Book Review: The Last Well Person: How to Stay Well Despite the Health-care System by Nortin M. Hadler
There appears to be a large discrepancy between how effective most people think modern medical practices are and the evidence that experts have presented suggesting that it does very little to extend life. This book gives the impression of describing a pattern of ineffective or harmful practices that might be offsetting the benefits of the practices that are known to work. But there are enough flaws in his argument that I can’t decide how much of his conclusions I should accept.
He starts by saying he’s a Popperian, but often acts like he’s following some other, more dogmatic, philosophy. I’m particularly annoyed at his certain feelings of inevitability that we will die by about age 85:
I am aware of no data to support the premise that we can alter the date of death. … When high-functioning octogenarians decline, it is because their time is approaching.
He starts by making a plausible claim that many people get cardiovascular surgery when there’s no evidence that it will benefit them (and is likely to create some risks).
But starting in the next chapter it becomes easy to find flaws in his arguments. He raises some plausible doubts about the evidence for statins, but then tries to imply that if the imperfect evidence that’s available shows that less than 2% of people who are prescribed statins will benefit, then we should doubt that those people ought to take statins.
He presents evidence that prostate cancer treatments save fewer lives than is commonly thought. It appears that sometimes the treatment merely changes the cause of death to something else. Yet he concludes that the treatment is useless, when the data he presents indicate nontrivial benefits. He hints that the evidence doesn’t meet the usual standard of statistical significance, but feels comfortable concluding (without even saying how close it is to being statistically significant) that the lack of proof is strong evidence of ineffectiveness.
He has a somewhat interesting proposal that the final phase of drug testing be done by the FDA rather than by drug companies. If the FDA were run by angels, that would solve a number of problems with the existing regulatory incentives, but with an FDA run by humans it would replace them with new problems. For instance, the choice of which drugs to test is something that only a few special interest voters (i.e. mainly those working for large drug companies) would understand, so their interests would be likely to influence those choices to the benefit of those companies.
Book Review: One of Us : Conjoined Twins and the Future of Normal by Alice Domurat Dreger
This book raises questions about peoples’ reactions to conjoined twins that may have important implications for many other unusual traits. It eloquently questions common assumptions about the desire to seem normal. It has led me to wonder about the extent to which healthcare is used to make people more normal at the cost of making them less healthy.
The book presents strong evidence that conjoined twins who remain conjoined are at least as well off as those who are separated, and some evidence that separations reduce the twins’ life expectancy, possibly by a significant amount.
Remarkably, of the twins who remained conjoined to adulthood, only one pair requested separation (they didn’t survive it), and among those whose refused separation are a number whose twin had just died (which meant that separation appeared to offer the only chance for the remaining twin to survive).
This doesn’t mean conjoined twins are better off that way (those who have been separated seem equally satisfied with their status), but it strongly suggests that decisions to perform separations are motivated by something other than concern over the twins wellbeing. And it suggests that people who claim things like “The proposed operation would give these children’s bodies the integrity that nature denied them” are imposing their values on others in ways which would be considered unacceptable if the victims had a little political power.
The book reports a fair number of statements by doctors (and occasionally parents) which suggest they consider a normal appearance worth risking health to achieve. The book also theorizes that having a normal child is an important enough part of parents’ identity to override their interest in their children’s’ wellbeing. The book also reports some indications that surgeons are biased toward surgery for unusual problems by the fame if can bring them.
Unfortunately, there isn’t as much evidence as there ought to be about the health effects of separations. The book claims (plausibly, but without supporting references), that “most medicine is not yet evidence-based”, with most surgical decisions being based on storytelling rather than careful studies.
The book raises some important questions about cases where doctors think the only way to save one twin is to kill the other. The author points out some strong similarities between the medical killing that is done in some of these cases and a hypothetical case where a heart is taken from a live singleton (i.e. not conjoined) donor to save another (which all would agree is wrong). One difference that she fails to consider is that if you consider the heart property, it looks like jointly owned property in one case and individually owned property in the other, and we should expect some differences to result from that (although doctors may still be more willing to kill one twin than that perspective would justify).
One interesting example that the book provides of medicalizing a difference is the attempt to get doctors to recognize Drapetomania, a “disease” which causes slaves to run away.
How widespread is the practice of impairing health to make people more normal? Surgeries on intersex children probably create modest health risks. Commonly used medicines to deal with ordinary colds suppress annoying symptoms that are tools the body uses to fight the disease, and tend to make the disease last longer (see the book Why We Get Sick : The New Science of Darwinian Medicine by Randolph Nesse). A child with 3 arms makes doctors want to chop it off, presumably at some risk.
Are these part of a wider pattern that would help explain why increased healthcare spending doesn’t seem to make us healthier?
On a loosely related note, I just ran across an unsettling complaint that Prozac seems to help too many people:
“There’s nobody nonsyndromal. You can give Prozac to anyone you want.”
Which is anathema to what medical science is supposed to be about. “We try to convince people there’s some specificity to what we do,” says Millman. “But this is embarrassing.”
Is this an indication that people don’t want drugs to do anything other than treat abnormal conditions (i.e. that they consider it wrong to improve on normal conditions)? Or does it reflect concern that there will be less demand for doctors’ skills if no diagnosis is relevant to the decision to use it? (This seems less likely given that they can still play a role in monitoring side effects).
I was inspired to read this book by a brief comment from Robin Zebrowski at the recent Human Enhancement Conference.
For those investors who (unlike me) can’t afford to do fundamental analysis on a large number of companies (and if you can’t afford to analyze thousands of companies, you’re probably using a questionable method to select which ones to analyze), there’s a new class of ETFs which sounds like fixes some of the worst problems with typical stock funds.
Most people invest in funds that are based on a capitalization weighted index, which means that any time there’s a bubble affecting some of the stocks in the index, the fund is buying those stocks at the peak. The more popular those funds are, the easier it is to create bubbles in the stocks they buy.
There’s a new ETF (symbol PRF) that weights its holdings on dividends instead, which will sell stocks that are affected by bubbles (except in the unusual case where the company increases its dividend in step with the bubble).
The Political Calculations blog mentions similar strategies which appear to work about as well (the dividend weighting selects against small immature companies, and it ought to be possible to avoid that).
Weighting on revenues sounds like it works well, although it overweights retailers and underweights successful pharmaceutical companies and oil producers that find cheap sources of oil.
Weighting on the number of employees should work (although that underweights companies that outsource).
I’m somewhat partial to weighting on book value, but instead of the standard book value, I’d use tangible book value plus an estimate of amortized R&D expenses.
Shorting the 5 or 10 companies with the largest market capitalizations would probably be a good way to invest a modest portion of a portfolio in a way that would reduce risk and improve returns.
These strategies do have the potential to underperform if they becomes as popular as buying and holding S&P 500 funds was around 2000, but it will take some time to become that trendy, and even if it does there will probably still be funds using unpopular versions of fundamental weighting that will remain good investments.
Book Review: 1491 : New Revelations of the Americas Before Columbus
by Charles C. Mann
This book does a good job of discrediting several myths about the nature New World civilizations before Europeans arrived. It implies that significant parts of the book Guns, Germs, and Steel are wrong (in ways that Diamond should have avoided by consulting experts) – Indians were quite capable of repelling Europeans when their advantage consisted of guns and steel. After smallpox spread across the Americas (faster than Europeans), guns and steel were largely superfluous advantages.
The book presents evidence (alas, not enough to be conclusive) that most of the land in the Americas had been altered by civilizations that were much more sophisticated and varied than is commonly realized, and the myth that Indians were primitive savages is largely due to people mistaking the disease-ravaged remnants that the typical European colonist encountered for the pre-European norm.
The book also provides a few bits of evidence against historical determinism by pointing out how differently some aspects of civilization developed in the two worlds. For instance, the New World seems to have been first to get the concept of zero, but only used wheels for toys, and valued metals for their malleability rather than strength.
One very intriguing report is that the Haudenosaunee (Iroquois) Confederation society was freer and more egalitarian than European society, and that this caused a number of Europeans to prefer Haudenosaunee society, but no Indians in that region preferred European society. It’s unclear how strong the evidence is for these somewhat controversial claims. I guess I ought to track down the books he references for this subject.
The book also describes the Inka empire as socialist, without any markets, but I’m disappointed at how little the books says about that (e.g. how broad a definition of market is he using?).
The main shortcomings of this book are the numerous anecdotes that add little to our understanding of Indian civilizations.
“I do not need to explain why I say things. That’s the interesting thing about being the president. Maybe somebody needs to explain to me why they say something, but I don’t feel I owe anybody an explanation,” – president George W. Bush (via Andrew Sullivan).
The conference on Human Enhancement Technologies and Human Rights this past weekend had many boring parts and a few interesting tidbits.
Many of the speakers were left-wing ideologues who seemed to be directing their speeches only to others from the same small set of left-wing academics. There were fewer libertarians at the conference than I expected, but still enough that it was strange how much of a disconnect there was between the ideology shown in the speeches and the ideology I knew from elsewhere that many people held but were being quiet about.
There was plenty of concern about whether increased control over one’s body would decrease diversity, but I heard little that enlightened me on that subject. There have clearly been many technologies that increased diversity, such as tattoos. There are some that have decreased diversity because there is a substantial consensus about what’s best (e.g. eyesight – it’s unclear why we should be concerned about a shortage of people who can’t see well enough to drive). Then there are a few traits such as degree of autism where there’s some uncertainty whether reduced diversity would be good. There are some pontificators (I didn’t hear anyone this focused at the conference) who think they know better than the masses what the right amount of diversity is, and that their opinions should be imposed on the masses. But the evidence for the pontificators’ expertise and the masses propensity to make mistakes is generally underwhelming, so I can’t find much reason to be as concerned about the effects of enhancement technology as I am about the desire to impose expert opinion on those who don’t want it.
Hank Greely pointed out that the letter of the law authorizes the FDA to regulate anything that could be considered a body enhancement, including clothing. So only the FDA’s interest in obeying the spirit of the law will deter them from regulating external enhancements.
One amusing report of unwanted side effects of an enhancement technology is the increase in sexually transmitted diseases in seniors following the introduction of Viagra.
Aubrey de Grey made an interesting argument that the most effective approach to convincing people to support a cure for aging is to persuade them that they are being logically inconsistent when they fail to do so. He has a point, but it’s weaker than he thinks. He gave several examples of problems that were allegedly solved by persuading society to be more logically consistent, but I generally doubt that’s what happened. One example was tolerance of homosexuality. I see few signs that logical arguments had much effect on that. I think the biggest change came from peer pressure, which became increasingly popular as gays became able to migrate to places where there were enough gays to safely start exerting peer pressure. Another factor was the shift away from the belief that the main purpose of sex should be reproduction. That initially happened due to changing circumstances (reduced reliance on children to support elderly parents). I’d say that has generally produced beliefs that are more inconsistent as people abandon the least convenient symptoms of the belief (e.g. contraception) but are much slower to abandon symptoms that are remote from their experience. I think similar theories could be made about some other examples he gave (slavery becoming more expensive to enforce when railroads made it easier for slaves to escape to a non-slave state).
Next time you hear someone implying that commercial development is the primary enemy of the environment, remember stories such as this one about how much harm a single wasteful Army Corps of Engineers project is doing to wetlands.