a promise of better health.
The product is peace of mind. The product is the knowledge that if you need health care, in particular expensive care, it will not bring economic ruin to yourself or your family.
This is the reason health insurance is usually popular, even in population segments that are seldom in need of health care.
If health insurance should turn out also to improve health outcomes, that is great. But if so it is an added bonus. It is not the point of insurance, public as well as private.
I don't buy this. I think "peace of mind" is definitely something insurance (and marketing for insurance) definitely tries to sell. I also think that in this modern age where emergency treatment doesn't ask how you are going to pay before treating you, and medical debt is something you can work around, that it is definitely a larger part of the product. But I think the core product that insurance provides is literally redistributing money to pay for health care.
Or cars. Or funerals. Or to replace your crops. Or to take care of dependents.
Just like a casino tries to put a fig leaf on "we just sell entertainment" (or donating to your local church, or state education fund), and it is entertaining, but the product is redistribution of wealth.
I think in the modern world of easy credit, or casual enjoyment of Poker Stars, we forget this. If the main product is really peace of mind, I'm sure there's a more efficient way to pursue that and insurance would have been outcompeted by now.
I do not expect to convince you otherwise in a comment section, but if you are interested in exploring the insurance-argument for why health and other types of insurance exist (and indirectly why all high-income states are "welfare states" today), I recommend the works by the economist Nicholas Barr, the historian Peter Baldwin and the philosopher Joseph Heath.
Many others have also written convincingly about insurance-demands (rather than demands for redistribution) being the core driver behind the history of modern (welfare) states, over the last 100 years. But these three stand out.
Maybe he doesn't consider insulin a medication because it's technically a hormone. Maybe he excludes *all* life-saving and life-extending treatments and medical procedures.
If he did this, there may be a compelling economic argument. But that's not the argument he's making.
Modern RCT trials are allowed to assume side effects are exactly zero if the P value of side effects is <0.05 between the control and treatment arms. Because of the base rates of other diseases, this can lead to treatments passing RCT that are neutral or even negative on net.
Most treatments have very high "number to treat", being in a hospital is dangerous because of chance for MRSA, surgical errors, etc. drugs studies get to ignore side effects unless they are really obvious, often they can get away with garbage proxy metrics as has been discussed by Scott often this blog.
RFK Jr (yes, I take him AND Bryan Caplan seriously) makes an interesting point in his little-noted most-recent book, The Wuhan Cover-Up, that vaccine research may kill as many people through lab leaks as they do, or might, save through effects of the resultant vaccines. Think COVID-19, though there are MANY others, obviously of smaller scale. The lab leaks are, indeed, VERY common, and potent, too.
Then, of course, there are capers like Anthony Fauci's with AZT, and so on.
There is a massive difference between "medicine doesn't help" and "lowering the cost of medicine doesn't lead to large jumps in health outcomes."
For my everyday life, my use of medicine is bottlenecked by inclination and time (as I have no pressing medical issues). For the majority of emergencies, I am similarly lucky enough to be able to afford healthcare. It's only that when the medical issues is very rare or the benefits slim that my insurance is likely not to cover me.
The most clear cut cases where medicine is needed, like the terminal illnesses Scott lists, have the best ratio of benefits to iatrogenic risks, and are probably already saturated in terms of medicine usage. The marginal increase in medicine consumption is going to be on some use-case much more marginal, where the ratio of benefits to iatrogenic risks is much worse. So the impressive results in section 1 of Scott’s post are entirely compatible with marginal increase in medicine consumption having null effect on health
>It would be easy to round Hanson’s position off to something weaker, like “extra health care isn’t valuable on the margin”. This is how most people interpret the studies he cites.
>I’ve spent fifteen years not responding to this argument, because I worry it would be harsh and annoying to use my platform to beat up on one contrarian who nobody else listens to. But I recently learned Bryan Caplan also takes this seriously. Beating up on two contrarians who nobody else listens to is a great use of a platform!
Does Caplan really think medicine is generally useless, or does he merely espouse the mostly uncontroversial position that "extra health care isn’t valuable on the margin?"
All he writes is that:
>I’m puzzled. The idea that the quality of health care has improved is already almost universally accepted. Economists who argue that healthcare expenditures are wasteful are self-consciously challenging this standard view, highlighting surprisingly strong evidence that marginal medicine fails to improve health. See Robin Hanson’s “Cut Medicine in Half” for details.
Not only does he reference that marginal benefit of medicine, his actual point is almost the opposite; that the conventional wisdom is that the quality of health care has improved. In that context, although he makes passing reference to Hanson, it isn't even clear that he espouses the weaker fairly uncontroversial version of the arguement. If, e.g. he thought there were a 25% chance that (the weak version of) Hanson's argument were correct, that could still qualify as "surprisingly strong evidence," given that he notes that the position challenges the standard view.
Hanson's point is about whether medicine works. Rather than add in the complexities of insurance coverage (RAND, Oregon and Karnataka) to refute his point, you could probably have just said "Look at the UK, Canada and other countries where healthcare is (effectively) free - or at least where the population doesn't worry about massive medical debt (contra the US studies) and knows how the, possibly new to them, system works (contra the Indian study) and lo and behold, health outcomes have indeed gone up MASSIVELY in the last century."
I mean, the article would have been shorter and more boring, but my first thought when I read Hanson was "Using the US isn't helping your case."
This isn't original to me, but I think it's worth flagging: five-year survival rates after diagnosis can be massively improved just by diagnosing earlier, even if you don't do anything to meaningfully improve cancer survival, assuming increasing lethality over time. I'm not saying that we've done nothing to make cancer safer, but I'd prefer a chart that looked at X years of survival after a Stage 3 diagnosis (or a more closely matched comparison).
I'm sure someone else has invoked the famous Orwell quote elsewhere in this comment section; but in case they haven't - "some ideas are so absurd that only an intellectual could believe them".
There's a trap that contrarians often fall into, of seeing the justification of outlandish propositions as some sort of cognitive challenge. Something like, "proving black is white is really hard, but I reckon I could pull it off." At some point such people are so caught up in their own cleverness that they lose track of whether what they're defending is actually true or not.
I’m generally very sympathetic to your side of the argument. However, if I was Hanson’s lawyer, exhibit A might be the opioid epidemic. It can arguably be traced back to the over prescription of opioids, and has had a massive negative impact on health in the US, an impact that wouldn’t show up in a health insurance RCT, because the epidemic eventually spread throughout society. Maybe medicine has or could create other issues like this (more resilient diseases?)? As counsel I would also discuss the direct evidence for medical care causing deaths through accidents, infections, etc. I don’t think these things would net out in Hanson’s favor, but would be interested to see you address them.
I appreciate you going into this topic. Hanson's position has always seemed both solid and extremely challenging to fit into any consistent model of the world.
(It would also be great to have a more general post on "How much evidence should we require before giving credence to '[entire area of study] just doesn't work' theories?")
I am biased in Scott's favor. But I was a bit disappointed that his argument seemed to proceed as if Hanson claims that there have been no improvements in medical outcomes over time. The question is not how much things have improved, but what caused it, which I think is harder to say. Maybe some of those studies address this, and it seemed too obvious for Scott to hammer on it (or I skimmed over his hammering). I have been surprised by things before, so I wish I thought this really settled the issue. If it did, I missed it.
I find it odd that economists - the pseudoscience to beat the bands - produces people who not just attack other more scientific fields (although medicine isn’t a very hard science) and prove their lack of statistical ability while doing so.
Being myself a physician, I tend to underplay medicine's success, but even I see that the main thing here is perspective. There's a bias to see anything that transitions from "cutting edge high tech" to "low tech" as obvious and commonplace, as "low hanging fruit" in retrospect. as something that was always there.
In the logarithmic graph of medical success, nothing will ever beat the 4 main things that brought us to where we are today - Sanitation, Obstetrics, Vaccination and Antibiotics - all are now so low tech so as to seem divorced from medicine, but they did originate as medicine technology. We can add exercise and nutrition as additional ones today.
The rest of medicine suffers from availability bias - if you don't know anyone close to you that has had a heart attack, stroke, cancer, physical trauma such as a car crash, appendicitis, need for an organ transplant, one of the plethora of autoimmune diseases, etc., it is quite reasonable to think the whole field is useless. But I think that's the hallmark of a functioning system, conceptually - it's invisible to you until you need it, and then it provides.
I'll join the chorus of voices saying that both Hanson's opinion and Scott's refutation are underspecified in exactly what phenomenon they are evaluating.
But consider some specific cases: not just obvious things like antibiotics for infection, but on one hand, take the random person whose debilitating ailment is alleviated by a very specific medicine. If you know older people you can probably name one. Then consider the other random person who takes a daily regime of a dozen pills prescribed by a variety of doctors, who can barely manage to figure out which pills they have already taken or not, and whose liver or kidneys or brain are slowly being intoxicated by the combination. My quick take is that #1 is beneficial, and #2 is harmful ("iatrogenic" is the word nowadays). But you can't easily have one without (some of) the other. By hypothesis #1's medicine is highly specific, so if you under-invest in medical care, patient #1 is out of luck and might as well kill themselves. But #2 is basically a question of *quality*; what they need is a good doctor to review their entire regime and rationalize it. So the balance points towards "we want better medicine" rather than less of it.
The other thing, if you take the broadest possible view, is that the entire modern-industrial-capitalist environment is making us sick and then turning around and selling us dangerous remedies for it. I can sympathize with this view. Barbara Ehrenreich (look her up!) explains it at length in her book Natural Causes. But at this kind of level it's hard to go from global diagnosis to practical applications. And it's not like pre-industrial people were known for their longevity and great health anyway.
It seems like something went wrong copying this quote or it's just shown incorrectly in my browser (firefox 124.01) .
> Using treatment group assignment as an instrument for coverage, we estimate that the average per-month effect of the coverage induced by the intervention on two-year mortality was approximately -0.17 percentage points. We caution, however, that the magnitude of the mortality eect is imprecisely estimated; our con dence interval is consistent with both moderate and large eects of coverage on mortality. At the same time, our estimated con dence interval is su ciently precise to rule out per-month eects smaller in magnitude than -0.03 percentage points, including the estimate from the OLS regression of mortality on coverage across individuals.
Seems like the fs got replaced everywhere except at the first effect where there also is an additional weird character.
Copying it directly from the paper "con dence" I get the same result. However, the text is rendered "correctly" in the pdf.
> I’ve spent fifteen years not responding to this argument, because I worry it would be harsh and annoying to use my platform to beat up on one contrarian who nobody else listens to. But I recently learned Bryan Caplan also takes this seriously. Beating up on two contrarians who nobody else listens to is a great use of a platform!
I'm out of the loop here. Is this intended to be playful ribbing? Because it sounds a little mean. I'm aware Hanson is a proto-LessWronger but not really aware of who Caplan is.
Caplan is an intelligent contrarian whose beliefs seem aligned with the LW/ACX subculture (and I think he attends LW/ACX meetups in his area, but I am not sure about it), and you should probably check out his books because you will probably like them. He definitely makes very good points... the question is whether his conclusions are overall good, or whether he just argues one side of the issue and takes to too much to the extreme.
For example, the argument in "The Myth of the Rational Voter" is that your vote is just one of many millions, so it has little impact on the actual result of the election, but your expressed political opinions have a large impact on how people around you treat you regardless of whether your favorite politician wins, therefore... we should not be surprised at all when people adopt harmful political opinions that make them popular among their peers, because it makes sense for them, selfishly.
In "Selfish Reasons to Have More Kids" Caplan argues that intelligent people should have more kids, especially the ones who actually would like to have more kids, but are worried whether they can provide them a sufficient quality of life, pay the necessary education, etc. The outcomes in life are correlated with intelligence a lot, so if you give your kids the high intelligence, they will probably be okay, even if you spend a little less money and time on each of them individually. (Caplan has 4 children, by the way.)
In "The Case Against Education" he reminds us that when schools brag about the outcomes of their students, they conveniently forget to mention that they already filtered the students at the entry exams, so it is questionable how much of the outcome is a result of something that "was already there" and how much is the actual "value added" by the school; and he uses various statistics to argue that it is mostly (about 80%) the former.
"Open Borders: The Science and Ethics of Immigration" seems like the classical libertarian argument, but with cartoons.
One problem with the funnel (especially for marginal care) is that at some of the steps, there's some probability that the effect will be bad. I go to the doctor more often when the doctor can't help me, and one of those times I catch the flu from one of the other patients. The attempts at diagnosis do me more harm than good--I have an allergic reaction to the contrast agent for the CT scan, for example. I get put on an additional drug for a marginal thing (the doctor gives me antibiotics for my cold to placate me) and have an allergic reaction to them.
I have no idea how big this effect is, but I'm sure it exists. And we should expect to see it have its biggest impact when we're going to the doctor for marginal stuff. If I suddenly go numb on one side of my body, my worries about medical error making me worse off are *way* smaller than my worries that I'm having a stroke; if I have an annoying cold and go to the doctor for it, the probability he's going to do me harm is higher than the very low probability he's going to do me any good.
I think you are arguing a straw man version of Robin Hanson's view. He does not claim that all medicine is ineffective. His claim is that the helpful treatments are offset in the aggregate by harmful interventions. I refer to the latter as "Hansonian medicine." His explanation for observations that greater access to health insurance does not improve health is that it increases access to harmful interventions as well as to beneficial ones.
Interesting post! I think the claim that all medicine doesn't work is too strong but you should check out the book "Medical Nihilism" for a nice Bayesian argument against efficacy of most drugs. Tldr: there are like 30 drugs doing all the work while the rest are free riding on that reputation.
I'm a HUGE fan of Robin Hanson, and for that reason I'm all the more thankful for Scott tackling the parts of his writing where Robin seems obviously egregiously contrarian to the point of being just wrong.
Thank you, Scott! Please engage Robin in the future, as well.
I cracked laughing out loud at the following:
"I’ll follow Robin’s lead in dismissing the entire medical literature - every RCT of every medication or treatment ever published - because it might have “huge biases,” and try to rely on other sources."
My mom eats like a saint and takes her blood pressure medication and she still struggles. No, she's not secretly cheating or something, I know how she eats. I have heard a lot of stories like this. Maybe the proven isn't medicine but blood pressure medicine?
I think the antihypertensive point furthers Robin's argument to a certain degree. Last time I checked, while lowering blood pressure is associated with lower all-cause mortality, the effect is pretty minimal. Don't get me wrong, there is a pretty significant *relative* effect, but the *absolute* reduction is minimal.
I think this distinction is what Robin's getting at most of the time. He's never really arguing medicine doesn't work, it's more like the cost of it outweighs the utility of it most of the time because our great treatments are not so great at extending lifespan in absolute terms.
When Scott says "nobody else listens to" Hanson, is he just implying that Hanson has a small audience, or does Scott mean that Hanson's audience may be large, but few are willing to "listen" in the sense that they will fully accept and take action on his conclusions?
I think using studies on medical insurance to make general statements on medicine in general is just idiotic. Extraordinary statements require extraordinary evidence. It's a load of bullshit. Let's close pharmacies, clinics and hospitals and see how it goes. You think it's hard to do that? Instead of studying the economics of Obamacare better study economics of war-torn African regions and see what happens when people can't become refugees in rich countries and are in civil wars for decades.
The good news is that with the ridiculous price increases on health care, the percentage of Americans on the worst plans will keep increasing. So there should be lots of data to analyze.
A bigger problem is the cost of the health insurance itself: at 18% of GDP, it is a larger and larger percentage of overall household spending, period. What are the health effects of too expensive health insurance? Of medical bankruptcies associated with the bad health care plans? Of the billing scorched earth war between doctors and their billing managers vs. insurance companies?
I totally agree. Health insurancies studies are really a bad starting point. It tests insurancies's efficiency, which is not that good, more than medicine's efficiency. The problem is that libertarians have blind faith in insurancy mecanism.
Free health care is marginal health care, which I think is his concern as an economist.
Sorry, say more?
Ever since the "marginal revolution", economists have sought to "think on the margin". Health care people buy for themselves is our starting point, and then granting them free health insurance causes them to consume additional healthcare, making that marginal healthcare. You could also reverse that if there were some kind of tax on healthcare imposed on people, then the healthcare they previously consumed but now forego could be considered marginal.
Ah, thank you. I clearly need to give these posts a re-read.
Actually, you need to re-read too perhaps. The first paragraph in this article contains: """It would be easy to round Hanson’s position off to something weaker, like “extra health care isn’t valuable on the margin”. This is how most people interpret the studies he cites. Still, I think his current, actual position is that medicine doesn’t work. """
Hanson took a position here:
https://www.cato-unbound.org/2007/09/10/robin-hanson/cut-medicine-half/
"Let us now summarize and interpret these results. Medicine is composed of a great many specific activities. Presumably some of these activities help patients, some hurt patients, and some are neutral. (Don’t believe medicine can hurt? Consider the high rate of medical errors, and see the Fisher & Welch Journal of American Medical Association 1999 theory article.)
We have observed many kinds of disturbances which change the distribution of medical activities, such as variations in local medical culture, local wealth levels, medical prices, and so on. Taken at face value, our inability to see much health impact from the disturbances we have observed suggests that such disturbances increase or decrease helpful and harmful medicine in roughly equal amounts.
This in turn suggests that if we were to reduce medical spending via a disturbance similar in character to the types of disturbances we have observed, such a spending reduction would also reduce helpful and harmful medicine in roughly equal amounts. The claim is not that there would be no harmful health effects of such a policy, but rather that harmful effects would be roughly balanced by helpful effects. And the claim is not that harmful and helpful effects would exactly balance, but rather that any net health harm will be small compared to the health gains possible by spending the savings on other health influences, and to the utility gains possible from spending the savings in other ways.
How much could we cut? For the U.S. it seems reasonable to project the 30% cut in the RAND results to a 50% cut, since the U.S. spends so much more than other nations without obvious extra health gains. I thus claim: we could cut U.S. medical spending in half without substantial net health costs. This would give us the equivalent of an 8% pay raise."
Scott also says that the reason he responded is because he learned Bryan Caplan takes Hanson seriously on the topic. This is what Byan actually wrote:
"The idea that the quality of health care has improved is already almost universally accepted. Economists who argue that healthcare expenditures are wasteful are self-consciously challenging this standard view, highlighting surprisingly strong evidence that marginal medicine fails to improve health. See Robin Hanson’s “Cut Medicine in Half” for details."
Note he is referencing marginal medicine.
Robin's response fits my interpretation:
https://www.overcomingbias.com/p/response-to-scott-alexander-on-medical
Or in other words, Scott defeated Hanson rhetorically so Hanson backpedaled.
Years ago in the Atlantic there was a cover story about healthcare as a percentage of GDP, and how money might be spent on other things a society might value. If that is all Hanson is saying it’s not terribly contrarian? Although someone like Tyler Cowen with his Candide-like complacency would assume we spend exactly the amount we like to spend and are signaling our enjoyment of healthcare.
But the trio’s rhetorical default is provocation without regard for absurdity.
If Cowen has that attitude then it's not well thought out. In almost no case is the person who consumes health care the one who pays for it.
I don't recall him writing that stress or sleep quality affect health.
Good find.
Behavioural change often works very well but is REALLY HARD to implement both individually but especially on a societal level. Medical interventions provide often much more realistic a solution (cases in point: obesity, blood pressure, psychosocial correlates of much psychiatric stuff) if not ideal.
Against the strongest versions of the claim, the obvious smallpox and polio; and antibiotics are good arguments too.
https://www.overcomingbias.com/p/africa-hiv-perverts-or-bad-medhtml
I think he separates vaccination out from other medicine. I agree antibiotics are a strong argument.
I am skeptical whether Hanson really believes what he's saying with real confidence.
If he has a significant bacterial infection, would he not take antibiotics? If he develops a treatable cancer, will he reject modern medicine? I sincerely doubt that would be the case. Revealed preference would be telling in that situation.
His stated idea is that he would be buying the socially approved experience of feeling cared for by a high status person, and acting out the cultural script about what he is supposed to do in the case of an illness, and that the whole belief about effectiveness is just a screen to justify the real reason he is doing these things.
So the revealed preference of his behavior is wholly consistent with his model that medical purchases are about getting something different than better health.
Having said that, I'm pretty confident he would actually want the antibiotics because he thinks they actually kill the bacteria, and he would actually want the chemo because he thought it worked if the clinical studies seemed to robustly claim that it worked -- my model of Hanson also does do what I would do, and actually read the clinical studies at some point before getting injected with the drugs.
"His stated idea is that he would be buying the socially approved experience of feeling cared for by a high status person, and acting out the cultural script about what he is supposed to do in the case of an illness, and that the whole belief about effectiveness is just a screen to justify the real reason he is doing these things."
Okay, then I'm sure we can source a witchdoctor for the next time he has the megrims.
I gather that treatment for severe, persistent headaches aren't very effective. (I'm not sure whether the megrims are the same as migraine."
If giving medical treatment doesn't work after a reasonable try, the witch doctor might work at least as well.
Even so, having *some* kind of painkiller is better than nothing. Undergoing severe pain with no relief at all is not doing any good to anyone. There are problems we don't have the answer to yet, but that is not to say that medicine doesn't work.
I get the feeling Hanson may be arguing something completely different - does having health insurance make a population healthier or not? - but he can't resist making a big (dumb) argument; this is the guy with the "gentle rape" thought experiment, after all:
https://www.overcomingbias.com/p/gentlesilentrapehtml
By the bye, does anyone know if Robin Hanson has ever been punched in the face? I do wonder!
> Okay, then I'm sure we can source a witchdoctor for the next time he has the megrims.
https://www.overcomingbias.com/p/faith-in-docshtml
"Regular docs are mostly in it for the money, and are also hard to evaluate. If we on average get near zero health from our last units of medicine, we are better off replacing those units with anything cheaper, at least if it also gives near zero net health effect and similar non-health benefits. Faith healing seems to fit this bill"
This is a completely self-defeating argument since he can't claim to a) understand the irrational unconscious forces that drive his behaviors and b) still be subject to them. At some level anyone who expects to be taken seriously has to present themselves as a self-consistent rational actor (at least on the subject they're talking about), otherwise they can be dismissed on the theory that their argument isn't actually the result of their honest beliefs but is the result of subconsciously adhering to the socially approved experience of being a contrarian public intellectual.
If you take the "everything is signaling" argument to its logical conclusions then the very prospect of rational debate collapses in a cloud of nihilism. Either accept that people CAN, on some level, respond rationally to the propositional content of an argument, or live the reality of rejecting it by shutting the hell up and doing whatever it is that stimulus-response automatons do. Sorry, but it's not elephants all the way down.
> he can't claim to a) understand the irrational unconscious forces that drive his behaviors and b) still be subject to them
Why? That's like saying you shouldn't be affected by gravity if you know how it works. Sure, you can do things to alleviate its affects, but it obviously still exists. And if you're only going to take people who are "self-consistent rational actors" seriously, then you can't take ANYONE seriously, because there is no human on Earth that could fulfill that description. Everyone sure as hell pretends, but their actions (in)consistently prove otherwise.
And yes, "rational debate" is somewhat of an oxymoron, but that doesn't mean there isn't truth to be found. Truth leads to understanding of the world, and that leads to power. And power is indisputable.
Is it really that important if humans are "rational" creatures are not? These "stimulus-response automatons," as you would call them, live, work, fight, and die, all while accumulating more and more power despite not even being able to directly observe reality. I personally find that beautiful. Don't you?
Perhaps a more precise way of stating it would be that he can't a) claim that his economic behaviors are dictated by social pressures but b) that his expressed opinions are not. And if his opinions are just an avatar of some socially-mediated subconscious consensus then there's no reason for me to listen to him at all - or anyone else for that matter.
>that doesn't mean there isn't truth to be found
Yes it does. If all behavior is social signaling then the only truth that can be discovered are truths about the structure of social signals. Sorry, but I'm only interested in the propositional content of arguments, not the subtextual implications that they may or may not imply.
>Don't you?
No. I find it horrifying.
"Either accept that people CAN, on some level, respond rationally to the propositional content of an argument, or live the reality of rejecting it by shutting the hell up and doing whatever it is that stimulus-response automatons do."
False dichotomy. Hobbies don't have to be useful, they just have to be fun. Debate is a fun hobby for a lot of people. This is only nihilism if I accept your world view, where you think the Marketplace of Ideas is drives human behavior and not vice versa. I have a different world view so trivializing rationality and debate isn't nihilistic in the slightest. My deepest held biases against pedophilia, incest, murder, slavery, monarchism...these principles aren't subject to rational debate, so they are invulnerable. Whereas the true believer in Rational Debate could hypothetically be talked out of one of these taboos by a better debater. So which side is more vulnerable to nihilism?
I assumed he was classifying antibiotics as “sanitation” rather than “healthcare”.
I think his point is not that all medicines do not work but rather some help and some hurt and they mostly cancel out. If that’s the case, “medicine” as a system is net zero EV but a drug or treatment can be very positive.
I am trying to reconcile this skepticism with his proposal to infect volunteers with low doses of covid before we had vaccines.
On one hand we have willingness to engage in radical medical intervention on positive EV suspicions supported by some but by no means iron clad evidence.
On the other hand wants to dismiss all medical literature because of p hacking. How does he decide what evidence he is willing to consider?
It feels like the anti-evolution people separating out 'micro evolution' (white moth to black moth) vs macro evolution (fish to monkey).
Sure, if we separate medicine into ones with large immediate effects, and those with marginal long term effects, the second group doesn't look as dramatically helpful. Not sure that says anything at all, and leads to his silly conclusion.
It might say something about the marginal treatments, especially if there are significant risks and costs.
So he separates out everything he admits is effective, and that's not medicine? What is it then, engineering?
"Yes, if you take away the fact that Jeff Bezos has a hundred billion dollars worth of shares in Amazon, then he's actually a pauper".
I think there’s something potentially meaningful here. If antibiotics and vaccination worked, but literally everything else medicine did was useless, then there would be some reasonable sense in which you could say “medicine basically doesn’t work”. Similarly, if someone owns stock worth billions and billions of dollars, but has literally no other financial assets (no house, no car, no income, no savings), then if there’s some reason they couldn’t sell their stock, there would be a meaningful sense in which they are poor. Theres a concept of being “house rich, cash poor”, where someone takes on too big a mortgage and has to pile all of their earnings into the monthly payments, and although their net worth goes up (particularly if there’s a boom in the housing market), they can’t actually access most of that wealth unless they move.
But isn't this just the No True Scotsman fallacy?
"Medicine doesn't work!"
"But antibiotics and vaccines do work (not counting some exceptions, like antibiotic-resistant bacteria)."
"Well then, antibiotics and vaccines are No True Medicine."
I mean, this seems like a semantic discussion.
If nothing in medicine works besides antibiotics and vaccines, that seems like a surprising and notable result that people should talk about. Quibbling about the exact words used to describe this result doesn't seem super beneficial.
I don't think that only antibiotics and vaccines work. But I do think that it's pretty uncertain to point to any random medicine and say, "This definitely works."
"No True Scotsman" is always a matter of degree. If someone keeps finding a new reason to reject every proposed counterexample, and there's no particular pattern to those reasons, then it's suggestive that their general principle isn't really very general.
But conversely, there's also the "exception that proves the rule" phenomenon. If I propose that all Scotsmen do X, and the only counterexamples you find are Scotsmen who moved to Paris at age 10 and lived there for 20 years before moving back, or Scotsmen who have been obsessed with anime their whole lives and visit Japan for a month every year, then it's suggestive that there's something meaningful here connected to nationality and attachment to the nation, even if it's not quite universal.
I personally think that Hanson is more on the "No True Scotsman" side, but it's always useful to have someone arguing the contrarian null hypothesis, just to push people to be more clear about measuring the real signal.
"No True "No True Scotsman""
That's not a true 'No True Scotsman' fallacy.
Iswydt
Then what *is* he arguing against? Blood pressure medication? Metformin? Anti-cancer chemotherapy? Gall bladder surgery? Removal of kidney stones? Obstetrics? Appendectomies?
"it's not medicine if it works"
But besides that, Mrs. Lincoln, how was the play?
Antibiotics were first used in medicine in the 1940s, and Insulin in 1922. The "Medical Nihilism" view is antibiotics, insulin, painkillers, and trauma care are valuable and substantive, but the valuable part of medicine is at most 20% of the medicine purchased. And Scott's pretty charts are all about the "benefits" and don't show the costs. No, I would not be impressed by his chart that blood pressure medication would lower my chance of dying by 1% in the next five years. That is a meaningless aggregate figure. There are a 100 other more important personal variables that effect my survival outcome, and anyway I would not trade sexual potency and other well-being factors for a 1% less chance of dying in the next five years.
That’s the motte.
The bailey is suggesting alternatives with even weaker evidence, since they don’t have medicine’s institutional baggage.
I’m not sure the latter describes Hanson, who does address the difference between “core” and “extra” care. He doesn’t appear to be grifting with an acupressure company or something, either. I still think it makes for bad epistemology.
Also, conditions that used to be routinely fatal, for which we have diverse novel interventions: appendicitis, type I diabetes, and end-stage renal disease leap to mind. Iatrogenic harm could conceivably balance these out, but is that the argument Hanson is making? It would also be odd if we had a smattering of high-quality, routinely life-saving interventions sprinkled amongst a bunch of neutral or harmful trash, produced by the same institutions using similar methods of discovery and evaluation and the same biological knowledge base. I think the prima facie conclusion to draw from the obviously life-preserving interventions is that less obviously life-preserving interventions which have the mentioned continuities are probably also mostly helpful.
Okay, now if THIS were what Hanson is arguing against, I'm inclined to agree with him: I DO think the situation you describe as "odd" is pretty much true. Terms like "smattering" and "sprinkled" might be a bit of an exaggeration, but I think there IS plenty of neutral or harmful trash produced by the same institutions that produce the good actually-life-saving stuff.
Agreed, much in the way that drug companies benefit from a few blockbuster drugs supporting a vast sea of unprofitable drugs, it's not unreasonable to suspect that the goodwill of modern medicine is propped up by a few blockbuster therapies supporting a sea of modestly effective/ineffective treatments (e.g. migraines)
The number of times I've had to put my kids on antibiotics because something frightening was happening to them is too many.
That said, if most of the benefits of medicine are from abx and vaccines it's still quite an indictment of the whole 20% of GDP system.
More than just antibiotics and (many) vaccines, I'd say painkillers, insulin, many (most?) surgeries, most cancer treatments, some cardiac stuff (blood thinner, defebrillators, that kind of thing), are also good.
The "20% of GDP" is just rent-seeking enabled by the FDA/DEA and the doctors' cartel. It is possible to get much better quality medical care for much cheaper.
Yeah. My kid developed some horrific abscess in his finger while we were on a trip. Overnight he developed a fever. We took him to urgent care the next morning for abx and to drain it. They charged $175 but were concerned he'd need IV anti-biotics so they refused to do anything and sent us to the ER. We thought that was not really necessary but took him to the ER anyway since the one doctor within 100 miles wasn't going to help us.
Thankfully, the ER agreed he did not need IV abx and gave us oral abx. They also drained his finger. He was there 2 1/2 hours total, mostly waiting. They've billed us... $4500 for this with a straight face.
At least urgent care refunded us our $175.
Also most trauma treatments: stitches, casts, restoring patency to occluded arteries in the heart / brain, etc
If optometry can be dismissed as mere physics, those can be dismissed as mere engineering.
Has Robin ever talked to a doctor or been ill? I need someone to explain to me why this isn't the stupidest thing anyone has ever said. Myself and my girlfriend have both had simple surgeries for life threatening problems, we'd both be dead without medicine.
I think his claim is that while medicine probably has some clear victories, it also probably kills some people through side effects, so it's hard to say whether it's on net good or bad, and we can't easily distinguish the good parts from the bad parts. See the casino quote early in the article.
What? That idea has been around just as long as the idea of "medicine".
Ah, I misinterpreted your initial comment.
This seems to me like a galaxy brained take where the galaxy was so dense it collapsed into a supermassive black hole
haha, this is exactly what i felt but put beautifully!
That's still kind of absurd. Yes, there are some treatments of ambiguous value, but there are tons of examples of conditions with roughly 100% mortality rates when untreated and nearly 0% when treated promptly: type 1 diabetes, ruptured appendix, adrenal crisis, ectopic pregnancy, HIV infection...the idea that one somehow can't tell that medicine works to treat these conditions, or that one can't distinguish treatments like insulin and appendectomies from the pool of treatments with more complex cost-benefit equations, is silly.
These are not good examples to criticize a study of insurance over for the obvious reason that they'll get treated regardless of whether the patient is insured.
For the same reason, they do not provide much of an argument for expanding insurance coverage.
Well... exactly! But they decisively debunk Hanson's claim, because Hanson does make that argument, just in the reverse direction.
Hanson doesn't make that argument. Scott provides a long quote from Hanson. Here's what he says about the seventeenth century:
> Europeans in 1600 likely prided themselves on the ways in which their “modern” medicine was superior to what “primitives” had to accept. But we today aren’t so sure: seventeenth century medical theory was based on the four humors, and bloodletting was a common treatment. When we look back at those doctors, we think they may well have done more harm than good.
Here's what he says about the modern day:
> When we look at our own medical practices, however, we tend to be confident we are in good hands, and that the money that goes to buying medical care – in 2020, it was 19.7% of our G.D.P. – is well spent.
> We believe in medicine, and this faith has comforted us during the pandemic. But likewise the patients of the seventeenth century; they could probably also have named a relative cured by bloodletting. Yet health outcomes are typically too random for the experience of one family to justify medical confidence. How do we know our belief is justified?
> This might seem like a silly question: in Europe of the seventeenth century, the average lifespan was in the low 30s. Now it’s the low 80s. Isn’t that difference due to medicine? In fact, the consensus is now that historical lifespan gains are better explained by nutrition, sanitation, and wealth.
> surely modern science must have some reliable way to study the aggregate value of medicine? Yes, we do. The key is to keep a study so simple, pre-announced, and well-examined that there isn’t much room for authors to “cheat” by data-dredging, p-hacking, etc. Large trials where we randomly induce some people to consume more medicine overall, and then track how their health differs from a control population
The seventeenth century is characterized by medicine doing "more harm than good". The modern day is characterized by the money spent on medicine "being well spent". That point is in dispute, and Hanson is pretty clearly correct to disagree with it.
You don't need to rely on Scott's weird interpretation of Hanson's argument when Scott leads off by quoting Hanson.
Hanson is making a mistake when he refers to "inducing some people to consume more medicine" as a way to study the aggregate value of medicine. It's a way to study the marginal value of medicine. Given a study that allows people to boost medicine consumption from low to normal levels, though, it does tell you a lot about the aggregate value of normal levels of consumption.
I'm not sure long-term diabetes care or HIV care will be given regardless of insurance status and/or that it will be the same effective care you'd get with insurance, compared to how you'll definitely get an appendectomy.
Once I tried to find info about outcomes on untreated appendicitis, and didn't find any good. I think it could be as well closer to 50% than 100%. If one gets perforated appendix, then it manages to heal, doctors could claim as well it was never perforated to start with and also doctors often handwaive conditions which just decrease QoL.
I believe it's "handwave," not "handwaive."
But also, I believe it should be updated to be "handwaive."
Just looking at this word makes me cringe. It looks so wrong.
"so it's hard to say whether it's on net good or bad, and we can't easily distinguish the good parts from the bad parts"
Okay, so I can't swear on here, but I'll tell Robin how we figure out "is medical care on net good or bad?" and we look at what happens when people don't get medical care.
They die.
Siblings of my mother died young because of lack of medical care. Is cosmetic surgery to give you zeppelin sized breasts on net good or bad? I'd say bad, but if we're talking about "gee, is chemotherapy for cancer good or bad?" then fuck yeah, Robin, if the cancer is found in time. Yeah, chemotherapy and radiotherapy are terribly hard on the patient, but if the cancer is too far advanced for these procedures to help, then the end is not a happy one and it's damn easy to see "is it on net good or bad to have this done?"
"Finding" cancer "early" only has a "net benefit" a minority of the time. See Vinay Prasad's post, https://www.drvinayprasad.com/p/why-you-should-not-get-a-whole-body?utm_source=profile&utm_medium=reader2
Well, had my mother's cancer been found before it was too goddamn late to do anything about it, maybe she wouldn't have died within four months of diagnosis. Even if she only got a few extra years of life, my family would have considered it worth it.
Looking at the linked post, I'm going to disagree here:
"All tumors start in a target organ (breast, lung or colon). The first grow slowly and are unlikely to shed cells elsewhere. These are not going to kill you in your natural life. You might feel them with your hand someday and cut them out, but even if you didn’t, you have nothing to worry about.
The second are those that spread microscopic cells very early on. Even if you find them when small, they have seeded other organs. There is almost nothing you can do to avoid dying by this cancer short of removing all your organs prophylactically— but then you have other issues. If you find this tumor and cut it out and take chemo— you still die of that cancer— but with a few more surgeries and more time on chemo than had you found it later.
The third type of tumor is the tumor that starts in the target organ, and was going to spread, and going to kill you, but because you find it and cut it out, you live much longer than you otherwise would. This is what we want to find!
Now consider that all three are indistinguishable under the microscope. All get the same treatment— surgery, radiation, and chemotherapy.
The problem is that finding tumors #1 and #2 is not good for you. You are subject to surgery, radiation and chemotherapy that you don’t need. These interventions can improve survival when done appropriately, but when done on people who don’t need them, result in a net loss of survival. Your life is shorter and worse off if you got these treatments when you can’t benefit."
Absolutely had my mother's fatal lung cancer been Tumour Number Two, it would have been worth it. She would have grabbed at any extra months of life, because she was terrified of dying. It's easy to go "theoretically in a hypothetical case, you might as well just forego the chemo and die naturally" but not when it's happening to *you*.
Things like whole body MRI probably are overkill and not worth it, but that's a different case. That's "I have enough money to spend on worrying about my health, without having anything seriously wrong" and having hospitals out there willing to do such procedures because it generates profit.
How about polygenic selection of embryos:? Is that going too far to try and prevent possible cancers? What about having mastectomies in case you later develop the breast cancer that is prevalent in your family? One person's 'overdiagnosed' is another person's 'vital preventative intervention'.
His trichotomy of tumors isn't even accurate. Both my cousin and uncle have had cancers where the tumors have spread to multiple places: too many to cut out, especially of sensitive areas like the heart. It was the radiation and chemo that saved them both.
This analysis is nowhere near sophisticated enough to be convincing to Robin; you need to not just identify the effects on one side of the scales but clearly be balancing it against the effects on the other side of the scales, to see which is larger.
^^ This.
If we count influential nutritionist scientists changing how we eat by publishing flawed or fraudulent work (Nicholai Anichkov and Ansel Keyes, for two - without mentioning 'smoking is healthy') they're killing us in droves (and only sometimes surgically delay the deaths they cause).
The casino quote doesn't make this clear at all, and in fact suggests a different situation altogether. If casinos had some games that were winners over time and others (like slots) that were obvious losers, it would be a better analogy for a mixed bag of excellent, neutral, and harmful interventions. Casino winners don't pick good games--possibly excepting a handful of expert card players, they just get lucky.
Eyeballing things Hanson has written, that seems to be the case - the contrarian portion of his position isn't that he thinks no modern medicine works; it's that he has an unusually high estimate of how much modern medicine is actively harmful.
This is a little weird, because it means that medicine, by this argument, is effective in some countries with much lower GDP - where the money is spent on the "easy wins" like antibiotics, vaccines, insulin, removing cancerous tumours, etc. Medicine is only ineffective when it's 20% of GDP.
I came to the comments section to say this too
Depending on your own lifestyle and a little luck, I can see how some people can get the idea that medicine is useless. If you're broadly healthy and take very few physical risks, there is just no good reason to visit a doctor. For myself, I literally don't remember the last time I visited one; It's probably half a decade ago or so? Most medication I get from the pharmacist is QoL-improving and I take it quite rarely, but the headache I'm suppressing is not going to kill me without it anyway. Among acquaintances, I know several older people who got treatment for something non-life-threatening, and then died in a way that is likely related to the treatment (knee and hip surgeries -> infection mostly). For these reasons, I actually agree with a version that says roughly, if your life isn't threatened or otherwise seriously compromised, don't go to the doctor, they're almost as likely to make it worse than they are to make it better.
But nevertheless, I agree that looking at medicine comprehensively it's hard to conclude that it is net-neutral. Surgeries for serious physical injuries, tumor removal and similar is certainly a big one. Antibiotics is another. Vaccinations as well.
> Depending on your own lifestyle and a little luck, I can see how some people can get the idea that medicine is useless. If you're broadly healthy and take very few physical risks, there is just no good reason to visit a doctor.
Well, do such people not have any older relatives?
Did you not read the second part of that paragraph? Questionable treatments are common enough among older people so that if you're not paying much attention or do deliberate statistics, you can get away with the impression that it's hurting as much as helping. Especially if your older relatives, like you, are disproportionally healthy as well (which is quite likely, bc this tends to run in the family, be it through nature or nurture).
To give another example, my late grandma was quite healthy for most of her life and never really visited a doctor. She got a serious fungal infection in old age that probably would have killed her pretty fast, but at least we have modern medicine! Except instead she got stuck in the hospital afterwards and slowly withered away over months. Not only was this very expensive, but she also was barely aware of anything, and complained about pain when she was. It's hard to say that this was preferably to dying quickly, let alone a good use of money in cost-adjusted QALY. And these aren't just cherry-picked, these are as common, if not more common, than medical success stories among my acquaintances and family.
I think some of these arguments separate surgery from medicine. Which should be the default assumption because if someone says "I'm going to take some medicine tomorrow" you would be extremely surprised if it turned out they meant "I'm going to hospital to have surgery".
From the above post, quoting Robin: "I, too, am a regular customer: I’m vaccinated, boosted, and recently had surgery to fix a broken arm."
I'm still not fully convinced Hanson's original post isn't actually a satire about expensive, poorly done studies on medical effectiveness rather than a genuine argument against medicine -- in the spirit of the famous BMJ study that showed that parachutes were not effective in preventing injuries when jumping from a plane https://www.bmj.com/content/363/bmj.k5094. When he writes "It seems we have three options: we can stick our head in the sand and ignore this unwelcome news, we can accept the difficult truth that medicine just isn’t that useful, or we can hope there’s some mistake here and check again. A mere 0.1% of U.S. annual medical spending, or $4.2 billion, could fund a far larger experiment, and hopefully settle the matter. What do you choose?" That isn't really intended to provoke a response of "oh yes, this op-ed has totally convinced me that we should spend $4.2 billion on a study of medical effectiveness, otherwise I just can't be sure if it's not a waste of money to vaccinate babies," is it?
This is easily resolvable by viewing life saving surgery as an extremely small fraction of medicine. Most medicine is people who feel somewhat under the weather being prescribed antibiotics, or fat people being prescribed to not be fat. These things largely shouldn’t be grouped together in analysis.
So I see your point but I do not think you meaningfully interact with what Hanson is saying - in fact it seems like what he brings forward does not effect how you respond to him at all. Even if we can grant that the maximum application of his thesis is just obviously incorrect by no other metric than the successful eradication of certain infectious diseases or things like soft-tissue repair, that does not invalidate everything he has said. That being said, if you are charitable with the person you are responding to, then certainly you should be given pause that for all the praise of modern medicine there are massive problems.
The chemical-imbalance theory of clinical depression has always been controversial and now that the theory is losing support you can only look out into the aftermath of prescribing people so many of these different anti-depressants to see the problems.
How many people were potentially harmed by following the tau theory in Alzheimer's?
How many women have been harmed by the overuse of C-sections for routine pregnancies?
How much medicine has been developed to treat diseases brought about by poor lifestyle choices like obesity or malnourishment from eating processed foods with no nutrients?
Medicine in America is run like a business, and that has some major problematic implications so your response comes off as being dangerously defensive of what may in fact be indefensible.
I think you are doing a mood affiliation thing where you say there are some things you don't like about medicine, and therefore all anti-medicine claims are correct regardless of their literal content.
I think you may have overupdated on some kind of unsophisticated contrarian attacks on medicine. I'm most qualified to argue your "chemical imbalance" claim, see my previous writings on this at https://slatestarcodex.com/2015/04/05/chemical-imbalance/ and https://slatestarcodex.com/2015/04/18/polemical-imbalance/
Except my post didn't say anything close to that at all - there is no need to be defensive if someone points out that you are being uncharitable to someone making a point about something by only attacking the maximal and almost absurd interpretation of what they are saying. In fact based on how quickly you replied I question if you actually read my response or just quickly skimmed over it and made some unfortunate assumptions.
Also this is not at all an attack on your content that you links (and thank you for that) but aren't posts from 9 years ago somewhat dated? Do you think they accurately reflect what is being discussed in regards to the chemical imbalance theory in the current moment?
I haven't seen any change in the argument in the past nine years that has led me to update that post. Part of the issue with how people present this is that they always talk about "we've learned it's not chemical imbalance!" as some kind of new discovery or crumbling orthodoxy, whereas in fact people have been talking about the ways "chemical imbalance" does vs. doesn't describe the territory for as long as anyone has used the term, usually with approximately the same arguments.
Are arguments data? Because certainly in 9 years (ages in some sciences) the data has been updated. Also by your statement in those posts you were new to the field - are you telling me in 9 years you have gained or seen nothing new?
You're talking about the chemical imbalance argument, which is a mostly philosophical argument about how to think about depression and its treatments given the facts we know. I hope those two articles will explain what I mean by that.
I separate that from the empirical arguments about the causes of depression or the effectiveness of depression treatment , which I've written dozens of posts on in the past few years. You can read a few randomly selected ones at : https://www.astralcodexten.com/p/all-medications-are-insignificant , https://www.astralcodexten.com/p/a-look-down-track-b, or https://www.astralcodexten.com/p/the-precision-of-sensory-evidence, and you can see my overall discussion of depression at https://lorienpsych.com/2021/06/05/depression/
Do you have an actual argument or are you just going to vaguely hint at stuff? If you think that modern medicine is indefensible then just say so and support it with facts.
(Also the irony of you accusing Scott of being defensive given your later posts here.)
>Even if we can grant that the maximum application of his thesis is just obviously incorrect ... that does not invalidate everything he has said.
No-one has ever claimed that. It seems like you clicked on an article called "Contra Hanson On Medical Effectiveness" and expected it to be about your own hobbyhorses instead of about a counterargument to Hanson. It's rather weird.
If you cannot understand my post you should just politely ask for clarification instead of taking the petulant road to nowhere, thanks.
Okay: please clarify. You seem to be disagreeing with something Scott said or agreeing with something Robin said but I can’t quite figure out what
Ok I will assume this is an honest question unlike some of the other commenters here: I am disagreeing with how Scott addresses the issues brought up by Robin in this post. Dr. Alexander's was completely uncharitable with the points raised by Robin and seems to be attacking an argument that is not being credibly made so that those points do not have to be addressed - even if Hanson is ultimately wrong, it is hard to discern that when the engagement is not honest or charitable.
What argument would you say Hanson is making?
It was indeed an honest question. You sort of answered it, but only vaguely. "attacking an argument that is not being made" ... I understand what claim he is attacking (medicine is, on net, not useful.) Are you saying Robin makes no such claim? But Scott quoted him extensively here, so you can't say the quotes are out of context, right? And he seems to be saying that. So where is the lack of charity? It seems he went through Robin's claims one at a time and for each explained "here's why I'm not convinced". What am I missing?
What opinion are you suggesting that people change? Are you just saying that people overestimate how well doctors and researches understand physiology (a claim I agree with), or is there more to your argument that I'm not seeing?
Based on how you responded to my comment, I am not sure you understand my point, Dr. Alexander's points, or Hanson's arguments.
The only way in which people have been harmed by following perhaps-wrong theories of Alzheimer's is the opportunity cost of pursuing other theories which could lead to effective interventions, an argument which concedes the effectiveness of medicine.
That is not the only way people are and were harmed - both Tau and AB have produced therapies that failed in various stages of trials and in some cases accelerated neurodegenerate decline or produced medically significant side-effects. What made you argue this point which is not close to true at all?
Yes, it is not literally true that this is the only way that people have been harmed in the process of researching drugs that didn't pan out. Because you highlighted the harm in the context of following a particular theory, as opposed to the harms of doing clinical research in general, I assumed you meant the harms /differentially/ caused by following a particular theory that has yet to pan out, and weren't just gesturing at the fact that clinical research can cause harm. Is there something else going on the case of research into tau in ALZ that makes the case worth pointing out?
Honest question, I thought tau theory was more popular now, and amyloid fibril theory was wrong? As for the damage caused by amyloid plaque theory, Aducanumab was pretty worthless but not very harmful and not many took it.
Unnecessary C-sections suck, but they cause serious harm to very few people. Necessary C-sections prevent many infant/maternal deaths. If the best you have against medicine is Aducanumab and some C-sections, that's a weak case.
Finally, I eat junk food because it tastes good, not because statins have been invented. I expect the same is true for pretty much everyone else who eats junk food. Notably poor people with the least healthcare access eat the most junk food, suggesting that medicine is not the cause of people eating bad stuff.
The Tau theory is certainly most interesting now that Amyloid-Beta seems to have faced intense scrutiny, but it is also old (nearly 40 years) hypothesis that has had its own string of therapeutic failures so going back to Tau Theory is not necessarily an advancement of treating the disease but certainly there is nothing wrong with further research.
Unnecessary C-sections cause massive harm to large numbers of women - what are you even talking about?! It seems to me like you are just giving your opinions - which is fine ultimately - but not stating that they are in fact just your opinions on the matter.
There is an FDA-approved drug that targets amyloid (lecanemab). The idea is that previous amyloid antibodies failed because they didn't target the right conformation of the amyloid protein, and lecanemab does. There was controversy over its initial approval since that approval was based on a surrogate endpoint. They have since completed a study on cognitive decline in early Alzheimers patients patients and found that it decreased cognitive decline significantly.
There are maybe some open questions that bigger trials and future drugs can answer, but calling the amyloid theory "wrong" seems like a stretch, or at least needs some qualifications.
https://www.yalemedicine.org/news/lecanemab-leqembi-new-alzheimers-drug
https://www.fda.gov/news-events/press-announcements/fda-converts-novel-alzheimers-disease-treatment-traditional-approval
https://www.science.org/content/blog-post/positive-amyloid-trial-finally
Thank you, this is very interesting and encouraging.
> How much medicine has been developed to treat diseases brought about by poor lifestyle choices like obesity or malnourishment from eating processed foods with no nutrients?
Isn’t this more evidence that medicine works and has positive health outcomes, making up for negative health outcomes caused by changes in nutrition?
To seriously answer your question: no it does not, it in fact makes health outcomes worse as therapeutically treating symptoms of chronic disease brought about by lifestyle choices does not address the cause of those symptoms in the first place, and puts you down a path of every increasingly worse outcomes.
"puts you down a path of every increasingly worse outcomes."
How does it do this? If the cause isn't medical (because it's just the simple cheap abundance of calories), why would medical amelioration (or more, a medical solution, as Ozempic may be for some) make things worse overall? Are you saying we shouldn't do any sort of medical intervention on obesity related health issues?
"Are you saying we shouldn't do any sort of medical intervention on obesity related health issues?" See this is what I mean about being disingenuous or uncharitable - the only person who said anything close to this is you, but for some reason you feel the need to question me on if I am saying that when clearly I did not. In fact I said that the problem was not addressing the root cause by instead addressing the chronic symptoms themselves - so obviously I believe there needs to be a medical intervention with obesity and reading anything else to me, comes off as completely dishonest.
To answer your question generally, treating the symptoms at best prevents further damage from those particular symptoms, but does not ameliorate the condition because the condition (in this case obesity) is not being treated, just the symptoms caused by it.
Using a simple analogy: imagine you have been driving on a tire that has lost most of its tread (a lifestyle choice), so you experience the symptoms of uneven turning, uneven driving, a loss of traction, and a loss of effective braking. Further, you run the risk of air pressure loss as the treads further wear into the steel banding and eventually a catastrophic accident while driving (analogous to a cardiac event of some kind.
In this instance you can either address the root cause (the bald tire), or go along a therapeutic route of driving more diligently, buying more powerful brakes, and putting chains around the bald tire to shore up the traction. Further, if you experience air pressure loss through leaks or through a small puncture in the tire you can use rubberized aerosol sprays to repair any damage and prevent further leaking.
All of those things address the symptoms and can address them to a degree that you are practically 'cured' of those symptoms even though the condition (balding tire you choose to drive on and further wear) remains and is worsening over time- just as remaining obese will worsen your health outcomes over time even if you address all of the symptoms successfully.
Rubberized aerosol (fix a flat) will successfully treat your more severe symptoms, and in keeping with your question regarding how this leads to worse outcomes despite successful therapy of symptoms, even severe ones - the fix a flat adds solid mass within the tire and the more you add (even it is always successfully prevents air loss) the more wear you put on the axel that now has to deal with the effects of this added mass, which is also going to increase vibrations which will damage other components of the vehicle even though they are not related to your balding tire whatsoever.
The therapy is also not making the tire any less bald - it is allowing you to ignore the balding tire, which means at some point you are increasing your risk of catastrophic failure of the tire while driving.
When all of this could have been prevented by addressing the bald tire and not therapeutically addressing the symptoms even if in doing so you are 100% successful in treating those symptoms.
In regards to obesity, not addressing the fat directly - and by necessity the life style changes that caused it, is going to worsen your outcomes over time in much the same way.
It's not disingenuous or uncharitable to ask for clarification in the form of mentioning one possible logical consequence of an underdetermined argument. The fact that so many people, by your lights, are acting disingenuous might suggest to you that you are not articulating something very well.
In this particular case, you've just set up a false dichotomy between effectively treating the non-medical root cause and treating the symptoms. Doctors treat the symptoms of obesity because, until Ozempic et al. at least, treating the root cause medically was ineffective. You can tell a patient to diet and exercise until you're blue in the face, but it's largely going to go unheeded. There hasn't been a very good medical intervention until Ozempic (and in some cases gastric bypass) that does lead to drastically lowered calorie consumption. It's just doesn't seem to be the case that, given a patient's failure to diet and exercise, treating symptoms puts a patient "down a path of every increasingly worse outcomes."
How does not treating the cause make things worse? I would think that since you at least treat the symptoms you make things better. It’s true that if you find a way to mitigate some of the harms from something that people like to do, then they often do more of that thing and thus experience more total harms. But you’re still helping them achieve a better overall value of life than they could achieve without this mitigation.
"How much medicine has been developed to treat diseases brought about by poor lifestyle choices like obesity or malnourishment from eating processed foods with no nutrients?"
A lot, and thanks God for it! How is this an argument against medicine? Also the way you sneak this in after listing two sides effects of medical procedures directly is deeply dishonest. In which ways did doctor make people obese? People make themselves obese (or start smoking, or pick up drugs, or do dangerous sports) and medicine does its best (which is quite better than nothing) to keep them alive anyway.
Your Caplan link doesn't work, should be https://betonit.substack.com/p/reflections-on-goff-and-the-cost
Cancer is a poor place to look for effects - and especially for a $ per QALY metric which a rough steelmanning of Hanson. Which obviously is orthogonal to a “medicine doesn’t work” argument but might support a “we spend too much money to help the elderly live a few more poor years” generalized argument.
Much better places to look are 1) antibiotics 2) emergency medicine 3) pre-natal and maternity care 4) general surgery, for starters - both on a mortality basis and a QALY basis.
If Hanson wanted to make a $ per QALY argument, I would argue against it (or maybe not, I don't really obejct to that). I really do want to stress that his real argument is "maybe medicine doesn't work at all".
Very fine post! Having read quite a lot of Hanson, I am not sure, this really is "his real argument" - though I admit your interpretation is legit. His "motte" seemed more along: 1. Naive claims that 'univ. h. care insurance are great' - are: naive / 2. the 20% of GDP thrown at the medicinal-regulatory-complex bring no justifiable added health value compared to spending, say, half of that (I'd guess: a quarter) / 3. if there were real added value it should turn up more in those studies (when all treatable health issues together should show up, even if each specific issue might not). - I assume Hanson can re-do the math better than me - and I am looking forward to his response. (Caplan will find a way to "prove" he was never wrong no matter what, I guess; btw: me BIG fan of all of you.)
ALL the studies quoted suffer from being too "short-term", imho. Here in Germany we had generations to adjust to "free care", and now we visit doctors on average 10 times a year (2018; Korea 17, Japan 12, Sweden: three). A change in my diet would improve my health much more than any medical intervention could. Got to go, wife called: 'lunch is ready!' Yummy.
Think about the Laffer curve: as you increase the marginal tax rate, eventually people start hiding economic activity (or moving it elsewhere) and so the amount of tax you collect actually decreases.
If someone said "our tax rate is too high, it's causing us to collect too little money", I don't think that's a claim that all taxes ever decrease government revenues. I think Robin is mostly saying that we're spending too much on medicine, such that we buy a lot of quackery that doesn't help on net (and quite possibly hurts). I have seen a bunch of cancer screening recommendations shift backwards in my lifetime, as doctors were over-treating patients; you've got to count that sort of thing in your net effect of our current level of medical spending.
I think this is pretty different from "maybe medicine doesn't work at all"!
Scott adresses this first thing in this article:
>This is a strong claim. It would be easy to round Hanson’s position off to something weaker, like “extra health care isn’t valuable on the margin”. This is how most people interpret the studies he cites. Still, I think his current, actual position is that medicine doesn’t work. For example, he writes:
>> [Multiple examples of Hanson claiming that medicin doesn't work at all]
As Scott says: it's fine if you want to make some other argument, but Hanson's actual position seems to be that medicine doesn't work.
I get that; I read the article. I also read all of Hanson's articles, and some of the original literature, and I think Scott is misunderstanding him / not adequately counting the health costs of the medical system. I, following Scott in Who By Very Slow Decay ( https://slatestarcodex.com/2013/07/17/who-by-very-slow-decay/ ), view the medical system as giving people _negative_ QALYs. When you subtract those from the positive QALYs it gives people, what is the result? (And then also the infections received in hospitals, the medications and treatments that turn out to be not worth it, and--)
But still, I think the Laffer Curve point is a better estimate of Hanson's true beliefs than "medicin doesn't work at all", as you put it. To state it another way, suppose medicine's contribution to expanded lifespans was 10% of the total effect. (See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827626/ as a source that answers a different question with roughly that number.) Is that more like 0% or 100%?
Hanson sees people describing it as tho it was 100%, and is trying to flip that on its head to be closer to the truth. People argue passionately about expanding access to health insurance, which, if you buy the estimate of 0 effect from those studies, is all wasted passion.
[I think Hanson should update more on the Obamacare study, and also I think the medical system is steadily improving--but I think Hanson is right that the way in which the system is improving is pretty slow and not actually very reliable. I buy his guess that cutting medical spending in half would probably not materially worsen outcomes, especially given what we could do with the resources freed up.]
Sorry, I was unclear in the beginning; I mean giving "some" people negative QALYs, by prolonging lives they would rather not be living; obviously this doesn't happen to everyone.
You seem to be going in circles. Scott say "I will write about Hansons opinion strong-X". You respond "But you should write about weak-X". And I respond "But he was writing about strong-X". And you respond again "But he should write about weak-X!".
Just accept that this post was about strong-X. Scott has written plenty about weak-X, see eg the posts on Amish healthcare costs.
If Scott were to say "strong-X is wrong", well, sure, we can have that conversation. But he writes instead "Hanson believes strong-X, which is wrong," to which I think it is fair to respond "no, Hanson believes weak-X." Like, I think this is a reading comprehension fail on Scott's part.
Now, maybe Hanson will respond saying "yeah, I actually do believe strong-X." But my guess is he'll say something more like "no, Scott is exaggerating my views." Feel free to register your predictions here: https://manifold.markets/MatthewGrayc2b2/will-robin-hanson-think-scott-alexa
Scott did not give a single example of Hanson claiming medicine doesn't work at all.
yup
Bit of a tangent here, but I have something to say about the Laffer Curve. The point at which people start hiding economic activity can be moved by using more brutal enforcement methods. Said brutal enforcement methods can be made palatable to the public by pairing them with populist measures. Price controls are a perfect example of this. Robespierre maintained support for his abhorrent Reign of Terror by linking it with populist price controls. (Conversely, you can actually make price controls work if you just brutally stamp out the black market. It's doable. If consumer choice and nonessential goods availability plummet, that's a small price to pay for equitable prices.)
I wrote about this in detail in another comment: https://www.astralcodexten.com/p/contra-hanson-on-medical-effectiveness/comment/54727872, but cancer treatment is on the verge of major changes that should dramatically improve $ per QALY.
Cancer treatments are likely to improve dramatically in the next 1 - 5 years, due to personalized and mRNA vaccines.
I hate the way this discussion is framed. Robin says "medicine doesn't work." Scott says "medicine does work." Why is the relevant object "medicine?" How does that make any sense? There isn't some one big, monolithic thing called "medicine." There are many different, heterogeneous pathologies, and many different, heterogeneous treatments. My null hypothesis would be some of these are great, and some of them suck (even worse than doing nothing). And having read the entire post, I still think that's exactly the case.
It's easy to believe that modern antibiotics are excellent for treating many bacteria infections. And that some forms surgery, perhaps spinal fusion surgery for degenerative disks, can be worse than doing nothing. And that medicine is a big mixed bag containing everything in between. There's no paradox or puzzle here, and it's just dumb to frame this as a fight between "medicine works" and "medicine doesn't work."
I think different levels of generality are appropriate in different contexts. We can get more and more fine grained into infinity - there's no one big monolithic thing called "cancer", there's no one big monolithic thing called "malnutrition", etc, etc. And that level of specificity is appropriate if you want to argue that the way we treat non-Hodgkin's Lymphoma is suboptimal or something.
But if for example you want to argue that the libertarian utopia doesn't need a state apparatus to raise taxes and pay for healthcare for those who can't afford it because medicine is fake and gay, you're going to be arguing at a higher level of generality.
An appropriate and useful level of generality requires prudential judgment and will differ by context, as you say. My point is that, in my judgment, both Robin and Scott have adopted too high a level of generality for their analyses to be useful.
I think of my father, who for reasons too complicated to go into, could never be told anything by a doctor (“diabetic” launched its own frenzy of confused starvation interspersed with binging, making mother’s life difficult about cooking, while away from home he would drop his new hobby and eat whatever he wanted; testing was a fun thing to do many times a day and there was lots to spend $ on) without going whole hog for treatment (in the same way he *had to* compulsively spend money on other things - he has no moderating judgment, and is probably bipolar, though alcoholism threw us off realizing that, had we known the word in those decades). So when he was told he had prostate cancer in his 60s, he didn’t consider forgoing treatment though I have no reason to believe he had other than the usual old man prostate cancer. He excitedly did something called proton therapy. I don’t understand why but when prostate cancer recurred some years later, the former meant he couldn’t do radiation. He had various surgeries and got a device for eliminating.
In time that failed or something and he got a catheter. Now he has two. He has enough sense, or maybe has been told, to realize that some over-doctoring got him into this position. I believe he *might* have died from prostate cancer, though I never heard any numbers - but on the other hand, I think it might have just grown slowly and he would not for years have required round the clock care from my mother and others; how much a round course of harsh chemo a couple years ago that so weakened him we and he assumed he was dying, has prolonged life I don’t know. (But having him down to a 100 pounds or so and still thinking he needed to pound Diet Coke and so forth was a little aggravating.)
But the health problems connected with a catheter are chronic and so hard to deal with … He is brave about pain, I’ll give him that; takes nothing more than Tylenol. And he has terrible pain now - though no doctor has ever said why, only that everything in his abdomen is messed up, which we can all see from a cat scan.
It has made me rather negative about catheters.
Just the sheer amount of stuff, changes, changes that didn’t work, ER visits because it didn’t work and he couldn’t go; constant abdominal infections and UTIs … I have wondered if diapers would be preferable and safer. He must wear them anyway, all the time, with boosters, because the catheter doesn’t carry everything away. So it seems like you get the inconvenience of both …
Some of this may be a rant about doctors not exercising judgment on behalf of patients who lack the capacity for understanding choices and odds.
Medicine, when practiced well, relies heavily on good judgment, taking into account the overall course of life. The Hippocratic dictum "first, do no harm," is not some abstract ethical principle. It is a very practical principle, stemming from the fact that, even within the range of standard treatments, there are many ways to do harm.
I think the idea would be that the general “we” are happy with the spending, collectively, and find in it no waste.
I think both authors are running a motte and bailey here.
Hanson is saying "medicine doesn't work" and making arguments about doctor visits. Alexander is saying "medicine does work" and making arguments about antibiotics.
I think you're right that "medicine" is an enormous bag of stuff. Some of it works quite well, other parts don't. There's another author who quoted an executive saying "At best only half of marketing works, but I don't know which half does."
I think Scott would argue that he's not using a motte and bailey, but rather engaging in legitimate "rounding" to a valid summary conclusion.
My argument is that, no, "medicine" is too big and heterogeneous for that rounding to be helpful. You simply have to decompose "medicine" a level or two to say anything helpful.
I love the motte and bailey framing and have found it useful...but they are kind of in the eye of the beholder. Or more cynically, if you start looking for them, it's mottes and baileys all the way down...
> I think if Robin wants to do something with these insurance study results, he should follow other economists, including the study authors, and argue about whether the marginal unit of insurance is cost-effective - not about whether medication works at all.
As far as I can recall, Robin Hanson generally talks about the marginal unit of healthcare, rather than whether medication works "at all". For example, in his long paper on medical behavior, he talked about "A near-zero marginal health-value of medical care" rather than whether medical care had any value "at all" (see https://mason.gmu.edu/~rhanson/showcare.pdf). I also recall him being clear to say that he's only talking about marginal effectiveness of medicine in his book The Elephant in the Brain.
I agree that the way he talks about this topic can be confusing. But ultimately I suspect that, if Hanson ends up replying to this post, he will say that you misunderstood his views on medicine.
I recall that, many years ago, Hanson published a piece in a libertarian website arguing that the US government should cut its medical spending to half its current levels. This supports the interpretation that he is talking about the marginal value of medicine, since otherwise why not cut the budget to zero? On the other hand, some of the quotes Scott provides support the opposite interpretation. My sense is that Hanson has not stated his views about the value of medicine sufficiently clearly.
I agree, I've been following Hanson for close to 15 years, read both Age of EMs and Elephant in the Brain, tend to agree he is misread very often and think basically all of his "I said this and people misread me"s are correct and I *still* thought his view was closer to "most medicine save antibiotics, bone setting and diabetes" does close to zero, rather than "the marginal rate is negative".
Why did I think this? He opens his chapter on Medicine in Elephant in the Brain with a detailed story about obviously fake treatments on a long where age is essentially tortured as a cure, and asks how this could all happen if the treatments didn't work and Medicine was about medicine. He repeatedly emphasizes the status of doctors, and how the status distorts treatment incentives. He probably said somewhere that he mostly thinks about the margin, I don't deny that! But when lots of points are stated like "here's why we wouldn't expect this to work all" instead of "here's why this works less better than it could", forgive a brother for misremembering.
Saying treatments have no effect and saying that they don't have any net effect are two different positions.
If you take antibiotics as an example, it's possible that a society uses antibiotics in a way where they are on net harmful because they destroy benefitial bacteria as well as harmful bacteria.
For ear infections, bronchitis, sinusitis, and sore throats Hanson even makes that point explictely "Patients with ear infections are more likely to be harmed by antibiotics than helped. [...] The same is true for bronchitis, sinusitis, and sore throats." (https://www.overcomingbias.com/p/medical-ideologyhtml)
Antibiotics are not special in Hanson's view. In general, just because a drug was benefitial in an RCT in a population that was carefully selected to benefit from the drug does not mean that the average way doctors use the drug is net benefitial to patients.
Hanson has now replied to Scott, and makes exactly the same point I did above:
> There’s also my 2007 article Cut Medicine in Half where I say:
>> In the aggregate, variations in medical spending usually show no statistically significant medical effect on health. … the tiny effect of medicine found in large studies is in striking contrast to the large apparent effects we find even in small studies of other influences.
> Obviously, if I thought medicine was useless at all margins, I’d have said to cut it all, not just cut it in half.
https://www.overcomingbias.com/p/response-to-scott-alexander-on-medical
None of this meaningfully disproves Hanson. Hanson's (correctly!) credits spontaneously occuring secular trends with the increase in life expectancy. Others did so before him and there are a bunch of other studies basically coming to the same conclusion, i.e. finding small to irrelevant effects for medical care. This is not new and not surprising, and anybody practicing medicine with open eyes has noticed that the presentations of new cases of practically all diseases seem to ameliorate over time and the clinically large/evident presentations of the past are practically absent in todays practice.
The error here is the same with all the other evidence that has been dragged in to refute this, in that people do not understand that incidence rules health, that comparably large increases in survival in lethal disease will not appreciably change the population's life expectancy when incidence is low, and that incidence has always been low even for those supposedly common deadly diseases of history. Adjuncts to these errors are the failure to understand that most chronic diseases of aging do not result in death or disability if left alone, most treatment fails to meaningfully alter the course of the disease it pretends to treat and the failure to understand lead-time- and length-time-biases, as demonstrated by the diatribe on cancer survival.
I understand the need to believe in medicine when you are working as a physician, but this is sloppy reasoning.
He also said I was 'doing some mood affiliation thing' which has nothing to do with the content of my reply at all and in fact ignored me when I objected to his radical misreading of what I said, then links me to some 2015 posts because it is 'mostly philosophy that hasnt changed in 9 years" - I do not think Dr. Alexander is being charitable at all.
He spent WAY more time engaging with the arguments than I would have. Props to him.
I don't appreciate replies with no content so please refrain from interacting with me in this way in the future - I'd be very thankful.
You've contributed very little actual content to this comments area and the blog host was perfectly reasonable to you. You don't really get to ask things like this.
I don't respond to people who make stuff up just so they can participate in a comment section over a topic that is beyond their discernment, thanks.
And instead of responding to any of the actual content in those posts, you simply said they were old and declined to elaborate further. I don't see anything worth being charitable to.
That is obviously not what I said as I asked questions and Dr. Alexander provided further links which I am reading. Way to read hostility into something that did not require it.
Reading the comment in question, I also think you were doing a mood affiliation thing. It's the only way I can make sense of citing three examples of mistakes in medical science/practice in support of the position that medicine literally does not work. They're completely unrelated questions, linked only by a general distrust of medicine- hence the mood affiliation accusation.
But actually you didn't think that, because the entire 'diagnosis' was made up and give you nothing to make that assertion in a credible way. I in fact used those as examples of Dr. Alexander not charitably engaging with Hanson and his points. You should read Hanson for yourself understand his arguments before bandwagoning something you do not understand on Substack.
I'm not quite sure what you mean, but I can assure you I do think exactly what I said.
I have read Hanson (whose blog is also on Substack now, by the way).
> I do not think Dr. Alexander is being charitable at all.
I saw your comments above and I don't think you're being charitable at all.
You should go back to school then and confront your teachers as to why you read things in a dishonest way.
That's awfully aggressive, given that none of your comments that I've seen have contained any substantial content at all.
Sir you make that up completely in your own mind but I am not offended, thanks.
Obviously population health trumps specific intervention
“Prevention is better than cure”
This uh
Doesn’t mean cure is irrelevant
Controversial I know
Have you ever been sick?
Or had a sick family member?
On the contrary, prevention is the most useless part of contemporary medical practice. No current intervention seems to appreciably change mortality on the overall population level.
I have been sick plenty of times and so have family members. Neither myself nor them were helped by medical treatment in any appreciable way. I cannot say the same for my patients, I take credit for saving a few lives each year, but that is because I work in a very niche field of medicine, and if you were to quantify the impact my specialty has on population health, it would be not detectable.
This is mostly what makes the Hanson argument commensurable with the fact that some medicine surprisingly does work: most does not, and the bits that do are far too rare to make any quantifiable difference to the population as a whole.
Heaps of interventions change mortality on the population level
Blood pressure control
Cholesterol treatment
Smoking cessation advice and treatment
Cancer screening
Vaccinations
I thought you were saying that preventive health (or "secular trends") were the big driver of improved life expectancy eg
- Vaccine development esp polio
- Iodine supplementation in foods
- Folic acid for prevention of spina bifida
- Fluoride supplementation in drinking water
- Improvements in sanitation
- Eradication of smallpox
Now I am confused as to what you are saying, but I'm very confident that you're wrong.
Nah - the secular trends do not seem to have really been caused by prevention. Sanitation and nutrition are not what this is about (they are probably responsible) - but even there you would be hard pressed to find an effect from fluoride on mortality for instance (might decrease cavities by a bit, bu so what? dentists are a thing). BTW: Europe does not do half the things on your list, and ife expectancy is higher there than in the US.
Which half of those are you claiming that Europe doesn't do? 'cause as far as I know, having lived in Europe all my life, all of those things are done here.
I'm sorry you and your family members were not helped by modern medicine, and I hope you guys are all OK! Please don't generalise to the literally billions of people who have been helped, however
If each individual intervention appreciably changed mortality rates at the population level, we'd all be living to the maximum human lifespan unless hit by trucks. Scott addressed statistical problems with evaluating individual interventions this way in the post.
"any appreciable way"
Well, you might try being more appreciative!
But jokes apart, I think this is key. You don't appreciate how much modern medicine has make the world so safe that with a bit of luck (yes, you and your family were lucky) you can avoid "visible" medicine.
I never got to be helped by iron lungs bc polio is extinct, thanks to vaccines.
I never got to be helped by treatments for tetanus, despite a childhood spent playing with rusty stuff, bc I'm vaxxed.
Thanks to Ozempic, my chances to avail myself of a cardiac bypass or similia are much lower.
Tons of examples like these
What is the NNT for avoiding cardiac bypass from Ozempic? Were you ever even told or did you look it up? Diabetes meds are probably the poster child for the Hanson argument: marginal gains, ubiquitous harms, overall effect for population health likely near zero, gargantuan costs.
I really don't get this argument. You do an RCT and find significant effects. In that case you are comparing the "just leave it alone and see what happens" (what you are talking about) to intervention. Intervention helps. So the treatment meaningfully alters the course of disease.
If you got a treatable cancer, would you reject treatment?
Most RCTs these days are not comparing against "no treatment", because we usually have an existing treatment. It's not moral to not give people treatment, so they compare the new one with the existing one.
And then at some point in the trial they often find that the new treatment is doing better, so it's not moral to continue not to treat people with the one that works better. So they switch to the new one, and try to write the paper afterwards.
This is not the point - the point is that most RCTs find in fact tiny effects on mortality (PCI famously improves survival by an absolute 2% IIRC) and if the indications are rare (to stay with this example, OMI is very rare indeed these days) this will not make an appreciable difference in life expectancy.
A secondary point is that there have been large declines in mortality from most diseases without any appreciable influence of specific medical interventions. Most of these declines started before the medical improvements were even conceptualised (i.e. there is a decline in heart disease mortality that started in the sixties, where medicine was famously useless at treating OMI that has pretty much stayed constant regardless of the interventions medicine offered).
Of course you go for indicated treatment that has proven benefit. But that does not change very much the statement that the effect medicine has at the margins does not account for the bulk of the gains in life expectancy since approx. 1850.
So you're saying that polio would have gone away by itself after some time or the effects would have reduced over time to the point where they aren't important any more and therefore spending the time / money / effort on the polio vaccine was pointless?
Okay... maybe... but we can be pretty sure that would have taken longer than the vaccine that effectively eradicated polio. So your argument is that the very large amount of patients that would have gotten polio, if not for the vaccine, would have been acceptable as the vaccine creation and distribution cost was not worth it?
It you look at how polio became such a big deal in the middle of last century, the story gets more complicated.
1. Before sanitation efforts, polio was ubiquitous. Babies were exposed, some died, the others pulled through.
2. Then sanitation meant that people were exposed later in life. One of the odd things about polio is that as far as I know the effects tend to be worse, the older you are on first exposure. At this point it became necessary to develop a vaccine, as people weren't going to stop the sanitation efforts.
3. So now we have polio vaccines, and sanitation is so good we pretty much have to import our polio cases.
Thank you for making my argument against Hanson stronger!
If Hanson's argument is that sanitation did most of the work and not medicine, then the case of polio specifically points out something that was made worse by sanitation and then fixed by mecidine! Go Medicine!
Polio was already in decline before the introduction of the vaccine, yes. Whether this trend woudl have continued we do not really know. But the Sabin vaccine has left no real signature in the mortality of children in some countries, so the effect on overall health is not at all that clear.
Is you argument that, since death isn't common, that means that interventions to prevent death can't, even in principle, be useful? I think most people would disagree with your definition of useful. The number needed to treat to prevent death over one year of a magical pill that completely prevented death would be quite high in most populations. Where's your line between that pill and useless interventions? I'll give concrete examples, because I think they'd be helpful in elucidating what you mean (in practice, access is a barrier, but that's irrelevant to whether healthcare works). I'd be interested in your take on these individually: GLP-1s; blood pressure drugs; imatinib.
Your magical pill would have to have zero harm associated with it, and that is not what we find for todays drugs or surgeries. But yeah, the NNT would be horrendous.
Re your examples: antidiabetic and blood pressure drugs have poor effects on survival. Imatinib is pretty rad, but CML was and is rare and the loss of life from it was approx. 10 years prior to imatinib. So that kinda proves the point that medicine works at the margins and the margins are not at all contributing to the bulk of improvement in life expectancy.
It sounds like you're saying that Hanson is right to claim that medicine is not the cause of increases in life expectancy, and the "large increases in survival of disease" exist but don't explain the life expectancy gains.
In that case you already agree with Scott over Hanson. Because as Scott took care to establish at the beginning of the post, Hanson is making the much stronger claim that medicine does not have a consistently positive effect on survival of disease (or any other health outcome).
But what SA doesn't get is that these positions are largely equivalent if you factor in medical harm. When marginal gains get eaten up by rare but devastating harm, you end up with no or negative effects on survival.
> Imagine someone claimed that casinos produce, not just entertainment, but also money. I would reply that while some people have indeed walked away from casinos with more money than they arrived with, it is very rare for anyone to be able to reasonably expect this result. There may well be a few such people, but there are severe barriers to creating regular social practices wherein large groups of people can reasonably expect to make money from casinos. We have data suggesting such barriers exist, and we have reasonable theories of what could cause such barriers. Regarding medicine (the stuff doctors do), my claims are similar.
This sounds pretty clear to me. “There are severe barriers to regular social practices wherein large groups can expect to see benefits from healthcare.” That’s not a marginal argument, but a structural one!
The incidence of heart disease is not low and the treatments for it are in fact very effective relative to pre-medicine baselines of doing nothing. Critical care units, pacemakers, stents, cardiac surgery, statins, imaging to detect cardiovascular disease, EKGs and echo and cardiac MRI to detect and differentiate diff types of heart disease, anticoagulants, etc.
You can see this in RCTs, you can see this with broad epi data finding cause specific mortality going down, you can even just grok this by reading biographies from different time periods 1900, 1940, 1980, 2010 and realize heart disease became increasingly better understood, better treated, much less of a death sentence, etc.
Nope, unfortunately not. The decline in heart disease mortality started in the 1960s, when treatment for OMI and vasoocclusive disease was useless/probably harmful.
What does this have to do with my response?
I'm having trouble reconciling "The error here is the same with all the other evidence that has been dragged in to refute this, in that people do not understand that incidence rules health, that comparably large increases in survival in lethal disease will not appreciably change the population's life expectancy when incidence is low, and that incidence has always been low even for those supposedly common deadly diseases of history" and "I understand the need to believe in medicine when you are working as a physician, but this is sloppy reasoning." Surely in the former you're arguing that medicine can work for individual people, but will not meaningfully change population outcomes because very few people get those diseases, yet in the latter you seem to be saying that medicine doesn't work at all. Could you unpack that a bit? What proposition exactly are you or Hanson arguing in favor of?
I have no clue what Hanson argues for deep down since I am not him. But I read his argument as that a) most medicine does not appreciably change life expectancy b) the bit of medicine that does is too rare to make a difference on the population level. Both of these statements I woudl get behind. What I meant by that last statement ist that these two realisations are hurting doctors' pride and sense of purpose and are thus fought tooth and nail when the data point sadly to exactly this conclusion.
I'm really curious what Robin would say to all the progress on cancer. One might argue that it's a poor use of money, but some of the new cancer treatments have huge effect sizes that would swamp his complaints for high noise.
"I’ve spent fifteen years not responding to this argument, because I worry it would be harsh and annoying to use my platform to beat up on one contrarian who nobody else listens to."
Admittedly I don't have as big of a platform as you do, but one solution I often use for this is to first argue with the contrarian about it behind the scenes, and then only publish the rebuttal if they don't self-correct.
The problem with not getting it corrected at all is that "who nobody else listens to" is wrong. E.g. for a period of time, I found it plausible that Robin Hanson was right, because I assumed he and others had done their basic statistics to check the validity of the claims (especially because I saw e.g. Eliezer Yudkowsky reference the results too). It's only after getting a better mindset for the statistics (many of the problems you mention here show up in *a lot* of studies) that I started disbelieving.
I don't know why you can't find the book. It's here: https://annas-archive.org/md5/be2a9bdb7087cc9b26659211f3cf8447
Agreed with this, and I particularly like seeing the improvement in mortality for specific conditions over time like this, it strikes me as a really strong argument for the effectiveness of medicine.
What I do think remains a valid sort-of anti-medicine point is that treatment is vastly less cost-effective than prevention, I recall hearing it being about 50 times less so, and so clearly vast savings could be made through government disease-prevention programs such as dissuasion campaigns against and fees on the externalities of risk factors for disease and especially the broad category of "ingested substances" whether food or recreational drugs and even air pollution; the feeing of externalities ("pigovian taxation") is of course the least econonomically burdensome and indeed in theory if we could properly calculate the value of the externalities it would be economically optimal, since it doesn't require making any government expenditure and to the contrary actually constitutes a source of income for the government and can substitute for an equal amount of economically harmful taxation, so that's what seems to me the most obvious major policy to help reduce healthcare costs, though frustratingly it's foolishly opposed by many and ironically generally the most so by the "taxation is theft" crowd.
Yeah I actually agree strongly with this. We need much more funding in primary care
Since I haven't actually read Robin on the matter, and have come across a few comments retorting that Robin isn't actually stating that medicine doesn't work at all (which would indeed be odd) and rather that medicine isn't clearly strongly net-beneficial, I feel compelled to clarify that at the very least it does appear that certain medical interventions probably have too little net benefit to justify their practice, and that there should be a greater effort to identify them and eliminate them from standard practice.
And I agree with others that actually the cancer survival data is skewed by increase in diagnosis, so I partly take back my support for that being a strong argument; however we do know that certain cancers (and other conditions eg bacterial infections and emergency conditions as has been mentioned by others) now do have a much more favorable outcome thanks to specific treatments that have been developed, to the extent that it seems very unlikely that there not be a net positive effect, and so if there are indeed many wasteful interventions, eliminating them should make the positive effect of these beneficial interventions become more apparent at the population level.
The prevention>treatment case is much more complicated than people think. The USPTF has a bunch of recommendations for prevention with strong evidence. They're quite bare bones - much less than people might think. Why? Because it's a lot trickier than people think to 1) tell if your prevention intervention is net good 2) if it's net good, it's cost effective
Like I replied to others, my first comment was rather unthinking and failed to specify that I was mostly thinking of lifestyle factors. Definitely something like screening is trickier since it can be quite expensive and can lead to excessive treatment causing even worth health outcomes through adverse effects, which would constitute an argument in favor of Robin's notion that medicine isn't helpful overall, though thankfully the screening that does get done usually precisely follows the guidelines which itself is based on quite rigorous evidence in favor of its efficacy - at least if we only look at health outcomes; admittedly another issue is that an intervention that does on average lead to improved health might still not be cost-effective. Ultimately the main conclusion is that there needs to be a good determination of the cost-effectiveness of interventions and resources should be allocated only to cost-effective ones and preferentially towards the most cost-effective ones. (Edit:typo)
>What I do think remains a valid sort-of anti-medicine point is that treatment is vastly less cost-effective than prevention, I recall hearing it being about 50 times less so
Whered you get that from? My impression was that its the opposite. Or are you taking about the "live a healthy lifestyle" sort of prevention thats cheap on paper but noone actually does?
>the "live a healthy lifestyle" sort of prevention thats cheap on paper but noone actually does?
<mild grumble>
The e.g. "eat healthy and exercise" advice is financially cheap on paper but not cheap in time and effort (exercise) nor cheap in foregone pleasure (pizza!).
</mild grumble>
Vague memory from med school, and yes I mean the live a healthy lifestyle kind of prevention, and the point is that people do in fact do it to some extent if they are nudged, and what I recall is that the saved medical costs downstream far outweigh the cost of that nudging, though admittedly I haven't researched the matter further; anyway like I said if we actually do externality pricing (eg slapping an extra fee on junk food) which is a form of nudging too then the cost is actually negative ie it's a source of revenue for the government.
Ok, that sounds more realistic. Still I imagine it really depends on the details. For example I vaguely remember that smokers are cheaper, because they die before needing expensive old-people things. That might still be consistent with what you heard, but your first comment sounds a bit too general.
I agree that subsidised healthcare logically goes with health paternalism like these taxes, but a lot of the steps in that direction actually taken do not inspire confidence.
Yes I agree that it's too general and thus kind of meaningless at best, I'm going to search for some studies on the matter.
Regarding smokers dying earlier, yes in a sense it makes them cheaper, but seen like that the most economical thing to do would be make humans extinct as soon as possible.
And pigovian taxation isn't just health paternalism but also simply economically optimal policy at least in theory, and it has already long been successfully used for ethanol and tobacco though typically not explicitly as such, and I am not aware of major problems with it there, though I do recall reading that for cannabis in California this didn't work well because it favored the perpetuation of an illegal market, and the author's recommendation which seems sound to me was to first have no such tax so that the legal producers outcompetes the illegal ones and only then once there is little illegal production left do you implement the tax at which point it will be difficult for illegal production to reconstitute itself.
>seen like that the most economical thing to do would be make humans extinct as soon as possible.
But then they wouldnt pay taxes. To be fair, the average person is net negative currently, but we dont expect government deficits to continue forever. And besides, if you dont like that perspective then you shouldnt take pigouvian taxes having negative cost to the government as a positive.
>it has already long been successfully used for ethanol and tobacco
I agree that those examples are successful. But there have been plenty of times when they picked the wrong horse too, especially on the diet-related topics.
>But then they wouldnt pay taxes.
Yes true, I was thinking in terms of gross expense rather than net.
I'm all for pigouvian taxation, but I think that the prevention vs cure debate is hopelessly muddled by semantical jerrymandering. Most cures for something are also prevention for the comorbidities of that something. To add, there are several layers of prevention to anything.
Case in point: somebody with a dog in the debate could have just waited to see whether Ozempic worked. Had it been useless, they could have grandstanded about yet another useless cure for obesity, and the need for more prevention (exercise, better nutrition, etc.). Now that it turns out it works, well, it's a startling victory for prevention! Saving so many QALYs and $s by making people thinner earlier rather than saving them from strokes later!
It's not *wrong*, but it's not particularly *fruitful*
Yes agreed, I was mostly thinking of lifestyle factors and in the context of primary prevention, I should have been more specific though there were already hints that that's what I had in mind.
Like of course the evidence is less clear-cut when you look at life-expectancy as a whole rather than specific diseases. You throw away a bunch of signal and then the snr gets worse. Surprised pikachu face.
Well yes, but in defense of the (at least alleged) Hanson position, if it indeed appears that medicine doesn't particularly improve overall life expectancy or quality of life, then it's true that it would be better to just not do any medicine rather than to pursue medicine as currently practiced, since it would mean there appears to be no net benefit from the latter, and meanwhile it incurs a lot of expense, though of course I would want much more robust evidence that medicine indeed fails in these metrics; obviously in practice we know that some interventions are particularly beneficial so it would be silly to eliminate them, at least if we don't take the position that prolonging life is actually typically detrimental due to increasing age-related diseases thereby increasing total healthcare costs.
If it "appears" that medicine doesn't improve life expectancy or quality of life, where are you looking that has a control group that doesn't get any medicine?
*Less* medicine, doesn't cut it unless you're making an argument at the margin.
Randomized controlled trials aren't the only way of determining things like this. Scott's original post covers Robin's arguments about why at least in his eyes it appears that medicine is ineffective and they are at least superificially sound; notably if overall mean lifespan doesn't increase significantly despite large improvements in medicine and without a worsening of other factors that could counterbalance these improvements, that makes medicine as a whole seem quite useless.
Of course in the United States the reason for the lack of increase in lifespan is a worsening of societal problems, and in other already-wealthy countries that have not experienced this, lifespan has in fact continued to increase, albeit more slowly since we are getting closer and closer to the limit imposed by aging, so actually there is no phenomenon of unexplained lack of improvement of lifespan despite advances in medicine, rendering that argument moot.
(Edit: typo)
So to look on the positive side, as a physician, I feel like I now understand better the perspective of police officers now in response to the Defund the Police movement.
What, Turtle, you don't think the Doctor's Office to Morgue pipeline can't be disrupted by getting a social worker to do your job instead? 😁 De-escalate!
I cackled. Well done.
Lol, the way things are going, in a few years people will be protesting in doctors' offices with photos of minorities who have been harmed by medical mistakes. End Medical Racism Now! Did you know the American Heart Association recently removed race as a risk factor for cardiovascular disease? Another shining example of the triumph of What's Right over pesky biology or truth.
Interesting. My lefty friends argue that racism is so bad it causes physical manifestations like heart disease by increasing baseline daily stress.
Why did the AHA remove this? Presumably, it's racist somehow? But, how, exactly?
I think basically that argument - racism is the real cause of any observed difference in rates of heart disease. Similar to the anti-criminal justice system argument of “racism is the real cause of disproportionate violent crime in the Black community.” Strikes me as profoundly disempowering for actual Black people.
In the case of medicine, sadly for the wokies, claims that there are no biological differences between races are easily falsified. Even beyond the obvious differences in Sun sensitivity with different levels of skin melanin, there are clear differences in the frequency of sarcoidosis, cystic fibrosis, haemochromatosis, sickle cell anaemia, and numerous other diseases between people of European and African ancestry. Here in Australia we know that Indigenous Australians have higher rates of diabetes and chronic kidney disease, and we use that information to help them, by instituting screening for these diseases earlier and more frequently.
This strikes me as the real problem with policies and practices that aim to elevate ideology above truth - they end up hurting precisely the vulnerable groups that you’re trying to help.
Wow, I wish people would either stop using generic generalizations or read the semantic literature on the variety of incompatible interpretations people make of generics. There is nothing scientifically respectable about summarizing a claim as a generic generalization.
Interesting. Can you perhaps recommend a succinct overview of this topic? Thanks
Yes, here: https://plato.stanford.edu/entries/generics/
Follow-up... the semantics literature gets technical very quickly but the reader's digest version is that generics are generalizations that are tolerant of exceptions, but how many exceptions they tolerate is not coherent. In turns out it is highly dependent on highly psychologized features like how much a subject is afraid of something or whether the generalization is about animals or artifacts or social categories or other such things.
Antibiotics starting with penicillin and moving forward ever since.
Insulin.
Primary PCI for STEMI.
There are many explicit examples where medicine “works”. And when a guy is willing to say a P value of 0.01 is “noise”, there’s really not much point engaging with the guy.
I agree with your distinction btw secondary prevention and primary prevention. Although I think the fundamental difference is in effect size (and NNT).
I think maybe where he “might” have a point (and this is the part that bothers me daily) is in the lack of precision medicine. When a certain treatment has an NNT of 10….that’s a blockbuster….yet in 9 of those people the therapy will provide no benefit, and we have no a priori way of knowing who that 1 lucky person (out of 10) is.
p<0.01 can be noise if the researcher (or the entire medical research profession, seen collectively) ran 100 experiments and only published the experiment in which p<0.01.
Of course, such a result will not be reproducible and other researchers will have a clear incentive to show it nonreproducible, so it seems unlikely that too many results of that sort will enter established medical practice.
This was the odd thing about the discussion of the three different studies Scott spent so much time analyzing. "Outcome A showed improvement from study X but not Y and Z, outcome B showed improvement from study Y but not study X and Z ..."
Noise. You're describing noise.
Makes sense. Which is why I think that part of the post was weak, and the "VII. Other, More Positive Studies" part was stronger.
>Come on! Thousands of clinical RCTs show that medicine has an effect. Robin wants to ignore these in favor of insurance experiments that are underpowered to find effects even when they’re there. Then when someone finally does an insurance experiment big and powerful enough to find effects, and it finds the same thing as all the thousands of clinical RCTs, p = 0.01, Robin says maybe we should dismiss it, because p = 0.01 findings are sometimes just “noise”. Aaargh!
You may want to steelman him here. When analyzing large, complex quasi-experimental data, there are many, many analytic choices to make. The more choices to make, the more opportunity to p-hack. As such, an apparent p value of 0.01 is not necessarily an honest p value of 0.01 because there are many ways to turn large than 0.01 values into apparent 0.01. How do we know the authors didn't cheat here? We don't know that. Would need a specification curve analysis or something like that.
Um... I think the more relevant question is, how did you come to the conclusion that this statistically significant result also represents a meaningful real-life effect? "We sent a letter to 4.5M people, then found the difference in frequency of an outcome between populations was <2%. We suspect this resulted in a downstream change in mortality of <<1%. But since there are enough people in the sample, we lucked out with a low p-value."
Why should I care about this? In Scott's words, "Come on!" The intervention is so far removed from the outcome as to be meaningless. Doesn't have insurance > gets a letter > gets insurance because of the letter > uses more health care services > actually takes treatments > treatments affect health > less likely to die. And Scott is mad at Hanson for being insufficiently skeptical of this? Can we PLEASE not settle for bad experimental results just because they support our priors? How about we just say, "yeah the arrow pointed the direction I agree with, but it's not meaningful," and then wait for the meaningful experiments to be done. Accepting bad study results just encourages this kind of behavior.
" But since there are enough people in the sample, we lucked out with a low p-value."
You mean "lucked out with a result that would occur less than 1% of the time by chance". Quite lucky, indeed!
Please address the substance of my argument. They had a large enough sample to detect a difference of 6 in 10,000 people. The argument of the study, then, is that 6 of every 10,000 people who got a letter changed their mind about getting insurance. The assumption is that as a result of getting the letter, they signed up for insurance, used healthcare resources they otherwise would not have gotten, those healthcare resources prevented deadly disease, and the people lived longer than those who did not get the letter and did not make this choice.
Yes, I'm saying this is a meaningless result. A p-value of <0.000001 would not change that. Results have to be meaningful, not just statistically significant. Larger sample size doesn't fix that problem.
Why is this meaningless? 6/10000 is not small you just don't realize how many people there are. An effect that size would save 210,000 Americans, more than have been killed by a number of ills we spend a great deal of effort and ink on.
If you want to argue the price was too high you can, but show your work. But it's definitely not small.
This was a natural experiment, not an RCT. Nobody sat down and said "We think that sending out letters to people telling them to buy health insurance is a powerful way to improve health care outcomes, so we're going to test that" they simply noticed that they had accidentally done an experiment on a very large sample size and decided to gather what evidence they could from it.
A small effect size would be meaningless if you were actually proposing it as a treatment worth investing in, but that doesn't make it meaningless for the question of "does more health insurance improve outcomes?"
Hanson's argument really is just absurd. I cannot imagine that he really believes it. Surely this must be the adoption of an extreme position in order to get attention.
It is possible for it to be simultaneously true that specific medical interventions are beneficial, while the entirety of modern medicine to have no effect, which I believe is closer to Hanson's position than "No medicine works at all".
Bloodletting gets a terrible rap, but we still practice it! It's the standard treatment for hemochromatosis. (Note: If you have hemochromatosis, and you go to a hospital for this treatment, you're both charged for the treatment, and also the blood is generally discarded, at least as of the last time I looked which granted was a few years ago. You can get your treatment for free (or, in some places, get paid for your treatment) by donating blood.)
This, I think, may be a good analogy for Hanson's position: We have a bunch of really effective treatments which are beneficial - and also a lot of treatments that are, on net, negative. If you're just looking into, specifically, blood pressure - you may be looking specifically at the treatments that are beneficial and neglecting the treatments that are harmful.
It's even possible for treatments that are strictly beneficial to be, on net, negative - I think a common example/argument in this direction is that you are more likely to contract a disease if you go to a hospital (as you're more likely to be in proximity to individuals with infectious diseases). Taking that example as a given, there is some level of beneficial hospital treatment where the benefit is precisely offset by that additional risk. This may be particularly obvious or intuitive during a pandemic, when the risk of going to a hospital may be sufficiently high that even very beneficial treatments can be, on net, negative.
Pointing out that individual interventions are beneficial doesn't really argue against the thrust of the claims being made, which necessarily requires extremely large trials like RAND - because the claim isn't that medicine is never beneficial, but rather that the average effect of medicine is not beneficial.
This is an argument one can make but none of the insurance studies Hanson cites are evidence for it. Simply because they are not powered enough to measure mortality. The only studies that are powered enough to test this are not really randomized but do generally show positive effects.
Bloodletting is also used for some benign proliferative hematologic disorders, and, interestingly, will work in a pinch for a large subset of cases of acutely decompensating congestive heart failure. My guess is that that last one drove meaningful success rates in the ages before dialysis.
> If you're just looking into, specifically, blood pressure - you may be looking specifically at the treatments that are beneficial and neglecting the treatments that are harmful.
I've looked into the science behind blood pressure before. It was disturbingly unconvincing. The pro-healthcare argument sort of slides around that, defining blood pressure as itself a health outcome but it's not. We only care about blood pressure because it's (claimed to be) associated with other more objective outcomes like heart attacks or strokes.
For example, and please don't ask me to cite this because I didn't bookmark it, but there was a study done where lots of people were prescribed anti-hypertensive drugs. The drugs definitely worked because incidents of fainting went up a lot, but the number of strokes etc didn't shift. Implying that the underlying theory may be wrong. It was nonetheless described as a success because the drugs lowered blood pressure. I think this is the sort of thing that drives people like Hanson to become "medicine deniers".
I think the literature on BP and controlling HTN is pretty strong for high-risk groups - especially men with a history of MI. The problem with BP is that it has been rolled out to the rest of the population writ large, then assumed to be some general factor for health. There's not much good evidence that a 35yo woman with no previous history of cardiac events is well served by hitting specific BP targets, yet we'll dutifully report it as some major health advance.
I strongly agree with the point that surrogate endpoints are way over-reported as 'health benefits'. That's not what anyone cares about. Scott spends way too much of the essay arguing that one surrogate endpoint or another equates to better health care outcomes. Those arguments are not valid.
There are two different questions: 1. Does medicine improve health while alive? 2. Does medicine reduce mortality? I believe the second can be shown to be true statistically, but the first one must be examined carefully.
Doesn't 2 very strongly suggest 1, since the difference between something that kills you and disables you is just one of scale?
I cannot convince you of otherwise, but very least cancer patients tend to get treatments that reduce mortality but at the cost of health. There ALSO patients who live their average-lifespan entire lives with a condition that would otherwise in Wordline B get medicated; if they get medicated, their health improves, but we will not know if they had lived help (it does not help most people who get diagnosized also get medicated). There are ALSO many treatments that improve health but do not least significantly reduce mortality such the drops you put into your nose when its stuck, many skin care products, and hair care products. Vaccination to a lethal and fast-killing enough disease that your health does not noticeably with side effect that disable 1% will also look weird on a plot of mortality reduction and health effects over time. There's very likely much more but I am not getting paid to write this.
Years ago, I read a study that surveyed oncologists on their use of cancer treatment. These oncologists were as likely to get first line treatments, but much less likely to get each subsequent line of treatment as early therapies failed. I've seen cancer patients fight tooth and nail for maybe an extra month of terrible side effects. I can understand an oncologist not signing up for that kind of torture just to eek out a few extra weeks of life. At least in oncology, 1 and 2 are sometimes inversely correlated.
Very interesting, thanks for sharing. Reminds me of this part from one of the greats: https://slatestarcodex.com/2013/07/17/who-by-very-slow-decay/
>You may have read the excellent article How Doctors Die. If you haven’t, do it now. It says that most doctors, knowing everything I’ve just mentioned above, choose to die quickly and with very limited engagement with the health system.
>I (and the doctors in my family whom I’ve asked) am pretty much like the doctors in the article. If I get a terminal disease, I want to wring what I can out of the few months of life I have left and totally avoid any surgery, chemotherapy, amputations, ventilators, and the like. It would be a clean death. It would be okay.
Thanks for linking! That may be what I was thinking about (it's been a long time). I do think it's a personal decision about priorities and not a binary one at that.
A few years back at a conference, we had a physician talk about her ongoing decision-making process with her oncologist about priorities. After adjuvant chemo failed, her discussion with her doctor was about how to survive until her youngest child graduated from high school and left the house. She survived, but then the goals of treatment shifted to minimizing side effects of therapy so she could do a road trip to her daughter's college. Quality of life versus quantity is, unfortunately, a major consideration in oncology therapy.
This would probably at least partially depend on whether we adopt the old, more externally-assessed ("absence of disease") or new, more subjectively determined ("general wellbeing") concept of health.
Big chunk of modern medicine is well being/quality of life related, and provides essentially symptomatic treatments. Pure anecdata here, but in middle age I get three treatments, all three little to do with mortality: while ultimately having my GERD treated might conceivably reduce esophagus cancer risk, at this stage in my life it's pretty much "making my life less miserable intervention". Painkillers for arthritis are fully symptomatic. HRT, same.
Reproductive health care: mostly same (tho it's possible my first child would have not survived without the c/s, and subsequent IV antibiotics for GBS, and I'd say perinatal care looks like a good candidate for medicine that works overall, even as it's ridiculously over applied probably causing some harms too).
So essentially -- no. Many things that disable, especially in a minor way, won't kill at scale, or might only contribute to slightly earlier death at the life end where gains are marginal anyway.
No, I think the easiest example of this would be Anabolic steroids, and Growth hormone, they very clearly improve health while alive and also very clearly *increase* mortality.
I think point 1 is even more obviously true than point 2. E.g. I had gallstones and they were extremely painful, and then the doctors took out my gall bladder and I feel way better.
1 is trivial to show in many cases.
I have Epilepsy.
Fap over weak studies all you want - My seizures are very well controlled by medication, and if I go off of meds they will come back like clockwork. It is rather easy to come up with many examples of medical issues and interventions like this.
I think "health" is a bit of a frail concept when used outside of formal contexts with a clear operationalization.
Still, I'd say the opposite: there are many painful and debilitating conditions that, assuming some sort of support, do not result in death. Eg leaving gout untreated would probably not significantly move life expectancy, but it would make life worse for many. To be morbid, people with missing limbs could survive to old age, obviously it was a less dignified life than having a prothesis.
So if you wanna account for health in general and not only survival, I don't really see how medicine comes out worse than nothing on net
Can we Aumann agree that the potentoal debate(s) should be *structured* this way? IE instead of "medicine works / does not", two distinguished debates: "medicine works for improving health / medicine does not work for improving health" & "medicine works for not dying / medicine does not work for not dying."
A few typos:
"For example, in the Oregon study, the insured group used about 33% more health care than the insured group."
Copying from the pdf for the Goldin, Lurie, and McCubbin paper left the "ff" glyphs out of your paste.
And the "fi" glyphs as well.
Pdf glyphs are the rotten core of our digital age.
https://xkcd.com/1683/
You have have the patience of Job. Hanson’s claims are so transcendently wrong I could barely read your debunking. I could certainly never even attempt that myself.
To what extent should this lead me to downweight the opinions of Hanson, Caplan, and a bunch of other "nuh-uh things aren't the way you think it is, just look at this one study" contrarians?
It's already reminding me strongly of Caplan's "Case Against Education" -- thing that everyone thinks is important turns out not to look unimportant when measured in some particular way and is therefore useless.
I think it is likely they are all completely nuts
Well, this depends on how much weight you were already giving them. Clearly some contrarian ideas are true, because the mainstream doesn't even perfectly agree on everything, let alone being infallible, but the outside view odds for any particular contrarian idea being true should be pretty low.
I find "Case Against Education" more plausible because it kind of forces us to confront not just mechanistic questions like "Does teaching Civil War history cause someone to know more Civil War history?" (and consider that even this is complicated; most 40 years olds don't remember much of the Civil War history they learned in school, and might learn it elsewhere anyway, so it's not obvious that teaching Civil War history at age 10 causes you to know more of it at 40) but also social questions like "Does teaching Civil War history at age 10 increase some kind of good outcome later?"
As I said above, "medicine" is a large bag of stuff, some of which works well and other things which don't work so well.
"Education" is also a big bag of stuff.
Teaching people literacy is pretty likely to increase lots of measures in terms of lifetime productivity, wealth, happiness, civil engagement etc.
Teaching people Civil War history? Probably some improvement, but maybe not as much.
Giving them 1000 hours of Civil War history? I doubt you could tell the difference from 500 hours.
I am of course speaking about a typical American, not a would-be history professor.
How do you know which people will be interested in Civil War history unless you expose them to it? Some may go on to be Civil War History professors. Others may take it as an impetus to interest in other aspects of war, or sociology, or even horses, if that is the aspect that catches their interest.
You don't need 1000 hours of Civil War history at age 10, but some hours seem worthwhile as introductory material, a set of common knowledge with which all adults would be expected to have some familiarity. Five hours each of 200 different subjects sounds like a more useful time spend.
...Why do we need Civil War history professors?
Why do we need history professors? Why do we need literature, art, or philosophy professors?
Who said all intellectual pursuits must have real-world applications?
But you're looking at it from the point of view of the student.
The case for public finance of education is that it makes for better citizens - able to do more things, think up better ways of doing things, etc. That case has been proved pretty thoroughly for literacy and numeracy.
The case for history would I think come under "civics", i.e. it is taught using public money so the student will know the background of how the government works and why it's that way.
It gets a lot muddier when you get to tertiary education levels of investment.
Not saying don't have it - universities have been around for at least seven hundred years.
Should the public be paying for large portions of the cost, for what is now (if I remember correctly) roughly a quarter of the population? That's much less clear.
"Does teaching Civil War history at age 10 increase some kind of good outcome later?"
I mean, the standard, banal, small-l liberal answer is that you should know your country's history so that you can understand why your country got to be the way it is, and can make better decisions about the future (decisions that influence how you vote/which politicians you support). That's how it's supposed to work, anyway. "Those who forget their history are doomed to repeat it." Whether it actually does work is a separate question.
Ah well the US Civil War is a special example. You don't teach the US Civil War to kids because you want them to understand the US Civil War, you teach it to kids because you want your side to gain a political leg-up in the present day. And it's a culture war topic so you can't stop hearing about it as an adult. I'm sure I never learned anything about the US CIvil War in school but I learned it from Bugs Bunny cartoons (seriously I think that's where I was first exposed to the concept) and I haven't stopped hearing about it ever since, to the exclusion of much more interesting Civil Wars like the English Civil War.
Three studies, not one.
Before coming to a conclusion about someone, you may as well follow the link to make sure they actually said what they've been quoted as saying. Cf. https://www.astralcodexten.com/p/contra-hanson-on-medical-effectiveness/comment/54751559.
I come to whine about methodology of measuring quality of cancer treatment and nothing else.
We check if someone survived cancer by checking if they were alive 5 years after we diagnosed them with cancer. We also scan more and better for cancer (ignoring even scanning younger people which would limit deaths from other causes), meaning we discover cancers earlier on in their development.
That's of course good for various reasons, but it also means that the same person with the same cancer could be considered a survivor today, but not 50 years ago, even if their cancer progressed and lead to their death in the exact same way, simply because we put 'start' indicator earlier in its development.
It can be corrected for, but you don't indicate you checked for it in any way, so here I am.
I indicated that I checked for it in the post by specifically saying
" Some of these changes (especially prostate) are a result of earlier diagnosis. But others reflect genuinely better treatment. "
Where the second sentence is a link to https://slatestarcodex.com/2018/08/01/cancer-progress-much-more-than-you-wanted-to-know/ , where I discussed this possibility and wrote 2000 words about why it's not the main factor.
I did not follow the link and that lead me to believe it's some form of 'thanks to earlier diagnosis, we get easier cases, so we do better'.
Thanks for pointing it out!
That's exactly the kind of complicated fragile argument that is subject to p-hacking that you said you would avoid in this post. If you want to talk specifically about cancer, it's good to write it out as an individual post (although I find it utterly unconvincing), but as part of this post I think it is net negative. Just stick to heart attacks and strokes.
Look up the 5-year survival for early-stage versus metastatic disease in … almost any tumor, but check out cervical cancer, or head and neck, to see the difference most clearly. There *are* cancers where early diagnosis probably amounts to overdiagnosis and/or overtreatment for a few patients at the margin (ductal carcinoma in situ in the breast comes to mind) but it’s not a central scenario.
Like you, I also came to whine about that. I confess I read past Scott's caveat.
But I am also unconvinced that that plot is a good indication of the claim. A plot measuring the five year survival rate given a fixed stage of cancer would be more convincing.
I guess that for some forms of cancer, you do not need extensive diagnostics. Looking at a weird-looking piece of your skin and thinking "I better ask a doctor if this is a melanoma" is something you could do just as well in 1970. (Still, it is certainly possible that people were less likely to do so in a rural area in 1970 where the nearest GP was presumably further away on average.)
On the other hand, for other forms of cancer, I would imagine that the modern apparatus of diagnostics (CT, MRI, ultrasound, biomarkers) are way more effective and less invasive than they were 1970, when you had the feeling in the fingertips of the doctor and (contrast) x-ray. (Handheld ultrasound was commercialized in 1963. Given how humans work, I find it unlikely that most licensed physicians had an ultrasound by '70. If the practitioner was 50 in '63, the probability of them being an early adopter who spends a lot of time getting the training to use and interpret it correctly plus the money to buy an ultrasound seems low. More likely that progress worked one funeral at a time, as so often.) Can you even diagnose a small brain tumor on contrast x-ray? Or would you depend on letting your doctor take a peek into your skull?
Also, Going from 50% 5-year survival to 67% does not feel much, but if you assume that survival follows an exponential decay (which is an oversimplification), then 50% correspond to an expected life time of 7.2 years and 67% correspond to 12.5 years.
Of course, share Scott's opinion that cancer treatment has made good progress (even I my understanding is certainly more shallow).
Another good example of medical progress is child birth. Here we do not have to rely on comparing outcomes over the chasm of time (with all the other general progress factors as confounders) because some people heroically take it upon them to be part of the control group and try to give birth at home instead of in a hospital. (As they are not randomly selected, this will probably add other confounders though.)
I think that it is hard to dispute that some medical interventions clearly work. If you have a broken arm, you are better off going to the hospital instead of just trying to keep it still until it stops hurting. Of course, that does not mean that every intervention works, and especially not that marginal interventions are cost-effective.
I have basically no doubt about medicine being useful, including cancer treatment. My issue is (was? I didn't go through text Scott linked yet) with using this specific measure in presence of what I'm point at.
So, I think the particular claim being made -- the concept that past-few-decades innovations are fairly unimpressive and medicine is miscredited for general improvements -- is probably true in some fields, but trivially disprovable for all-medicine by one example:
Neonatology.
Neonatal intensive care units are places where reality breaks. A baby can be far sicker and far more premature than you think possible, and be carried out of an NICU by their parents weeks later. In the early 1970s, the leading pediatric textbook wrote that the limit of viability must be about 28 weeks -- the tiniest preemies that could survive. Today, about half of 23-weekers get to grow up. A normal pregnancy is 40 weeks.
There's a measure called the "Apgar scale" routinely used to assess the health of newborns. It's scored from 0 to 10, with 0-2 points available in five different areas (activity, pulse, grimace, appearance, respiration). A score of 0 in one area means nothing -- a baby that doesn't move, or doesn't cry, or doesn't breathe. A baby with a total Apgar score of 0 is in any conventional sense dead.
There are articles with titles like "The long-term outcome in surviving infants with Apgar zero at 10 minutes" and "Improving infant outcome with a 10 min Apgar of 0". These exist because there are so many babies that are born dead, stay dead for ten minutes, and *come back to life*. Extrapolate from there to babies with Apgar 0 at 1 or 5 minutes, which are the usual times when scores are taken. The prognosis for Apgar 0 babies is...not fantastic, but it is not 100% mortality, which it would be by any natural physiological measure. There is at least one baby reported in the medical literature with an Apgar score of 0 at *twenty* minutes who, in a childhood follow-up, was alive and had absolutely no developmental problems of any kind.
This isn't a tradeoff of "they're alive but profoundly disabled", either. Developmental issues are more common in NICU survivors than the general population, but don't track cleanly to such a framework. The definition of "neurodevelopmental impairment" in follow-up studies is rather broad -- amongst other things, it includes literally any level of cerebral palsy, despite the supermajority of people with the commonly-caused-by-prematurity forms of cerebral palsy being able to walk without assistance. The rates of "any 'NDI' including imperceptibly mild cerebral palsy" amongst extreme preemies consistently go down with the death rates; "unimpaired survival" is a metric that improves just as "survival" is. Truly profound disabilities are pretty rare in this population -- a lot of studies and practitioners use the term "severe disability" in ways that don't actually match what parents think of (a recent large study, https://dranniejanvier.com/wp-content/uploads/2023/05/tchildren-10-0088.pdf, found that clinical vignettes of the most common outcomes called "severe NDI" in follow-up studies are rarely considered significant problems by parents).
There's no way neonatology can be called an improvement in non-medicine. 23-weekers -- hell, 22-weekers -- and babies with 10-minute Apgar scores of 0 aren't surviving because sanitation got better. They're surviving because people have pushed up against the limits of reality.
Infant mortality as a whole is a big win, but a lot of it is nutrition-sanitation-etc. A lot of the remaining improvement past that is vaccines and antibiotics, which seem to be carved-out exceptions from Hanson's claim. Neonatology can't be carved out like this -- a baby born at 26 weeks had *absolutely no chance* of survival in any time before a few decades ago, and today will probably survive without serious disability. NICUs are intense places precisely because these babies don't survive by accident.
Thank you; I came here to write the same thing. There's no plausible universe in which my very premature baby would have survived (and is now a thriving child) without modern medicine. There's no room for ambiguity here in neonatology, as you say.
That is not a criticism of medicine, thats a criticism of people and incentives.
Thats fine but you made the claim about c sections in india, not Hanson, and that was what I was responding to.
Yes, and I'd extend this to perinatal care generally. Not just neonatalogy but maternal mortality, where some gains are to do with sanitation, but much is medicine (infection control, antibiotics, surgery).
Not to mention a society-changing medical advance which is genuine, highly reliable and practically doable contraception possible without celibacy.
Exactly right. If my daughter had been born in 1980 or earlier she would 100% without a doubt have died within a week of birth due to a congenital heart condition. Today she's alive and well thanks to ob-gyns with the technology to spot the defect long before birth and surgeons who were able to intervene shortly after birth. These days someone with her condition has an 80% chance of surviving to age 30, compared to the 0% chance of surviving to one month without treatment. She's alive because medical interventions can work, and because we've spent the last forty years inventing new techniques, technologies, and surgeries that improve on what we had before.
Hi, what condition does she have?
We have an 8 month old with an Absent Pulmonary Valve and Intact Ventricular Septum. He had a BT Shunt at 5 days old and a Glenn procedure just after Thanksgiving.
Like your daughter, just a decade or more ago he would have died in the first few days or weeks of life without the medical care and surgeries he has had. I wish great things for your daughter and my heart goes out to you and your family.
Tricuspid atresia: her right ventricle never developed. She had a BT shunt put in three days after birth, and she's had a Glenn too. We're actually getting ready for her (knock on wood) final surgery, a Norwood, a few years after the Glenn.
I don't know much about APV with IVS, but I know how hard it is to see your newborn go through open heart surgery. I want you to know that my daughter has grown and thrived into a sweet little girl, and she lives a normal life (with the exception of having to take heart meds every day, but she doesn't even know that's unusual at this point). I wish you the same for your child.
Exactly.
As I mention below, my son has a congenital heart defect and would be dead were it not for advances in medicine over the past few years.
I think for most people they interact with medicine almost exclusively when they or someone they love is at the end of their life. They see suffering, decay, and death highly correlated with medicine.
When you have the contrary experience - huge medical interventions at the beginning of life - you see flourishing, growth, and life. It is so clear, for these children, that medicine works.
The quotation from the Goldin, Lurie, and McCubbin paper seems to have some strange formatting that causes the "f"s to drop out of "effect". There are three instances of "eect" in the block quotation.
also confidence => condence.
This happens because some fancy layout software uses ligatures for "ff" "fi" and "ffi".
Hanson closes with "A mere 0.1% of U.S. annual medical spending, or $4.2 billion, could fund a far larger experiment, and hopefully settle the matter."
It is a call to reflect on the questions to ask and then separate wheat from chaff.
Yet most of you seem to strawman. "Look at all that wheat".
All three studies only look for the effect of insurance. None of them actively blocked access to medical treatment. An interesting third way would be "health credit". If the non-insured are so good at choosing the right subset of treatments, we can use that to drop two unfavorable cases:
* the patient judges a particular treatment to be beneficial, but cannot afford it right now
* the patient is of indifferent opinion to a particular treatment. But since cost is covered by insurance, he does the doctor a favor and gives in.
I see!!! He is, essentially, a medicine communist. "Capitalism has all these flaws and is inefficient, so we should kick it to the curb and try something else." Thank you for helping to clear that up. \S
Thats fine but then why have the first three paragraphs of his piece which imply modern medicine is falling for the same fallacies as 17th century medicine?
Reading the whole thing left me with one update for my(!) world model: There might be low (lower than i previously thought) hanging fruit to better tell two categories of medical treatment apart. That of treatments we should apply more often, and those we should apply less often. (will not elaborate on it in this reply).
Now the actual reply to your post:
since i value the piece for giving me that interesting pointer i(!) am willing to mark everything else there as the "hook story". If i find a golden nugget in a lake of mud, i pick the nugget and don't bother for the quality of the lake.
Rereading my post, i acknowledge i could have expressed myself better.
So here my update:
I don't bother whether Hanson is in total right/wrong good/bad.
I even don't bother whether a particular essay is right in every detail.
From reading this one i did not extend my basket of beliefs.
But i now have another question to carry around and pick up evidence where i see it in future. For that i value Hanson's essay.
Second update (thanks to your reply):
I am now more open to other ppl to react in a different way to it.
Heck, it is meant to be controversial!
I just don't accept the distinction between sanitation and medicine. I understand that we can see sanitation as preventive, and medicine and reactive. But it's the same science that generates both.
And even if he has a point about the benefits to lots of treatments being small on a statistical level, I think that's clearly a different kind of failure mode from blood-letting. Blood-letting literally didn't work; it did nothing to treat (mitigate or cure) the diseases it was used for. Modern drugs have all been checked to see if they do that. It's possible that a subtle health thing is happening, as he suggests, e.g. the overall effect of many modern drugs includes a bunch of side effects that mean the drug is basically a wash, and the apparent gains to life as they are being used are in fact due to a bunch of other factors, like doctors keeping cleaner hospitals... But if all that's true, it's still a qualitatively different kind of failure.
Blood-letting *sort* of worked; for example, if you have dangerously high blood pressure, then losing some volume of blood will temporarily relieve it (we achieve the same result today with diuretics to cause greater urine output and reduction of fluid volume).
Or excess iron in the blood, where we still use blood-letting (but call it by a different name) today:
"Haemochromatosis is an inherited condition where iron levels in the body slowly build up over many years.
This build-up of iron, known as iron overload, can cause unpleasant symptoms. If it is not treated, this can damage parts of the body such as the liver, joints, pancreas and heart.
Haemochromatosis most often affects people of white northern European background and is particularly common in countries where lots of people have a Celtic background, such as Ireland, Scotland and Wales.
There are 2 main treatments.
- venesection (phlebotomy) – a procedure to remove some of your blood; this may need to be done every week at first and can continue to be needed 2 to 4 times a year for the rest of your life
- chelation therapy – where you take medicine to reduce the amount of iron in your body; this is only used if it's not easy to regularly remove some of your blood".
So blood-letting was a procedure that could be observed to be helpful in some cases, and like all cures, it was then subject to "if it works for X, could it work for Y? let's try it!"
I don't believe that it was first observed to work for people with haemochromatosis and then spread to others. Just as treating the weapon rather than the wound didn't begin with a case where it actually worked https://occludedsun.wordpress.com/2009/08/19/treating-the-weapon/
I didn't mean it that way, I meant "this procedure was used for a reason, and it was observed to be effective in some cases, which then reinforced the idea that it was useful".
We know *now* why it worked in some cases but was not the effective cure they believed, but that's blaming people for not knowing things they couldn't know. If we were still in the stage of performing blood-letting for a general cure-all, then yes, go ahead and criticise modern medicine. But while it may be correct that there are current treatments that in future will turn out to be the modern equivalent of blood-letting, we can't know until we know. So just shrugging and saying "We can't tell, so we won't do anything" is not a solution, either.
Look at the guy on here with cancer who is desperately trying to get on to all sorts of clinical trials in the hopes that something, some experimental drug, some novel therapy, will extend his life for a bit longer. You could say to him "Just give up, you can't know what will work, why put yourself through all this suffering when it's inevitable you will die?" but that's not the advice he or his wife want.
I still don't believe "this procedure was used for a reason". I don't believe actual usefulness was noticed. I think it was like other useless treatments at the time, where it is basically just by random chance we now believe there are any conditions it helps.
I will blame the past (broadly speaking) for not doing any control trials, and thus for not discovering regression to the mean in health. It doesn't actually require advanced mathematics or anything, it's just something people didn't bother to do. Medicine could have started making actual progress long ago, but instead it was on-net harmful for an extraordinary length time time, worse than doing nothing.
A diagnosis was performed, and current medical analysis proposed a treatment, which may or may not have worked successfully. If it did not, does that mean the analysis was faulty? Not necessarily. If the diagnosis and analysis were both sound, then it is reasonable to try the treatment again in similar circumstances.
Scientific treatments must be judged in light of the evidence. Experiments must be repeatable to able to be shown correct, but confounding factors mean not every such experiment will give the same result.
The "analysis" which led Paracelsus to believe that treating the weapon would be effective was obviously faulty. The problem is that the experimental method didn't even exist, so people were not improving the stock of knowledge by discarding treatments that didn't work.
"It doesn't actually require advanced mathematics or anything, it's just something people didn't bother to do"
You're blaming people for not discovering methods earlier than they were discovered, which is a dangerous game to play. *You* have the benefit of hindsight, being born into the era of "this is how we do science today". Drop you four hundred years into the past with no experience or knowledge of same, how obvious would it be to you to do such a thing? We've had the same arguments about "but why couldn't people simply believe the obvious truth Galileo stated about the earth orbiting the sun?" Well, because it *wasn't* obvious, any more than "regression to the mean" or "double blind control trials" was obvious in the 2nd century BC.
Anyway, an interesting article on "Therapeutic bloodletting in Ireland from the medieval period to modern times", and indeed that it was the 17th century when 'modern medicine' began to be established:
https://muse.jhu.edu/article/838623/pdf
"As Standish O’Grady’s description of Gaelic physicians as ‘staunch Arabians’ indicates, they adhered to the classical medicine of Hippocrates and Galen. But by the sixteenth and early seventeenth centuries traditional medicine was changing. The publications of Andreas Vesalius’(1514–64) De humani fabrica corporis, Ambrose Paré’s (1510–90) La Méthod de traicter les playes faites par les arquebuses et aultres bastons à feu, and William Harvey’s (1578–1657) Exercitatio anatomica de motu cordis et sanguinis in animalibus challenged medieval ideas about anatomy, surgery and physiology, and laid the foundations for modern medicine. The whole tradition of Galenic medicine was attacked by Paracelsus (1493–1541) who espoused iatrochemistry, a fusion of alchemy, chemistry and medicine. He advocated chemical treatments for disease including the use of a combination of mercury, zinc and opium which he called laudanum. Later the Belgian physician Jean Baptiste van Helmont (1580–1644) believed that each disease had a vital principle of its own that could be countered by chemical treatments. Bloodletting had no part in this philosophy and van Helmont, who was familiar with medical practice in Gaelic Ireland, disapproved of it altogether. He made the very modern suggestion that a randomised trial of the treatment of fever with and without bloodletting be conducted using the patients’ funerals as the end point of the study.
...At the beginning of the eighteenth century, Henry Cope, twice president of the Royal College of Physicians of Ireland articulated the established medical view on bleeding in his book Medicina Vindicata. He stated that ‘bleeding, vomiting and purging are the chief operations in physic, by which diseases are cured and health preserved’; all accepted this philosophy ‘excepting a few enthusiastic chemists, who…boasted that all…diseases might be eradicated by one medicine’. While physicians recommended bleeding it was the surgeons and apothecaries who performed the procedure. Very often non-physician practitioners and others proceeded to ‘bleeding, vomiting and purging’ on their own initiative, eliciting a robust response from the physicians; in 1725 they petitioned the Irish House of Commons for a bill ‘to prevent abuses in the practice of physic’. In response Humphry Markwell argued that the physicians were motivated by avarice and pointed out that they had been unable ‘to convince the hundredth part of this city that they can cure folks better than their neighbours’. The bill did not pass, but the century was dominated by rivalry between the various medical professionals, eventually resolved by the emergence of separate regulatory bodies for physicians, surgeons and apothecaries.
...By contrast, in a very detailed report from the Waterford Fever Hospital, Dr John King Bracken said that in 1817 he never used bloodletting ‘by any mode, in any case’. In 1818 he did resort to bleeding and reported a small observational study of fifteen of his patients: ‘six completely or very much relieved, three moderately relieved, in four the relief was partial, temporary or uncertain, and two not relieved at all’. He commented that bloodletting might be used safely in the management of fever but ‘to do no injury is one thing and to relieve is another’. Dr John Murray from Cavan was also unimpressed by bloodletting: ‘bleeding did not form a part of our general practice and I verily believe that none of our patients died for the want of it’.
...Although bloodletting continued to be described in medical textbooks, it no longer had a place in the management of infection. It was used for treating heart failure, hypertension and cerebral haemorrhage. On 12 August 1922, Arthur Griffith, president of Dáil Eireann collapsed from a stroke at a nursing home in Dublin. The surgeon Oliver St John Gogarty found him lying dead at the top of a stairs:
His left arm was outstretched and bloody. A long incision of four inches gaped where his pulse was. It was not bleeding, though the artery had been severed by Mr Meade, who was on the spot, the only attempt that could be made to counteract cerebral haemorrhage."
As to why people continued to engage in practices like blood-letting, despite evidence it did little good and indeed caused death? Because sometimes it worked for fevers/inflammations (see ending of excerpt below about availability of iron), and until people knew what really caused disease, you go with pragmatism:
"Bloodletting in Ireland has a very long history. Based on the humoral medical tradition traceable to Hippocrates and Galen it was used to maintain health and treat disease. It is possible that Irish physicians of the early medieval period were aware of the classical theories and bled patients, but the evidence is scant. Bloodletting probably came to Ireland in the twelfth century and was practised thereafter by both the Anglo-Norman and Gaelic communities. Although challenged by new medical knowledge in the late sixteenth and early seventeenth centuries, bleeding continued to be pursued as a treatment for illness until the latter half of the nineteenth century. A variety of practitioners performed bleeding by opening a vein or an artery, or by the application of leeches. Cupping with or without scarification was also used. The discovery of microorganisms and the development of the germ theory of disease in the late nineteenth century finally put an end to bleeding as a therapeutic option for most conditions, but it continued to be recommended for problems such as heart failure and stroke. Venesection is still used today in medicine to deplete iron stores in haemochromatosis and leeches are used following some plastic surgery procedures. Complementary and alternative medical therapists also use cupping either on its own (dry cupping) or with bleeding (wet cupping) for several conditions, especially the relief of pain. Iron is an essential element for metabolism in all living cells. Reduced bioavailability of iron in a host deprives an invading organism of this vital nutrient thereby inhibiting its virulence. While modern medicine considers bloodletting an example of early therapeutic ignorance, it is just possible that as part of a health maintenance regimen bleeding may have provided some protection against infection to people in Ireland in the past."
Some of the empiricists were *for* blood-letting, as against the 'theoreticians' with what was becoming modern science:
https://bcmj.org/premise/history-bloodletting
"At the Edinburgh School of Medicine Dr William Alison (1790–1859) and Dr Hughes Bennett (1812–1875) were a study in contrasts. The former was a dignified old-timer and strong believer in bloodletting, while the latter was an arrogant newcomer and resolute debunker of bloodletting. Whereas Dr Alison followed the old tradition of clinical experience and empirical observation, Dr Bennett believed in the new methods of pathology and physiology supported by the microscope and the stethoscope.
Central to their debate was the observation that the improved outcome of patients with pneumonia paralleled the decreased usage of bloodletting. While Dr Alison ascribed this to a “change in type” of illness which had gone from sthenic (strong) to asthenic (weak), Dr Bennett believed it due to diminished use of a dangerous therapy.
Both were implacable in their point of view, thereby underlining the significant gap between their beliefs in empirical observation versus scientific verification. Dr Bennett had the advantage of the latest techniques and “grounded his rejection of bloodletting on pathologic concepts of inflammation and pneumonia derived from microscopic studies of inflamed tissues.”
No, Galileo was not obviously correct. Heliocentrism would not be confirmed until much more accurate measurements (particularly those from Tycho Brahe) were available than previously, finally enabling Kepler to come up with a more accurate model (Copernicus' was less accurate and featured more epicycles to boot, but it also incorrectly consisted of perfect circles which is why Copernicus himself believed it). And Paracelsus does not refute my point about the pseudoscientific nature of medicine back then, since he's the one who came up with the "treating the weapon" theory that I've been pointing to as obvious pseudoscience that nobody should have ever believed.
I think he separates sanitation out because we don't have doctors do sanitation (or even nurses in many cases - those are often done by people without those designations).
What are surgeons doing when they scrub up before surgery if not practicing sanitation? To us, sanitation seems separate from medicine because sanitation is not new to us, but when Semmelweis proposed that maybe doctors were killing their patients by not washing their hands, that was a new, revolutionary thing!
Not to mention Semmelweis was a physician - a doctor "doing" sanitation.
I think we're now in "lumpers vs. splitters" territory.
In a government budget "medical" is generally separate from "public health" and "public works". Often because the first has insurance providers (either public or private) involved, but not generally in the others.
What I think of as "sanitation" tends to include more of the latter two than the first.
The origin of the idea of pollution is religious. not scientific. If you think of sanitation as "pollution control and removal", then it's pre- our idea of medicine anyway.
Agree. Is "midwives washing hands before sticking them up the birth canal" sanitation or medicine? Much infection control straddles domains but it's driven by MEDICAL knowledge.
Honestly this just strikes me as a disingenuous take by Hanson from the top. He uses medicine. I strongly suspect Caplan also uses medicine. Medicine is manifestly and obviously useful for treating major injuries and curing directly treatable illnesses through a cause-and-effect mechanism: We can repair broken bones, we can destroy once-fatal illnesses with antibiotics, trauma surgeons save the lives of people who are shot or in car wrecks. All of this is indisputable so it's far more reasonable to conclude "our ways of measuring medical outcomes miss something" than to argue "medicine doesn't work."
Broken bones heal on their own, and did so long before modern medicine. Your other examples are better.
"Europeans in 1600 likely prided themselves on the ways in which their “modern” medicine was superior to what “primitives” had to accept. But we today aren’t so sure: seventeenth century medical theory was based on the four humors, and bloodletting was a common treatment. When we look back at those doctors, we think they may well have done more harm than good."
Hanson seems to conflate medieval medical theory and practice. From a historian:
https://acoup.blog/2021/05/20/meet-a-historian-robin-s-reich-on-making-sense-of-medieval-medicine-humors-weird-animal-parts-and-experiential-knowledge/
TL;DR: There was a total disconnect between medical theory and practice. Those who practiced medicine on actual patients didn't write about it, and the people who wrote about the centuries-old theory (e.g. the four humors) didn't ever practice. Modern medical theory being bad because the "four humors" theory was bad (as we would understand it today) does not follow.
Some quotes from the article:
"[We] have a doubly difficult time understanding what medieval medicine was, because the people who practiced didn’t write about it, and the people who wrote about medicine thought practice was beneath them."
"This [archeological evidence from leper colony burials] suggests that medieval understanding of these diseases in practice was a lot more sophisticated than theoretical writings suggest."
"There’s only one thing left: leeches and bloodletting, real or no? Real, but not what you think. Bloodletting, leeches, cupping, and cautery were all popular methods of balancing humors, but they were only practiced by the elite. Cupping has been making a comeback in recent years, and leeches never really went away. None of these were done frequently."
I can't really speak to Hanson's other arguments, but drawing parallels to pre-modern medical theory does not help his case.
Telling “just so” stories based on wrong history seems to be a common vice among economists. See also the famous, and false, story that teams of Chinese workers would hire someone to whip them to prevent individual incentives to slack off.
Yes, the elite could afford to hire doctors while they poor couldn't. That's why they had higher maternal mortality once doctors started displacing midwives (while they were also handlling infectious corpses).
You quoted some of the caveats in that last study, but I think it's worth emphasizing that their numbers are kind of sketchy. They say
> we estimate that the average per-month effect of the coverage induced by the intervention on two-year mortality was approximately -0.17 percentage points.
But this would give you -4 percentage points over the whole two years, or -2 percentage points in a single year. That's implausibly huge - life expectancy in the US is more than 1/0.02, so a 2 percentage point risk of death is more than your entire annual mortality risk! You could salvage this if the insurance signups were concentrated in really old people, but mostly I just don't buy it. In fact the authors don't buy it either:
> We view the effects at the lower-magnitude end of our confidence interval as most plausible, given the treatment effect magnitudes reported in prior research
They also note that extending the month-level effects linearly might be a bad idea:
> We also present suggestive evidence that the steady-state effect of annual coverage on mortality is less than 12 times our estimated per-month effect due to concavity in the relationship between coverage and mortality
I haven't dived into the statistics for this study enough to independently have opinions about their analysis, but "we found an implausibly huge effect, but our confidence interval extends to the effect size being 6 times smaller than observed, which wouldn't be as implausible, but luckily the confidence interval still misses zero" is not the kind of epistemic state where I feel _great_ about the conclusions.
I thought this too. Those are crazy high numbers.
As in the usual Bayesian meme, "I will bet you $10 sun doesn't explode", or in this case "I will bet you $10 that your arm surgery worked"
Scott mentions the leukemia drug imatinib and the lymphoma drug rituximab, both of which I was able to be on (a more powerful successor of imatinib called dasatinib, actually, which I still take daily) and which were the main crux of the regimen which saved my life when I was diagnosed with acute lymphoblastic leukemia in my mid twenties.
My leukemia is driven by a mutation called Philadelphia chromosome only present in a small minority of A.L.L. cases. It was, fun fact, the first cancer mutation ever identified, since it is visible under a powerful microscope by causing some *very* wonky stuff with the 22nd chromosome - they first saw it in 1959.
Previously, leukemias had proven treatable in many cases with the advent of bone marrow transplants: leukemia is bone marrow cancer, so we use intense radiation and chemotherapy to fry your bone marrow into oblivion and then replace it with someone else's who is similar enough to you that you can get by.
But, it didn't really help people with Philadelphia chromosome, which for some reason was much more resistant to treatment. Even a couple of decades ago, other kinds of A.L.L. were seeing 5 year survival rates around 50-60% while diagnosis of Philadelphia chromosome was a death knell; survival rates hovered below 10%. Treatment could usually induce a remission but it almost always came back stronger within weeks or months.
And then, in the early 2000s, a miracle; the development of the first mutation-targeted medication for a cancer, in a weird twist of fate for the first kind of cancer whose mutation was ever identified. Imatinib is a tyrosine kinase inhibitor - a tyrosine kinase being, to my understanding, a kind of enzyme that signals cellular reproduction and which Philadelphia chromosome causes its cells to make a broken version of which is always on, always signaling for reproduction. TKIs find cells that have the broken enzyme and cause cell death. (And also to some amount of regular blood cells too I'm pretty sure since mine makes me continuously anemic and immunocompromised, but I'm not going to look a gift horse in the mouth here, it hits the mark most of the time)
This finally gave patients with Philadelphia positive A.L.L. some hope, as well as patients with chronic leukemias, a much higher proportion of which have Philadelphia mutation origins. People began living longer, and some even began being cured and remain alive today.
There are now two successor generations of TKIs, generation two is dozens of times more powerful than imatinib and generation three is hundreds of times more powerful. Two years ago when I was diagnosed, my doctor gave me a prognosis of not just a 70% chance of 5 year survival, but a 60% chance of reaching a cure - and unlike Philadelphia-negative A.L.L., without even a bone marrow transplant. Outcomes for ph+ and ph- A.L.L. are now more or less similar and it seems possible that in the future, ph+ leukemia could actually be regarded as a favorable mutation for prognosis.
Also part of my treatment regimen (which included more medications than I can count on my hands) was rituximab, because my leukemia also came with the C.D. marker rituximab is able to treat. I'm not too sure on exactly what a C.D. marker is and it seems like neither are most non-hematologist doctors I've asked, but I'm thankful for it, and it improved my chances considerably.
Anyways, cheers to modern medicine! I literally could not get by without it. My leukemia isn't cured - yet, growth mindset - but it's controlled to an extent that it's undetectable on tests most of the time, and if it ever decides to come back I still have several lines of treatment and more powerful TKIs left available to me, even more than I had when I started out.
Great to hear! Hope you stay in remission!
Minor point but I wouldn’t waste much time with the “patients are just diagnosed younger and therefore do better” line wrt cancer. In many common tumors the cancers typically found in younger people are biologically and clinically different, and often much worse (faster-progressing with a shorter prognosis), than those typically found in older people.
(Breast and lung especially should really be thought of as multiple disparate diseases at this point and imo it makes this kind of broad conversation difficult to illustrate with them, let alone with “cancer” writ large; much better if feasible to zero in on a specific, coherently characterizable tumor type that fits your specific example needs. But I do get that this is a lot to ask in a thirty-thousand-foot-view essay about Medicine Y/N lol.)
The claim "medicine doesn't work" is obviously false, but is likely a straw man argument.
There are several reasons to believe that a large part of approved therapies today, either don't work at all or don't work as they claim they do.
The problem is, Robin makes a specific claim I think is false, and if I don't refute it, then other people start thinking it's true and repeating the claim. It's not a straw man argument if it's the literal position a lot of people are making! I can refute that argument without necessarily refuting some other argument that other people on vaguely the same side should have made.
I confess I don't know this guy.
Let me re-phrase: this is surely a straw man argument in any intellectually meaningful discussion.
But if the goal is refuting hyperboles and foolishness, I agree.
Is this specific claim "Medicine doesn't work"?
Because that has two straightforward interpretations, and you've chosen the less charitable interpretation, which happens to fail to be consistent with the dozen+ posts he has written on the subject, to argue against.
I think his claim is that some medicine is helpful and some is harmful, not that nothing does anything.
Robin himself appears to regard this is as a strawman argument: https://www.overcomingbias.com/p/response-to-scott-alexander-on-medical
I am not sure I agree with Robert here, but I see a few gaps in your arguments.
1. Survival rates. These are heavily dependent on detection timing. Imagine a world where we cannot treat cancer at all, but suddenly discover a technology to detect all cancers 6y earlier. Then the correct comparison would be between 5y survival rates pre-discovery and 11y survival rates post discovery. The cancers we observe post-discovery are much less deadly, on average, than the ones we observed pre-discovery. 5y survival rate would get to a very high level, but it is not clear what the benefit would be as we would be still unable to treat any cancers. Thus, your comparisons of survival rates are biased by better and earlier diagnosis.
2. Bayesian chaining. It is not obvious to me that a claim "medicine does not work" applies only to step 4 of your causal chain. Step 4 corresponds to the "medicines/medication do not work" claim. I think Robert is arguing about "medicine", not "medication", so it is not very nice to switch the goal to "medication" as do in your conclusions.
It is possible that there is a breakdown at steps 2 or 3 in our healthcare as a system that renders it useless while some medicines do work when used properly. I think it is fair to call these step 2 and 3 breakdowns "medicine does not work". For example., imagine a world where doctors make diagnoses completely at random irrespective of the underlying conditions. Then step 2 would be badly broken, and we would not observe good outcomes for the group with greater access to doctors. I think it would be fair to describe this situation as "medicine does not work". (And, yes, I am aware that this hypothetical is not compatible with perfect detection hypothetical in 1)
1. See https://slatestarcodex.com/2018/08/01/cancer-progress-much-more-than-you-wanted-to-know/ , as linked in the post. Also, there's no equivalent to "detecting heart attack earlier"
2. I think it depends what you want to prove. If you want to prove that society shouldn't spend money on doctors (because people will never go to them anyway), you care about step 1. If you want to know if you personally should take medication a doctor prescribed you, you should care about step 4. So it matters a lot which of these steps fails!
(also, my position is that none of them fail, you just lose statistical significance at them)
1. Thank you, I read that 2018 post now. It argues that most of cancer survival rate improvement is not due to a shift in detection stage. However, it makes this argument by referring to several published papers. This is a perfectly respectable argument, except that in today's post you seem to accept to play the game of assuming that we do not trust a single published paper on treatment efficiency. If the argument "medicine works because this published scientific article confirms it in this particular case" is allowed, Hanson point is clearly untenable.
2. You quote Hanson to claim that "medicine does not work" so it would make sense to build an argument to disprove that premise and not a related one.
There is detecting weaker heart attacks however. Things that a prototypical farmer might have shruged off and died of the n-th time propably go to the ER more often now.
And don't forget preventative public health measures! These are part of medicine too. Better to not have cholera or dysentery or polio or HBP or excessive LDL (name your condition) in the first place, than to seek treatment after these conditions become a problem. Preventative measures are generally a good thing, and have been driven by biomedical research. Medicine is not only treatment for a preexisting condition: it's also about preventing the problem arise in the first place: and often the interventions are cheap pharmaceuticals. Sun block, statins, polio vaccine, clean water, etc. The counterfactuals here are weird: should we just close all our primary treatment centres and not bother putting in tents, repairing compound fractures, or whatever?
> And don't forget preventative public health measures! These are part of medicine too.
I think this is controversial but semantic. (That is, I don't think Hanson considers them to be part of medicine.) At issue is whether "patient-facing medicine" is net helpful / how well we can estimate it, which we should be able to account for separately from public health improvements.
>Even Robin admits this is a real effect; he just classifies it as more physics than medicine.
Does he have the same opinion about really obvious surgery? Clearly everything that ever works is physics in the end, even if we can't discern all the intermediate steps in most cases.
I was raised in Christian Science, a faith-healing cult that avoids all medical intervention (this is an excellent comprehensive documentary on the topic: https://www.youtube.com/watch?v=E7RT4wNhiYQ).
My grandmother died slowly and horribly and pointlessly of a skin cancer which would have been trivially easy to treat (it has a 99% survival rate).
I, and every single surviving family member also raised in Christian Science, now have varying degrees of permanent damage from benign medical neglect.
Had Robin Hanson looked into Christian Science, he would not have formed these conclusions.
"Had Robin Hanson looked into Christian Science, he would not have formed these conclusions."
Oh I think this is too... optimistic? a take. It's hard for a man to understand something when his whole identity* depends on not understanding it.
*"I am the one who sees things you mere mortals don't! See this blue sky? let me tell you why it's not blue. It's not even a sky."
You know what, fair enough. Many of Christian Science's mandates indeed optimize for health - teetotaling, abstinence from tobacco, daily deep meditative prayer - and then of course medical malpractice is difficult to experience if you don't have medical attention.
When I'm in the mood to explain why Christian Science got a foothold, I like to say, "It REALLY works until it doesn't."
I don't know if Robin has mentioned Christian Science, but Greg Cochran has:
https://westhunt.wordpress.com/2016/03/31/medicine-as-a-pseudoscience/
Nassim Taleb argued that religion was selected for in the past because it kept you away from doctors (who were harmful). I don't think that applies as well to sects other than Christian Science.
That and prohibiting tobacco and alcohol had significant health benefits, too.
>I, and every single surviving family member also raised in Christian Science, now have varying degrees of permanent damage from benign medical neglect.
Could you give some examples? Its hard to tell what sort of thing youre talking about if you only have experience with normally medicine-using people.
Yeah, my brother dislocated his shoulder while attending a Christian Science boarding school and the adults in charge didn't have him medically treated. He has some permanent pain and weakness now, 25+ years later. He had it seen later as an adult, and the doctor said that because it wasn't properly reset and I-don't-know-what-else, it never properly healed and it's dubious if an attempt to correct it now would be successful.
My mother was effectively crippled by arthritis, especially in her hips - the surgeon who eventually performed her hip replacement said the imaging was "ten out of ten bad," some of the worst he's ever seen. She's now had both hips replaced and is *much* better, but has some knock-on effects in her knees and etc from not having had the hip replacement 20-25 years ago and compensating by hobbling around instead. She also had a shoulder injury from tennis about 30 years ago which was never seen and prevents her from being able to lift her arm above her shoulder - doctors say it would be unwise to do the surgery now (I gather. I wasn't in any of these rooms).
My uncle has a potential prostate cancer thing which he's decided to treat with diet and fasting. He is also divorced from a Christian Science practitioner who was diagnosed with BPD during the incredibly contentious divorce - while not technically physical injuries, she deeply and very likely permanently damaged him with (what turned out to be demonstrably false) accusations and totally alienating their son from him - he hasn't spoken to him in at least a decade and even had to hire a private investigator to find him to distribute inheritance (when my grandmother died horribly).
(If the alienation thing seems implausible, let me assure you, my uncle's ex is the most powerfully charismatic person I've ever met, she 100% could have started the kind of cult which would end up in a Netflix documentary, but she put all that charismatic and influence into her son instead.)
I got out of Christian Science earlier in my life than my various family members and maybe I can't claim the same kind of "permanent" injury, but untreated PCOS starting in puberty led to a hormone imbalance which caused a perfect absence of sexual desire. I eventually read about this "totally normal" orientation called "asexuality" and embraced the identity - only to have it accidentally 100% reversed in my 30s.
(I have Many Thoughts about the profound effect of hormones on perception, motivation, and personality. )
Was missing out on 15-20 prime years of sex and romantic relationships a "permanent injury?" I'd argue yes, especially if you consider that I was blocked from the opportunity to partner with someone and consider having children in the proper window of opportunity for those things.
And then there was my grandmother, who did indeed die extremely slowly and horribly. And because I was the most lost-cause atheist in the family at the time, quite a bit of the end-of-life daily medical care fell to me, because she didn't want anyone else's faith shook by the reality of cleaning an infected tumor the side of my palm.
I never understood why some dying people would tell their loved ones, "Don't come to my deathbed, I don't want you to remember me like that," but now I do. The sheer gruesome absurd horror of the last three months of her life became my most vivid and primary memories of her, despite her being a third parental figure most of my life. I don't think I'll ever be able to disassociate them from her full and awesome life.
And for Christian Scientists, my family was actually relatively lucky!
I have now subscribed to your Substack on the hopes that you will at some point share your Many Thoughts about the profound effect of hormones on perception, motivation, and personality. I too have Many Thoughts about this and how it interacts with identity, self, control, etc. and based on your writing here today I believe I would enjoy reading your Many Thoughts.
Heh.
While I have Many Thoughts, they're largely based on a sample size of one, and are probably highly cancelable.
Perhaps on a hidden thread?
Maybe! I'll think about how to round them up.
I mentioned this down-thread, but I wrote a bit about my experience in the comments of a letter to Captain Awkward (https://captainawkward.com/2016/11/18/918-im-no-longer-asexual-and-feel-like-im-letting-my-community-down/#comment-152423), and was immediately scolded by some other commenters, both in response to my entry and in their own comments, for saying my asexuality was actually sexual dysfunction and suggesting that sexual dysfunction should be ruled out before embracing asexuality as an identity. This comment, in particular, still makes me actually laugh out loud today, and also shudder at the thought that a real person might exist who really believes this (https://captainawkward.com/2016/11/18/918-im-no-longer-asexual-and-feel-like-im-letting-my-community-down/#comment-152661).
I didn't even think about the cancellable aspect, in spite of living with someone on hormones from a group of people that people get quite defensive about. Sorry about that!
I was more of thinking about how hormones interact with people not from any specific subgroup, and also actions that can cause or stop hormones, and thinking about if that's a kind of mind control... also, who is the person, the person "without" hormones, the person under the influence of a "normal" set of hormones, etc....
Thanks for responding. Many thoughts about this. Firstly, most of those sound surprisingly normal. Grandmas untreated cancer is weird, and the hip issues might be depending on the age they happened, but everything else sounds like it could happen to normal people the same way. By contrast, where my relatives were saved (when younger) by medicine its very clear-cut, like one was hours from his appendix bursting for example.
Secondly, this extrapolates to large numbers of working-age people with disabilities in e.g. the middle ages. That seems weird but I really have no idea if its true.
Id also love to hear how you felt/feel about getting a sex drive.
I know that some "normal" people avoid doctors either because they just don't like seeking medical care or they can't afford it, but I should underline that my mother and brother suffered excruciating pain from their injuries in these examples. Not only did they not seek formal medical care for their very obvious injuries, but they didn't take *anything* to treat the pain - not even acetaminophen. My mother's hip replacements were 15 years later than a normal person would have had them, because a normal person would have refused to tolerate the kind of pain and infirmity my mother suffered if medical care was a viable alternative.
Likewise, grandmother concealed the excruciating pain from her tumor for a couple of years, until it was so debilitating that she was half-dragged to urgent care and after that into medical care in general. You didn't know her, so you can't understand how much pain it would take for my grandmother to concede defeat in Christian Science, but let me assure you, it was a truly awesome amount of pain, the kind a normal person would find unthinkable. I was present for several different doctors' appointments and home care visits and watched all of the medical staff blanche, universally unable to conceal their shock and sympathy.
My family happened to have the good luck to not have life-threatening events like appendicitis, so I can't say for sure what would have happened if we had. My father, who is not a Christian Scientist, later said he would have over-ridden my mother and grandmother and gotten us medical care had we kids ever appeared to be seriously injured or dangerously ill, but I have to imagine that would have been a very late intervention indeed, much later than a normal family's.
And yes, while bad divorces are common, Christian Science's insistence on *very literally* denying the existence of negative things (sin, sickness, malice, etc) made my uncle far more tolerant of his ex-wife's destructive behavior than I think most normal people would have been. Of course, plenty of normal people are human doormats, but in this case, the religion strongly guided my uncle to deny/ignore the problem instead of addressing it.
I actually wrote about my mistaken case of asexuality in a comment on a letter to Captain Awkward ((https://captainawkward.com/2016/11/18/918-im-no-longer-asexual-and-feel-like-im-letting-my-community-down/#comment-152423), and was promptly scolded in the comments for acephobia. LOL.
>I know that some "normal" people avoid doctors either because they just don't like seeking medical care or they can't afford it
Thats not what I meant. Dislocated shoulders not fully healing is common even with medical attention, I even knew a guy whose just kept popping out for years despite many doctors visits. PCOS is easily missed even for medicine-positive people. I dont think I would have seen it in a medical light if I had never developed a sex drive, theres no one clearly pathological symptom in general - doctors understandably dont notice often. Unmanaged mental illness is mostly down to side effects and bad decision making resulting from said mental illness, less often to attitudes about medicine. Benign prostate tumors are recommended to monitor only in some places, though propably not the US. Those things I had in mind.
Thanks for your personal story. Sorry for what happened to you and I wish you lots of fun now.
Yeah, Christian scientists have lower life expectancies than other groups nowadays (they used to have comparable/superior, since their teetotalling stuff helps with health and medicine used to be a game of Russian roulette). They make for a pretty good natural experiment on the overall impact of medicine.
I'm surprised the argument centers narrowly on survival. Medicine is also good for improving bodily function and alleviating symptoms.
For example, anti-epileptic medications might be life-saving (I don't know the data), but they certainly help people to live more normal lives. Opioids and benzodiazepines have made the dying process for many people less horrific. Trauma surgery means broken bones can be fixed and a once disabling injury now is only a temporary set-back. There's durable symptomatic control of many chronic diseases with medication (e.g., rheumatoid arthritis, inflammatory bowel disease, SLE, COPD).
I think it's an inevitable epistemic challenge that there are things we don't know now that we'll know in fifty years about the interventions we're currently using - either there are unintended negative consequences or we thought some things were working when they really weren't (e.g., cancer drugs approved via the accelerated pathway end up showing no benefit when tested more rigorously). That's just the nature of how science evolves over time. In the face of this epistemic challenge, though, is it better to do nothing or something? I think that's the question best asked on a disease-by-disease, person-by-person basis. Will this intervention help this person right now? I spend a lot of my time in palliative care helping folks to navigate just those kinds of questions.
FYI Hanson & Caplan are not alone, this skeptical position is also the main point of Jacob Stegenga, Medical Nihilism (https://www.amazon.fr/Medical-Nihilism-Jacob-Stegenga/dp/0198747047) : "This book argues that if we consider the ubiquity of small effect sizes in medicine, the extent of misleading evidence in medical research, the thin theoretical basis of many interventions, and the malleability of empirical methods, and if we employ our best inductive framework, then our confidence in medical interventions ought to be low"
I do not agree Medicine is not effective, but I think his point is more about what dominates in terms of increasing lifespan and the sort of cost-benefit analysis. For example, it could be that all the cancer, cardiovascular etc medicine we have only increases lifespan on aggregate by like 2 years (because people who have these diseases are likely to die of some other affliction soon enough.) There was a paper arguing that curing *all* cancer would lead to an increase in lifespan of ~ 3 years. I think it's fair to ask: is it worth spending so much money for such small benefits or could this money be used better? I do not think these questions matter a lot because people will still prefer getting medicine, but it's a fair question and I do think we might overestimate the average add in lifespan from medicine beyond antibiotics and stuff like this.
That being said, to me this is the best argument to invest in ageing research.
actually, I was wrong, I do think these questions matter. Pondering just how little cancer treatments would add to lifespan was an important reason why I became interested in ageing.
Clearly reasoned (absence of evidence is not evidence of absence), but are you tilting at windmills? Hanson's perspective seems preposterous. Can we seriously question that diphtheria vaccine has no effect? that antibiotics for bacterial pneumonia are worthless? that insulin is useless for type 1 diabetics? that antihypertensives have no impact on malignant hypertension?
The other angle to do this is doing it bottom-up. Surely dialysis and kidney transplants work against diabetes? Surely getting your broken arm put in a cast works? Surely antibiotics work? Surely having surgeons treat that stab wound works? Surely having your infected appendix removed works? Surely the Covid vaccine worked? Surely antihistamines work? And so on and so on - once you've established that vast slews of medical interventions *obviously* work, then any odd statistics that claim they don't must surely have methodological errors.
As a MD and a researcher setting up clinical trials, I found Robin Hanson considerations absurd and obsolete. It is like discussing if the earth is flat or at the center of the solar system. I think there are far more relevant thought experiment to discuss such AI doctors, AI as a government to avoid needless wars, robot assisted society, space colonization etc.
The Scott Alexander answer is excellent. Vaccines, antibiotics, antidiabetics, antiarythmics, immunotherapy, robot surgery have demonstrated their clinical efficacy in terms of survival rates, quality of life, autonomy and mobility etc.
Okay, can anybody explain to me why Robin Hanson is taken seriously about anything? From my view, the one thing he's done is write some SF about emulated humans in a computer. But that seems to make him a Respected Big Thinker.
The guy comes out with "yeah I had my broken arm fixed, but are we *really* sure medicine is any good?"
Now, do we have contemporary theories that will eventually turn out to be like the four humours? Probably, but that will be due to the advancement of knowledge like everything else. Next time Hanson breaks his arm, do you think he'll stay at home and do some deep breathing, because medicine is still on the level of Galen, or will he head to the local hospital?
The only sense I can make out of all this is that he enjoys being a feckin' eejit, I mean contrarian, and taking the "if everyone jumped off a cliff, would you do it do? yes, mom, I would!" position. That's fun, but do it consistently and you don't come across as a gadfly, you seem to be a silly person.
What's next - "is food actually necessary? history shows primitive peoples believed you could acquire the characteristics of a creature by consuming its flesh, hence they would eat the heart of a lion to become brave, we know today this is nonsense, but Big Agriculture and Big Dietician Industry has convinced us we need to 'eat' to live, I propose instead that all you need is air".
Ah,ah,ah excellent and funny answer ^_^ I agree totally with you. Let's ask Robin Hanson to stop eating to be sure ;-).
The Breatharians are right, it's just that modern medicine refuses to conduct the experiments properly! 😁
https://en.wikipedia.org/wiki/Inedia
EDIT: I admit, I rather admire this man for his sheer cheek, now *this* is the kind of fasting I can get behind! Though even I blanch at the idea of a double quarter pounder:
"Wiley Brooks (1936–2016) was the founder of the Breatharian Institute of America. He was first introduced to the public in 1980 when he appeared on the TV show That's Incredible! Brooks stopped teaching shortly before his death in 2016 to "devote 100% of his time on solving the problem as to why he needed to eat some type of food to keep his physical body alive and allow his light body to manifest completely". Brooks claims to have found "four major deterrents" which prevented him from living without food: "people pollution", "food pollution", "air pollution", and "electro pollution".
In 1983, he was reportedly observed leaving a Santa Cruz 7-Eleven with a Slurpee, a hot dog, and Twinkies. He told Colors magazine in 2003 that he periodically breaks his fasting with a cheeseburger and a cola, explaining that when he's surrounded by junk culture and junk food, consuming them adds balance.
Brooks later claimed that "All McDonalds are constructed on properties that are protected by 5th Dimensional high energy/spiritual portals", encouraging the consumption of Diet Coke and McDonald's Double-Quarter-Pounder/with cheese meal ("It is also acceptable to combine 2 quarter-pounder with cheese burgers to make one double-quarter pounder if you can't get the double-quarter-pounder with cheese where you live"), and discouraging the consumption of "water of any kind". The idea of separate but interconnected 5D and 3D worlds was a major part of Brooks' ideology, and Brooks encouraged his followers to only eat these special 5D foods, as well as to meditate on a set of magical 5D words."
I would love to see someone make the same case for 1600s medicine or modern education.
I’m glad to see you pushing back on this claim as it may undermine the urgency for much more investment into medical research. I would like to see 10x the amount of medical research being done. And why not? There is a lot of room for improvement when it comes to reducing the suffering from physical and mental health problems.
You can increase medicine use with no effects on questionnaires or measured health outcomes. When I was younger, I was very allergic to tuna and salmon. I went and reintroduced them into my alimentation. It took a lot of time, probably shot me to the top 5% of medicine use for my age and country, but did not change a lot on how I would have responded or scored on most questionnaires. I was very good a avoiding my allergies, so I doubt my adverse event rate or death rate moved any direction. I was also not very stressed about the allergy or the procedure and would have not scored differently on mood or stress. You could build a case that nothing changed and that it was useless with the kind of metrics tracked by those studies. Except from the fact that I can eat tuna and salmon now, and that while it's probably not the most efficient use of medicine, it still works and I am happy with it.
But surely that's not medicine, that's pharmeceutical-assisted luxury. Is plastic surgery part of what Alexander and Hanson are looking at?
How quickly we forget! Does he even know that the mid-thirties were once called "the heart attack years"? I saw a huge change in heart disease over my forty years in practice, partly due to less smoking, but also partly due to diet and statins. Another example: when I was diagnosed with CLL, I looked up the stats and they were dismal. Fortunately things have changed, with targeted treatments the outlook is vastly better, and I may even be cured by an HSCT.
I'm surprised to hear this about the mid-thirties - any source? I thought heart attacks were happening more often in young people now (because of obesity)
Google books and google ngrams suggests that is not true. If you have a more precise claim about time, you can limit google books to that period.
https://books.google.com/ngrams/graph?content=heart+attack+years%2Cthe+heart+attack+years&year_start=1800&year_end=2019&case_insensitive=on&corpus=en-2019&smoothing=3
https://www.google.com/search?q=%22the+heart+attack+years%22&tbm=bks
Thank you for writing this! I know you said no one takes Hanson and Caplan seriously, but I definitely take them seriously, even I do not always agree with them. I work in healthcare, and though intuitively I thought Hanson was wrong, I could not figure out exactly where his mistake was. This left me with a gnawing feeling that I might just be biased and everything I do for my job is pointless and doesn’t help anyone. This article reduces that feeling.
> This might seem like a silly question: in Europe of the seventeenth century, the average lifespan was in the low 30s. Now it’s the low 80s. Isn’t that difference due to medicine? In fact, the consensus is now that historical lifespan gains are better explained by nutrition, sanitation, and wealth.
Wow. Hanson is committing one of the best-known statistical errors here. First off, it doesn't pass the basic "smell test." (Does anyone *really* believe that 300 years ago we had a bunch of elderly people in their 30s running around?!?) I can't help but wonder, does Hanson not realize just how well-known of a mistake this specific claim is? It's practically a textbook example of wrongly grouping together unlike data.
"Historical lifespan gains" are virtually nonexistent. Modern conditions have improved things a little bit at the margin, but certainly not by decades! That "average" is explained almost entirely by throwing a whole bunch of 0s, 1s, and 2s into the data that skew the overall number far too far to the low side, and then we came up with vaccines and other treatments that did away with infant mortality almost entirely.
Once you separate infant mortality from adult mortality, a very different picture emerges: the ancient figure of 70-80 years for a human lifespan (Psalm 90:10) has remained almost completely unchanged for millennia, and we're just barely starting to improve on it today.
> That "average" is explained almost entirely by throwing a whole bunch of 0s, 1s, and 2s into the data that skew the overall number far too far to the low side, and then we came up with vaccines and other treatments that did away with infant mortality almost entirely.
Well, apart from medicine, irrigation, health, roads, cheese and education, baths and the Circus Maximus, what have the Romans ever done for us?
> the ancient figure of 70-80 years for a human lifespan (Psalm 90:10)
lol
You appear to have missed the point entirely. I'm not saying there's anything bad about getting rid of infant mortality; I'm saying that it is statistically entirely different from, and unrelated to, adult lifespan, and mixing the two together is a well-understood error.
Sorry for my superficial reply. Let me try again.
> I'm saying that it is statistically entirely different from, and unrelated to, adult lifespan, and mixing the two together is a well-understood
Okay, then I did misunderstand your point.
Yes, from what I know, average lifespans were a lot longer if you discount deaths in the first few years. However, there were plenty of opportunities to die before reaching 70: death from childbirth (practically solved today), death from bacterial infections (practically solved today), death from appendicitis (practically solved today), death from viral infections (much less serious today – keep in mind that the bubonic plague killed about 50% of Europe's population in the 14th century; COVID-19 killed something like 0.2-03%). And that doesn't even consider deaths that are prevented by medicine, like deaths from malnutrition or unsafe working conditions.
All this makes it very hard to imagine that the average lifespan (even discounting infant mortality) hasn't increased by at least 20 years.
> the ancient figure of 70-80 years for a human lifespan (Psalm 90:10)
Sorry, but I can't get myself to take demographic statistics picked from a Bible passage even remotely serious.
What’s to take seriously? He said it was the ancient figure. What other than ancient texts could we use to determine ancient people’s understanding of age ranges?
Of course the Bible is not a definitive source about how long people in that time lived. But the author(s) would be expected to use a figure that readers would have found plausible, just as “man is born to trouble as the sparks fly upward” relies on the reader knowing that sparks do indeed fly upward.
> What other than ancient texts could we use to determine ancient people’s understanding of age ranges?
Bob's claim wasn't about "people's understanding" of lifespan, but about actual lifespan. The former is irrelevant to this discussion, and the latter can't reliably be determined from a single passage in the Bible.
As for plausibility to the readers: A contemporary reader would say "Yeah, I know one or two geezers that look so wrinkly they might as well be 80, sounds about right for maximum human lifespan", and not take into account all those people in his village that died between the ages of 2 and 70. Because that reader wasn't a statistician meticulously collecting data across a large population.
And then there's the issue with translations and misinterpretations of ancient texts. Can we be sure that the author really meant "average life expectancy", which is what we're talking about here, or rather "maximum age"/"top percentile", which is a very different concept, and which is today much higher than "70 to 80".
>the bubonic plague killed about 50% of Europe's population in the 14th century; COVID-19 killed something like 0.2-03%).
Thats because they are substantially different viruses. If Covid had swept Europe in the middle ages, they wouldnt even write it down as a plague year. There has never been an airborne virus as dangerous as the bubonic plague, and thank god, that could very much still wreck us today.
Moderation warning: comments like this will get bans in the future.
Fair enough. I'll try to write a more constructive reply to Bob's post.
In all honesty, I'm glad to see that you're back to keeping an eye on post quality again.
I think saying “no” to “does modern medicine work?” encompasses multitudes, the possible answers being (strongest no to weakest, clickbaity no):
1. It’s all fake and pointless, all medicine may as well be sugar pills, surgery’s just a more drastic alternative to acupuncture.
2. A few bits and pieces work (eg antibiotics) but the same’s true of witch doctor potions and Chinese medicine; most of it’s pointless.
3. Quite a few of the pills work; most are overrated and some are rubbish. Doctors themselves are a pointless bureaucratic hurdle to pill-buying who add no value.
4. Modern medicine has some kind of paradigm/worldview which is better than chance but fundamentally wrong (a bit like Cartesian vertices).
5. The average person’s life will not meaningfully be improved by access to healthcare (even if a few individuals’ lives will; cf. https://slatestarcodex.com/2017/09/27/against-individual-iq-worries/).
6. Health insurance achieves nothing, in spite of the pills working.
7. Health insurance is overrated.
Hanson’s position seems to be 2, but his studies only get him to 6 at best. The study you’d need for 2 is a comparison of effect sizes (or a better measure of efficacy) against placebo for a panel of medicines weighted by how commonly they’re prescribed.
It might be too difficult, especially with easily available data, but maybe some extra stats could make a stronger case from a lot of these studies -- if the main problem is a largeish number of marginal results.
(I'm not sure how much further effort it's worth going to on this topic but I think the below is generally interesting and worth trying.)
Karnataka measured over 80 outcomes and there are various others.
Unlike published RCTs maybe we can hope they don't suffer from selection (publication) bias, after all they seem to have published a lot of non-results.
Hopefully they also published anything that looked like the medicine was harmful!
Case 1 (no real effect): We'd expect to see a range of results, with no particular bias towards positive outcomes and some marginal results in both directions.
Case 2 (beneficial effect of medicine): We'd expect to see a range of results but with a positive drift. It might be hard to produce well powered formal test, though there are some simple things one could do:
a. Plot effect estimates with CIs, maybe there's a visually obvious positive bias
b. A sign test: What fraction of findings suggest a positive effect vs. negative.
@Scott: If you have or know where the get the data relatively easily, I'm happy to poke around, make some plots and try some tests. Maybe with some kind of pre-registration of what to try, once the basic parameters of the data are clear?
> the 1970s state of the art was doctors saying “You should try to stop smoking and eat better.”
They have updated since then. Now it's "You should try to stop smoking, eat better, and exercise more."
Can the correct medical treatment work if administered properly? Yes, for many diseases the effect is massively positive.
Is going to the hospital and doing what the doctors tell you to likely to increase your health? This is where Robin has the chance to be correct. He identifies a huge gap between what we think medical intervention can do (massively increase our length and quality of life) and what it actually does in practice (very specific and often marginal improvements in a subset of the ailments humans have). This gap creates a huge mismatch in expectations which is extremely dangerous. Patients are massively biased towards intervention. They get frustrated with the modest gains of real medicine and will seek more and more intervention to try to get the increases in health they imagine medicine should be able to give them. Intervention is dangerous. Doctors are likewise frustrated with the mismatch between their very high social status and their very modest ability to heal. They will go along with or even encourage the unnecessary interventions. Every surgery has risk, every medication has side effects. If people seek intervention far out of proportion to real benefits, then the iatrogenic effects of treatment can cancel our the small positive effects of medicine. In this way, even if medical treatment is real, the total effect of the medical sector can plausibly be negative or within statistical error of zero.
I think your on expectations vs. reality is really onto something. I think there is an issue with spheres of control that is not sufficiently set out. Modern medicine is at its strongest dealing with visible, physical phenomena - broken bones, neurosurgery, repairing joints, etc. But that is also, in some ways, closest to the competency of pre-modern medicine. I think that if you had given a pre-modern surgeon access to modern imaging technology and anesthetic and scalpels (and forcibly washed his hands) he would have had a relatively short learning curve to accomplish many of these interventions. Egyptians were trepanning millennia ago - presumably not very successfully, but still.
Just at or below this tier is germ theory and antibiotics. Taking a tangible sickness caused by a microscopic (but observable) physical foreign organism and treating, not just its symptoms, but the underlying antigen. Vaccination falls here as well.
Below again are diseases caused by failing systems of the body. Interventions here are subject to many compounding factors and treatments range from quite effective to virtually useless to harmful. Cancer, chronic illness, etc.
Below even further is Scott's area of psychiatry and psychopharmacology. His own posts have noted the absolutely abysmal effectiveness rates of almost all anti-depressants, for example. Below even this are fields that are effectively pseudo-science the quality is so bad, nutrition being an example.
In essence, the simpler and more tangible an ailment's cause, the closer it is to the central sphere of control of medicine. The further out you go, the lower your expectations should be. I think many folks encounter medicine in a central context, then are disappointed when they try it for a less central ailment. For example, I knew a brain aneurysm patient who received quick and effective care, neurosurgery within 48 hours, and ICU care for several weeks. The doctors were able to control BP during that time like turning a thermostat dial, accurate within 2 points on either side. Intracranial pressure was monitored and corrected, and eventually a permanent shunt was placed. Following some therapy, full recovery was achieved. It was a triumph of interventional medicine. Shortly thereafter, another patient I knew was diagnosed with advanced pancreatic cancer. Care was perfunctory at best by doctors (probably due to expected futility) and side effects were severe; probably no intervention would have been a better choice. It was jarring, after watching body processes be manipulated with machine-like precision, to realize that medicine was basically helpless or actively harmful. But that was an expectations issue. Had I not recently seen the one, I would have been less surprised at the other.
What surprised me is that Scott, who practices on the bottom rung of medicine's effectiveness ladder / outermost sphere of control, doesn't recognize this effect. Of course most of what he does is poor quality medicine with minor effects. He's posted over and over about how nothing really works in mental health (or conversely everything works, but with low reliability). Internal medicine has similar hierarchy problems. The more complicated the system, the more useless medicine has become. Hanson basically accepts the low-hanging fruit of the inner spheres, and dismisses the rest. This is too simplistic, but it's fair to say that medicine in those outer spheres is useless IF your expectation for "useful" is set by the inner sphere.
I should clarify that I'm not at all saying Scott is a poor medical practitioner. I meant "poor quality medicine" only in the sense that it is in the most-complex and lowest-confidence area of medicine.
I'm not sure if the astonishing success medicine has had with infectious disease is "close to competence of premodern medicine". Before salvarsan (roughly) there was pretty much nothing.
As to psychiatry. I think we focus so much on the common maladies largely treated in outpatient care that we forget the ABSOLUTELY REVOLUTIONARY impact of antipsychotics (yes, including the first gen neuroleptics). I'm not a physician but I did a very comprehensive psych degree which included psychiatry, and neurology taught in hospital environment by medical doctors and while I'm not old enough to remember it, I'm old enough to have been taught by some people who remembered their advent as something borderline miraculous, notwithstanding the heavy side effects and that they were not by any means a cure, the development of drugs that could reduce or stop acute psychosis made a big difference.
Okay, to steelman the argument: without antibiotics and the advent of techniques such as x-rays, 21st century medicine would be as ineffective as 17th century medicine, where high mortality rates were due in part to deaths from infections that could not be treated either prophylactically, as with inoculations and vaccinations, or concurrent with the advent of the infection.
Lack of effective painkillers and anaesthesia was also contributory, as well as lack of knowledge about dietary requirements and deficiencies, basic hygiene theory, and knowledge of organ function.
Since they did not yet have advanced understanding, they propounded theories to explain illness and disease which we know now to be grossly mistaken. Similarly, in future, there may be theories which we today assume to be correct or at least to have explanatory power, but further advances will reveal to be mistaken.
That being the best I can say for Hanson's argument, even in the 17th century they did have *some* effective treatments. Medicine was based as much on a practical and pragmatic view as on theoretical; you might not know exactly how foxglove or willowbark worked to cure, but you could see that dosages of these were effective:
https://www.rmg.co.uk/stories/topics/health-17th-century
"Were any important discoveries made in the 17th century that helped improve doctors knowledge?
In the 1620s an Englishman named William Harvey, who had studied at the great Italian medical school in Padua, discovered that blood circulates around the body, the heart acting as a pump with valves to control the flow. King Charles I encouraged Harvey’s efforts after seeing his work. King Charles II, who came to the throne in 1660 after the death of Cromwell, was also interested in everything scientific, including medicine.
In 1661, a chemist called Robert Boyle published a book called The Sceptical Chemist, which described how the body takes in something from the air to breathe. Boyle also established that without this important gas, which we now know as oxygen, animals and birds would die. In 1662, Charles II granted a Royal Charter to the Royal Society and this encouraged scientists to attempt new experiments. However, despite such promising developments, many superstitions were still accepted as truths in the 17th century."
In the 17th century some effective medical techniques might have existed, but they were outweighed by the multitude of harmful treatments that doctors of the time thought were effective.
Yeah, but that was down to lack of knowledge. On the face of it, he's doing the equivalent of complaining that there was no Apollo program in the 17th century. Well, no, there wasn't and for very good reasons.
I don't think it's the equivalent at all. But if we tried to treat the science of space comparably, an imaginary version of Hanson (perhaps like Stephen Williamson's "Right-Wing Anti-Krugman") could say they took astrology seriously back then, and that means we should distrust astronomy now.
> after you’ve already gotten the cancer, so it’s hard to see how nutrition, sanitation, etc could explain this
If a person gets cancer or a heart attack, it seems like an obvious hypothesis that they might improve their nutrition, exercise, etc.
The fact that this hypothesis isn't even considered in this article is a great microcosm of the overconfidence of modern scientists.
And I'm guessing there isn't great data on it, but it's fascinating how biases rear their heads on all sides of an argument, and most people don't see it.
It seems to me that while so many people appeal to science, they use poor quality science to rationalize biases and intuitions, rather than saying, "Hey, the science here sucks. Let's bring everyone together from all sides and design a great study to evaluate." COVID is a perfect example: the world was ready to run RCTs on a massive scale and all we got was tiny, crappy ones and decisions mostly based on non-RCTs.
There seems to be data that being overweight/obese is worse when it comes both to risk of developing cancer and if you contract cancer:
https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/obesity-fact-sheet
Exactly! Most of modern medical stats about health care outcomes will be dominated by the Big Three killers: heart disease, diabetes, and cancer. Yet we know that all three of these are much rarer in low-income countries and in the past. In other words, there's an inflection point somewhere between dying because you're "undernourished" and dying because you're "malnourished". One, you're not getting enough to eat and you can't fight off disease or outrun a predator or whatever. The other, you're overweight and never take a walk so your vital organs stop working right.
We know the way to prevent 90% of these chronic conditions is to be thin and fit. Medicine is a poor substitute for when people fail to achieve that aim, but it's also the *universal* substitute. I think you'd have fewer arguments like these from the likes of Hanson if good nutrition did its job and medicine could focus on its strengths, instead of fighting losing battles.
Maybe the whole reason we're here isn't because nutrition is so good, but rather the opposite. It's not clear to me that the last 50 years of 'advances' in nutrition have been a net positive. I know the standard line is that lifestyle and eating habits are getting worse and if people would just listen to the experts they'd get thin and healthy. What does it say about modern nutrition science that massive increases in every metric for nutrition advice have been directly proportional to increasingly widespread malnutrition?
Maybe the constant preaching has increased because the need increase (maybe it's a lagging indicator, not a causative one?). Okay, but it's hard to argue that it helped health get BETTER than it would have without the experts. I personally suspect a causal relationship (nutrition advice is on net bad for public health). Maybe if we went back to the era where people didn't count calories/monounsaturated fats/carbohydrates/riboflavin/whatever we'd be healthier. We at least know it's not a requirement for good health to track any of those things.
I determined, in about March 2020, from news saying COVID was an mRNA virus (thus prone to mutations) that a vaccine was about as likely as a vaccine against the common cold. About June of 2020, I looked at studies, from before 2020, about mask effectiveness, and determined masks may reduce susceptibility to the virus, but not significantly unless properly using an N95 (or better) mask.
It seems to me that people ignored the basic science of the pandemic for non-health reasons, such as to ensure the public that everything was under control, not to panic, and that everything would be fine if we all followed their guidance. I do not think COVID policy was science-based.
I believe that the workings of healthy bodies aren't studied nearly enough. Unless I've missed something, the result is treatments usually drugs) aimed at relieving symptoms, but the treatments have serious side effects, and sometimes weird side effects that aren't related to the ailment in any obvious way.
There are billions of people who don't have schizophrenia and don't have dry mouth, either. How does this work?
I realize it could be hard to get financing for what seems like abstract knowledge that isn't closely related to a specific illness or a cure for it, but abstract knowledge can end up being very important.
I have no strong opinion about how much of medicine as now practiced is worth it, though I would be on more than Hansen says and less than people who trust the whole system think.
A lot of basic research aims directly at the kind of healthy mechanistic understanding of human biology you describe. Ironically, often the best way to understand basic mechanisms is by either breaking the system or looking at a broken system and comparing it to healthy systems to see what's different. And not just in studying human disease. Early genetics research was literally this, where scientists would irradiate cells, look at what was different, then go back and check which gene(s) had mutated. If a fruit fly got covered in fungus when you knocked out Toll receptors, that probably meant the Toll receptors had something to do with fungal defense.
Actually, it's a lot harder to design a treatment for a specific disease than you'd think. Much easier to take something we already have, see what it works on, then go hunting for a disease that might be affected by that thing. There are ways to reverse this process with libraries of chemicals - and we do try to design specific therapies! - but if you're watching a commercial about restless leg syndrome or whatever, it's a good bet that therapy was a product of the research and not the other way around.
I'm sleepy, so I might just be being stupid, but this doesn't seem 100% coherent at first glance:
> "In Robin’s model, these extraordinary studies would have to be bias or chance, and totally coincidentally at the same time somehow better nutrition made leukemia patients (but not uterine cancer patients) twice as likely to survive."
If we grant that the study/medicine is somehow bullshit, then surely we're granting that the survival rates you're referencing here are bullshit data? Or maybe I'm misunderstanding the association between this data point and the research in question. Like I said, I'm sleepy.
Fwiw I’ve read a lot of what Hanson wrote about this, and my impression was always that his framing was “medicine doesn’t clearly work in aggregate”, instead of “no individual type of medicine works”. My understanding might be right or I might be implicitly taking a saner-but-wrong interpretation.
In any case, I think there is a very good question here: if we assume medicine really, obviously works, e.g. by using arguments in this article (and tbc I do), then why can’t we support this with population-wide sociological studies? We spend a very significant fraction of our total wealth on medicine, and it should distress us that we can’t (or simply don’t try hard to) find a high-level aggregate effect.
I think a stronger argument would be, "most medical spending doesn't work" as opposed to the blanket statement that "all medicine doesn't work". This is why Hanson's argument falls on deaf ears. People can see clearly effective medical interventions that nobody argues with and they dismiss the argument out of hand. Meanwhile, most of the money is spent on preventative care for chronic conditions, not because there's good evidence that those treatments make people better off over time or prevent early death, so much as because they create permanent patients who feed the industry forever.
Two things can be true: medicine can be really good at reactive treatments, and really bad at preventing low-frequency bad outcomes through preventative care.
(With some overlap both directions, such as bad some bad cancer treatments that don't do much more than let you die just as slowly but with bad side effects, or vaccines that prevent measles. The overlap probably just serves to confuse the problem, allowing people to overgeneralize in both directions.)
"Medicine never works" is sure catchier than "some medical interventions don't work very well," but it is only the latter than has a chance of being plausibly defended. When I was in my late 30s, I ruptured a disc in my back at L5-S1. This was excruciatingly painful, to the point that even sitting was close to impossible. I had to lie on the waiting room floor prior to surgery. I had a very successful laminectomy, without which I would be walking with a cane and taking opioids every day of my life. If this happens to Hanson, what's his plan? If he really believes medicine never works, then he might as well go to a witch doctor, or "traditional Chinese medicine," or do nothing at all. Get a cane and some oxycodones, I guess.
My impression is he would say "that's not *medicine*, that's *surgery* which is completely different!" He had surgery on his own broken arm, yet comes away with "still how can we know medicine net good or net bad?"
I think he includes surgery as a category of medicine. https://www.overcomingbias.com/p/treatment-futurhtml
Surgery for a broken arm or appendectomy clearly works in a way that can be evaluated without a study. There are surgeries that don't seem to work reliably, off the top of my head I'm thinking of hernias and nasal passage repairs, but even these are basically auto mechanic work on the body, there's no great unknown here, they just weren't able to fix it for the same kind of reason that your mechanic wasn't able to fix your engine (skill deficiency, or an undetected flaw in a really complex part that made typical repair protocols fail.)
These all seem of a different kind to me than pharmaceuticals, where there's a host of unknowns and the replication crisis has given us real reason to wonder if we're in our own "leeches and humors" bubble of ignorance.
Upon further reflection, Hanson will have to forswear canes and oxys too, as they are medicine. Just walk it off.
Without taking an overall position on the debate (yet), a couple of points:
"[This paper] finds that “plan effects on blood pressure” were three times higher for hypertensives for non-hypertensives; that is, unlike statistical flukes (which we would expect to affect everyone equally), the effect was concentrated in the people we would expect doctors to treat."
This seems mistaken to me -- conditional on the assumption that blood pressure is the 1 of 30 that coincidentally had positive effects, high effects on hypertensives specifically is something we should *expect* to find.
"Third, you need the diagnoses to result in more treatment (eg blood pressure medication)."
An additional factor that could be a separate step of the funnel or could be lumped into this third step is medication compliance, which we know is often poor.
Generally when I'm making the argument that medicine doesn't work, I look to country data. Time series life improvements don't really impress me when those same improvements show up everywhere in the world regardless of how much medical spending those countries are doing.
Spending a short amount of time looking up some numbers, the US spends some thirteen thousand dollars per capita on healthcare. Ecuador spends around five hundred dollars per capita. Life expectancy at 15 is 80 in both countries.
Nice, but lots of confounding factors between countries. For example, suicide rate in the US is twice that of Ecuador. We could control for that, plus violent crime, plus genetic differences, plus ...
Eventually we have to concede that cross-country analyses like these aren't any simpler than time series or other arguments.
My problem with using controls like that is, it's plausible that medicine causes suicides, and etc.
I would argue that once you're spending a fifth of your wealth on something, the benefits should be fairly obvious and should be visible without using a more complicated algorithm than a linear regression between healthcare and life expectancy at age two.
I find that simple standards tend to be best, because confirmation bias. The more specifically accurate you try to make your model, the more of your own assumptions you're feeding into it, the more your original worldview starts feeding into itself, and thence, the more circular your logic becomes.
Conversely, random factors shouldn't tend to favour one side or the other anyway, so it's not normally useful to control for that stuff anyway.
In sum, if our medicine is worth a fifth of our wealth, why can't the effect sizes eclipse such factors?
I agree that in theory there should be a huge difference. If the point you're trying to make is that we get diminishing returns for our money, or that there's a lot of wasteful, poorly allocated spending I'm right there with you.
But cross country analyses have a lot of assumptions built in, and the biggest of those is that there is some equivalent health baseline. Do you believe that? Would you drink the water in Ecuador without first looking it up? Would you vacation in Ecuador's countryside without first figuring out whether you need certain travel advised vaccinations?
Assuming a model is simple isn't the same as that model actually being simple. Comparing expected number of feet by averaging out all members of my household seems straightforward until I remember the dog.
I guess I've been burned too often by the seemingly simple approach to trust it like you do. I agree you shouldn't trust complex regression analyses, though. Natural population level differences are all suspect in my mind.
I should note, my argument is that, I'm sad that we have this whole argument about whether healthcare works at all without addressing what seems to me to be the obvious elephant in the room. Going a step further to what I actually believe, diminishing returns with lots of wasteful poorly allocated spending, isn't so far off from my position, though I could go further in that it does seem to me to be somewhat likely that healthcare is net negative to health.
I should note, in my definition of healthcare as used above, clean water is not healthcare.
So, getting to simplicity, I sense that there's a divide in our definitions, I'm more using simplicity as in, simple to define? Whilst you seem to be indicating towards, simple to operate? So, like, under my definitions, there's no assumption needed, the model just is simple. That doesn't mean it works for the problem at hand, just that the code needed to convert the input into the output takes fewer operations than some other model's code (simplicity is relative).
Regarding equivalent health baseline, I think your sense of scale is not being reasonable here? The confounders just aren't that significant. Ecuadoreans are not elves.
Of course, I wouldn't actually expect the confounders to favour America to begin with. If America had longer life expectancy than Ecuador, then perhaps that could be better healthcare, or it could be something else. But there's not as much room for America to have lower life expectancy than Ecuador and yet still have a working healthcare industry which consumes a fifth of our economy.
Right, we don't have an argument on "health care spending is a good bargain". We don't even disagree that some medical interventions are likely harmful - and more than just because they cost money. Look at the old PSA standards, or other screening tests that produced too many false negatives for the populations they were being applied to.
The biggest disagreement is that you don't think there's enough room in your quick and dirty analysis for "health care spending produces some net gain". I'm not sure this is knowable, since to accurately assess this we'd have to quantify:
1. All positive effects from healthcare treatments
2. All negative effects from healthcare treatments
And then net that number out. Now, before you get upset I do hear you that you believe your analysis moots the whole issue. But it's one thing to say, "on net there's no effect", a stipulation that requires more precision than saying, "20% GDP is getting what we paid for". The second statement isn't in dispute. It's the first one.
And no, you're not doing an assumption-free test. Any time you compare two things, you're implicitly assuming that those two things are comparable. I'm questioning to what precision your comparison is valid. That's standard practice, to question your assumptions.
Why does any of this matter? For me, there's a difference between saying, "All healthcare spending is good/bad", which suggests implicitly trusting/distrusting the system as a whole, versus saying, "On net it's probably beneficial. But given that the magnitude of the effect is difficult to parse, any individual intervention deserves scrutiny the efficacy of its claims."
Reducing the rate of mortality by 0.06% is implausibly high, at least if I'm understanding it right. Preventing 1 out of ~1,600 people from dying is a plausible result from providing those 1,600 health insurance, but that's not what happened. Only about 1% of people who were sent a letter actually got insurance, so that means that about 1 out of *16* people who got insurance had their life saved in the next two years as a result of getting insurance. I don't believe that in the slightest.
Yeah, much of that analysis seems flawed. Like, what's the probability that:
1. You get the health insurance
2. You get sick enough within the next two years to kill you
3. Your death is preventable by modern medicine
4. You wouldn't have gone in and gotten that medical treatment but for the insurance?
If you fall off a roof and are rushed to the hospital, you're not going to die because you didn't have insurance. Maybe you don't go in for medical screening, but that's a long-run effect. What's between, "if I don't go to the doctor I die today" and "if I don't go to the doctor I die in 5 years" that's frequent enough to show up in this 2-year statistic?
Something about this study smells wrong. The low p-value wouldn't compensate for that even if this were a direct intervention, let alone one that's at least twice removed from cause-effect.
Yes, I go into more detail on that in my response. https://www.overcomingbias.com/p/response-to-scott-alexander-on-medical
I personally know intelligent, educated people who profess views similar to Robin's (so it's more than just two contrarians). Sometimes this is just a basic failure of reasoning: only sick people go to the doctor, so if you never go to the doctor, you'll never get sick. But often, I think it's some form of mood affiliation or virtue signaling: medicine is artificial, unnatural, "Western"; natural, "Eastern", or "native" solutions must be better.
Robin's own stated explanation for increased life expectancy contradicts his argument, anyway. Sanitation is good because unsanitary conditions make people sick. Improving sanitation is straightforwardly a form of preventative medicine.
I don't think that's contradictory at all. You are calling sanitation "medicine", but most people wouldn't. Elsewhere in this thread it was pointed out that trauma surgeons are better at treating victims of car crashes & bullet wounds. I think that's true. But seatbelts and kevlar vests are not considered "medicine", nor are roads designed to be safer.
For what it's worth, I don't view sanitation as 'medicine' per se as opposed to medical procedure. I would be surprised if most people viewed hand washing as medicine qua medicine.
> Robin’s argument (that medicine doesn’t work) assumes that the only possible failure is at step 4, and that the failure must be a true failure rather than one of statistical significance. But in fact there are failures at every step (although I kind of have to stretch it for step 3), and the authors of the papers tell us explicitly that these are most likely failures of statistical power.
Is that his argument? I think if doctors randomly assigned diagnoses to patients (i.e. complete failure at step 2), Robin's overall argument would be correct, since he's talking about the medical system as a whole, not just medicine.
I wish Hanson wouldn't insist on making the most insupportable version of the argument. It's a waste of everyone's time. If we were debating the medical and cost effectiveness of specific treatments, that would be great. We should do that. Let's not have the college dorm room stoner version of the debate.
The Technology of Medicine by Lewis Thomas, c 1970
https://archive.is/F4NhI
Isn't healthcare very likely one of the main mechanisms wealth actually leads to better health (especially if we're already pulling out nutrition and sanitation as separate mechanisms)?
Maternal mortality would seem to be another line where one could argue that medicine works. Especially potent since it's one of the cases where medicine was very likely a net negative (in the 1700's and 1800's) and has now moved to be a definite positive.
Also traumatic injury, hasn't treatment of, for example gunshot victims, improved survivability enough that many of the contrarian folks (though perhaps not exactly these contrarian folks) have hypothesized that it messes some with the crime statistics?
AIDS medications? AIDS went from a death sentence to a manageable condition with targeted therapies. See also curing hepatitis-c.
Really medicine is such a broad category that, as others have noted, it seems just crazy to treat it as one thing. There are undoubtedly parts of it that 'work'. Treatment of infections diseases (vaccines, antibiotics, targeted anti-virals) and traumatic injury/event treatment would seem to be exceptionally clear cases. Of course there are parts that don't work or are even negative to health, and in some cases we have a pretty good idea what those are, in others it's less clear. And the claim for health insurance working is more nuanced (particularly for the marginal increase thereof, and the specific implementation may make substantial difference). And many parts scream out of better cost/benefit (and not just monetary, consider over screening and associated unnecessary treatment side-effects that are argued around, for ex. breast and prostate cancer). But just saying it doesn't work is nuts.
Feels that it is somewhat fair to say that the marginal expense side of medicine has lost efficiency. But, that is a banal statement that relies on how effective our groundwork of medical treatments even is today? Stated differently, I would expect that research dollars spent on medical treatments will not go as far today; because they first have to cover known advances that we are building upon.
Taking that to a stronger statement that medical treatments don't work is markedly absurd. Just look through a family tree going back a hundred years. Be sure to ask how many kids aren't included because they died before they were 5. Then pay attention to how many died of sepsis in the past.
"everyone knows that glasses help your vision"
Myopia is increasing not decreasing.
I love Hanson. One of the amazing things about him is that, despite his self-identifying as not very good at social things, he appears to be a natural at some of the Dark Arts. This is a perfect example: by the time you're arguing about specific claims you've already lost. You might as well be arguing with the sportscar salesman about what kind of shirt you'll look coolest in driving this convertible. If medicine were as great as some think it, nobody would have to get down into the weeds to discuss at what ages people are getting cancer.
I mentioned in another comment that if we count 'nutritionists' as medical researchers, folks like Anichkov and Keyes ('saturated fat is bad for obligate herbivores like rabbits therefore it' s bad for you' and 'let me just hide the findings about saturated fat that don't agree with my conclusions) likely have contributed to more cancer than all the rest of the researchers have managed to cure.
Yeah obviously childhood vaccines and acute trauma care are effective, but anyone who has been in public somewhere that isn't rich and trendy can immediately see how sick everyone is. It's bad out there.
I think Robin would probably agree that a drug works. Not all of them but sure, they exist.
The real question is what is the outcome of all medical interventions as typically practiced by the system? If there’s a common drug that helps leukemia and a common surgery that kills more cvd patients then it helps, how do things actually net out? How could you possibly know?
Probably medical system helps but the big takeaway for me is do we really know? Put this in the category of other questions like Caplans do we know education helps kids?
I come away from this thinking A) at least some medicines and condition-screening "works", and B) providing free health care is a bad deal for taxpayers when the recipients are under 45. The rational health policy this would lead to is one where Medicaid expansion is limited to older people, and to the extent certain types of coverage are mandated for insurance carriers it would be heavily focused on things like annual screenings for cancer and hypertension.
While some of this is reflected in PPACA coverage minimums, it also forces insurance companies to provide care that the majority of "customers" will never use, notably substance abuse counseling, pharmaceutical interventions for addiction, expensive patented pre-exposure drugs for unmarried/promiscuous gay males to avoid HIV, and a range of birth control products. And as a result, we have deductibles that aren't far off from the $5K ones RAND considered "very bad" in the 70s, back when insurance was mostly seen as a way to cover accidents and emergencies rather than an overall care plan.
It also continues to baffle me that the people who seemed the most politically active in advocating for various "Medicare 4 All" style programs in the past decade were the younger Millenials in their 20s and 30s, statistically the people for whom increased access to care does demonstrably nothing and who are decades away from any of the mandatory screenings that have benefits. It leaves me to wonder whether these people are particularly neurotic and overuse health care access, particularly sickly, or whether their immediate concern was for older family members. The people most likely to agitate for student loan relief are people who owe a lot of student loans, but the people most likely to agitate for health care access are the people who don't need it?
...Wait what? Why would you want to give free medical access to the people with the least number of productive years left? If increased access to care for younger people does nothing, then that's an argument to get rid of nearly all public health spending.
Assuming Cjw's understanding of effectiveness is correct and assuming your value to optimize of ROI, then this can be reconciled as: "Giving healthcare to increase productivity of individuals at their most productive / highest earning time of their life. The longer we can keep them healthy, the longer they stay employed and out of retirement. In fact for high-earning individuals, not only are we providing free healthcare, but we're requiring regular screening and health checks in order for you keep your license (driver, professional, whatever it takes)."
Welcome to the DMV, check in for your appointment. Make sure you have a copy of your colonoscopy and cholesterol panel with you as well as a filled form C-1. If you do not have your C&C&C on hand, leave and get it immediately. Your appointment will not be held for you if your number is called and you do not have your documents.
>>providing free health care is a bad deal for taxpayers when the recipients are under 45.
No data, but I'd speculate that providing BASIC free healthcare for under 45yo is probably by far the most effective way to spend money because in this demographic we have the problems where medicine brings clear, obvious benefits to survival, reduces disability and (economically) improves productivity, including trauma care (not mental obvs, you'd never afford that with current self diagnosis rates ;), infectious disease (vaccination and treatment), fixing of some easy to fix congenital problems (eg cleft palates), basic reproductive health care (contraception, basic perinatal care for mothers and neonates), t1d.
It's in the late life that the more problematic situations start to dominate.
I've always understood Hanson's considered claim as "we have a huge overemphasis on medicine" not that "modern medicine doesn't work." That's why he suggested cutting medical spending by half, not entirely. This piece doesn't rebut that claim.
Yeah, if that's the argument, it's something to be engaged with. But Hanson can't resist being provocative, so he leads off with "modern medicine is as useless as 17th century medicine with its humours and leeches" and that's not so.
He's never said that. Scott and others are misreading him.
I get the sense that Robin Hanson is trolling people for the lolz.
When I was ten years old, I developed abdominal pain. My mom took me to the doctor, who palpated my abdomen and announced that my appendix was about to burst and I needed surgery immediately.
The post-op recovery sucked really badly, especially for a child (I couldn't laugh, because it hurt so much; I had to eat gross pureed carrot soup and wasn't allowed any fried foods or chocolate for months; I hate carrot soup to this day). But the surgery SAVED MY LIFE. Yes, yes, n = 1 anecdote blah blah, but this particular anecdote is MY LIFE. I'd like to see how Europeans in the 1600s, with their leeches and four humors, would have taken care of my appendix.
Robin Hanson can take his contrarianism and shove it where the sun don't shine.
Wait, I disagree with that. Seeing Scott start from the basics to support something all of us take for granted, and probably should take for granted, still exercises some intellectual muscle that I like having flexed. (Or maybe this is all elementary and I'm a big dum-dum who likes hearing wise tribe elder say smart thing).
In any case, I'd like it if this continued with stranger and stranger stances until we landed on "Contra Krugar the Skulltaker on Cannibalism Benefits" or "Contra the Desert Apostles on Global Warming Accelerationism".
"Contra Krugar the Skulltaker on Cannibalism Benefits"
You know I have to do it 😁
THE HIGHER UNITY
"The Rev. Isaiah Bunter has disappeared into the interior of the Solomon Islands, and it is feared that he may have been devoured by the natives, as there has been a considerable revival of religious customs among the Polynesians."
A real paragraph from a real Paper; only the names altered.
IT was Isaiah Bunter
Who sailed to the world's end,
And spread religion in a way
That he did not intend.
He gave, if not the gospel-feast,
At least a ritual meal;
And in a highly painful sense
He was devoured with zeal.
And who are we (as Henson says)
That we should close the door?
And should not Evangelicals
All jump at shedding Gore?
And many a man will melt in man,
Becoming one, not two,
When smacks across the startled earth
The Kiss of Kikuyu.
Ironically there's starting to be some push in medicine to cut back on appendectomies in appendicitis cases, instead opting for antibiotics, rest, and observation.
Not saying that in your case a modern, current-educated doctor wouldn't have chosen to take yours. Just thought it was ironic.
It seems like the dodge of attributing longer lifespans to “nutrition, sanitation, and wealth” is dumb? Wealth is the dumbest since it manifests as better nutrition and better sanitation (and access to medicine, but we can ignore that for now), so it’s redundant. But even nutrition and sanitation are sus since….aren’t those kind of medicine? Like I guess one could say medicine is only drugs, but is it? Why have nutrition and sanitation gotten better if not for “medical” research?
To me the explanation is obvious. The way insurance works, or is intended to work, is that people rarely need healthcare but would struggle to afford it when they are the rare person who needs it. If a particular condition affects 1/1,000 people and costs $1,000 dollars to fix, then insurance charges everyone $1 and pays for the people who need it. At least in theory and discounting administrative costs, etc.
There are some problems with this simplistic model. The chain of events mentioned in the article is the source of most of it. You can't get people treatment if you don't know they have the disease, which you can't know if they aren't getting to the doctor, which they can't do if they can't afford it/don't have insurance. So instead of 1/1,000 of the population getting treatment, you have a much much higher percentage getting checked for the condition, some proportion getting a more significant follow-up check to confirm, and then some final number getting treated. This final number is likely higher than 1/1,000 because it includes people who are mistakenly diagnosed or who fall below some threshold where treatment is necessary but still get the treatment anyway (which the patient will often demand and medical malpractice makes difficult to say no to).
So the costs that should be a certain figure are significantly higher, and most of the difference is not helping actual patient outcomes. You're still only benefitting 1/1,000 of the population, while spending resources on most of the population.
If he's taking the strong stance that all medicine is bunk, then I strongly disagree. If he's taking the weaker stance that a significant portion, likely an overwhelming majority, of our expense on healthcare is wasted/ineffective, I do agree with that. In fact, I think that explains why we get such small results over the population despite knowing that medical interventions *have* to be working in many cases.
Roughly speaking, I would guess that the first 1% of GDP put into healthcare is likely miraculous in results, the next few percent are very effective, the next few percent are actuarily measurable, the next few are a wash in a cost/benefit sense, and the last few are actually making things worse. Averaged out over the whole cost, we end up being unable to link spending with outcomes in a measurable way.
I think his claims totally make sense if you think about the almost 20% of GDP spent compared to how difficult it is to measure positive outcomes. The problem is not that medicine is worthless/ineffective, but that we spend a majority of our healthcare money on things that even in theory can't help people feel better (diagnostics, real estate, administration) to find the small minority of cases that we can help with relatively cheap medical care (relative to the total cost).
If you look at how the US is a *massive* outlier in many analyses of the relationship between healthcare expenditure and outcomes (at this short notice I can only supply this life expectancy chart, but even that is fairly striking:
https://ourworldindata.org/grapher/life-expectancy-vs-health-expenditure )
... maybe the question of whether medicine works should be replaced by one of how come your healthcare system works SO BADLY. To the point that countries which spent between the fifth and tenth of what the US spends per capita achieve comparable life expectancies -- this would favour massively decreasing marginal returns hypothesis -- but also, countries that spend relatively higher amounts, still nowhere near as high as the US but more like half to three-quarters of the US spend (Switzerland, Norway, Canada - I'm ignoring Japan because of too much cultural difference) have life expectancies higher by a good few years. So, extra spending does make a difference, but seemingly not in the US?
Can't Baumol explain a lot of that spending difference? I know this chart is in international dollars, but US doctors make an average of $350k/year while Japanese doctors make an average of $100-150k/year in 2022 international dollars. I know doctors are only one part of the system, and the system is what contributes to doctors being paid so much (and we should almost certainly relax restrictions on supply), but the spending numbers wouldn't look so bad without the Baumol effect.
Right, but why do you think this effect would be so much stronger in the US than Japan or EU, for example?
Also that US average for ALL DOCTORS seems *astonishingly high*: average UK doctor earns a bit more than 2x average UK teacher, but in the US is a factor of 7x....
The US is richer. In Japan if the doctor had decided to be a programmer, what would they make vs if they if the opted to be a programmer in the US? (Lean 2 Code doctors!)
Or for a more similar skillset: opted to be a small business owner (which many doctors in the US effectively are).
Don't get me wrong, the hellish hazing they put doctors through definitely artificially restricts supply. But even accounting for PPP, many jobs (particularly high-end jobs) pay a lot more in the US than elsewhere.
The reason Robin interprets null results as negative results is that studies do not fall from the sky (except natural experiments). The RAND study was designed to detect a certain level of effect. Its failure to detect that effect is a statistically significant rejection of the hypothesis of effectiveness held by the designers. This is a dangerous line of thought, but also having a prior on a non-quantitative hypothesis like "medicine is real" is also a dangerous line of thought. The zero point isn't magic. Medicine has obvious health costs. If marginal medicine is designed to have a 10:1 health benefit to health cost and then it is discovered to only have 1/10th the benefit it was believed to, it is quite easy for it to be net negative.
Lots of problems with this analysis on both sides. Imagine a trial where you give out free aspirin to people and track how their headaches improve. The biggest finding is that people didn't have to go out and buy their own aspirin as much. Okay, so this study wasn't about whether people got aspirin (giving it away for free isn't the same as preventing people from getting it) so much as the financial benefit of having to pay for something or not.
I'm mostly NOT sympathetic to Hanson's point, but the decrease in depression and reduced financial burden might be correlated with "didn't have to pay for health insurance" in the Oregon study. Let's take a charitable middle ground argument and say that at least 15% of health care spending obviously works (especially a lot of interventional stuff people in the comments have mentioned; I'd also add cancer therapies with good overall survival benefits, like imatinib, but probably not most modern medicines).
On the other side, let's say at least 50% of health care spending is just ineffective cope for "your lifestyle choices made you unhealthy and we're going to pretend to fix all that". We'll set aside the other 35%, for now, as 'uncertain benefit'. If we cut health care spending from 20% of GDP to 10% of GDP, would people be better off?
(Would people be better off if we shifted 10% of GDP to helping people get fit instead? Probably not. Increased nutrition advice seems to be inversely correlated to people getting thin and fit. Either it doesn't work or it harms people. We need good evidence on this one before we roll it out widely.)
The assessments of whether health care make you better off or not are terrible. That increase in HTN meds? First, I would assume the most severe cases start off on the meds, so increasing HTN medication availability should yield diminishing returns. But what were those returns? Lower blood pressure. Really?! Who cares whether their BP is 140/90 vs. 137/87? Patients care about whether they get headaches, or SOB, or more importantly whether they're going to die of a heart attack. It's death and pain that people get hung up on.
Doc: Where does it hurt?
Patient: In the HbA1c.
Nobody does this. People don't care about their hemoglobin's post-translational modifications, the salinity of their urine, or how much triglycerides are in their blood. They care about living long, better lives. So the real question is: do people live better and/or longer with the intervention. Most of these studies don't measure that over the long term, and aren't designed to. Therefore we can't conclude one way or the other about efficacy.
The correct study is to look at either lifespan or overall survival over long time horizons. There's a reason nobody is doing this. That study is impractical and by the time you get the results it's been a half century and medicine has changed. There's no exception that says "bad data can be substituted for good data because it's impractical to do it right". The exception is, "if we can't do it right, then we just don't know."
>Doc: Where does it hurt?
>Patient: In the HbA1c.
LOL!
>The exception is, "if we can't do it right, then we just don't know."
Yup. I must say, I tend to cringe at studies where the end result is a biomarker change... Even if the biomarker is a valid predictor in an unmodified population, once you start to modify the population, how sure is anyone that the biomarker is still a valid predictor?
I'd be interested in his analysis of addiction treatment. One argument would be that after a brief medical detox, treatment does nothing to increase the odds of sobriety. The other argument would be that people who want to remain sober need multiple interventions across many domains such as economic, housing, emotional, social, and legal.
I'm stopping near the beginning to comment. My spouse is a highly cited, known medical researcher of integrity, and he has been saying the exact. same. things. for years. Our educated friends dismiss him out of hand in spite of hard data and extreme expertise. He thinks statins made a difference in quality of life late in life, and they meet the criteria for validated research. He likes my hip replacement; surgery matters. Antibiotics in moderation matter.
But in general, much medicine and especially socialized medicine is an elaborate grift at the top, supported by well-meaning people who do not question simplistic, conventional narrative.
There are a some things in medicine that work. Vaccines. Anti-hypertensives. Statins. ACE inhibitors. Pap smears. Post-MI care. There are a million studies showing disease-specific as well as all-cause mortality benefits to those interventions. (And some studies that challenge those, but the preponderance of evidence is in favor of mortality reduction.) But there are a million devices, medicines, tests, and woowoo for which we either have no evidence or evidence of no, and which we let the medical system sell with impunity. Population health improvements have been striking. Covid barely made a dent in what we have been able to achieve over the past 200-300 years. Some of that is clearly nutrition, sanitation, etc. And some medical technologies clearly help spin the wheels underneath those mortality reductions but beyond the obvious suspects, we do not know what else is helping. Just some ballpark numbers: out of about 1 million devices, medicines, and tests, maybe 1000 are clearly effective. That's 0.1% with clear benefits. That's enough to account for the majority of the ~2-3mo improvement in life expectancy yearly. But it's also not enough for someone to claim with pretty good certainly that >99% of the stuff in medicine is probably nothing (and I include placebo in nothing).
I very much doubt effective treatments are only 0.1 percent of all medical interventions that are done. But accepting it for the sake of argument, it then reminds me of an old biology/ecology joke:
We have reason to believe that 99.9 percent of all species that have ever lived, are extinct.
Therefore, as a first approximation, we can assume that all species are extinct.
...perhaps this is the reasoning behind the "all medicine is bunk" assumption.
I largely agree with your conclusions. People are far too quick to assume that more expensive insurance leads to better treatment. Medical insurance is actually very disconnected from health outcomes, as you show in your funnel. That is why expanding health insurance yields tepid results.
I think the problem is not that modern medicine does not work. It is largely about diminishing returns per marginal dollar invested, and the fact that there are other factors that are far more closely liked to health outcomes.
Genetics and healthy habits do far more for long-term health than medical treatments and insurance.
What he actually proves is that intelligence does not make you smarter.
It will save a lot of effort for readers of this blog to recall that Scott is not pedantic and therefore the phrase "claims that medicine does not work" is an extremely valid rhetorical description of the fact that Hanson is arguing that the marginal value of health care is literally zero - even dismissing the Obamacare study with significant statistical power
Furthermore if you do find the 'marginal health spending is not relatively valuable' argument to be persuasive and wish to defend it you should probably support the concept that the argument should be specifically made in a more defensible and persuasive manner!
Scott's post about how the media rarely "lies" shows that he's pedantic, after all.
> Likewise for weight loss - the 1970s were in the unfortunate interregnum between the fall of methamphetamine and the rise of Ozempic.
This is such a banger line lmao.
I too see the 20th(and a solid chunk of the 21st) century as a corpulent interregnum between famines and Ozempic
I own the book and flipped to the relevant chapter, and the section about modern medicine opens with this sentence, "Medicine today is different in one crucial regard: it's often very effective."
I suspect he will just say that he doesn't believe that medicine doesn't work and that this is a strawman.
I don't have the book in PDF, so I'm going to great pains to write these quotes, but here's more.
"The big historical improvements in medical technology don't tell us much about the value of the marginal medicine we consume in developed countries. Remember we're not asking whether some medicine is better than no medicine, but whether spending $7000 in a year is better for our health than spending $5000. It's perfectly consistent to believe that modern medicine performs miracles and that we frequently overtreat ourselves."
So you're effectively saying that Scott's contra is arguing against a non-existing claim, and Hanson is making a borderline no-brainer claim about the highest spending countries?
Yes, that's basically it. The US spends a ton on healthcare and it's perfectly natural to assume there is a lot of waste. Scott takes issue with some studies that Hanson uses to make this point, but in terms of priors it's a sensible claim.
THIS claim seems sensible. It would be potentially sensible even if ALL treatments worked. It's an economics/budgetary claim -- if literally every treatment was net effective, provided they had very high unit costs and/or very high NNTs.
The claim Scott is arguing with is a claim that (charitably) *as a whole* medicine as a system doesn't work, anywhere in the world (more charitably: in the US but they include the Indian study), or (most preposterously) that while some medical treatments might be net effective, as a total they do nothing. Which isn't at all what your quotes suggest.
Very interesting, thank you for typing those in!
Given that higher aggregate health care spending is often seen as, roughly, a "good thing" by many people, it probably isn't accurate to call it a "no-brainer" claim.
Ok, fair. The notion of marginal costs and diminishing returns evokes distaste when applied to things like medicine, yet obviously all (or maybe not all, maybe only socialised ones) systems assign monetary values to DALYs or whatever other measure they use when allocating resources or approving treatments or devices.
True, not sure what we conclude from that though? Using cost/benefit measures for top-level funding decisions is a long way from the practice of medicine at the front line.
Are these quotes from Hanson's book, or from the book that was written by the study authors?
Hanson's book
Do most people think that higher life expectancies are due to medicine treatments? I don't think most 70 year olds have had a life saving medical procedure during their lives.
A lot of money in medicine is spent doing stuff "just in case" (like unnecessary tests, MRI's, check ups) as well as making the experience more pleasant for the patient. You could design a maximally cheap health care system from the top down where patients can't choose their physician, can't see a specialist without fulfilling specific guidelines, don't get access to any examinations that aren't evidence based, where there are long waiting periods for everything that isn't urgent, -- and this would save a lot of money probably without statistical detriment to outcomes. Patients would hate it though. (This is what public health care is like in some countries.) A lot of people with enough money or private insurance would still spend a lot of money to get more "luxurious" care (like going to a specialist right away or getting an MRI even when there is no strict medical need.) The point is that only part of the money in medicine goes to medical outcomes, per se.
I mean, if European countries that spend about 10% of their GDP on health care get about the same outcomes as the United States that spends nearly 20% (and has a higher GDP per capita), it is pretty clear that theoretically the United States could save a lot on healthcare. You don't need to try to argue that "modern medicine doesn't work any better than blood letting".
In terms of life expectancy at least, better outcomes in many EU countries.
Even the UK, in comparable cultural/lifestyle universe, has a slightly higher LE than the US while spending about half the money (less than half in absolute terms, bit more than half as GDP %)
The average pay for a doctor in the UK is 94k in 2022 international dollars. In the US it is 350k. Physician pay isn't everything but the salaries of other roles in the system probably is similarly inflated. Nurse pay in the US is about twice UK in international dollars. How much of this is Baumol? Or is it all wealth extraction by a cartel?
I'm sure a lot is systemic in various Moloch-y ways. Even leaving aside medical professionals pay you have the fact that with socialised healthcare paying the vast majority of the drug costs, the price of drugs is negotiated (functionally: regulated) at a national level. I'm not sure if Medicare / Medicaid do that in the US. It wouldn't surprise me if much of the "excess spend" went directly on drugs and med professionals pay.
Feels more like some kind of cartel effect because from what I've read your teachers' salaries aren't all that wonderful and they should be subject to Baumol effects?
Same effect with teachers. I didn't Google too hard but the average pay for teachers in the UK was mostly expressed as ranges, but it looked like 24k-35k GBP which translates to 34k-50k international dollars, whereas in the USA it's 66k international dollars.
Of course that doesn't take into account total compensation package, don't know how generous retirement benefits are in the UK, but in the USA the retirement benefits are known to be a large part of compensation.
(No, I don't believe medicare/medicaid negotiates drug rates, in fact I think they are prevented from doing it.)
Of note, it doesn't look like overall median pay for all professions in the US is double that of the UK. 60k USA vs 48k UK. But if there's a significant premium for teachers and medical professionals, I'd be curious to know which professions are paid less in the US than in the UK.
> Do most people think that higher life expectancies are due to medicine treatments? I don't think most 70 year olds have had a life saving medical procedure during their lives.
Of course medical interventions affect life expectancy. Looking at ONE common condition, something like 6.7-8.6% of the population gets appendicitis at some point in their lives[1]. It has a 50% death rate untreated[2] and had a 26% death rate (with treatment) 50 years ago[3]. The current death rate is <1%. Treatment for that one condition probably adds at least several months to life expectancy.[4]
Obviously we're overpaying for that treatment in the US, but that's overpaying in the "seems like I could pay less for the same service" sense, not the "there is no consumer surplus, why bother?" sense.
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9945388/
[2] https://www.merckmanuals.com/home/digestive-disorders/gastrointestinal-emergencies/appendicitis#Prognosis_v758089 "Without surgery or antibiotics (as might occur in a person in a remote location without access to modern medical care), more than 50% of people with appendicitis die."
[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1422654/ "There has been a dramatic reduction in the mortality rate attributed to acute appendicitis over the past 50 years from nearly 26% to less than 1%."
[4] I didn't do the calculations, but eyeballing the chart in the link, it seems like the average appendicitis case has decades of life left. https://www.researchgate.net/figure/Annual-incidence-of-appendicitis-per-100-000-people-in-Taiwan-according-to-age-group_fig4_282047087
Yes, but what I meant was that in general, “what the life expectancy of a human being is” is not set by “medicine keeping people alive”.
"Human life expectancy is a statistical measure of the estimate of the average remaining years of life at a given age." (https://en.m.wikipedia.org/wiki/Life_expectancy) that is definitely affected by medicine keeping people alive.
Are you thinking of life span ("the maximum amount of time that a member of a given species could survive between birth and death, provided circumstances that are optimal to that member's longevity")? There are no treatments that I know of which have been shown to extend human life span, though some exist for worms and mice.
I mean how long people expect to live. So in a more colloquial sense that is somewhere between those two concepts.
Obviously saving anyone’s life increases the calculated life expectancy of a population somewhat but the effect is marginal.
Even the oldest known surgery, trephination, worked, as fossils show the trephined lived lives after the procedure.
That just proves it didn't kill them, not that they needed the procedure.
Don't statins pretty neatly bust Hanson's claim?
Heart disease is a top killer. The NNT_5 for the absolute lowest risk group on statins is 400.
NNT_5 is too short even, because statin benefits compound over decades.
Statins are also cheap and well tolerated
Given higher risk groups have a lower NNT, and people will be on them for decades, aren't we likely saving millions of lives?
Trephination is still done occasionally today. When a person gets a concussion, the brain swells inside the cranium. Trephination relives the pressure and minimizes brain damage. No doubt there were many, many, head traumas in early human evolution, so it seems reasonable that the procedure was thought out and its usefulness deduced. I forgot to mention that trephination is known in early human history all over the world, so it's unlikely it was local religious myth of some sort. References available in my Fundamentals of Cognitive Science (Routledge).
The quote starting with "The rate of mortality among previously uninsured 45-64 year-olds" seems to have had some copy/paste errors, there are missing letters and extra spaces inserted.
I'm dying from recurrent / metastatic squamous cell carcinoma of the head and neck (R / M HNSCC_frustrating), so the sections about cancer in particular stand out to me. Regardless of the current state-of-the-art for cancer treatment, personalized and mRNA vaccines are likely on the verge of revolutionizing cancer treatment.
Take the HNSCC that's killing me: I got a partial glossectomy in Oct. 2022. Mine had some high-risk features, but I was assured that, with radiation therapy, it wouldn't recur In retrospect, I obviously should've done chemo and radiation, but at the time I was pleased to not need chemo, and I foolishly didn't look deeply into the data on recurrence, which is common for HNSCC, and I didn't seek second opinions.
Docs are reluctant to impose systemic chemo because of the side effects. But Transgene has a personalized vaccine that is supposed to prevent HNSCC recurrence: https://www.nec.com/en/press/202304/global_20230418_01.html: "In the head and neck cancer trial to date, all patients treated with TG4050 have remained disease-free, despite unfavorable systemic immunity and tumor micro-environment before treatment," And most of these personalized vaccines have essentially no side effects.
Moderna's mRNA-4157 platform also looks good: https://jakeseliger.com/2024/04/12/moderna-mrna-4157-v90-news-for-head-and-neck-cancer-patients-like-me/, not only in R / M HNSCC, but in melanoma and lung, too. Right now mRNA-4157 is only being tested in the recurrent / metastatic setting, as far as I know, but the logical time to use it is probably when initial surgeries are done: cut the cancer, sequence it, and then vaccine against it to prevent recurrence.
Right now, from a society-wide perspective, the healthcare I've been getting probably fails the cost-benefit test (apart from the fact that the data I'm generating for clinical trials helps move the state-of-the-art forward). My quality of life is low, and while treatment has been extending my life, it almost certainly won't lead to remission. And even if a clinical-trial drug somehow leads to complete remission, I'll never be able to sleep or speak normally again (https://jakeseliger.com/2023/08/27/on-being-ready-to-die-and-yet-also-now-being-able-to-swallow-slurries-including-ice-cream/). A few months ago my brother casually referred to me being disabled, and I was momentarily confused: Who was he talking about? But he was in fact right: I'm disabled and unlikely to ever be able to think or work in the way I did before losing my tongue.
But that should change! Part of the reason I'm so frustrated by the FDA is that mRNA-4157 and TG4050 should already be available for HNSCC. Instead, they're stuck in trial hell, while HNSCC patients like me suffer recurrences and then die.
I remember the 2008 Oregon experiment. I assume that the researchers had to throw something together very quickly if in order to take advantage of the opportunity to perform a controlled study with random assignment. That's why they ended up with self assessment questionaires that the researchers acknowledged might not reflect actual improvements in health, and measures of clinical results where the improvements were too small to be statistically significant
After the study was released, David Brooks claimed on the PBS New Hour that it showed that people didn't benefit from Medicaid--but I note that Brooks never announced that he was giving up <em>his</em> health insurance.
US health spending as a percentage of GDP has been just over 17% every single year since 2008 except for two specific years: 2020 and 2021. Those two years obviously were impacted by COVID on both sides of the ratio, and for 2022 the percentage settled right back down to 17.3%.
My point here is not about whether 17.3 compared to 19.7 (the 2020 peak pct) invalidates Hanson's argument. Rather it is that his cherry-picking of an obvious outlier year, and then rounding it up rhetorically to represent the norm ("we spend 20% of GDP on medicine"), is enough to me to conclude that he's not presenting any actual serious argument he's just internetting.
Scott concludes: "I think if Robin wants to do something with these insurance study results, he should follow other economists, including the study authors, and argue about whether the marginal unit of insurance is cost-effective"
...fair enough, but you seem to forget what the product insurance (all types of insurance) provides/is meant to provide.
The product is not better health, or a promise of better health.
The product is peace of mind. The product is the knowledge that if you need health care, in particular expensive care, it will not bring economic ruin to yourself or your family.
This is the reason health insurance is usually popular, even in population segments that are seldom in need of health care.
If health insurance should turn out also to improve health outcomes, that is great. But if so it is an added bonus. It is not the point of insurance, public as well as private.
I don't buy this. I think "peace of mind" is definitely something insurance (and marketing for insurance) definitely tries to sell. I also think that in this modern age where emergency treatment doesn't ask how you are going to pay before treating you, and medical debt is something you can work around, that it is definitely a larger part of the product. But I think the core product that insurance provides is literally redistributing money to pay for health care.
Or cars. Or funerals. Or to replace your crops. Or to take care of dependents.
Just like a casino tries to put a fig leaf on "we just sell entertainment" (or donating to your local church, or state education fund), and it is entertaining, but the product is redistribution of wealth.
I think in the modern world of easy credit, or casual enjoyment of Poker Stars, we forget this. If the main product is really peace of mind, I'm sure there's a more efficient way to pursue that and insurance would have been outcompeted by now.
Yeah well, it's your prior (as they say here....)
I do not expect to convince you otherwise in a comment section, but if you are interested in exploring the insurance-argument for why health and other types of insurance exist (and indirectly why all high-income states are "welfare states" today), I recommend the works by the economist Nicholas Barr, the historian Peter Baldwin and the philosopher Joseph Heath.
Many others have also written convincingly about insurance-demands (rather than demands for redistribution) being the core driver behind the history of modern (welfare) states, over the last 100 years. But these three stand out.
Maybe he doesn't consider insulin a medication because it's technically a hormone. Maybe he excludes *all* life-saving and life-extending treatments and medical procedures.
If he did this, there may be a compelling economic argument. But that's not the argument he's making.
Modern RCT trials are allowed to assume side effects are exactly zero if the P value of side effects is <0.05 between the control and treatment arms. Because of the base rates of other diseases, this can lead to treatments passing RCT that are neutral or even negative on net.
I am broadly with Hanson on this one.
Most treatments have very high "number to treat", being in a hospital is dangerous because of chance for MRSA, surgical errors, etc. drugs studies get to ignore side effects unless they are really obvious, often they can get away with garbage proxy metrics as has been discussed by Scott often this blog.
RFK Jr (yes, I take him AND Bryan Caplan seriously) makes an interesting point in his little-noted most-recent book, The Wuhan Cover-Up, that vaccine research may kill as many people through lab leaks as they do, or might, save through effects of the resultant vaccines. Think COVID-19, though there are MANY others, obviously of smaller scale. The lab leaks are, indeed, VERY common, and potent, too.
Then, of course, there are capers like Anthony Fauci's with AZT, and so on.
I wholeheartedly endorse beating up (metaphorically) of all contrarians all the time.
There is a massive difference between "medicine doesn't help" and "lowering the cost of medicine doesn't lead to large jumps in health outcomes."
For my everyday life, my use of medicine is bottlenecked by inclination and time (as I have no pressing medical issues). For the majority of emergencies, I am similarly lucky enough to be able to afford healthcare. It's only that when the medical issues is very rare or the benefits slim that my insurance is likely not to cover me.
The most clear cut cases where medicine is needed, like the terminal illnesses Scott lists, have the best ratio of benefits to iatrogenic risks, and are probably already saturated in terms of medicine usage. The marginal increase in medicine consumption is going to be on some use-case much more marginal, where the ratio of benefits to iatrogenic risks is much worse. So the impressive results in section 1 of Scott’s post are entirely compatible with marginal increase in medicine consumption having null effect on health
>It would be easy to round Hanson’s position off to something weaker, like “extra health care isn’t valuable on the margin”. This is how most people interpret the studies he cites.
>I’ve spent fifteen years not responding to this argument, because I worry it would be harsh and annoying to use my platform to beat up on one contrarian who nobody else listens to. But I recently learned Bryan Caplan also takes this seriously. Beating up on two contrarians who nobody else listens to is a great use of a platform!
Does Caplan really think medicine is generally useless, or does he merely espouse the mostly uncontroversial position that "extra health care isn’t valuable on the margin?"
All he writes is that:
>I’m puzzled. The idea that the quality of health care has improved is already almost universally accepted. Economists who argue that healthcare expenditures are wasteful are self-consciously challenging this standard view, highlighting surprisingly strong evidence that marginal medicine fails to improve health. See Robin Hanson’s “Cut Medicine in Half” for details.
Not only does he reference that marginal benefit of medicine, his actual point is almost the opposite; that the conventional wisdom is that the quality of health care has improved. In that context, although he makes passing reference to Hanson, it isn't even clear that he espouses the weaker fairly uncontroversial version of the arguement. If, e.g. he thought there were a 25% chance that (the weak version of) Hanson's argument were correct, that could still qualify as "surprisingly strong evidence," given that he notes that the position challenges the standard view.
Hanson's point is about whether medicine works. Rather than add in the complexities of insurance coverage (RAND, Oregon and Karnataka) to refute his point, you could probably have just said "Look at the UK, Canada and other countries where healthcare is (effectively) free - or at least where the population doesn't worry about massive medical debt (contra the US studies) and knows how the, possibly new to them, system works (contra the Indian study) and lo and behold, health outcomes have indeed gone up MASSIVELY in the last century."
I mean, the article would have been shorter and more boring, but my first thought when I read Hanson was "Using the US isn't helping your case."
This isn't original to me, but I think it's worth flagging: five-year survival rates after diagnosis can be massively improved just by diagnosing earlier, even if you don't do anything to meaningfully improve cancer survival, assuming increasing lethality over time. I'm not saying that we've done nothing to make cancer safer, but I'd prefer a chart that looked at X years of survival after a Stage 3 diagnosis (or a more closely matched comparison).
I'm sure someone else has invoked the famous Orwell quote elsewhere in this comment section; but in case they haven't - "some ideas are so absurd that only an intellectual could believe them".
There's a trap that contrarians often fall into, of seeing the justification of outlandish propositions as some sort of cognitive challenge. Something like, "proving black is white is really hard, but I reckon I could pull it off." At some point such people are so caught up in their own cleverness that they lose track of whether what they're defending is actually true or not.
I’m generally very sympathetic to your side of the argument. However, if I was Hanson’s lawyer, exhibit A might be the opioid epidemic. It can arguably be traced back to the over prescription of opioids, and has had a massive negative impact on health in the US, an impact that wouldn’t show up in a health insurance RCT, because the epidemic eventually spread throughout society. Maybe medicine has or could create other issues like this (more resilient diseases?)? As counsel I would also discuss the direct evidence for medical care causing deaths through accidents, infections, etc. I don’t think these things would net out in Hanson’s favor, but would be interested to see you address them.
Bryan Caplan tweeting: If I know robinhanson, he's writing a response to acx/slatestarcodex
as we speak. https://twitter.com/bryan_caplan/status/1783253216399880380?cn=ZmxleGlibGVfcmVjcw%3D%3D&refsrc=email
I appreciate you going into this topic. Hanson's position has always seemed both solid and extremely challenging to fit into any consistent model of the world.
(It would also be great to have a more general post on "How much evidence should we require before giving credence to '[entire area of study] just doesn't work' theories?")
I am biased in Scott's favor. But I was a bit disappointed that his argument seemed to proceed as if Hanson claims that there have been no improvements in medical outcomes over time. The question is not how much things have improved, but what caused it, which I think is harder to say. Maybe some of those studies address this, and it seemed too obvious for Scott to hammer on it (or I skimmed over his hammering). I have been surprised by things before, so I wish I thought this really settled the issue. If it did, I missed it.
I find it odd that economists - the pseudoscience to beat the bands - produces people who not just attack other more scientific fields (although medicine isn’t a very hard science) and prove their lack of statistical ability while doing so.
Does the contrarian ever explain why he had surgery to fix a broken arm instead of going medieval on it?
Being myself a physician, I tend to underplay medicine's success, but even I see that the main thing here is perspective. There's a bias to see anything that transitions from "cutting edge high tech" to "low tech" as obvious and commonplace, as "low hanging fruit" in retrospect. as something that was always there.
In the logarithmic graph of medical success, nothing will ever beat the 4 main things that brought us to where we are today - Sanitation, Obstetrics, Vaccination and Antibiotics - all are now so low tech so as to seem divorced from medicine, but they did originate as medicine technology. We can add exercise and nutrition as additional ones today.
The rest of medicine suffers from availability bias - if you don't know anyone close to you that has had a heart attack, stroke, cancer, physical trauma such as a car crash, appendicitis, need for an organ transplant, one of the plethora of autoimmune diseases, etc., it is quite reasonable to think the whole field is useless. But I think that's the hallmark of a functioning system, conceptually - it's invisible to you until you need it, and then it provides.
I'll join the chorus of voices saying that both Hanson's opinion and Scott's refutation are underspecified in exactly what phenomenon they are evaluating.
But consider some specific cases: not just obvious things like antibiotics for infection, but on one hand, take the random person whose debilitating ailment is alleviated by a very specific medicine. If you know older people you can probably name one. Then consider the other random person who takes a daily regime of a dozen pills prescribed by a variety of doctors, who can barely manage to figure out which pills they have already taken or not, and whose liver or kidneys or brain are slowly being intoxicated by the combination. My quick take is that #1 is beneficial, and #2 is harmful ("iatrogenic" is the word nowadays). But you can't easily have one without (some of) the other. By hypothesis #1's medicine is highly specific, so if you under-invest in medical care, patient #1 is out of luck and might as well kill themselves. But #2 is basically a question of *quality*; what they need is a good doctor to review their entire regime and rationalize it. So the balance points towards "we want better medicine" rather than less of it.
The other thing, if you take the broadest possible view, is that the entire modern-industrial-capitalist environment is making us sick and then turning around and selling us dangerous remedies for it. I can sympathize with this view. Barbara Ehrenreich (look her up!) explains it at length in her book Natural Causes. But at this kind of level it's hard to go from global diagnosis to practical applications. And it's not like pre-industrial people were known for their longevity and great health anyway.
It seems like something went wrong copying this quote or it's just shown incorrectly in my browser (firefox 124.01) .
> Using treatment group assignment as an instrument for coverage, we estimate that the average per-month effect of the coverage induced by the intervention on two-year mortality was approximately -0.17 percentage points. We caution, however, that the magnitude of the mortality eect is imprecisely estimated; our con dence interval is consistent with both moderate and large eects of coverage on mortality. At the same time, our estimated con dence interval is su ciently precise to rule out per-month eects smaller in magnitude than -0.03 percentage points, including the estimate from the OLS regression of mortality on coverage across individuals.
Seems like the fs got replaced everywhere except at the first effect where there also is an additional weird character.
Copying it directly from the paper "con dence" I get the same result. However, the text is rendered "correctly" in the pdf.
> I’ve spent fifteen years not responding to this argument, because I worry it would be harsh and annoying to use my platform to beat up on one contrarian who nobody else listens to. But I recently learned Bryan Caplan also takes this seriously. Beating up on two contrarians who nobody else listens to is a great use of a platform!
I'm out of the loop here. Is this intended to be playful ribbing? Because it sounds a little mean. I'm aware Hanson is a proto-LessWronger but not really aware of who Caplan is.
https://en.wikipedia.org/wiki/Bryan_Caplan
Caplan is an intelligent contrarian whose beliefs seem aligned with the LW/ACX subculture (and I think he attends LW/ACX meetups in his area, but I am not sure about it), and you should probably check out his books because you will probably like them. He definitely makes very good points... the question is whether his conclusions are overall good, or whether he just argues one side of the issue and takes to too much to the extreme.
For example, the argument in "The Myth of the Rational Voter" is that your vote is just one of many millions, so it has little impact on the actual result of the election, but your expressed political opinions have a large impact on how people around you treat you regardless of whether your favorite politician wins, therefore... we should not be surprised at all when people adopt harmful political opinions that make them popular among their peers, because it makes sense for them, selfishly.
In "Selfish Reasons to Have More Kids" Caplan argues that intelligent people should have more kids, especially the ones who actually would like to have more kids, but are worried whether they can provide them a sufficient quality of life, pay the necessary education, etc. The outcomes in life are correlated with intelligence a lot, so if you give your kids the high intelligence, they will probably be okay, even if you spend a little less money and time on each of them individually. (Caplan has 4 children, by the way.)
In "The Case Against Education" he reminds us that when schools brag about the outcomes of their students, they conveniently forget to mention that they already filtered the students at the entry exams, so it is questionable how much of the outcome is a result of something that "was already there" and how much is the actual "value added" by the school; and he uses various statistics to argue that it is mostly (about 80%) the former.
"Open Borders: The Science and Ethics of Immigration" seems like the classical libertarian argument, but with cartoons.
Thank you!
One problem with the funnel (especially for marginal care) is that at some of the steps, there's some probability that the effect will be bad. I go to the doctor more often when the doctor can't help me, and one of those times I catch the flu from one of the other patients. The attempts at diagnosis do me more harm than good--I have an allergic reaction to the contrast agent for the CT scan, for example. I get put on an additional drug for a marginal thing (the doctor gives me antibiotics for my cold to placate me) and have an allergic reaction to them.
I have no idea how big this effect is, but I'm sure it exists. And we should expect to see it have its biggest impact when we're going to the doctor for marginal stuff. If I suddenly go numb on one side of my body, my worries about medical error making me worse off are *way* smaller than my worries that I'm having a stroke; if I have an annoying cold and go to the doctor for it, the probability he's going to do me harm is higher than the very low probability he's going to do me any good.
I think you are arguing a straw man version of Robin Hanson's view. He does not claim that all medicine is ineffective. His claim is that the helpful treatments are offset in the aggregate by harmful interventions. I refer to the latter as "Hansonian medicine." His explanation for observations that greater access to health insurance does not improve health is that it increases access to harmful interventions as well as to beneficial ones.
That’s how I viewed it too. Liked your book btw.
Interesting post! I think the claim that all medicine doesn't work is too strong but you should check out the book "Medical Nihilism" for a nice Bayesian argument against efficacy of most drugs. Tldr: there are like 30 drugs doing all the work while the rest are free riding on that reputation.
Killer read. Thanks Astral : )
My response: https://www.overcomingbias.com/p/response-to-scott-alexander-on-medical
I'm a HUGE fan of Robin Hanson, and for that reason I'm all the more thankful for Scott tackling the parts of his writing where Robin seems obviously egregiously contrarian to the point of being just wrong.
Thank you, Scott! Please engage Robin in the future, as well.
I cracked laughing out loud at the following:
"I’ll follow Robin’s lead in dismissing the entire medical literature - every RCT of every medication or treatment ever published - because it might have “huge biases,” and try to rely on other sources."
Maybe one of the reasons for low effectivity of medicine are side effects from prescription drugs!?
https://brownstone.org/articles/prescription-drugs-are-the-leading-cause-of-death/
Why are people getting cancer younger now?
Just wondering.
Hanson and Caplan are not undermining the stereotype that libertarians would say the Earth was flat if that's what it took to reduce taxes.
My mom eats like a saint and takes her blood pressure medication and she still struggles. No, she's not secretly cheating or something, I know how she eats. I have heard a lot of stories like this. Maybe the proven isn't medicine but blood pressure medicine?
I think the antihypertensive point furthers Robin's argument to a certain degree. Last time I checked, while lowering blood pressure is associated with lower all-cause mortality, the effect is pretty minimal. Don't get me wrong, there is a pretty significant *relative* effect, but the *absolute* reduction is minimal.
I think this distinction is what Robin's getting at most of the time. He's never really arguing medicine doesn't work, it's more like the cost of it outweighs the utility of it most of the time because our great treatments are not so great at extending lifespan in absolute terms.
Please do Ioannidis in the same fashion. Basic idea, science has issues, but science works.
When Scott says "nobody else listens to" Hanson, is he just implying that Hanson has a small audience, or does Scott mean that Hanson's audience may be large, but few are willing to "listen" in the sense that they will fully accept and take action on his conclusions?
I think using studies on medical insurance to make general statements on medicine in general is just idiotic. Extraordinary statements require extraordinary evidence. It's a load of bullshit. Let's close pharmacies, clinics and hospitals and see how it goes. You think it's hard to do that? Instead of studying the economics of Obamacare better study economics of war-torn African regions and see what happens when people can't become refugees in rich countries and are in civil wars for decades.
The good news is that with the ridiculous price increases on health care, the percentage of Americans on the worst plans will keep increasing. So there should be lots of data to analyze.
A bigger problem is the cost of the health insurance itself: at 18% of GDP, it is a larger and larger percentage of overall household spending, period. What are the health effects of too expensive health insurance? Of medical bankruptcies associated with the bad health care plans? Of the billing scorched earth war between doctors and their billing managers vs. insurance companies?
I totally agree. Health insurancies studies are really a bad starting point. It tests insurancies's efficiency, which is not that good, more than medicine's efficiency. The problem is that libertarians have blind faith in insurancy mecanism.