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What will January 20th do for science-based medicine?

Make no little plans; they have no power to stir men’s blood.

—Daniel Burnham

Politics is deadly to science-based medicine, and while I don’t often go for politics, the last eight years have seen subtle and not-so subtle predations on the practice of medicine. Will the new administration be able to promote the kind of change we need? Let’s review some of the challenges facing the Obama administration.

Ethical apocalypse

Bush’s evisceration of the Constitution of the United States has affected health care professionals. The military has likely always used psychologists to assist with interrogations, but the last eight years has seen a huge increase in the number of secret charges, unconsitutional imprisonment, and “forceful” interrogations. Military psychologists have been put in the position of choosing between what their country demand of them, and what their ethics and responsibilities to other human beings requires…

More…Additionally, the (now former) administration worked tirelessly to push through so-called “conscience clauses” during the waning days of their power. Given the challenges of the Mid-East, the economy, and other crises, it’s hard to imagine why they would think this should be a priority, but apparently giving health care providers legal protection to advance their own needs above those of their patients seemed like a good idea at the time.

Health care justice

For both ethical and economic reasons, health care should be acknowledged as a human right. Bush made some strides toward improving health care for seniors in giving them Medicare Part D, which helps pay for prescription drugs, but in every other way, he has failed to acknowledge our nation’s health care crisis. With millions of Americans uninsured and underinsured, we are all paying a heavy price.

Ethics demand a lot of physicians, independent of our political context. We cannot of course ignore context, as only a very few will be in a position to risk their lives or livelihoods in the name of ethics, but a good government will encourage ethical behavior. Ours has not.

Ethics are embedded in culture, so universal statements are often problematic. The AMA, hardly a left-wing organization, and one clearly arising from American soil, has a 9-point statement of medical ethics which should serve as a guide to American physicians, members or not. Following ethical principles toward social justice can be made easier or more difficult with the help of the government. Let’s take an example:

Principle VI: A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

Principle VII: A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

Principle IX: A physician shall support access to medical care for all people.

Doctors must be given the freedom to choose whom to treat. If I were forced to treat all-comers, I would quickly go broke an be of no use to anyone. However, my ethics dictate that I do my best to provide for good public health, and to advocate for access for all. The outgoing administration has made it perfectly clear that increasing access to health care is not a priority, and as millions have lost their jobs (and therefore their insurance) we have had to take care of more and more people for free, and more importantly have had to turn many away. As a healer, I can tell you it’s a lousy position to be in.

Politicization of science
It is perhaps inevitable that government appointments will be political, but the CDC has taken a real beating over the last eight years. In one famous incident, the Bush administration significantly altered the CDC’s evaluation of the effect of climate change on health. This is not a fringe issue—climate change effects public health through food, clean water, emerging infectious diseases, for example.

Moralistic inanity trumps science

The Bush administration has been praised for its efforts to fight AIDS in Africa, but many of their policies have made a mockery of medical science. AIDS activists in Africa understand the difference between faith-based and science-based medicine:

“We are now seeing a shift in recent years to abstinence only,” she said. “We are expected to abstain when we are young girls and to be faithful when we are married to men who rape us, who are not necessarily faithful to us, who batter us.” The women in the audience, several waiting to share their own stories of marital rape, applauded.

Were [a Ugandan AIDS activist] exhorted her audience to “denounce programs that are not evidence-based, that view AIDS as a moral issue, that undermine the issues that affect us, women’s rights. I want to be very clear — the abstinence-only business, women must say no!” (emphasis mine. –PalMD

Abstinence-only policies are not just for export. The Bush administration has made them a priority, despite their complete failure.

Politics kills science-based medicine

When politics trumps science, medicine suffers. If we are willing to compromise our science and our ethics as physicians for political expediency, we have failed our most sacred duties. If politics can open the door to deciding what is fact and what is fiction, then invalid medical ideas can walk right in. Dr. Gorski has written on how language can be co-opted to destroy meaning. When politicians join the war against science, they bring the power of the entire government to bear (for example, in funding agencies such as NCCAM). If science regains its position as the best way to understand reality, then the next four years may bode well for science-based medicine. I am cautiously optimistic that the next four years may turn the power of government toward better science and better health.

Posted in: Science and Medicine

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86 thoughts on “What will January 20th do for science-based medicine?

  1. tarran says:

    Dr Leeson,

    I must respectfully disagree strongly with you concerning this post.

    If you wish to depoliticize medicine, then you have to get government completely out of the health care business. Do you honestly think that anything government controls will ever be depoliticized? Politicians and government officials are human beings. They exercise the powers of their offices to satisfy their personal desires – whether those desires are corrupt or altruistic, short-sighted or forward-looking is irrelevant. A significant portion of these officials will exercise their offices for their personal gain, whether by providing kick-backs for people in industry, or selling favors to the highest bidder.

    Furthermore, the notion that the government has an ethical duty to provide health care demonstrates very confused thinking.

    “It is important to remember that government interference always means either violent action or the threat of such action. The funds that a government spends for whatever purposes are levied by taxation. And taxes are paid because the taxpayers are afraid of offering resistance to the tax gatherers. They know that any disobedience or resistance is hopeless. As long as this is the state of affairs, the government is able to collect the money that it wants to spend. Government is in the last resort the employment of armed men, of policemen, gendarmes, soldiers, prison guards, and hangmen. The essential feature of government is the enforcement of its decrees by beating, killing, and imprisoning.

    -Ludwig von Mises Human Action

    If I were to show up at your door with a sick child, and threaten to shoot you if you didn’t cure him, you would probably be outraged. If I showed up at your door and oferred to pay for this service, and you were to find out I had mugged your neighbor to get your payment, you would be aghast. The fact that it is people’s employers performing the mugging on behalf of the government does not make the thefts required to pay your fees, and the violence threatened against your unlicensed competitors any more ethical.

    Furthermore, the notion that it is an economical necessity is laugheable. Health care costs too much because of govenrment interventions. The state restricts the pool of service providers and the medicines available to consumers. The state encourages overconsumption by direct subsidies and by tax laws that encourage third party payments. By restricting supply, while encouraging people to pay more for medical care, the government makes health care increasingly difficult to afford.

    See my essay at http://www.thelibertypapers.org/2008/10/20/is-free-market-medicine-heartless/ for a more detailed examination of these phenomena.

    For well over a hundred and fifty years, starting with the alleopaths who wished to outlaw their competitors, the medical profession has used the government to ensure that providers were well renumerated. This rent seeking has resulted many needless deaths and suffering. If you take the ideas behind the Hippocratic Oath seriously, you should rather be divorcing medicine from the state, not calling for them to be more interlinked.

  2. Jules says:

    And what about the new ruling that protects pharmacists and other health care workers from “discriminatory actions” when they won’t give women Plan B/birth control? (Plan B, I can sort of understand, but birth control is just over-the-top) The reasoning, as I understood it, was that health care workers shouldn’t be forced to compromise their morals (my solution, that health care workers who don’t want to compromise their morals should find other jobs, was sadly left out ;-) ), that they shouldn’t be discriminated against. Unfortunately, there was no equal protection–if indeed, there is any–for health care workers for whom Plan B and/or birth control is not a moral compromise.

  3. wertys says:

    @tarran

    the idea that a nationalized medical service must inevitably result in ‘violent actions or the threat of violent actions’ is contrary to the experience of most of the developed world who have high-quality, freely accessible medical care which is managed to varying degrees by the state. It works, period.

    The’alleopaths’ (to add a misspelling to a false dichotomy) to whom you refer have nothing to fear professionally from fringe, unscientific practitioners, as the recurrent experience of developing nations such as China, India and parts of Africa is that the coming of scientific medicine to these communities makes rapid gains in mordibity and mortality, and it is in fact the local ‘traditional healers’ who are the biggest obstacle to the people’s health. As an example, I submit the documented re-emergence of polio in parts of Nigeria where the local shamans and political leaders have waged a scare campaign against vaccination, and uptake rates have plummetted. The loss of herd immunity has resulted in epidemics beginning again, exactly as one would predict using scientific medicine, and no goats or chickens were sacrificed to make that prediction.

    While your post makes a number of calumnous accusations against politicans and office holders, it gives no evidence to support these extreme opinions. Again, the experience of the developed world outside the US is that state-managed health care is perfectly capable of being organized, administered and delivered with minimal evidence of systematic corruption of the type to which you refer. The idea that all Americans are as self-centred and oafish as you clearly believe them to be is offensive, and I see no reason why the US could not make steps to catch up with the rest of the developed world and produce some type of national insurance scheme which would be no less than such a wealthy and smart country would deserve.

  4. maus says:

    “If you wish to depoliticize medicine, then you have to get government completely out of the health care business.”

    Oh Libertarians. Always talking “governmental dystopia” and offering “free market utopia” as an alternative.

    “starting with the alleopaths who wished to outlaw their competitors”

    Yet another statement that offers more mistruth than useful information. Also, with the subtle hint of anti-Western science and scientific models. You’re not winning any friends with this attitude.

  5. maus says:

    That above poster is just one of the people angered by the transition back to science, and I couldn’t be happier.

  6. tarran says:

    Wertys,

    In the 1840′s, when the AMA was founded, alleopaths (thanks for correcting my spelling BTW) were far more likely to kill their patients than homeopaths. Remember this occurred before Pasteur came up with his at the time controversial germ-theory. Of course, today the whole alleopath/homeopath/osteopath war is over. The alleopaths gave up their quackery while the

    Furthermore, we can compare free and state run medical systems side by side. In Canada, for example, there are plenty of anecdotes of people having similar conditions as their pets, such as gallstones, and being able to get immediate treatments for their pets while languishing on waiting lists for their own personal care.

    Ad far as attacking politicians without evidence, I would suppose that the George Bush presidency would be evidence enough for most. however, for you, here is some reading:
    Wikipedia on Public Choice Theory
    Milton Friedman’s famous appearance on Donahue discussing greed

    I also strongly recommend you read my essay that I linked to above. The notion that the choice is between the government doing something and it not being done at all is a false dichotomy that is not borne out by experience. In fact, I would argue that those who think that the government coercion is required to widely disseminate health care who are being oafish. From a similar debate I had many moons ago:

    You seem to feel that people are rotten to the core, and only armed policemen can accomplish this later aim by threatening to kidnap people who don’t donate moneys to be distributed to the poor.

    I believe that the best charity is that which is freely given, and that any society where people are so rotten that they have to be threatened into acts of charity is one where the charity will misdirected anyway. …
    Let’s say I raised an army and conquered the world. So I march my armies into Finland and I announce that the Finish government is hereby denied the right to levy a tax on anyone. And being a heartless bastard, I announce that I won’t be providing any welfare. So, will the productive Finns celebrate and get down to ignoring the unfortunates in their midst? Will the government officials who administered the welfare programs walk away from their jobs an refuse to try to set up charities that accomplish the same ends? Will the broad mass of people who voted in governments that provided the welfare system now turn a blind eye to the charities which plead for donations? Will these voters instead pocket the newfound wealth that previously went into taxes and ignore the plight of the poor?

    I am not, repeat not, opposed to science based medicine. Far from it. I am, however, amused by the bizarre notion that having the state provision medicine is somehow an improvement, when the only quality that the state has that other organizations lack is the ability to use violence.

  7. tarran says:

    Whups, I deleted part of the first paragraph which should have ended:

    The alleopaths gave up their quackery while the the homeopaths have not. My doctor has never, for example, tried to treat me with bloodletting or with mercury injections. If he were to, however, I probably would be worse off than under a homeopath’s relatively beinign treatment of distilled water injections.

  8. Peter Lipson says:

    Just to clarify, tarran, are you for real or are you a parody? I’d like to know before I spend time on a response.

    One of the reasons I ask (aside from the content) is that you misspelled my name despite its being right there on the page, and you continued to misspell “allopath” despite having been corrected and having acknowledged the correction.

  9. maus says:

    “Far from it. I am, however, amused by the bizarre notion that having the state provision medicine is somehow an improvement”

    When the alternative is “no medicine”, the degree to which is well documented, state provisioned medicine is an improvement.

    In the fantasy world where private care is available to all, we can fully discount socialized medicine.

  10. maus says:

    “The alleopaths gave up their quackery while the the homeopaths have not. My doctor has never, for example, tried to treat me with bloodletting or with mercury injections. If he were to, however, I probably would be worse off than under a homeopath’s relatively beinign treatment of distilled water injections.”

    Again, you have no history to back your claims but a whitewashed “homeopathy never killed anyone!”. There were just as many killers in CAM.

    One of my favorites-

    http://www.quackwatch.org/11Ind/brinkley.html

  11. tarran says:

    Dr Lipson,

    I am not a parody. I happen to have been studying economics for a while.

    I look forward to your response. However, as a courtesy, I ask that you read the essay I linked to in my first post before you craft it. It will, I think, save us both some time in any debate.

  12. tarran says:

    Maus,

    I suggest, respectfully, that you argue with what I write, instead of with the strawman libertarian in your head. Unless you are arguing that injecting someone suffering from typhoid fever with calomel is better than injecting them with distilled water? Which treatment, do you think, is likely to leave the patient worse off?

  13. maus says:

    “Unless you are arguing that injecting someone suffering from typhoid fever with calomel is better than injecting them with distilled water? Which treatment, do you think, is likely to leave the patient worse off?”

    Again, false dichotomy when it comes to the actual practice. Constant bloodletting is unhealthy, but you assert that non-AMA homeopathic practitioners stuck only to the diluted “dynamised” solution and did not have any other unhealthy practices.

    Either way, doctors in the time of Brinkley were not known for being charged for killing and harming their patients. With advances in medicine being what they are, it is of the utmost importance to root out quackery, poor statisticians, frauds, and all those who intentionally or not harm the populace.

    As of right now “Big Pharm’s” influence on our government is just as much of a worry to me as the CAM lobbyists who do not have the greater public’s interests at heart.

    And again, not one bit of your argument proves that CAM is not quackery even with all revisionist history, and it does not prove that medical care is available and affordable for all.

  14. maus says:

    Also, that article brings up terrible counters to the need for better medical care, allowing “free market medical licensors” will bring us on par with the current Free market triumph of the Toxic Debt Swap, and China’s concern for safety.

    Don’t expect to be taken seriously when you are offering utopian “truly free market” solutions as an alternative to an imperfect reality. Willful ignorance of the abuses of the free market is fairly loathsome and what makes Libertarianism a joke, certainly in respect to how much respect the free market has to science and knowledge.

  15. Fifi says:

    tarran – The main reasons that there are waiting lists for some procedures in Canada is that there aren’t enough specialists or GPs (just like in the US, people go into specialties since they pay more), younger doctors are usually less willing to work insane hours like the older breed of doctors and there’s an aging population. (All industrialized nations are facing social issues related to the bulge of aging Boomers on many fronts.) This has been compounded by stupid immigration laws that make it hard for immigrating doctors to practice here (those are starting to be changed, which will make Canada a much more attractive destination for doctors who want to emigrate and also bring more medical professionals into the system). Canadians are still free to pay for CAM and many people’s work health insurance covers it (along with dental, massages and psychotherapy). You can also write off any health related expenses from your taxes. There are certainly things that could be done to improve healthcare in Canada but privatization wouldn’t achieve any of them (certainly not more privatization than exists, doctors can work entirely outside of the medicare system and many psychologists and some psychiatrists do – it’s not like doctors are forced to work for the state at gunpoint). Rich Canadians can, of course, just drive over the border to the US and pay for private healthcare if they so choose.

    Of course, in the US those who can’t afford health insurance just don’t get healthcare (or those who can then find out that they’re being refused best care or needed care or being redirected to useless but cheap CAM “treatments – something they usually have to fight their insurance company about when ill!). I understand that it’s also starting to become more common for insurance companies to “outsource” medical treatment and send patients to hospitals overseas because it’s cheaper than paying an American doctor. I understand that it’s also common for people to lose their home trying to pay for needed treatments.

  16. maus says:

    “or those who can then find out that they’re being refused best care or needed care or being redirected to useless but cheap CAM “treatments – something they usually have to fight their insurance company about when ill!”

    To a libertarian, all these are acceptable and encouraged, because with the beauty of the Truly Free Market, you can just go to another Insurance company! They believe that since monopolies and collusion are virtually IMPOSSIBLE without government intervention, surely it is in their best interests to forego profits and be competitive on that massive scale.

    Candyland, gumdrop trees, a childishly simplistic view of “rational actors” while defining the these actors differently depending on the audience and what they are trying to shill to us.

  17. tarran says:

    And again, not one bit of your argument proves that CAM is not quackery even with all revisionist history, and it does not prove that medical care is available and affordable for all.

    Maus, that’s not surprising, because I think most CAM is quackery (I won’t say all because I am not familiar with all CAM arguments, and it’s possible that the woo peddlers might get something right someday), and have never argued that it isn’t.

    My argument is that you can have the government provide health care with decisions being made politically, or you can have private entities providing health care economically. You cannot have economic allocation of resources politically. No matter how hard you wish otherwise that will always remain the case.

    Moreover, it is impossible to provide health care for all, unless you do to health care what the Soviet’s did for military development. Note that their world class military came at the expense of nearly everything else, resulting in a fair degree of misery for the population, and still could not ensure victory in Afghanistan. Medical care is a scarce resource. It has to be rationed by some means. I submit that political incentives do a worse job than economic incentives in rationally allocating scarce resources.

    Free market triumph of the Toxic Debt Swap, and China’s concern for safety.

    Like the irresponsible businessmen who were going bankrupt under the free market until the government bailed them out. Do you really want to go there?

    Or the Chinese suppliers who started having trouble finding willing buyers when their pissed off customers abandoned them?

    Or shall we talk about the USDA which forbids slaughterhouses from testing cattle for Mad Cow disease? You want to go there too?

    Your rebuttals to my post have consisted completely of mischaracterizations of what I’ve written and hand waving, unsubstantive dismissals that what I write is so obviously bullshit. It’s the sort of tactic that woo peddlers use when the evidence goes against them (not that I think my arguments are conclusive, I expect that there will be some interesting and well-thought out counterarguments to my claims). And you expect me to take you seriously? LOL.

    Tell you what, look at my essay, and tell me what paragraph you think I go wrong at. It’s relatively well-organized and relatively free of spelling and grammatical errors compared to my usual work. I doubt you will have trouble following it and pinpointing where my wheels go off the rails. I look forward to your response.

  18. David Gorski says:

    Furthermore, we can compare free and state run medical systems side by side. In Canada, for example, there are plenty of anecdotes of people having similar conditions as their pets, such as gallstones, and being able to get immediate treatments for their pets while languishing on waiting lists for their own personal care.

    The plural of “anecdote” is not “data.”

    What’s the data?

    Are outcomes any worse in Canada than in the U.S.? No. They are not.

    Are outcomes any worse in the U.K. than in the U.S.? No. They are not.

    Are outcomes any worse in any Western European country with a nationalized health care plan? Again, the answer is no. They are not.

    In fact, in many areas they’re better.

    I used to be a big free market capitalist kind of guy. Then I started practicing medicine in the real world. After about a decade, my mind is starting to change. Right now, I have a patient with breast cancer who does not have insurance and probably doesn’t qualify for Medicaid. She’s having a hell of a time. If patients like her were an occasional occurrence, that would be one thing, but they’re not. They’re an every day occurrence.

    In actuality, the U.S. has the worst of both worlds. We have a system where the government sets the price of pretty much every medical service through its control of DRGs and setting of Medicare rates, upon which most private insurers base their negotiations to set. Contrary to what people think, physicians do not set their own prices, by and large, except for “boutique” practices that do not belong to any insurance plans, PPOs, or HMOs. So we have the worst of a government health care system. Yet we do not get the benefit of a government health care system, which is universal access to care. We have something like 40 million uninsured.

    I don’t know what the solution is, but I’m a lot less resistant to a single payer plan than I was even five years ago. We already have in essence a government-run health care system. Worse, we have nearly all of the drawbacks of such a system but none of its benefits–truly the worst of both worlds.

    It’s also a fantasy to think that some sort of Libertarian free market utopia is going to take care of the problem. Medicine has gotten too expensive. When relatively simple operations cost thousands of dollars and some medications cost hundreds of dollars a month, tax breaks and medical savings accounts are unlikely to do much for the problem, as they’ll only produce sufficient benefits for the well off who do not have chronic health conditions.

    As for the load of B.S. you laid down about “alleopaths,” well, others have dealt with it; so I don’t feel compelled to.

  19. tarran says:

    Dr Gorski,

    The fact remains that government is both limiting the provision of medical services while encouraging overconsumption. A free market in health care is precisely what is needed to fix this problem. This is not utopian.

    People want medical care. They will pay as much as they can afford to get it. If the government subsidizes it, then the prices will rise until once again the demand is balancing supply.

    If the government were to abandon all subsidies, you would see prices drop like rocks. Why? Because service providers would have to slash costs to start getting paying customers again. End the tax code that encourages employer provided health care, and employers would pay their employees the money that is diverted toward premiums, and the employees would then decide how to best spend it, including how much of their income they direct to helath care.

    As to tour penultimate paragraph, there is a flaw in your argument that will take a very long essay to explain. The overly short explanation is that new technologies, by increasing the marginal productivity of service providers, allow them to charge less money from customers. Capital improvements that are overly expensive (Using MRI machines to diagnose hangnails, to pick an absurd example) will not meet this rule and not be adopted.

    Yes, the direction of research would be different. Fewer people working for treatments to Hunter’s syndrome, and more people working on treatments for lifestyle “diseases” like ED perhaps. However, the research would continue to be aimed at what researchers thought would be the most rewarding direction, however, they would be trying to satisfy a different set of consumers.

    While it is tempting to look at medicine as being divorced from the rest of the economy, this is a bad idea. Again, the U.S. government could, in theory, have a personal doctor treating every citizen for a short time.The cost would be prohibitive, and the economy would collapse under such a scheme. There will be scarcity, there will be untreated patients under any system.

    Yes, under a free market, some outcomes would be upsetting to people. However, I cannot see how politicized system would not be more unjust. Do you really want George Bush deciding how much money should be apportioned to abortions? Do you want guys like Gupta deciding what treatments are legitimate and which are not? Pick a random youtube video and read the comments. Do you really want the politicians who are able to attract the votes of the majority of those commenters to be making decisions about medical care?

    The free market is essentially a matrix of voluntary transactions, where participants engage in trades of gift-giving because they want to. The only way to deviate from it is to force participants to engage in trades of gift giving by force or threat.

    BTW, where have I BS’ed about allopaths? Everything I have read about medicine prior to about 1875 is pretty scary. I honestly think that many of you are confusing me with some woo peddler. My doctor is an MD who teaches at Harvard Medical School. I have never asked his opinion about accupuncture, because we don’t care about it. Personally, I want nothing to do with homeopathy. I consider them to be frauds. The fact that some of my family members were pushing the stuff on me when I had a bout with a stress related stomach disorder (treated succesfully with changes in diet, starting an exercise regmien and quitting my job) was a source of incredible frustration to me.

  20. tarran says:

    Incidentally, I forgot to say that I agree with you completely about the system being the worst of all worlds. The current system is incredibly inefficient thanks to rent-seeking by all manner of special interests.

    Moreover, the current system is not sustainable. The U.S. economy cannot afford the taxes required to maintain the current system. At some point, either by plan or by breakdown, it will be abandoned.

  21. SD says:

    Ah, dear God.

    Tarran, nice try. I have to say that you’d be a better advocate of libertarian points of view if your English was a little better. Unfortunately, poor spelling == Instant Epic Fail in most parts of the blogoverse. I will further note that presenting libertarian theory poorly does it a disservice, since it permits ideological enemies to seize the tactical high ground by attacking form instead of substance.

    I will say that a link from mises.org is a point in your favor, but of those who see it, perhaps 1% will read it and 1% of those will grasp it. Good way to sow seeds, though. You never know.

    However, I fear you’re largely missing the point. I will illustrate with an analogy: you are arguing with the Politburo about whether or not Leninism is a good idea. I gently submit to you that this is perhaps not a fruitful endeavor, owing to the natural antipathy between your points of view, something over which no amount of logic or rhetorical skill can triumph.

    No MD on Earth will knowingly surrender a position of economic privilege once it is obtained, any more than anybody else will or ever has. Attempts to convince recipients of this largesse of the moral superiority of yielding that privilege, no matter how flawless the arguments are, are doomed to failure – the recipients of this argument will engage in the most astonishing psychological yoga to explain how that “privilege” is actually a “natural right”, on the same level as, say, the right to one’s life or property. Reread some of the posts here; this yoga sticks out like a sore thumb, if you’ve some practice reading the output of various yogis. The few that accept this argument and yield their privilege willingly are, statistically, outliers and of no practical political or economic consequence. All of this is part and parcel of the intrinsic evil of granting such privilege in the first place; it is nearly impossible to get rid of it.

    If you wish to continue – something I do not endorse, it is a waste of time – I would suggest attacking Cde. Gorski by asking why the solution to a program that is failing is “more failure”, as opposed to “dispensing with prior interventions and privilege grants”. That seems somewhat non-evidence-based and non-scientific to me, owing to its lack of support on both evidentiary and theoretical bases. Perhaps that is my uncontrollable urge to be an asshole striding to the fore, though. I wouldn’t work the “allopath vs. homeopath” trope any more, unless you’re trying to make mouths foam.

    To everyone else: Love the blog, guys! I smile every time I read it!

    “Not a woo peddler, though I hate the term woo, though on the third hand I love the bent rhetorical skill it took to create it”

    -SD

  22. SD says:

    Noscript caused this one to get et the first time – can’t be too careful on teh intarwebz – so let’s give this another shot.

    Ah, dear God.

    Tarran, nice try. Good initiative, bad judgment. I have to say that your effort is marred by poor spelling, and that presenting libertarian theory poorly does it a disservice, by allowing ideological enemies to attack form rather than substance.

    You do score bonus points for a cite from mises.org, although fewer than 1% will read such a link in entirety and fewer than 1% of those will grasp it. Still, a good way to sow seeds; you never know.

    I pronounce your effort a waste of time. I will illustrate the difficulty here with an analogy: You are arguing with the Politburo about whether or not Leninism is a “good idea”. The ensuing gulf of opinion is not easily bridgeable by rhetorical skill or logic, owing to the diametric opposition of the viewpoints involved.

    No MD on Earth will willingly surrender a position of economic privilege once granted him, any more than any other provider of any other economic good ever will or does. This is a straightforward application of basic economic theory – the technical term is “rent-seeking behavior” – and it is why grants of privilege are colossal and subtle evils: they ratchet only one way (in the direction of greater rents) and can nearly never be gotten rid of through peaceful means. Attempts to convince the grantees to surrender this privilege willingly by moral suasion invariably fall on deaf ears, for nobody wants to hear plans for how they can make less money and be less important, regardless of the irrefutable a priori argument that such an outcome leads to better care at cheaper prices. The few that are swayed by such arguments are, statistically, outliers and are correspondingly politically and economically irrelevant.

    If you elect to persist – something I do not advise, it is a waste of time – I would suggest inquiring of Cde. Gorski why the cure for a program that he admits spawns failure is “more and better failure” as opposed to “get rid of the failure-spawning interventions and privilege grants”. The prescription for “more failure” strikes me as somewhat non-evidence-based and non-science-based, owing to its twin deficiencies in both theory and observed outcome, but perhaps that’s just my uncontrollable urge to be an asshole striding to the fore. A second question might be the origins and values of the data that lead to the conclusion that “completely-socialized-and-called-socialized” medicine in Canada/UK/&c. produces outcomes better than the “mostly-socialized-but-still-not-called-socialized” medicine in the US, as well as the support for the assertion that they are better, and in what ways, and to what extent any of the above are “weaselable” or dubious, a fruitful sphere of inquiry all its own. A third question, flowing from that wellspring of uncontrollable urges again, would be an invitation for comparison with other countries of the present and past with either total or partial socialization of medicine, such as Eastern Europe (why were outcomes restricted to “Western Europe”, again?), the erstwhile Soviet Union, China, Zimbabwe, Ethiopia, Nicaragua, or anywhere else in the global South that “enjoyed” or “enjoys” command-economic central provisioning of goods like “medical services”. (I hesitate to approach Godwin even elliptically, but there were, er, still other socialized medical regimes in other times and places.) You also might also inquire of the exact sources of the “expensiveness” of US medical care, and the expensiveness to whom, and as compared to precisely what, and what the recommended solutions are.

    (This last question is primarily encouraged so as to yield insight into the internal workings of the mind of the opponent. It is also didactic, in that I hope to teach you the lesson that yielding the initiative also yields the argument. *He* explains, *you* ask questions and make snotty comments, not the other way around. If you insist on attacking, at least make a good show of it.)

    I wouldn’t work the “allopath/homeopath” trope any more, it accomplishes nothing except hyperventilation.

    To the owners: Love the blog! I grin each time I read it!

    “Not a woo peddler, although I loathe the word, although on the third hand I LOVE the bent rhetorical skill it took to create it”

    -SD

  23. tarran says:

    Oh blast! Serious type-o in my 9:27 post. The second to last paragraph should have read:

    The free market is essentially a matrix of voluntary transactions, where participants engage in trades or gift-giving because they want to. The only way to deviate from it is to force participants to engage in trades or gift giving by force or threat.

  24. ConradBeckwith says:

    While I agree with many of Dr. Lipson’s points, I wish to observe the inherent tension (if not contradiction) between his thesis that “politics is deadly to science-based medicine” and “health care should be acknowledged as a human right”.

    As soon as a good becomes perceived as a right, its distribution becomes entirely political. If government has any purpose, surely one must be to adjudicate the conflict of rights? So if you have a right to health care, it must sometime come into conflict with my right to ownership – how else will you fund your right. Adopted whole-heartedly, Dr. Lipson’s good intentions will only increase the influence of politics on health care.

    I would also like to mention in passing the profoundly problematic notion of assigning the status of “right” to a good or service that is subject to scarcity. If one has a right to Oreos, but there are no Oreos, what does the right mean?

    I am a strong supporter of science-based medicine, and share the horror that many writers have here expressed about Bush administration policies. But I am also an advocate of markets and deeply skeptical of the ability of the government to efficiently or fairly distribute resources. One does not need to pine for a “libertarian utopia” to be aware of deleterious unintended effects of the behavior of governments.

    By the way, the differences between a large corporation and the government are twofold: governments have the right to use force on you, while large corporations must buy that right from governments and (2) governments generally disallow competition in their domain, whereas large corporations must buy their monopoly power from governments.

    I would prefer if we had another blog to discuss public policy and keep this one focused on the subject of its title. Whether or not medical care is a right, or should be paid for by this or that entity, is neither the province of science nor of medicine.

  25. Fifi says:

    What a worn out cliché and political (not to mention worldly) naiveté to call anyone “comrade” if they’re not a libertarian or NeoCon while spouting off frivolous ideology with no practical knowledge or understanding to back it up. Why does it not surprise me that the affiliation is to CAM and quackery?(And that the advocates of “free marketism” that have coopted Libertarianism are now recommending that their ideological anti-science and anti-medicine stance be hidden to profit their argument – much as they’d hide any toxic ingredient in SCAM they’d peddle since it’s “buyer beware” not “ethical business”.) It’s pure narcissistic greed expressed as ideology and pretending to be “freedom” (do they sell Freedom brand handcuffs in the US too? Made by prisoners in Abu Grhaub…). What’s most hilarious is the attempts by the greed motivated libertarians – as opposed to the ones who lean towards anarchy but can’t call it that because it’s “unamerican” and doesn’t fit into the patriotic mythology and nationalistic self identity of the American male – to pretend they’re “freedom fighters” (just like with http://www.healthfreedomusa.com – same “patriotic” meme being sold) and promoting a “natural” dog eat dog competition. Of course, science continues to show us that it’s actually much more natural for humans to collaborate and to form trusting societies where we help each other, being social animals and all. The whole Ayn Rand Promethian genius and lone heroic bullshit is a myth peddled by so-called libertarians and NeoCons, same fairytale to justify individual greed and antisocial behavior. Bunch of sick puppies (or apes) the lot of you. Being anti-communalism is essentially being antiscience – science is at it’s best and most effective and efficient when it’s a collective endeavor where information and knowledge are shared.

    I can see why SCAM promoters would want total deregulation though and why they’ve invested so much money in lobbying the goverment to change the laws to be more profitable for them even if it endangers others. Once again, with SCAM it’s buyer beware if you go by the Libertarian SCAM philosophy being promoted here just like the http://www.healthfreedom.org is (and look at the kooks and spooks and SCAMmers involved in that!)

  26. Fifi says:

    Where there are people involved there are politics – it’s part of being human and our social game (some are formal politics – the game -and some are informal but just as important social politics). Libertarians are also infusing politics into medicine – they’re just doing so in a way that means there’s no checks and balances so that the politically/economically powerful have more rights and agencies than others.

    There are no societies without politics, they’re the result of organizing ourselves to live together and do stuff (in many ways organized religion is just an aspect of politics). Libertarians simply like to believe there would be no “politics” since they assume they’d be able to impose their will using economic or physical force so never need to negotiate or compromise (a rather lonely existence, even with underlings who’ll be parasitic toadies to survive). It’s an incredibly childish and unsophisticate philosophy that’s not much more emotionally or psychologically mature than a five year old since it’s all about me, me, me….waaaaaah.

    Like cognitive biases, politics are a natural part of being human that we need to deal with via honesty, awareness and creating a context where they don’t interfere with science or the interference is minimalized and transparent. It’s not suprising that the libertarian ideal that is being promoted is essentially anti-science and pro-SCAM.

  27. qetzal says:

    I agree with Dr. Gorski that the current system is, in many ways, the worst of both worlds. I’m uncertain whether a move towards a more socialized system would be better or worse than a more towards a more free-market system.

    The difficulty I see is that we have real examples of the former – including Canada, the UK, and much of Europe. I doubt even the staunchest defenders of socialized medicine would claim any of these is without problem, but as Dr. Gorski commented, one can reasonably argue that they provide equal or perhaps better outcomes overall, relative to the current US system.

    But where are the examples on the free market side? Is there any country that medical free-market proponents point to as even a partially successful example?

  28. Fifi says:

    Actually the question of whether medical care is a right cuts to the heart of medicine and being a doctor (research is a separate issue). It is an ethical question and ethics are integral to medicine and part of the practice of medicine. Just as questions about a doctor’s involvement in torture aren’t political but ethical at their core. Anyone who thinks ethics and social responsibility have nothing to do with medicine is unclear about the differences between selling shoes and practicing medicine, and why doctors take an oath and can be lose their license for unethical behavior while shoe salesmen (generally) don’t and have no license to lose.

  29. Fifi says:

    qetzal – Only an ideologue would proclaim they have a system that doesn’t/won’t have problems! Even the most exclusive hospitals have internal issues…why? Because there are people involved and that means a social organization, which means politics. In the real world, where people live and need medical care (often to continue living or making a living), you have to deal with people and what we do that clogs up “systems” that look good on paper as ideologies but that don’t take human nature into account.

    Here’s an intro comparison between the US and Canadian systems (from what has been written here, quite a lot of people don’t seem to understand how the Canadian system works so this is a good intro).

    http://en.wikipedia.org/wiki/Canadian_and_American_health_care_systems_compared

  30. Peter Lipson says:

    To clarify, the last 8 years have been more destructive than most when it comes to politics directly interfering with medical science and medical ethics in a negative way.

    Access to health care for all is a well-established ethic both in the US and elsewhere…it is not some weird lefty creed.

  31. qetzal says:

    Fifi –

    Actually, I have a bit of direct experience with the Canadian system, although not enough to really judge its strengths and weaknesses first hand.

    What I really want to know, ideally from folks like tarran, is this: what countries (if any) currently have a relatively free-market health care system?

    We have Canada, UK, and various European countries as presumed exemplars of socialized medicine. We also have the US as an example that arguably combines the worst of socialized and free-market systems. We can make real-world comparisons of the US vs. various socialized systems, and ask which performs better by whatever metric we have available.

    Do we have any ‘good’ exemplars of the free-market system, to allow real-world comparisons? If so, what are they? If not, why not?

  32. maus says:

    @SD

    Libertarian thinktanks are terrible at convincing others because premises are assumed to be true, not because we’re all commies. The Politburo analogy was an especially classy touch.

    @Fifi

    “It’s an incredibly childish and unsophisticate philosophy that’s not much more emotionally or psychologically mature than a five year old since it’s all about me, me, me….waaaaaah. ”

    Well, they don’t call Libertarianism “fuck you, i’ve got mine.” for nothing.

    @Peter Lipson

    “To clarify, the last 8 years have been more destructive than most when it comes to politics directly interfering with medical science and medical ethics in a negative way.”

    Yes, the problem is ideology driving the results and substituting itself for actual research.

    The Libertarian (as in the “Truly Free Market”) bent being one of the more harmful invasive ideologies, prioritizing marketing, perception, and deception over actual research. After all, the consumer and the market are the ultimate arbitrator of what is valid, what is “true”, and what is “real”.

  33. maus says:

    “Do we have any ‘good’ exemplars of the free-market system, to allow real-world comparisons? If so, what are they? If not, why not?”

    http://en.wikipedia.org/wiki/Kevin_Trudeau ? :)

    In the Truly Free Market, he would be championed as a true success at fighting the “medical establishment”.

  34. Fifi says:

    qetzal – You pose good questions, I’ll be interested to hear tarran & folks answers if there are any.

  35. Prometheus says:

    While I am whole-heartedly in favor of universal health care (at least, in the abstract), I have some serious concerns about calling health care a “right”.

    At least in the US, those things that have traditionally been called “rights” have largely involved preventing “the government” from interfering in the actions of individuals. Thus, we have the right to free speech, assembly, security from unreasonable search and seizure, etc.

    All of these involve keeping “the government” from doing things. They do not guarantee that a person will, for example, get a newspaper to publish their ideas, just that “the government” won’t interfere.

    If “health care” becomes a right, we would then have a “right” that involves either “the government” being obligated to provide a service – no matter the cost – or we would have a class of individuals (i.e. “health care professionals”) who would be obligated to provide a service for whatever remuneration (if any) “the government” sees fit to provide.

    I realize that most of the people talking about “health care rights” are not thinking about it as an actual “right”, but as an entitlement. However, rhetoric often takes on a life of its own; if we don’t mean “right”, we shouldn’t say “right”.

    If we are to talk about a “right” to health care, we need to also consider the rights of doctors, nurses, etc. to be able to refuse to provide their services. And if someone is legally able to refuse me my “rights”, well, they weren’t “rights” after all.

    Without the ability to obligate the providers of health care (note: hospitals and insurance companies don’t provide health case, they are merely brokers) to provide it to all who ask and for whatever they are offered, health care cannot be considered a “right”. Without said obligations, the providers have a legal and ethical right to refuse to provide their services.

    On the other hand, if people are seriously considering obligating doctors, nurses, etc. to provide their services to whoever demands them and for whatever compensation they are offered, can someone explain to me how this differs materially from slavery? Are patients the only ones who will have rights under the new system?

    Prometheus

  36. Peter Lipson says:

    Now that’s an interesting analysis. Of course, most of my post was devoted to subjects other than this concept of health care as a right.

    More properly, we as a society have an obligation to design a system that allows reasonable access to adequate health care for everyone.

  37. tarran says:

    Unfortunately, I will not be able to respond promptly to all the questions that have been raised since my last post. I will, however, try to cover as much ground as I can before I have to get back to work:

    1) First, I wish to ridicule SD who claimed to agree with me while pronouncing argumentation on this site a waste of time. Let us assume, for the sake of argument, that I am right and that government provisioning of health care is a bad idea. This idea is widely held and has a good chance to be enacted into law. If we are right, these ideas will be responsible for thousands of needless deaths every year that they are in force. It is even possible that SD and I would be included among these victims. There is nothing wrong with an attempt to warn people that they are making a mistake.

    To accuse the MD’s on this site of being unwilling to listen to dissenting voices or to be open to reason merely because the AMA is a rent seeking organization is to engage in a fallacy called “guilt by association”. I doubt most MD’s are cackling in the Lexi as they plot how to rip off the consumer. I strongly suspect most of them are decent people trying to make the world a better place, and we should talk to them.

    2) Fifi, you are, unfortunately making a common mistake when you declare:

    Libertarians simply like to believe there would be no “politics” since they assume they’d be able to impose their will using economic or physical force so never need to negotiate or compromise (a rather lonely existence, even with underlings who’ll be parasitic toadies to survive). It’s an incredibly childish and unsophisticate philosophy that’s not much more emotionally or psychologically mature than a five year old since it’s all about me, me, me….waaaaaah.

    Much of libertarian political theory and economic analysis is concerned very much with how people negotiate agreements in the absence of coercion. You are effectively arguing a position along the lines people who are opposed to rape must be promoting asexuality. :)

    3) qetzal asks

    But where are the examples on the free market side? Is there any country that medical free-market proponents point to as even a partially successful example?

    This is a very interesting question. I doubt there is a pure free market medical system that has modern MD’s as practitioners anywhere in the world. Pretty much every modern state adopts medical licensure by default.

    We can look at various systems comparatively, although merely looking at medical outcomes won’t be enough. We must look at the number of resources consumed, which can be quite high. Furthermore, we also have to look at statistics with a jaded eye. For example,in certain counties the British police force have been caught red-handed systematicall manipulating crime statistics in order to reduce the incidence of apparent criminal activity. Those of us who have participated in organizations of any size probably can point to experiences with managers who attempted to massage the numbers to paint a rosy picture. This is a pretty huge problem in studying public policy. Moreover, comparing different systems runs into problems with accounting for variations in culture etc.

    Incidentally, I am surprised by Dr Gorski’s claim that studies of the U.S., Canadian and British systems all show the same outcomes. I would expect that there would be some difference given the variations in culture, wealth, and medical systems. The idea that despite all these differences everything works out the same strikes me as a very unlikely coincidence. I would love to see links to those studies since I think it would be highly educational.

    Some other ideas are to do a systematic comparison of veterinary and medical systems in the same country. Of course, there are knotty problems there in performing such an analysis.

    The big thing that I warn those who are opposed to free market systems in health care is that they ignore public choice theory at their peril. Under a free market system, since the people who are producing the resources are deciding how they are used, funding tends to be far more reliable, and there is far less social conflict between disagreeing camps. George Bush, for example can donate to charities that don’t facilitate abortions, and I can fund groups that do, and there is little need for us to fight.

    Additionally, the U.S. government cannot sustain current levels of spending, let alone increasing it by making the U.S. government the purchaser of all medical care. Many of the economic problems we are facing currently have at their root the money printing that has been funding a significant portion of government expenses.

    Unfortunately, at this point I must dash.

  38. maus says:

    “Additionally, the U.S. government cannot sustain current levels of spending, let alone increasing it by making the U.S. government the purchaser of all medical care. Many of the economic problems we are facing currently have at their root the money printing that has been funding a significant portion of government expenses.”

    The claim that because our current federal budget is unsustainable is irrelevant to the claim that all implementations of socialized medicine are unsustainable.

    The claim is also insincere as it attacks the straw position that socialized medicine would be tacked onto the same Fed bailouts and military/useless “national security”/”war on drugs” expenditures. No person suggesting we move to UHC is suggesting we keep the Bush/Fed status quo.

  39. maus says:

    “The big thing that I warn those who are opposed to free market systems in health care is that they ignore public choice theory at their peril. Under a free market system, since the people who are producing the resources are deciding how they are used, funding tends to be far more reliable, and there is far less social conflict between disagreeing camps”

    Can you break down how you are applying this to the current system of uninsured parties?

    Why are you speaking as if private care will be outlawed? Why can’t private care be a separate (usually, but not always preferable) option, as it is in countries with socialized medicine?

    That private care is available renders your “truly free market” evangelism powerless, showing it to be the false dichotomy that it always has been.

    And no, free market pricing and the actions of insurers does not necessarily make funding more reliable. Your framing fudges numbers just as deceptively as any police statistician.

  40. qetzal says:

    tarran writes:

    I doubt there is a pure free market medical system that has modern MD’s as practitioners anywhere in the world. Pretty much every modern state adopts medical licensure by default.

    I’m not really asking for a pure free market medical system. Just one that’s substantially closer than what we have now.

    (As an aside, I think even a relatively free market system could still include state licensure of MDs. Plenty of other professions in the US require licensure, yet are much closer to a free market system than our health care. Seems to me the important question is to what extent gov’t controls the price of and access to health care. Obviously, licensure has some effect on access, but it needn’t be an inordinate limitation.)

  41. maus says:

    “Obviously, licensure has some effect on access, but it needn’t be an inordinate limitation.)”

    What distinction are you making here?

  42. SD says:

    Sprach Maus:

    “Libertarian thinktanks are terrible at convincing others because premises are assumed to be true, not because we’re all commies. The Politburo analogy was an especially classy touch.”

    (a) Premises (“starting points”) are *always* assumed to be true. Astonishingly enough, that’s why they’re called “premises”. Did you perhaps mean something else, perhaps “assuming the conclusion” or perhaps “begging the question”?

    (b) Thank you. I thought the analogy was well done too, if I do say so myself. I was looking for something that conjured up the image of “playing to a hostile crowd whose beliefs are the ineluctable consequence of their ideology”. For some reason, the Politburo was the first template to come to mind. It’s a crazy world, you know?

    Incidentally, regarding the remainder of your posts, I suggest that you review the effect of subsidy and/or exclusionary legislation on the provision of a good or service, and then think through all of the implications. Big Hint: one of the first consequences is the creation of a black market and the corresponding exclusion of legitimate providers of the good or service. A review of Gresham’s law might induce the appropriate state of mind to approach this exercise with.

    Thanks!

  43. SD says:

    Wow! This is almost, but not quite, a perfectly misleading post. That’s pretty good!

    Although I hate pointing out logical fallacies – it’s generally too nitpicky for my taste – I feel obliged to do so in this instance. This post, taken as a whole, is what we call a “straw man”. The procedure followed by this post can be summarized thus:

    (1) Erect a false caricature of the opposing argument (“straw man”).
    (2) Demolish false caricature.
    (3) Proclaim victory.
    (4) Bask.

    Needless to say, this does not achieve the goal of refuting the opposition’s argument, unless you’re doing it in front of second-graders.

    I will now break down the individual statements of Fifi’s post and highlight the failure contained therein:

    “Where there are people involved there are politics – it’s part of being human and our social game (some are formal politics – the game -and some are informal but just as important social politics).”

    Vacuous statement. Where there are people involved there are sweat, farts, and respiration going on too. This is irrelevant to the questions of whether or not coercive wealth transfer is moral or a good idea.

    “Libertarians are also infusing politics into medicine”

    False equivalence. Decrying political manipulation of economic activity, while ineluctably incorporating the idea of politics by reference, is not “infusing politics” into a situation.

    “they’re just doing so in a way that means there’s no checks and balances so that the politically/economically powerful have more rights and agencies than others.”

    Outright falsehood. The phrase “checks and balances” is a vacuous canard all its own, but taking its commonly-understood meaning, libertarians do not propose the abolition of any check or balance on anything. They propose restoring “checks and balances”, in fact, by returning sovereign power where it belongs, to the consumers of goods and services.

    “There are no societies without politics, they’re the result of
    organizing ourselves to live together and do stuff (in many ways
    organized religion is just an aspect of politics).”

    Ill-formed and vacuous plural assertions without factual or rhetorical support. Saying a thing is true does not make it true.

    “Libertarians simply like to believe there would be no “politics” since they assume they’d be able to impose their will using economic or physical force so never need to negotiate or compromise (a rather lonely existence, even with underlings who’ll be parasitic toadies to survive).”

    Massive ad hominem, and false to boot. A more-or-less basic tenet of libertarian philosophy is the fundamental invalidity of “imposition of force”, and another is the fundamental need to negotiate and compromise within a framework of absolute property rights, to include self-ownership (“I own me”). The parenthetical bit is, frankly, word salad.

    “It’s an incredibly childish and unsophisticate philosophy that’s not much more emotionally or psychologically mature than a five year old since it’s all about me, me, me….waaaaaah.”

    I think I’ll let this one stand on its own merit.

    “Like cognitive biases, politics are a natural part of being human that we need to deal with via honesty, awareness and creating a context where they don’t interfere with science or the interference is minimalized and transparent.”

    It is extremely amusing that you mention cognitive bias at the tail-end of a post that showcases a perfect example.

    Nobody proposes “interfering with science”. Can you define “science” for me, please? Could you also, while you’re at it, define for me the parameters for “interference with science”, and then explain whether libertarian philosophies have the net effect of decreasing or increasing such interference? If we are discussing serious things, I prefer to ensure that all parties to the discussion are using the same terms with the same meanings. It’s sort of a fetish of mine.

    “It’s not suprising that the libertarian ideal that is being promoted is essentially anti-science and pro-SCAM.”

    If you completed the above exercise, then you should have reached the conclusion that the idea of “interference with science” is a bald vacuity. “Interference with scien*tists*” is not, though, and is fundamentally opposed by every honest libertarian, part of that whole much-maligned “laissez-faire” thingy that people keep heaping calumny upon. Perhaps you can then explain to me where this idea that “the libertarian ideal” is “anti-science” and “pro-SCAM” [sic] came from.

    You know, from your responses so far, I’m not sure you’re really up to the task of participating meaningfully on the level I’m interested in, so I’m going to bait a nasty trap for you and let you play with it for awhile, okay?

    Tell me what is wrong with the following proposal, Fifi:

    “An MD, upon initiation of any treatment for a disease, stipulates that in the event that the treatment does not meet certain specified criteria, that the MD will refund the patient

    (a) his own fees in relation to that treatment;
    (b) some portion (I lean towards 100%, on the strength of the idea that the patient wouldn’t elect the treatment at all but for the efforts of the MD involved, but could be convinced of a number as low as 50% on the basis that the patient enters into the agreement of his own free will) of the total cost of the treatment itself;
    (c) various monies related to ill effects suffered as a direct result of the treatment.”

    I look forward to hearing your answer. Thanks!

    “… done dirt cheap!”
    -SD

  44. Peter Lipson says:

    Medicine is a unique economic activity. First, the idea of an economic rational actor is ludicrous in medicine. Sick people are very vulnerable, and very irrational. Also, they cannot have adequate access to information, one of the most important tools of a rational actor, as medical information is highly technical and must be given via an intermediary (a doctor).

    Second, the ill health of others affects us all. Vaccines, for example, cannot rely on a brownian collection of individual actions—they must be made freely available and actively encouraged or everyone suffers.

    To address your final points:

    “An MD, upon initiation of any treatment for a disease, stipulates that in the event that the treatment does not meet certain specified criteria, that the MD will refund the patient

    (a) his own fees in relation to that treatment;
    (b) some portion (I lean towards 100%, on the strength of the idea that the patient wouldn’t elect the treatment at all but for the efforts of the MD involved, but could be convinced of a number as low as 50% on the basis that the patient enters into the agreement of his own free will) of the total cost of the treatment itself;
    (c) various monies related to ill effects suffered as a direct result of the treatment.”

    Any physician would be foolish to do this, and any patient would be a fool to see this kind of doctor. Human beings, being somewhat less predictable than widgets. For example, I may know, based on the evidence, that I am likely to reduce your cardiac risk by X percent if I treat your blood pressure and cholesterol properly. However, you, as an individual, may not perform as well as the average. You may also experience side-effects from treatment that were worth the risk, given the higher risk of cardiac death.

    Medicine just doesn’t fit into a libertarian ideal very well (or into any real business model for that matter).

  45. qetzal says:

    maus writes:

    “Obviously, licensure has some effect on access, but it needn’t be an inordinate limitation.)”

    What distinction are you making here?

    Licensing to ensure competence, with no limit on the total number of licensees (provided each meets the standards, of course), versus limiting the number of available licenses to some arbitrary number.

    The first case will have some effect on access, because even among potentially competent providers, some may choose not to incur the costs of licensing (e.g. fees, time, effort, etc.). Fewer providers means less access, but I suspect the effect there is relatively small.

    The latter case can dramatically affect access, if the number of licences is kept well below the number of potentially competent providers. Taxi cab licenses and liquor licenses often work this way. Health care provider licenses can as well, but I see no obvious reason they have to.

  46. SD says:

    Ah, Mr. Lipson.

    That trap was laid specifically for Fifi, but if you want to wander into it, well, sure! It is a nasty trap, though – I wasn’t kidding about that.

    Would you like to retract or amend your statements above, in part or in toto? I yield an opportunity to you to do so.

    “it’s almost… too quiet.”
    -SD

  47. gaiainc says:

    tarran: “People want medical care. They will pay as much as they can afford to get it.”

    I agree with the first statement. I completely disagree with the second statement. People will pay more than they can afford as well not pay at all as much as they can afford. People are not rational actors. Period. Particularly it seems to me in medical care, particularly with the majority of my patients.

    As to what the new presidency will do for science-based medicine, I hope that Obama will put science above woo, that he will come to his senses and not choose Gupta as the new Surgeon-General, and a lot of the nonsense that Bush imposed on the health care field gets cleared away. It was a great speech, but the devil will be in the details.

  48. Peter Lipson says:

    Um, @SD…if you think you’ve laid some clever trap that i’ve wandered into i think it’s lost on everyone except pec…

    If you are shocked that i should admit that medicine is an imperfect science, then you haven’t been reading here very much.

  49. Fifi says:

    The idea of an “economic rational actor” is silly to begin with if one deals in reality and understands how supply and demand works in a world where corporations spend more money on advertising to create demand than they do on on the product. All in all, I’m not surprised that “Libertarians” and the peddlers of woo share the same ethos and philosophy about medicine and see it as being purely about profit (at least that’s more honest than pretending they support science – though they use the same lame tactics where they “set traps” rather than discuss, the mark of any ideologue who is a right fighter not a free thinker). Though I suspect this is just another take on the http://www.healthfreedomusa.org Big SCAM propaganda we see around here so much since the new age SCAMmers and the Libertarian/NeoCons kind of join each other at the extreme fringes of the circle of life with their desire for freedom without responsibility – all very childish really, despite all the bluster and big man posturing.

  50. tarran says:

    Couple of quick points:

    SD, you are a jerk. Seriously. Please note Dr Lipson’s response to Prometheus’s well thought out and respectfully reasoned argument above. That is an example of good argumenation. You on the other hand have insulted every person you have addressed here. This is not how one convinces people. At this point, I doubt anyone will consider your arguments because all you have done is buttressed fifi’s impression that libertarians are emotionally immature. You defintiely have not falsified her claim.

    Now to Mr Maus.

    The claim that because our current federal budget is unsustainable is irrelevant to the claim that all implementations of socialized medicine are unsustainable.

    Which again is not what I am arguing. I am arguing, however, that regardless of the benefits of various implementations, an expensive implementation in the United States is currently not feasible.

    The claim is also insincere as it attacks the straw position that socialized medicine would be tacked onto the same Fed bailouts and military/useless “national security”/”war on drugs” expenditures. No person suggesting we move to UHC is suggesting we keep the Bush/Fed status quo.

    Have you seen the latest budget figures? The Obama administration has accepted the Pentagon’s request to increase military expenditures by 10% last year. They are now predicting 1 trillion dollar defecits at a minimum…

    To be honest, I am pretty fed up with your nearly perfect track record of misrepresenting my arguments. Listen, I understand that you dislike me to the point that if I were to say the sky is blue you would automatically gainsay it as being cyan or something. However, please don’t let your antipathy towards people who advocate freedom blind you to what is actually going on around you.

    Fifi,

    I think you have been reading way too much Naomi Klein. Libertarianism and neoconservatism are diammetrically opposed on nearly every issue. After September 11 attack, Francis Fukuyama was crowing that the attacks had finally put a stake through the heart of libertarianism, while libertarian extremist Lew Rockwell has written <a href=”http://www.mises.org/article.aspx?Id=1539″a great essay you might find enlightening discussing a libertarian take on neoconservatism. Honestly, you will find more commonality between neoconservatives and Hillary Clinton’s faction of the Democratic party than you will between libertarianism and neoconservatism.

    Now as to the whole rational actor thing. People are not rational actors, they are purposeful actors. People attempt to satisfy their needs and desires through the choices they make. Their choices are based on what action they think will benefit them most in the ex ante sense. Of course, sometimes their predictions are correct, and sometimes they are incorrect. They learn from both their own experiences, and watching what happens to other people.

    Whent heir choices appear to be baffling or irrational, it merely means that they are a) using a bad theory, b) responding to a different set of needs than the observer thinks they posess.

    The notion that free markets only function in the presence of so-called rational actors (aka homo economicus) is a strawman argument that has been advanced by people who oppose free markets. Most proponents (except for members of the neoclassical school) don’t accept that precondition, since all people are constantly comparing of outcomes to predictions and adjusting their behavior. This feedback loop eventually results in the outing of frauds and quacks. This blog is a market response to quackery (and, I might add a valuable aid in my battle with woo-loving family members).

    Moreover, people also make the mistake of assuming that free markets are purely concerned with profit. In a sense fifi is right, although she is wrong as to what constitutes profit. The people contributing to this blog are engaging in a free market activity. They are providing a service (writing essays) to satisfy their needs. These needs probably vary from individual to individual. Some, no doubt, feel pleasure when people use the latest knowledge to inform their decisions, some hate quacks and want to save people from them, some may want the fame that comes with contributing to an influential blog, some take pleasure in the act of writing. I don’t know which set of needs each contributor is satisfying in writing for this blog. The fact that they write articles, of their own volition, demonstrates that they are predicting the benefits of writing outweigh the costs, in the form of lost income, or time that could be spent chasing girls (or boys), reading books or drinking beer. In other words, they feel that their contributions are a profitable use of their time.

    And this brings me to the crux of my disagreement with Dr Lipson’s argument.

    Dr Lipson argues that society has an obligation to provide medical care to all. This is, of course, a projection of his own moral code upon all those around him. If Dr Lipson had said, “I have a moral obligation to provide medical care to all,” I would not have been moved to utter a peep.

    What Dr Lipson wishes to do, though, is to commandeer resources of others, to impose this “obligation” that he feels he has upon others. here I draw the line. If he calls for volunteers to help him supply such care, I would offer him what help I could, either in the form of time or money without hesitation. I refuse, however, to turn to my neighbor who is struggling to put her kids through school and to demand that she fork over some of her hard earned wealth to satisfy moral obligations that I feel I have.

    Nothing I have written is opposed to providing medical care to those in need. I think I made a persuasive case in the essay I wrote that charities that are dependent on voluntary donations of time or money will generally do a superior job to the state without consuming more resources than people are willing to give up to care for others. Certainly society benefits from having such institutions, not only because they help those who need help, but because they also make those who fund them feel good.

    The problem that I see here is that many people are conflating the state with society. The state is merely an organization, like Walmart or the Cosa Nostra. In fact, it has fare more in common with the latter than the former – in that it uses threats of violence to earn revenue, violently attacks competitors that move into its turf, and claims to be protecting those it extracts its revenues from. If I were to argue that the mafia should take a more activist role in medicine, people would laugh at the absurdity of it. Similarly, there is little – other than its ability to commandeer massive amounts of resources and redirect them toward very low priority ends – that the state brings to the table in the field of medicine.

    From another Rockwell essay:

    From the political point of view, economics seems like a series of strictures against doing things that politicians naturally want to do and intellectuals want to tell them to do. So it is no wonder that intellectuals and politicians resent market logic. And yet, economic logic is not a fiction.

    Economic logic is intellectually constraining in another sense. To the extent that you move away from market means, you leave the sphere of voluntarism and enter the sphere of coercion. Markets do not exist as a “policy”; they are the de-facto result of respecting rights to person and property. It is impossible to move away from market means without violating the rights to person and property. Since markets, trade, and voluntarism are the basis of civilization itself, to reach for something else means to move toward de-civilization and the rule of the brute.

    When a libertarian argues that the state is a bad vehicle for providing that service, he or she is not, repeat not, arguing that the service should not be provided. We are merely arguing that any service that people sufficiently desire can be provisioned through voluntary action.

  51. SD says:

    Oh! Okay, then. No problem.

    “Medicine is a unique economic activity.”

    Of course. You’re special!

    Wow, nobody’s ever heard *that* before. “I am special, therefore I deserve different rules than everybody else, because I’m special.” And no, it never gets tiresome witnessing the tragic global flailing in all countries and continents against the consequences of *that* madness, nosir.

    “First, the idea of an economic rational actor is ludicrous in medicine.”

    Of course. Why presume that somebody is capable of rationality when the other choice is so much more appealing?

    “Sick people are very vulnerable, and very irrational.”

    If sick people are vulnerable and irrational – an unqualified and broad presumption that is extremely belittling, incidentally – then why assume them to possess any sort of cognitive agency at all? Since they are, as you imply, incapable of making decisions (or at least the “correct” ones), why not simply remand them to the custody of a local hospital upon diagnosis of a disease, there to be treated until death or remission, regardless of their presumptively-”irrational” wishes in the matter? Then, the right decisions can be made for them, which will work out for the best anyway. Right?

    (Before you answer, this is the case with madmen, also considered “vulnerable” and “irrational”. They do not get to choose their treatment, being incapable of it; they are in some places permitted by law to refuse some aspects of the treatment, but are in any event sequestered for treatment or lack of it until their disease is considered “managed”. Curiously, the only instance in which they are not is the case where they check themselves in for treatment, on the presumption that since they are sufficiently rational to decide they are sick, they can be presumed rational enough to decide to leave. Hm.

    Also, before you answer, this has been done before in other places. An exercise to the reader is to identify where and when refusal to submit to treatment for illness has been overruled by political authority on the basis of presumed personal incapacity or a “greater social good”. What are the attributes of such societies and their political systems?)

    “Also, they cannot have adequate access to information, one of the most important tools of a rational actor, as medical information is highly technical and must be given via an intermediary (a doctor).”

    That’s a slick bit of casuistry, but false in every particular. Interestingly enough, we live in the “Information Age” now, where the actual no-shit business model of many fine companies is to *provide* adequate access to information, a task at which they excel. This does not require the intervention of a doctor.

    You are arguing that there are magic, secret things that you know whose substantial content cannot be imparted to laymen except through the offices of a personal lecturer there to “dumb it down” to the level that ordinary morons – I’m sorry, “patients” – can grasp with their feeble intellect. Leaving aside for the moment the colossally condescending mindset that implies, I wonder what all those little printed pamphlets are about, then, hanging on doctor’s walls across the known universe. “ABOUT HIGH BLOOD PRESSURE” “Your Kidneys And You” “Managing Diverticulitis” &c. Are those lies? Dangerous redactions of the truth, used to mislead patients? How about the various discussion groups and Web sites available, in which people discuss their illnesses? Libraries? Information about medicines, available from Hell to breakfast? You mean to tell me that all these things are not accomplishing their main goals?

    But I will agree with you about one thing: Patients do not have all the information needed to make decisions about their medical care. In fact, many very valuable bits of information are typically missing. For instance, statistics about individual MDs are not easy to find, and are never published by the MDs themselves. “Of 1,000 patients I have treated in the last year, 100 have died, 93 in circumstances presumed to be beyond my control [list generic circumstances], 7 related to the medical conditions I was treating them for. Of those seven deaths, no evidence was found by the [Board of Particular Specialty], [Competing Board of Particular Specialty], [Insurance Industry Analysis Consortium] that my care or my treatment recommendations hastened them in any way.”

    (God, I’d like to see *that* stencilled on a placard in a waiting room. An MD that was willing to wear his kill ratio in public on a regular basis would probably be crushed to death beneath prospective patients, and correspondingly richer than Croesus to boot, assuming that his numbers weren’t completely appalling.)

    “Second, the ill health of others affects us all. Vaccines, for example, cannot rely on a brownian collection of individual actions—they must be made freely available and actively encouraged or everyone suffers.”

    Now there’s a handful of falsehoods of the first water.

    (a) I dislike your evocation of the image of “unreliable brownian collection of individual actions” – that’s Brownian, by the way, capitalized – because the ineluctable implication is that a better result can be achieved with a thoroughly regimented program that dispenses with all of that icky randomness caused by ‘individual action’. The astonishing result is that that ain’t so, of course – the theoretical arguments to this effect are very compelling, if you grant a couple of plausible basic premises – but I will not go into them here.

    (b) There is a very definite free-rider effect associated with the use of vaccines. One unvaccinated person in a population of the vaccinated is statistically nearly guaranteed to not get sick from an infection spread by personal contact, simply because the odds of running into anyone infected is so small.

    (c) Vaccines also rely on that oh-so-eeeeeevil libertarian principle called “enlightened self-interest”. I do not get vaccinated because it ensures the Glorious Health of the People. I get vaccinated because I don’t want to die horribly of a mosquito-borne hemorrhagic plague, or slowly gag to death on my own mucus while covered in buboes. The possibility of other people not experiencing these joys due to my choice to get vaccinated runs a very distant second in my analysis of “whether or not I shall get vaccinated today”. Funny how that works, innit? This is one of those situations of “good things happening in toto because people mind their own goddamned business and take care *of themselves* and their own interests”. There are lots of these, if you look.

    (d) “Everyone” does not suffer. The people who do not get vaccinated may or may not suffer; the risk, and reward, is theirs. (Risk: they may get ill or die from the illness being vaccinated against. Reward: they don’t have to get a shot, don’t have to pay for a shot, don’t have to worry about what’s *in* the shot, don’t have to worry about their reaction to the shot, &c.) The only case in which “everyone” suffers is the case where “everyone” is coerced into paying for one person’s foolish decision, as is the case in every socialist enterprise. The problem in this state of affairs is not the foolish decision, then, but the coercive apparatus forcing everyone else to bear the cost of that foolish decision. (von Mises and von Hayek both elaborate on this as the driving force behind the conversion of partial piecework interventions in human activity to eventual totalitarian socialism, since any “free actions” taken within the context of an interventionist system tend to disrupt the interventions, requiring that these behaviors themselves be controlled, leading to a iterative eradication of “free” domains of behavior until all behavior is moderated by the State.) The cure: get rid of that apparatus.

    “Any physician would be foolish to do this, and any patient would be a fool to see this kind of doctor.”

    Ah, now to the meat of the matter. Why would a physician be foolish to offer such a guarantee? It is considered common courtesy in essentially all other spheres of voluntary human activity to *at the very least* refund what you charged a customer in the event that have proven unable to satisfy him. You hang up a shingle as a physician on the premise that you can help patients. You are unable to help patient X, who has paid $Y for your fees, and $Z for the treatment your prescribed. Isn’t there some justice in the idea of making X whole again by giving him at least $Y, since you proved unable to help him? Can you make an argument against giving him at least half of $Z, on the theory that X tried the treatment on your say-so and that your advice – demonstrated to be bad in that particular instance – cost him money that he might have otherwise spent elsewhere on a successful treatment?

    More importantly, why would a patient be a fool to see this doctor? As a patient, given a choice between two MDs – Dr. A, who offers this guarantee, and Dr. B, who does not – I would think the following:

    (a) “Dr. A has a built-in, iron-clad, guaranteed incentive to offer me the treatment with the greatest chance of working, period. Dr. A also has the best incentive to know about any gotchas and to check them, since if one of those gotchas leads to the treatment not working, he’s on the hook to refund me for it.”

    (b) “Even if Dr. B has an equal probability of offering me the best treatment, and even if it is successful, if I seek treatment from Dr. A and if for whatever reason it doesn’t work, I stand to lose less than I would if I patronized Dr. B.”

    (c) “The longer Dr. A is around, the more likely it is that he knows what he’s doing, since anybody who has to continuously refund money to his patients isn’t going to be in business very long.”

    Indeed, the studies showing how efficacious a particular treatment is are just what the doctor ordered in this instance – *rim shot* thank you! thank you! I’ll be here all week! Try the veal! – because they guarantee that you know the odds that a treatment will be successful, don’t they? Hell, Vegas turns over billions a year on the basis of an aggregate edge for the house in the range of fractions of a percent. Most treatments allege substantially better performance than that, some reaching 99+% improvement over alternatives. Them’s betting odds for sure. So what’s the deal? If you tell someone that there’s a 90% probability of a five-year cure for a particular cancer with your treatment, isn’t that worth betting your fees that you’re right, considering what the patient stands to lose if you’re not? Hell, if you treat ten patients, odds are good you’ll only have to refund one of them. Is that an onerous burden?

    “Human beings, being somewhat less predictable than widgets. For example, I may know, based on the evidence, that I am likely to reduce your cardiac risk by X percent if I treat your blood pressure and cholesterol properly. However, you, as an individual, may not perform as well as the average. You may also experience side-effects from treatment that were worth the risk, given the higher risk of cardiac death.”

    Really. Although this response provides fruitful grounds for several lines of inquiry, I will focus on one: Is it just okay, then, to say “Screw you, I’m keeping your money”, on the basis of the idea that you told the patient up front that the treatment *might* be a failure?

    Be careful about how you answer that question.

    “Medicine just doesn’t fit into a libertarian ideal very well (or into any real business model for that matter).”

    The problem is not that it doesn’t fit, it is that you don’t like the implications of medicine in a libertarian model, since it lacks certain features that you find appealing. While I can certainly understand that, I remain unconvinced that “liberty” is a good trade for “making you feel good”.

  52. SD says:

    Tarran:

    “SD, you are a jerk. Seriously.”

    Yes, I seriously am. That was not a hugely insightful observation, Tarran.

    I am a jerk because “jerkiness” is demanded when dealing with hardened opponents, a fact you will learn after a few rounds of doing it. “Nice” is a prescription for screwing up, losing the argument, and going home to contemplate your prolapsed asshole after providing the opposition the opportunity to chalk up a(nother) nice easy win in the minds of the audience. That doesn’t do anybody else any favors.

    I encourage you to reread Fifi’s posts for an example of how an semiskilled ideologue can be driven to self-caricaturing agrammatical disorganized keyword-spam blather through the application of the Mallet of Socratic Inquiry and the Stiletto of Forensic Discrimination. The use of those tools is denied to the “nice”. You’ll notice that she still hasn’t even bothered to try to answer any question posed her.

    I admit that I am mildly surly about the pompous silliness over “science-based medicine” in general. One of the neat things about having a better method than the competitors is that you don’t have to worry about who’s going to win in the long term; the outcome is statistically guaranteed, though it may be hard work and slow going in the meantime. Sitting around and sniveling for protection from the “woo practitioners” and complaining to each other about how they dare to show their faces in daylight is at an absolute minimum unproductive, because if you have a better solution to a particular ailment, eventually there will *be* no “woo practitioners” dealing with it, any more than there are traveling leech wagons roaming the interstates today looking for customers to suck blood out of to heal their ills. And if you don’t have a better solution, then your time is better spent working to find that better solution, innit now? And if your solution isn’t any better than theirs, then what the hell are you complaining about, and on what basis do you claim that they need to be run out of town on a rail?

    Sitting around and sniveling for protection is, in fact, the traditional activity of someone who doesn’t *have* a better solution, or at any rate is not confident of it, and seeks to have their solution bolstered by coercive agency. I submit that the arguments advanced so far in favor of that coercion make an unconvincing case for my participation in this scheme, as one of those asked to pay for it on multiple levels, and I demur on that basis. I have no illusion of changing minds or halting such policy, of course, but I can at least win a couple of rhetorical jousts for my own amusement along the way.

    If you have a better idea, then whip it out. That, ladies and gentlemen, is science. Let the facts do the talking, and let people ignore those facts at their peril, as it is their right to do. Time will prove you right without anyone else’s help, and will cull the population of doubters to homeopathic concentrations. (You can call this the ‘reverse Galileo argument’; today, we are *all* Galileans, regardless of the best efforts of his competitors to stifle his argument. Bullshit did not triumph. Reality and facts won the day. Yay, facts and reality!)

    Now, if you’re talking fraud, that’s a different story. But note carefully the nature of this quicksand mire, which Mr. Lipson is on the verge of sinking in: the success of any treatment cannot be guaranteed in any instance, though in some instances approximate probabilities can be estimated. “Fraud” means, roughly, “damaging someone based on a material misrepresentation of facts”. Well, that’s a pretty nonweaselable fact – no treatment can be guaranteed to work. So, if you admit that a treatment may not work, then what is the objection to someone else offering a treatment, so long as they make the the same stipulation? What is the basis for calling that fraudulent? If it is not fraudulent to offer a treatment which may not work in one instance, then how can it be fraudulent in another? This is one major intellectual gap in which quacks hide, and the source of an extremely potent argument: “Allopaths[sic] can’t/won’t guarantee their treatments, either!” How do you answer that – along with the hidden implication that it is okay to offer any treatment at all, on the theory that “hell, you never know” – given that it is completely true? If it’s not fraudulent to offer the treatment if you say that it might not work, then on what basis can providers of that treatment be prevented from so doing?

    “Please note Dr Lipson’s response to Prometheus’s well thought out and respectfully reasoned argument above.”

    I did read it. “Yeah, that’s interesting!” is not a response that indicates serious consideration of the points addressed.

    Prometheus did beat me to that particular punch, probably pithier than I would have done to boot. Good on him. One problem with the desire to seek from the State protection from competitors in a particular field – medicine, in this case – is that the resulting protected caste, in admitting the legitimacy of political intervention in their affairs, becomes a prime target for further intervention when it becomes politically expedient. We’re about to get the short course in the wide and very unpleasant variety of possible interventions here in the US, I think, much to the probable dismay of the members of that caste. Another related problem is that it provides a lucrative target for their competitors, who regroup and infiltrate the resulting oversight apparatus, then hijack it for their own ends. Hmm, lookit that, there’s a bunch of articles on this site lamenting the hijacking of government medical policy to favor “woo practitioners”… My God, who could have seen *that* coming, huh? What a shocker!

    As an example of how this works I can, from the premise of Mr. Lipson’s argument that everybody “deserves” medical care and with legitimacy equal to his position that the medical caste deserves “special treatment”, argue that the optimal “special treatment” from the perspective of “society” is that every member of that caste be enslaved and made into a public utility, like a sewer. More importantly, I could back up *my* claim, on the basis of an impressively and unassailably mathy “Greater Good” argument complete with dollar figures, and even include in the value of that “greater good” the cost of enforcement of slavery, to include the flogging of uncooperative doctors and nurses, selective breeding of “good” doctors and nurses to yield a steady supply of future medical slaves, and the return and punishment of runaways (hobbling, castration, &c.) Those numbers would be good, and very very compelling. Technology has made tracking real easy and cheap, in fact, what with all those little GPSy ankle-bracelets and automatic electric shock devices. Why, we could have “medical centers” staffed by people who never get to leave, with little barracks and cafeterias inside for the medslaves, flogging posts and pillories outside for the recalcitrant, signs above saying “FREE MEDICAL STATION”, happy and healthy citizens coming and going to have their owies remedied without concern or cost, guards watching screens to ensure that the white-gowned do not leave. Slaves that malfease, e.g. by causing intentional harm, or accidental harm, or by sabotage of equipment, or by providing less than a certain customary level of treatment to their patients – we could call it a “standard of care” – could be punished in the parking lot. (Hey, no more malpractice worries! They don’t have to pay for it, and neither do we! Plus, what an incentive!)

    While I somehow imagine that the Swiftian nature of this Modest Proposal will be overlooked in favor of hyperventilation over its hyperbolic excess, I hope that it is immediately obvious to at least some. This argument is of course made without reckoning the *moral* considerations that “doctors and nurses are people”, and that by virtue of their peopleness they have rights that must be respected, like the right to own themselves, and to own their own property free from interference by others, and to perform their jobs according to their own particular gifts, and to do as they please with their own lives, and to engage in those activities which please them when it pleases them to do it so long as they do not infringe on the rights of others to do the same. I simply wonder why their rights are more “special” than everybody else’s. Somehow I think I’m going to not hear a good reason for why that is. Hope springs eternal, however.

    In that vein, I suggest a careful evaluation of this statement:

    “… we as a society have an obligation to design a system that allows reasonable access to adequate health care for everyone.”

    That sentence fragment contains the intellectual antecedents of a wide variety of evils, jutting out from the surface like the tip of the iceberg that sank the Titanic. The advanced reader is advised to meditate on them and their consequences, the exercise is illuminating. In response, I have above, for my own amusement and to satisfy that uncontrollable urge again, created just such a system (“Medical slaves and the patients who love them”). I think that with some careful explanation of the very substantial savings to be achieved – not to be sneezed at in these economically difficult times – we could get some real support going for it, since all of the non-doctors among us (>99% of the population) stand to benefit in a real big way from it. Isn’t democracy grand when we think of things in terms of “we as a society”?

    “That is an example of good argumenation.”

    Son, I believe the saying is, “Don’t tell your grandmother how to suck an egg”. I amuse and inform more people with one snide crack than you do with an entire post.

    “You on the other hand have insulted every person you have addressed here. This is not how one convinces people.”

    I haven’t insulted a single person, at all. My sin so far has been not “being nice”, not using comfortable terms, not cloaking things in euphemism, not pretending that we’re all just a bunch of friends out to have a nice walk in the park and have a nice little chat where we can compromise our way to the truth, instead of a pair of dirty streetfighters out to icepick each other in the rhetorical kidneys until someone cries “Uncle”.

    Let me reiterate: These people wish to employ men with guns to truncheon their competition into nonexistence, to ensure that their economic position is bountiful and unthreatened, and to secure a position of control over your behavior, all at your very significant expense. This is their actual, no-shit, publicly-stated purpose. Even if we are charitable and assume that this purpose stems from the highest motives and a sincere desire to do good (insert quote from CS Lewis here on the tyranny of those who seek to do good), it is still morally unjustifiable on every level. They wish to deny you, by fiat, your right to do a wide variety of things. (Yes, this variety of things is mostly covered by a simple description of “being a goddamned idiot”. That isn’t the point. You still have the right to be a goddamned idiot if you please, and it is still important to have that right, and a right which you cannot practically exercise owing to coercive agency does not exist.) Do you really and honestly think you can “reason” with such people? The best you can accomplish is to impress an audience, and you’re not doing a very good job of that – they’ve got arguments that are more “bellyfeelable” to the average reader than you’ve presented.

    I’ve been doing this (political argument with socialists and statists, and researching how they make their arguments) for quite some time now. You will learn, eventually, that “playing nice” does not achieve anything meaningful, that in large part their rhetorical methods are geared to environment where people “play nice”, and that this works because the opposition does not have any interest in “playing nice”, they have an interest in screwing you until you scream and then screwing you some more. You are laboring under the misapprehension that you are somehow going to cause the scales to fall from the eyes of hardened socialists and statists with a vested interest in the status quo by a series of simple and apparently-obvious statements of truth. I’ll save you some time: that doesn’t work. If you ever do get it to work, let me know, because I’d love to hear how.

    You are promoting a political philosophy. Okay, so this political philosophy embodies the idea that the political means is a colossally inefficient, unfair, and destructive way of doing things, and that the economic means is infinitely better at achieving the goal of rationing scarcity and enabling progress by whatever measure is used to evaluate it, whether moral or practical. This is still a political philosophy. Political arguments are not “nice”. They are easy to screw up, too. One reliable way to screw them up is to present them in an incompetent fashion, to include presenting them mildly or timidly. If you are not correct, then there is no point in making your argument. If you are correct, then there is no point in making a compromise. If you do not believe in the correctness of your argument enough to present it vigorously, then better not to make it at all.

    “At this point, I doubt anyone will consider your arguments because all you have done is buttressed fifi’s impression that libertarians are emotionally immature. You defintiely have not falsified her claim.”

    I have not been making arguments, I have mostly been asking questions. These questions have remained substantially unanswered. Now, why is that, precisely? Presumably because I have, quite intentionally, selected “uncomfortable” ways of phrasing them. An astonishing thing about “scientific inquiry” is that it is dispassionate; the identity or personality of the seeker is *irrelevant*. Whether the debater is correct or not lies in the facts disputed and the arguments made, not in how they are phrased. This is Lesson Zero of the Method.

    I find the idea that Fifi has conclusively demonstrated my emotional immaturity, um, really, really, funny, like “laugh myself into a seizure and cardiac arrest”-type funny. Are you kidding me? Are we reading the same Fifi?

    I have made several statements, as well, which remain unrefuted and unaddressed. Hope springs eternal there, too, however unrequited.

  53. Fifi says:

    An interesting BBC documentary taking a look at the corporate lobby around Obama’s healthcare plan.

    http://rawstory.com/news/2008/BBC_documentary_takes_on_Obamas_plans_0125.html

    I’ve read plenty of libertarian propaganda, a great deal of it is the same kind of childish, hate and fear filled rhetoric as the NeoCons trot out around election time and why they put Palin on the bill. Like the NeoCons, it pretends to be about “freedom” but really is just about self interest/greed. So, NeoCon and Libertarians may want to distinguish themselves from each other ideologically but on practical levels they’re the same (no regulations on industry but regulations about personal freedom and choice, using the courts to pursue self interest – which is going to create more and more governmental beaurocracy, and no fiscal or social responsibility for the environment or society). It’s just that NeoCons are the elite ideologues and Libertarians are their footsoldiers. Essentially they both want to destroy the government and get rid of regulations because it gets in the way of the rich getting richer and shooting people in the face if you disagree with them (though the elite do get away with the shooting in the face stuff, while the footsoldiers get discarded once no longer useful).

  54. Fifi says:

    All in all, it’s nice to see that Americans have elected someone who isn’t pathologically antisocial and is no longer promoting sociopathic ideals.

  55. Fifi says:

    tarran – So you’re proposing that this blog is a “market response to quackery” and is really all about how quacks but into medicine’s bottom end and not a concern for patients and public health? You essentially believe that the authors have a profit motive and not a social motive? So, really, the blog authors are no different than Big Pharma or Big SCAM and should be viewed accordingly?

    I see that the insurance industry will be coopting “libertarianism” to try to convince the public (particularly the drinkin’, drivin’ and shootin’ sector) that pulic healthcare reduces their freedom. Heh, I guess that makes SD and tarran the medical industry’s Sarah Palins – now THAT’S entertaining. I’m expecting to see the Fundies to get in on this too since they’re tied in with Big SCAM and have lots of money to lose if Obama’s apparent focus on science and practical solutions is real and not all for show.

  56. Fifi says:

    tarran – So you’re proposing that this blog is a “market response to quackery” and is really all about how quacks EAT into medicine’s bottom end and is not motivated by a concern for patients and public health, and ethical concerns? You essentially believe that the authors have a profit motive and not a social or ethical motive? So, really, the blog authors are no different than Big Pharma or Big SCAM, are motived by greed, and should be viewed accordingly?

  57. Fifi says:

    I’ve noticed that a lot of people in the US confuse anarchism and libertarianism – I suspect that’s because anarchism in the US is historically associated with women’s rights, working people’s rights and pro-union activity, while Libertarians often promote racism and sexism, closed borders, might makes right ideals, etc (which they label ‘freedom’ even though it’s only the freedom to repress like back in the good ole days of slavery to which they wish to return as the masters…it’s not surprsing that Liberterianism is essentially a bunch of middle aged white guys with guns who feel powerless and impotent in the face of society and the government).

  58. Fifi says:

    tarran – “(a) “Dr. A has a built-in, iron-clad, guaranteed incentive to offer me the treatment with the greatest chance of working, period. Dr. A also has the best incentive to know about any gotchas and to check them, since if one of those gotchas leads to the treatment not working, he’s on the hook to refund me for it.”

    Clearly it’s in Doctor A’s best interest to never treat a patient who may actually be ill and need treatment (or who will die before they realize a treatment isn’t working so they can’t ask for a refund). Ideally, he’ll only ever deal with “wellness” issues or find a way to blame the patient if the patient isn’t “satisfied”….hey, wait a minute…that’s how SCAM operates…oh, right, they get clients to sign waivers so that the patient CAN’T hold them responsible if they do harm. So, really, tarran is arguing that all medicine should be deregulated like SCAM and that doctors have no ethical responsbility to their patient (who should be regarded as a customer not a patient).

  59. SD says:

    “Clearly it’s in Doctor A’s best interest to never treat a patient who may actually be ill and need treatment (or who will die before they realize a treatment isn’t working so they can’t ask for a refund).”

    (a) I thought that doctors were operating from a deep wellspring of ethical and social concern, Fifi, and not a profit motive? Remember, I’m talking about a real hard-nosed science-based practitioner here, those bastions of selflessness that defend us against the Forces of Darkness. Surely such a simple act as offering a refund – itself a charitable and human act, come to think of it, returning to a patient who is unsuccessfully treated some portion of that patient’s substance so that the patient might have the means to try something else – cannot be wrong? Can you argue with a straight face that giving somebody their money back is a corrupting influence?

    Never mind, don’t answer that question. I think that you are sufficiently delusional that you could argue that Elvis is being secretly held prisoner by UFOs with a straight face.

    (b) Um, Fifi, were you aware that debts owed to a decedent – including refunds – are still owed to the estate? Killing the patient doesn’t get the doctor off the hook.

    (c) There is a real easy way to induce a doctor to take on a risky case even in the presence of a custom of refunds for unsuccessful treatments – bid up the price. At a high enough price, it becomes worthwhile to take the risk. Unless you’d like to argue statistics, too?

    “Ideally, he’ll only ever deal with “wellness” issues or find a way to blame the patient if the patient isn’t “satisfied”….”

    You mean like they do now?

    “hey, wait a minute…that’s how SCAM operates…oh, right, they get clients to sign waivers so that the patient CAN’T hold them responsible if they do harm.”

    As opposed to the forms you sign in triplicate as a patient for even a mundane medical procedure, stipulating that a normal outcome of the procedure is for your head to wind up floating in a jug of formaldehyde in a tourist trap in Tijuana, or whatever other dreadful outcomes the hospital legal department thinks will spare them a lawsuit?

    “So, really, tarran is arguing that all medicine should be deregulated like SCAM and that doctors have no ethical responsbility to their patient (who should be regarded as a customer not a patient).”

    That was me, and the patient *is* a customer, you ignorant little tit.

    Your ability to deny the obvious is comical. What color is the sky on your planet, Fifi?

    Oh, and here’s a nickel’s worth of free advice: If you were genuinely interested in assisting the practice of “science-based medicine”, you’d stuff a sock in your mouth and read quietly. The support of a shrieking latah like you has a certain mock-making effect on the discussion of serious issues, sort of the way that a mental defective staggering through a quantum-mechanics lecture while flinging feces at the podium has a minor disruptive effect. I personally hope you continue to respond, because I find it funny, but perhaps your hosts weary of it somewhat.

    “incredulous”
    -SD

  60. Fifi says:

    SD – You’ve managed to alienate even tarran who shares some of your beliefs so I’m not sure who you actually think you’re convincing here.

    You never did answer the obvious question, do you think the doctors who write this blog are doing so out of a profit motive?

  61. SD says:

    “SD – You’ve managed to alienate even tarran who shares some of your beliefs so I’m not sure who you actually think you’re convincing here.”

    Oh, I specialize in alienation. You appear to be under the impression that I’m participating in a popularity contest here. Mostly I’m amusing myself, and looking for Truth. I *can* be swayed by a good argument, I just haven’t heard one. Until then, I’m right, having found to date no evidence that I am wrong.

    “You never did answer the obvious question, do you think the doctors who write this blog are doing so out of a profit motive?”

    Yes, they are. The idea that they are not is prima facie goofy. There are obvious profit motives (“exclusion of competition” topping the list, on the one hand “… from participation in the marketplace for our class of goods and services, leading to a a labor shortage, leading to higher prices that labor can command”, and on the other “… from competition for funding from various private and public funding sources, leading to more available per capita for us”), but also less obvious ones (“psychic profit”, a la Rothbard; this is “doing something because it makes you happy”, viz. “refuting non-science-based methodologies” or “bitching about non-science-based methodologies to relieve personal upset”, both psychological positives for the actors if not purely economic ones).

    People do not do things for no reason. They do not do things that do not enure to their benefit in some way, as they see it. The few that do engage in these behaviors are, to use the technical term, “crazy”. The assertion that people do is, ahem, counterfactual, and *always* politically motivated, it being a practical necessity to first convince others that they possess no or diminished agency before one may rule them “for their own good”.

    I dunno, Fifi. Do *you* think the authors are getting something out of writing this blog? What, precisely, do you think that “something” *is*?

    As an aside, I note that while I am entreated to be skeptical of CAM practitioners on the presumption that they are solely driven by greedy profit motives, I am simultaneously entreated to trust SBM practitioners implicitly, on the presumption that they are not. “Selective skepticism” of this type is one of those red-letter warning signs of woo. “Trust me, because [other guy] is evil and only looking out for his own good!” I believe that one appears in the same list as “The check is in the mail” and “I promise to pull out in time”.

    Since we appear to be answering questions for the moment, quid pro quo: Can you provide evidence or support for any of your assertions about libertarian philosophy, specifically the following:

    (a) that it is a “bunch of middle-aged white guys with guns”
    (b) why it’s okay or a good idea to make that assumption
    (c) why it would matter, even if it were true
    (d) that it supports “regulations about personal freedom and choice”
    (e) that it supports “using the courts to pursue self interest” [sic]; actually, do us all a favor and describe what the hell you’re talking about first, then tell us how libertarian theory supports that conclusion
    (f) that (e) will lead to “more and more governmental beaurocracy” [sic]
    (g) how libertarian theory implies a lack of “fiscal or social responsibility for the environment or society” [sic]
    (h) which aspects of libertarian theory are incompatible with science, medicine, or science-based medicine, and what your assertions about (a-g) have to do with them

    Any one of these would be really nice. All of them would be spectacular. Full sentences would be awesome. Properly-spelled and -punctuated sentences would cause me to faint. Coherent strings of sentences that led to some kind of point, even if I disagreed with it, would make me drop dead from shock. Now, I’m not saying anything, I’m just sayin’.

    “dubiously seeking Fifi”
    -SD

  62. SD says:

    Oh yes, uncontrollable urge again, Fifii:

    You never did answer the obvious question [that I asked]: Can you argue with a straight face that giving somebody their money back is a corrupting influence?

    “waaaaaaaaaiiiiiiting…”
    -SD

  63. Fifi says:

    I’ll let the blog authors explain their motives and why they invest their time here supporting and promoting science-based medicine instead of getting rich quick off of “integrative medicine” and SCAM. However, clearly you believe they’re in it for the money so I’ll let them either agree with you or refute your assertions.

    You’re pretty pointless to discuss anything serious with, even people who share your beliefs think so – clearly if even people who share your beliefs don’t think you’re worth having a serious discussion with about those beliefs, it’s a waste of time for anyone else to take you seriously.

  64. SD says:

    “I’ll let the blog authors explain their motives and why they invest their time here supporting and promoting science-based medicine instead of getting rich quick off of “integrative medicine” and SCAM. However, clearly you believe they’re in it for the money so I’ll let them either agree with you or refute your assertions.”

    See, now, that isn’t what I said, is it now? What did I actually *say*, Fifi? I said that they are influenced by the profit motive, and outlined a couple of ways in which they profit from it, in addition to the obvious ways in which they profit from having their work promoted. This does not equal “… in it for the money”, although I reiterate that the idea that they are not influenced at all by a profit motive is ludicrous. Do you have any discriminatory capacity at all, in there, or is all that gray matter just fused together into one big ball of crazy?

    It is this sort of dishonesty that fluoroscopes the fundamentally unfair and politicized core of your arguments. When we think about the mindset that engages in this sort of snakelike twisting and writhing around the truth, manipulating and lying to gain converts and hamstring opponents, we see coiled in the heart of the promoter, Alien-like, a core of woo waiting to burst forth in a spray of gore. (And you wonder why people don’t trust you, or believe what it is that you’re selling, preferring instead to deal with your competitors.)

    How does it feel to be a woo cheerleader, Fifi?

    I will say that it is particularly clever for the owners of the blog to permit their latah – you – to frustrate and obfuscate the argument, wasting the energy and time of commenters in responding to your cheap sophistry instead of substantive discourse. You are one hell of a labor-saving device, I have to hand it to you.

    “You’re pretty pointless to discuss anything serious with,”

    … as evidenced by the mountain of apparently simple questions I’ve asked which remain substantially unanswered. Yes, I know, what a dreadful asshole I am for requesting that you provide some background for your assertions. What was I thinking? Sheesh.

    “even people who share your beliefs think so – clearly if even people who share your beliefs don’t think you’re worth having a serious discussion with about those beliefs, it’s a waste of time for anyone else to take you seriously.”

    I jumped in because Tarran was about to commit the error of being hijacked by you, because I doubt he’s ever experienced the joy of witnessing an otherwise pleasant argument get dragged off beneath the Earth and drained unto lifelessness by the rhetorical equivalent of Shelob. Now, I have the advantage, having experienced your brand of refractory folly before, before which all calm logic is defeated; you’ve hijacked me instead, and I’m a lot nastier than Tarran appears to be. Most people haven’t dealt with your type before, and fall easily for the cheap tricks you’ve trotted out. I simply hope to showcase a couple of convenient, relatively efficient methods for dealing with those tricks, that’s all. Oh, and ask a few open-ended questions to get people thinking about SBM, CAM, woo (in both domains), and the general desirability of State-oriented medicine. Oh, and encourage you to embarrass yourself. (But that’s just a bonus.)

    (To the audience: Fifi does a wonderful job of “cherry-picking”, and of tactically ignoring the substantive core of the opponent’s argument, focusing primarily on irrelevancies and on her own fantasy-based interpretation of what was said. The logical fallacies are a pathology all their own, which I have addressed above.)

    I note that Cdes. Gorski and Lipson appear to have abandoned this thread, dashing any hope of getting the actual organ-grinders to sit down for a chat instead of letting the monkey continue to throw poo at us. Oh well. Sic transit gloria mundi, and all that.

    “waiting for Godot”
    -SD

  65. David Gorski says:

    As an aside, I note that while I am entreated to be skeptical of CAM practitioners on the presumption that they are solely driven by greedy profit motives, I am simultaneously entreated to trust SBM practitioners implicitly, on the presumption that they are not.

    What a risible straw man argument, at least if you’re applying it to any of the bloggers at SBM!

    You are entreated to be skeptical of CAM/IM because of the evidence and science that show it to be, for the most part, not only wildly implausible but, when tested, generally no more effective than placebo. Science is what we argue.

    Oh, I specialize in alienation. You appear to be under the impression that I’m participating in a popularity contest here. Mostly I’m amusing myself, and looking for Truth. I *can* be swayed by a good argument, I just haven’t heard one.

    Ah, yes. A troll. I thought as much. You wanted to know why I haven’t bothered to come back until now. Now you know.

  66. weing says:

    Even though I am a physician, my beef with government funding of CAM is that it is a waste of taxpayer money. That includes my money. I don’t want to see it wasted on nonsense and prefer that it be used for research that can be fruitful. If someone is stupid enough to buy the CAM nonsense, that is their choice, and they are free to donate their own money to it, but not mine. I do not see this blog as an attempt to crush my competition. MDs compete with each other already, I have no problem with that. I think it’s good.

  67. tarran says:

    Fifi,

    Sorry to be so tardy responding to you.

    You’ve got it all wrong, on so many levels that I don’t know where to begin:

    First, I don’t think the writers for this blog get a financial benefit from it. In fact, I would guess that they spend far more money than they earn from its operation, assuming they earn anything at all.

    However, they clearly are getting something in return, most likely in the form of satisfying a desire, what economists call psychic satisfaction. Now, if the cost of operating the blog were increased, say to $20,000 per contributor, you’d probably see a few contributors give it up, even though they could afford the cost. For those people the cost (the money + other opportunities foregone in order to blog) would now outweigh the benefits and they would stop doing it. On the other hand, in the current situation, they are clearly finding the benefits both psychic and economic of contributing outweighs the costs.

    This is, in fact, a market response. Remember, the free market is really a term that describes a matrix of transactions between people where all the participants are free to enter (or to forego) transactions with each other. These transactions are not solely entered into for some financial gain. In the end, all economic activity is driven by people’s desires to satisfy their needs/wants, and most of these needs or wants are driven not by say hunger, but by taste and other emotions. In other words, people don’t just want bread that fills their tummy’s but rich textures and unusual shapes that please their pallate. A desire to steer people away from quackery is one of those psychic needs.

    Secondly, libertariansim in its purest form is anarchism. In fact much of libertarian philosophy was shaped by 19th century individualist anarchists like the abolitionist Lysander Spooner and Gustave de Molinari. The intellectuals driving the modern libertarian movement are dominated by anarchists. In fact, modern libertarianism is riven by infighting between the radical wing composed of anarchists and the ones who are in favor of the existence of government (who call themselves minarchists), which is provides for very repetitive and depressingly predictable name calling on libertarian message boards.

    Nor are libertarians proponents of slavery. Far from it. I strongly encourage you to read Murray Rothbard’s For a New Liberty: A Libertarian Manifesto, which calls for among other things:
    1) And end to slavery of all kinds including the abolition of conscription and anti-strike laws
    2) Legalization of abortion
    3) An end to corporate welfare
    4) An end to government courts permitting businesses to pollute the land that belongs to others

    From your writing, I doubt you have actually ever encountered Libertarianism, and have formed impressions based on the smears of poeple opposed to it. You will find the real deal is a far different beast than what you have been told.

  68. SD says:

    “What a risible straw man argument, at least if you’re applying it to any of the bloggers at SBM!”

    Mostly I’m applying it to Fifi. Fifi fits the “cheerleader” template. SBM has ‘em, too.

    There is no “straw-man” about it; I *am* entreated to be selectively skeptical, both individually and by proxy (through the action of legislative agency). You want better treatment for SBM than for CAM, on the basis that you’re right, and that they’re not. To claim otherwise is brazenly disingenuous. I suggest to you that while you might be correct in that assertion, it is illegitimate on every conceivable basis to prevent access to CAM on the theory that you are “working for the greater good” or whatever other justification you claim. I further submit that it is a bad idea, because CAM will die of its own accord when it is unable to produce results; no political action is required to see it on its way. In fact, political action is counterproductive, in that it prolongs the fight and moves the center of gravity of this battle outside of the realm where CAM is weak.

    Note that I wholeheartedly support the defunding of CAM. It is only when we hear the other shoe drop – “more/continued funding for SBM” – that I raise my hand and say “Uh, wait a minute.” It is when I hear claims for the “specialness” of medicine – a trope which has been trotted out millions of times, and is still amazingly every bit as specious as the very first time it was uttered – and the profession’s immunity to economic law that I become incredulous and combative. I do find it to be a source of amusement, because medical practitioners were told, both explicitly and indirectly by centuries of historical record, what precisely would happen if they pursued legislative sanction against their competitors to exclude them from the marketplace *on whatever basis*. This smorgasbord of consequence includes, a priori, the targeting of that legislative apparatus to provide cover for those competitors, and its use once compromised to turn the tables. Funny thing, that; that appears to be in the process of happening. You squawk about it on a daily basis, it seems. Payback’s a bitch, isn’t it? Question: Do you think, based on the evidence to date, that perhaps a strategic error was made in seeking legislative sanction against competitors, instead of, e.g., simply focusing on the science and letting your results speak for themselves? Loaded question: If you admit strategic error, do you find any change of priorities or beliefs to be in order?

    “You are entreated to be skeptical of CAM/IM because of the evidence and science that show it to be, for the most part, not only wildly implausible but, when tested, generally no more effective than placebo.”

    Important question: SO WHAT? While there is an argument here about the interaction between science and implausibility (hint: one reason the ‘Galileo argument’ works so well is because it’s true, there is more than a hint of pomposity and hubris in the idea that one may know with certainty the outcome of any experiment in advance, particularly one that cannot be repeated, as in the case of the usual medical treatment), we will assume that you are correct, that CAM treatments are in the aggregate are no better than rubbing a lucky coin. SO WHAT? I have the right to rub a lucky coin if I wish to. So long as I do not lie to the purchaser – and yes, saying “These may or may not work, caveat emptor” is telling the truth – I have the right to *sell* lucky coins. You find the idea of a lucky coin to be bullshit – correctly, as it turns out, having presumably some moderate background in statistical theory – well, good for you. SO WHAT? While public excoriation of lucky-coin vendors is healthy and entertaining, what justification can you possibly have for a position that the sale of lucky coins should be considered an act of fraud in se and punished? How can that justification be defended against the observation that the ad copy for the lucky coin (“It may or may not work. Caveat emptor!”) differs in no material way from *your* ad copy (“This treatment may or may not work. Caveat emptor!”) What answer can you make to that argument?

    “Science is what we argue.”

    When you enter the political arena with demands for political action, you very much are not arguing science, you are arguing for a place at the head of the trough. This does not inspire confidence in those who listen to you, who have heard the clarion call to “please give us more and better privilege” many times before and been stung by it. It inspires a certain “sod you” frame of mind, in which those who detect the dishonesty of the argument being made conclude on that basis alone that your opposition must have something worthwhile, and seek it out on that basis.

    “Oh, I specialize in alienation. You appear to be under the impression that I’m participating in a popularity contest here. Mostly I’m amusing myself, and looking for Truth. I *can* be swayed by a good argument, I just haven’t heard one.”

    “Ah, yes. A troll. I thought as much. You wanted to know why I haven’t bothered to come back until now. Now you know.”

    How is it “trolling” to be looking for the truth, to be looking for a good, solid argument to be swayed by?

    Hint: An argument that will convince an asshole like me is one that would be useful to have in your quiver for dealing with others. A straightforward implication of the resurgence of CAM is that SBM has what we refer to as a “credibility gap”. How do you propose to fill that gap, without reference to legislative fiat? *Can* you fill the gap without resorting to the political means? And if you cannot, what does that say about your position?

    I am not a troll. Calling someone a troll is a wonderful way to dismiss the argument, something which you presumably do not wish to do, since the fulfillment of your desire involves as a prerequisite convincing people like me that you are substantially correct. What I am, again, is “not nice”. I don’t have to be, frankly; we are a long way past the time when “nice” was appropriate. I note, however, that “nice” is not a prerequisite for discussion; “coherence” is, and I believe that I have made several coherent points, and a multitude of coherent questions, that just might merit consideration. Again, I have no illusions of their being seriously considered, or even answered, but hope does spring eternal.

    “the best of all possible worlds”
    -SD

  69. Fifi says:

    tarran – I’ll leave the doctors to speak about their own motivations for contributing this blog – you can make as many assumptions and assertions you want about what you think their motives are, how they’d act in a certain context and why you believe it supports your political ideology. I’ll let them speak for themselves rather than assuming to know their hearts and minds.

    No, libertarianism isn’t “anarchy”, though I’ve met some libertarians who lean towards anarchy apart from all the American nationalism and it makes sense that Libertarians have appropriated anarchist writings for their own ends. You can deny being aligned the libertarians who call for closed borders and are anti-abortion – and who place their faith in some magical huge legal system that will somehow exist while the rest of government shrinks – but they’re still Libertarians and they’re the public face of your belief system and the most likely to have political power. I mean, really isn’t it up to media and the market to define what the TRUE libertarianism is? Seems to me that Ron Paul is what people are buying and is outselling your apologist brand of libertarianism.

  70. SD says:

    “Even though I am a physician, my beef with government funding of CAM is that it is a waste of taxpayer money. That includes my money. I don’t want to see it wasted on nonsense and prefer that it be used for research that can be fruitful. If someone is stupid enough to buy the CAM nonsense, that is their choice, and they are free to donate their own money to it, but not mine. I do not see this blog as an attempt to crush my competition. MDs compete with each other already, I have no problem with that. I think it’s good.”

    Good for you, weing. However, the critical realization is that other people feel the same way; they do not enjoy their money being hijacked to others’ pet causes either, no matter how “good” the cause is on its face. “Special” fields are always bullshit from somebody’s perspective, and coercing people to fund what they consider to be bullshit is immoral. The solution is not to pick and choose who gets to hijack funds according to a metric of “goodness” – for that can always be argued – but to settle on a gentleman’s agreement of “no hijacking”, i.e. we get to keep our own damned money and do with it as we please. In such a milieu, bullshit quickly dies.

    So what does that mean? It means no funding for CAM, but also no funding for SBM, either. There are other more radical implications as well, of course, as well as negative consequences. When true costs are reckoned, however, those negative consequences are fairly benign.

    “laissez-faire!”
    -SD

  71. Harriet Hall says:

    Motivations…

    Even the most generous self-sacrificing charitable action is ultimately self-serving: it assuages the donor’s conscience and improves his self-image.

    It’s true that we “profit” psychologically from the blog by the pleasure of seeing our words in print, the esteem we garner, and the satisfaction of knowing we are doing our little bit to support science and reason and improve the world.

    But balance that against the psychological debits: we open ourselves up to irrational criticisms, to unfair attacks from true believers, and to insults like the suggestion that we are writing for profit.

    Weighing both sides, I think we can conclude that we are a bunch of idealistic masochists, gluttons for punishment in a cause that often seems like tilting at windmills.

    For the record, I have never been paid for anything I have written, and I have no ties to Big Pharma.

  72. David Gorski says:

    I am not a troll. Calling someone a troll is a wonderful way to dismiss the argument, something which you presumably do not wish to do, since the fulfillment of your desire involves as a prerequisite convincing people like me that you are substantially correct. What I am, again, is “not nice”.

    And denying that you are a troll and proclaiming yourself instead a “not nice” sort of “truthseeker” is a wonderful way to make excuses for being nothing more than obnoxious, particularly when it is clear that you don’t really want to do much more than stir things up.

    You are not the person whom my message and arguments are directed at; so I do not feel the need to “convince” you of anything.

  73. SD says:

    Harriet Hall:

    “Motivations…

    Even the most generous self-sacrificing charitable action is ultimately self-serving: it assuages the donor’s conscience and improves his self-image.

    It’s true that we “profit” psychologically from the blog by the pleasure of seeing our words in print, the esteem we garner, and the satisfaction of knowing we are doing our little bit to support science and reason and improve the world.

    But balance that against the psychological debits: we open ourselves up to irrational criticisms, to unfair attacks from true believers, and to insults like the suggestion that we are writing for profit.”

    Serious question: Why is it an insult to suggest that you do things for profit? Would you rather be thought of as a naif? Completely incapable of agency, of acting in your own interests? Do you feel that your own interests are somehow worth less than others’? Perhaps you think that you are due nothing for your skills, or that you cannot accomplish anything good with the surplus you generate (“profit”), that you will squander it or use it in evil ways? Do you think it is evil to profit from helping people?

    Deep epistemological question: What is *wrong* with profit?

    “Weighing both sides, I think we can conclude that we are a bunch of idealistic masochists, gluttons for punishment in a cause that often seems like tilting at windmills.

    For the record, I have never been paid for anything I have written, and I have no ties to Big Pharma.”

    Whatever floats your boat. I am glad that you are proud of maintaining your objectivity in that context.

    Here’s an interesting question: Why does it matter if you have “ties to Big Pharma”? How do you square the presumption of bias in “ties to Big Pharma” with the presumption of completely bias-free objectivity elsewhere, say, in arguing for political intervention in one sphere and not elsewhere?

    “profit? we don’t need no steenking profit!”
    -SD

  74. SD says:

    “And denying that you are a troll and proclaiming yourself instead a “not nice” sort of “truthseeker” is a wonderful way to make excuses for being nothing more than obnoxious, particularly when it is clear that you don’t really want to do much more than stir things up.”

    And yet, being obnoxious doesn’t have anything at all to do with the truth of the statements made or the validity of the questions asked, does it now?

    If your feelings are hurt, I understand. But there is little place for “feelings” in scientific endeavor. You might think of this as a spirited inquiry into the question of whether or not your activities are a good idea, and whether they have worked, and whether the consequences of your philosophy can plausibly be believed to lead to a good end result. Everything I’ve seen so far suggests that the answer is “no, these activities are a bad idea, and contain failure, and the philosophy behind them is screwed up on multiple levels”.

    I expect that you disagree, of course. But then, you’d better have a good reason for why, one that will resonate with someone other than your (apparently small and ostracized) consensus-cluster. Clearly, you don’t; that’s one reason why CAM is so popular. Okay, so what the hell are you going to do about it? Fighting on the political level has not worked. I will predict its continued failure, for the reasons I’ve stated. What does that leave you? It leaves you with the need to indulge in a little navel-gazing, to see the predisposition to failure embedded in your assumptions (“political maneuvering and coercive means as valid strategy”), and to rethink your assumptions. Tarran has identified a wellspring of some alternate assumptions that you might make that, taken as a whole, would have a very salutory effect on your endeavor to refute quackery. These other assumptions require you to give up certain shibboleths involving individual rights and the extent to which they can be violated in a good cause. I think you might find the trade worthwhile, if you are interested in actually advancing your stated purpose.

    “You are not the person whom my message and arguments are directed at; so I do not feel the need to “convince” you of anything.”

    Surprise: my message and arguments are directed to the very same people.

    “just zis guy, you know?”
    -SD

  75. Harriet Hall says:

    SD,
    There is nothing wrong with doing anything for profit, but the common insinuation is that we might let our intellectual honesty be warped by financial motives.
    The reason I don’t accept pay for writing is that I have an adequate retirement income as an Air Force colonel and I take pride in offering pro bono services to partially thank the world for the many benefits it has bestowed on me. It is also handy to be able to reply to accusations that I wrote something only because I was paid to.
    It should not make a bit of difference whether we have ties to Big Pharma: all that matters is whether we let such ties interfere with our judgment. Nevertheless, that is one of the most common allegations against us – that we are shills for the industry.
    Let me revise my comment about laying ourselves open to insult and give another example: a chiropractor called me an IGNORANT HO. No, words can’t hurt me, but I really don’t need that kind of hostility, and it can easily extend to situations like that of Dr. Offit who had to hire a bodyguard because of threats to himself and his children.

  76. tarran says:

    No, libertarianism isn’t “anarchy”, though I’ve met some libertarians who lean towards anarchy apart from all the American nationalism and it makes sense that Libertarians have appropriated anarchist writings for their own ends. You can deny being aligned the libertarians who call for closed borders and are anti-abortion – and who place their faith in some magical huge legal system that will somehow exist while the rest of government shrinks – but they’re still Libertarians and they’re the public face of your belief system and the most likely to have political power. I mean, really isn’t it up to media and the market to define what the TRUE libertarianism is? Seems to me that Ron Paul is what people are buying and is outselling your apologist brand of libertarianism.

    That’s actually an interesting point. The name ‘libertarian’ was originally coined by people who were frustrated that the word ‘liberal’ had been coopted by socialists, and people who, in the 19th Century would be called liberals, that found themselves without a convenient label to describe their ideology.

    When the Bush administration started blackening the name of conservatism, suddenly many people started calling themselves ‘libertarian’, including such people as the Iraq-invasion supporting Bill Maher (really!). Ron Paul was such an opportunist – when he and Reagan had their falling out, he switched allegience to the Libertarian party, championed by radical anarchist Murray Rothbard, who saw in Paul a chance to break champions of small government away from the Republican party. People assume that the Republican Party is a free market party. It is not. the Republican Party has historically advocated a big government that intervenes to support business interests. The free market guys used to be Democrats. In the late 19th century, a faction arose in the Democrat party that advocated traditional liberal goals but sought to accomplish them through government intervention. The faction completed its takeover of the Democrat party with the election of FDR (FDR was the last Democrat to run on a free market platform, which he did in his first campaign for president). During the reign of FDR, the supporters of free markets and small government defected from the Democrats and joined the ranks of the Republicans who were, at that point the lesser of two evils.
    Things were further muddied in the second wave of defections from the Democrat party when the racist segregationists, who hated the Republicans for the invasion of the Confederacy were driven out of the Democrat party (although some like Robert Byrd did remain). Thus, the free market supporters came to be lumped in with racists and fans of corporate wellfare.

    Yes, plenty of people who don’t really believe in freedom for others are calling themselves ‘libertarian’. Many of them are good on a few issues, and worth making common cause with. And that is fine. For example, the opposition to the Iraq invasion had a libertarian contingent. Libertarians showed up and marched in the marches, libertarian speakers harrangued crowds and wrote essays attacking the venture. Would you reject such support? Would you turn them away from the assembly points for protest marches?

    Ron Paul is wrong on several social issues. He is very right on monetary policy. In fact, he is one of only a few Republicans who fought Bush on his insane print and spend policies. In that respect he is an asset. And it is that economic record which is the source of his national support (for the most part). His support in Texas, on the other hand is another matter

  77. weing says:

    Yes, it would be nice to keep all our money and spend it as we see fit. But it ain’t gonna happen. No way. I think the best that we could do is to see to it that the money is spent wisely on something productive and not on CAM. The choice is analogous to spending money on researching flying broomsticks a la Harry Potter versus money on researching more fuel efficient engines, electric cars, solar power, etc.

  78. tarran says:

    weing, much of that is not wise spending either.

    Seriously, much of what is being proposed are horribly unecomomical. Look at all the money being thrown at ethanol. Wind power, at best, produces a fraction of the power per dollar of capital investment that conventional natural gas plants produce etc.

    Political processes produce wasteful results. We would be far better off if were successfully to demand that both txation and spending be reduced. Absent such a change, the Congress will continue to waste taxpayer money until the economy is thoroughly wrecked.

  79. weing says:

    Agreed, but it’s not going to happen. Do you have an army to stop them? Just look how they are wasting my money right now. To paraphrase Rumsfeld, we have to deal with what we’ve got not what we would like to have. I just want to limit the damage.

  80. Peter Lipson says:

    I guess I’m losing track of the discussion here.

    First:

    But there is little place for “feelings” in scientific endeavor.

    “Feelings” will always be a part of implementing medical science.

    Anyway, there is of course an inherent danger any time government is involved in a major endeavor…it is a powerful tool/weapon. The question is what is the best way to provide health care. To know the answer, we must know the question better.

    Is equal distribution of resources important? How about equitable distribution? Or should we be more utilitarian in our approach?

    Whatever values we infuse, government will always play a role, and must, as the only way for us to afford any real health care is by pooling risk and distributing shared monies—-the government is both the best and the worst institution for this. Individuals cannot provide for their own care, as it is too expensive, so it will fall to collectives, either private insurers or government. Government is beholden to many special interests, whereas private insurers are beholden to fewer but less beneficent special interests.

  81. tarran says:

    Dr Lipson,

    I wonder why you think Government is beholden to more beneficient interests that private parties? Why should the ratio of benefactors to malefactors be improved over that of the regular population?

    It seems to me that government is far more attractive to malefactors than private enterprises because the rewards of office are so much greater. You have sovereign immunity from prosecution, you have the ability to direct police forces to arrest people etc.

    I think you might find the following book illuminating on the subject:
    Bureaucracy by Ludwig von Mises

  82. weing says:

    I personally think that some form of universal health care will be implemented. I also think it will be along the lines describe by Ezekiel Emanuel, Rambo’s brother, in his book Healthcare for All. It has a consumption tax to fund it and a governing body similar to the Federal Reserve.

  83. teeps29 says:

    I stopped reading at “Bush’s evisceration of the Constitution of the United States.” Please keep the political hyperventilation out of SBM.

  84. Peter Lipson says:

    The fact that you do not agree with the statement does not make it less true, or less relevant. The suspension of habeus corpus, illegal detentions, extraordinary renditions all affect the health care providers/psychologists in the armed forces. Ethics and science-based practice overlap considerably, and although I can see an argument for not including this piece on SBM, my judgment obviously was that it belongs here.

    I appreciate your feedback, and I can appreciate that the statement is controversial, but to simply wish the issue away is not helpful. To discuss it is.

  85. weing says:

    Not that other presidents haven’t done similar things. Lincoln and FDR immediately come to mind. Unfortunately we seem to be picking our leaders on the principle of the lesser of two evils. I still don’t understand how keeping someone awake and exposing them to loud music is considered torture but taking half my income (acquired by keeping awake among other unpleasantries) in taxes is not.

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