[extropy-chat] Effectiveness of Medicine (was: Robin Hanson onCynicism)

[Brett Paatsch]

Robin Hanson wrote:

> At 12:08 AM 9/24/2005, Brett Paatsch wrote:
>>>>In your essay [http://hanson.gmu.edu/feardie.pdf] you say
>>>>"fear of death makes us spend  15% of our income on medicine from which 
>>>>we get little or no health benefit, while
>>>> we neglect things like exercise which offer large health benefits".
>>>>
>>>>But I can't see where you answer the basic question what does Robin mean 
>>>>by medicine? You seem to assume that
>>>> *everyone* just knows what medicine is. I think that is not
>>>> a valid assumption. Your essay surveys work done by others
>>>> but it is not clear that *they* have defined  medicine the same
>>>> way as you or indeed as each other.
>>>You baffle me.  The usual intuitive definition of medicine is "the stuff
>>>that doctors do".
>>
>>This isn't my intuitive definition of medicine. That would be like 
>>thinking economics was stuff that economists do. Or music is what
>> is produced by those people that call themselves musicians.
>>To me, intuitively, medicine is about treating ailments.
>>
>>>You know going to them to get advice, some of which is
>>>to take drugs, undergo surgery, and so on.  The RAND experiment
>>>operationalized that in the obvious way - they gave folks money to
>>>go to the doctor more.
>>
>>That's poor method in my opinion.  Give money to go to the doctor
>>to uneducated poor people and of course they will use it. People like
>>getting attention (Hawthorne studies).
>
> You still baffle me.  How would *you* study the aggregate effectiveness
> of "treating ailments"?

By first making explicit what the class of ailments under consideration
would be. I would NOT try to cluster all the treatments of real and
imaginary ailments together into a superclass and call it medicine. (That's
potentially dangerous some dill might read my confusion and formulate
more bad policy based on it.)  I'd personally only study the stuff that
had a physiological basis not stuff that doctors treat with no clue as to
its basis. In computer parlance that approach to medicine seems like
garbage in garbage out. I'd argue doctors that treat without knowing
what it is that they are treating aren't practicing medicine at all.

>  And if you think that people given money to
> spend on medicine wouldn't spend it wisely to gain health, then why
> would you think people spend their own money on medicine any more
> wisely?

Because those with money to spend, rather than those holding vouchers
that are only good for going to the doctor type services, retain the
discretion to spent that money on other things. I think people will only
spend money on reducing dis-ease that they actually experience or take
action for problems they actually know they have (you might be
forewarned in your youth about a higher risk of heart disease because
your father had it) if there is an opportunity cost to them of pleasures
foregone by money wasted. When they have no dis-ease they will
spend the money on things they actually want. They'll act to increase
their pleasure rather than act to reduce the pain they aren't
experiencing.

> It seems as if you agree with my claim that money spent on
> medicine doesn't produce much health.

I don't disagee with it. I'm agnostic on it. I started off neither agreeing
nor disagreeing with it and that is still where I am now.

Your, and economists, and politicians equating medicine with whatever
the hell doctors might do is very counter-intuitive to me.  I can't forget
that doctors (as a class) are still just people with all the silliness that
encumbers for long enough to revere their authority as a class and to
forget that its the dis-ease that needs treating not the doctor that I
need to be concerned with running off to get advice from.

If I have a broken arm, I'd go to a doctor or a hospital where there
would be a doctor or perhaps a nurse and the doctor would put it in
a cast. My medical ailment is a broken bone, which is painful and
disfunctional for me. I go to a doctor because its clear I am dis-eased.
I want the function back in my arm and it just so happens that I know
that the doctor or someone at the hospital will be able, probably, to
set the bone and thereby reduce my state of dis-ease. They have the
necessary technology there (xrays etc to see the nature of the break)
to do the physical repair job.

For me, all real medical ailments fall into that category. They have a
physiological basis which if understood can be turned to a physiological
remedy which will return function and remove the state of dis-ease
(pain or concern about loss of function).

Although I won't claim this is intuitive to me that there is a physical
basis even for things like moods I also accept as true. When drugs
work they either work on that physiological basis or they just plain
don't work at all. Or they may do harm because they interact on
a physiological basis somewhere where the biological mechanism
wasn't impaired before.

Making judgements about the effectiveness of treatments based on
correlations rather than direct observations only makes sense when
it isn't known what the physiological basis of the disease is and so its
particular mechanism of causing dis-ease is unclear.

And if you give a drug which acts by unknown mechanism to fix a
disease that arises through unknown mechanism then all you are
really doing whether you call yourself a doctor or medicine-man is
sucking it to see, and keeping track of correlations. If the result, the
after level of dis-ease, is worse than before then the treatment is
contra-indicated.

For much of history that has been all people including doctors have
been able to do because the physiological basis of disease wasn't
understood.  The dignostic tools weren't available. Nor the scanning
tools.

>>>>I'm obviously missing something here Robin.  I can't see any real
>>>substance in the essay. To me you just don't cut down to anything
>>>substantive.
>>>I find it hard to imagine what would count as substance to you.
>>
>>Major things that people die of are heart disease, cancer and diabetes.
>>All these diseases have given ground to medicine since the Rand study
>>was done in 1979 or earlier.
>>Insulin for diabetes. Angiograms then stents and bypasses for heart
>>disease. Chemo and radiation treatment followed by treatment
>>with stem cells.
>>The Rand study didn't look at the young or the old. It excluded the
>>frailest cohorts. The groups that would have been most likely to
>>benefit.
>
> The RAND study did as much as they could at the time.  They couldn't
> look at free vs. full price medicine for the elderly because the elderly
> already got free medicine from Medicare.  They did look at children.
>
> I'd love to see a new experiment done like the RAND experiment, but
> until that happens this is the only aggregate experiment data we have.

Okay. And at present that data isn't enough for me to move to agree
with your assertion that the US spends 15% of its income on medicine
for which there is little or no health benefit.

I'm not saying your conclusion is wrong. I'm just saying I am not
persuaded yet on the basis of the data your essay provides me.  I'm a
bit concerned that some dill politician might read only the abstract of an
essay you write and conclude that economists think all contempory
medicine is largely useless. Your essay has August 2005 on it even if
the dates of the underlying aggregate research you rely on is substantially
older than that.

> We do have lots of correlations-in-the-world studies done more recently,
> many of which include the elderly.  I mentioned one in my paper; what is
> your beef with that study?

I haven't read the Skinner and Wennberg study itself just the summary of
it that you included in your essay. The summary didn't contain enough
material to compell me to agree with you. Nor did it show anything that
made me think their method was obviously flawed. So I stayed agnostic.

To agree with the key propositions in your essay I have to agree on two
stages. First that the US spends 15% of its income on medicine for which
US citizens get little or no health benefit. And second, and this is really
what *your* own essay is about, that the reason that the US does that is
because people fear death.

I can't be persuaded to your second point without going over the first
and I'm not currently getting past the first point. I'm just not persuaded
on the data you show me in your essay that your statement that 15%
of our income spent on medicine yeilds us little or no health benefit.

This doesn't mean that you are wrong. It just means that you haven't
succeeded in moving me to agree with you on the basis of what you've
written.

This *could* be because I'm being thick headed, and not engaging
with the underlying research right now, or it could be because I'm
not willing to let you have me join you in drawing too long a bow
on the basis of too little evidence.  Or there might be other
explanations :-).

Brett Paatsch