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

[Brett Paatsch]

Robin Hanson wrote:

> At 09:48 PM 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, ...
>>>>>>You seem to assume that *everyone* just knows
what medicine is. ...
>>>>>... intuitive definition of medicine is "the stuff that doctors do". 
>>>>>...
>>>>To me, intuitively, medicine is about treating ailments. ...
>>>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.
>
> The personal policy decision people face is whether or not to go to the 
> doctor and do what he says. People do not face
> the decision of whether or not to treat a real ailment or to treat an 
> imaginary ailment, because they do not know at the
> moment of decision whether the aliment is real or imaginary.

It would be possible though for governments to decide not to
provide subsidies for some of the categories of treatment that
some people would be willing to buy thereby having more funds
to allocate to medical treatments that are actually going to be
effective. I don't want to see iridology consults and shakra
realignments subsidised.

The Australian Pharmaceutical Benefits scheme used to work
on a principle whereby the federal government would act as
a consolidated pharmaceuticals buyer and it would only make
one or perhaps two drugs available from within different
categories. The drugs would be compared (by experts)
for effectiveness and cost against rival offerings.  In this way
a lot of the consumer choice was removed. There is obviously
good and bad consequences of that approach.

>  Similarly a commonly discussed government policy decision
> is whether or not to subsidize or support medical spending. For
> example with Medicare or Medicaid, or tax free employer provided
> health care. You don't get to say "we should only subsidize real
> ailments" because that's not one of the options on the table.

I think there is going to be so much political pressure in this area
in coming decades to contain health costs that some health
economists will get a chance to have input into policy. I just hope
that the research that gets listened too by politicians is genuinely
useful.  Telling a politician that wants to cut the costs of medicine
and just about everything else, that medicine is largely useless is
likely to make some health economists very popular with that
politician but they could be a real pain in the arse to the public
good if their research isn't rock solid.

> Doctors say all the things they treat are real, after all.

But I don't believe them and neither do you.

>>>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.
>
> That really doesn't make much sense to me.  Of course if there is no
> opportunity cost they might spend too much.  But among the things they
> choose they should choose the best things as they see them.  If they
> can't make good choices among the options in one case, they can't in
> the other case either.

I probably do need to take a closer look at the RAND study.

But your essay says "in the late 1970s, most of 5816 non-elderly
adults (sic)... were randomly assigned". So where did the children that
were reported to have had "fewer decayed and more filled teeth" come
from?  Something isn't right there.

Your source for the RAND study isn't the RAND study directly its
(Newhouse & Group, 1993).  Do you have the actually RAND
study? Can I see it?

>>>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.
>
> Do you have an opinion on the subject?

Yes. But in fairness to you my opinion isn't much more than a prejudice
at this stage.

On the other hand in fairness to your readers as a writer when you make
a claim in the title of an essay or in the abstract of it you are putting a 
flag
in the ground and asserting something to be true. Don't you agree that
the reader should be entitled to expect that the essay that follows will be
about the writer accepting responsibility for make the case for the truths
he is asserting?

> If not, why object that I have one?

I don't. I like that you have one. Your opinions are usually well
grounded and interesting.  When you speak on health economic
matters though I am aware that your opinions might matter a bit more
than the average. As a teacher of health economics your opinions
(or that of your students) might actually get to influence policy
somewhere. I wouldn't want you convincing politicians of something
that wasn't true. I don't think you want to either.

> If you do have an opinion, what is the basis for it, if you reject the
> best evidence we have as not good enough?

My opinion is that in the aggregate medicine will be more effective
than no medicine. As I find evidence for or against the proposition
I'll bear your interest in this topic in mind.

I'm interested in the questions you have legitimately raised about the
effectiveness of medicine. But I'm time constrained and I don't want
to have to look too far beyond your essay for substantiation of the
claims in your essay.

To the extent that you provide corroborating stuff in your essay and
I don't read it closely enough then its entirely fair for you to call me
to account for that.

Brett Paatsch