Some thoughts about denialism

Before we can democratize the institutions, processes and findings of science, we have to democratize thinking. That is, a major percentage of the cognitive processes that are reflected in popular belief and public discourse are not of a nature that leads to truth. Really getting to the roots of why people are so bad at thinking, which we usually imagine to be the one thing we really do well and which we fancy distinguishes us from lesser creatures, is beyond the scope of a blog post and could well be a life's work.

Many people have set out to catalog common forms of fallacy. Here is one commendable effort, although on careful reading I find that the author has managed to embed a couple of his own. Well, clear thinking isn't easy, and that's one explanation for why it's often in short supply -- sheer laziness. But that's just the beginning.

The NYT dedicated this week's Science section to the 40th anniversary of the first human landing on the moon. John Schwarz offers a glimpse of the movement, still going strong, that insists the whole thing was a hoax. What an odd belief to cling to -- think of the massive conspiracy required to convince the world that people had walked on the moon on six separate occasions. What is the motive? Why has no one of the hundreds, or more likely many thousands of necessary co-conspirators never come forward? And of course, as soon as anyone knowledgable looks at their evidence it is immediately clear that it is transparently wrong and ridiculous. (A couple of hints: the reason shadows on the earth, as on the moon, are not pitch black has nothing to do with the atmosphere. It's because of scattering of light from solid surfaces. And, the reason shadows do not all point in precisely the same direction, on the moon as on the earth, is because the terrain is not flat, but rather presents varying angles to the sun.)

But evidence and argument make not a dent in denialists, whether the subject is the moon landing, anthropogenic climate change, or evolution. Conspiracies of thousands or millions of scientists are deemed far more plausible than an unwanted conclusion. As it turns out, the Christian fundamentalists actually consider this a feature, not a bug, and they are proud of it. They call their preferred mode of reasoning Vertical Thinking. There's even a "Christian" magazine for young people called Vertical Thinking, but I'm not going to link to it.

The basic idea behind vertical thinking is that you start with your conclusion -- e.g., God, six days of creation 6,000 years ago -- and then you interpret whatever facts you come across so as to conform with your conclusion. If a fact seems not to fit, that's by definition impossible so there must be something wrong with your observation or some arbitrary explanation for it must be found. (E.g., God put those fossils there to test our faith.) Horizontal thinking, which Mike Huckabee and his friends decry, is when you look at a bunch of facts and you try to reason out the most likely explanation for them. New facts may require a reorganization of your arguments and new conclusions. Then so be it.

The advantage of vertical thinking is that you can hang out with all your like-minded buddies, in the church, the bar, or the Internet, and share your regard for each other and your contempt for all those who do not Believe in the Truth. So again, it comes back to a kind of laziness, complicated by cowardice. But this is really a developmental disability. It is constructed in childhood, by our parents, by the way they instruct us and model the human attributes of thought and belief. For an adult to unlearn the delusions of childhood is very difficult.

I should add that some people develop bizarre fixed ideas as adults, which is no doubt the typical story of the moon landing deniers. I don't actually know why that happens. I happen to think that moon landing denial is sufficiently bizarre to qualify as a delusion and might merit a diagnosis, but actually what is and is not a psychotic delusion is purely a matter of social convention. 6,000-year-old earth does not qualify, but Ted Kaczynski's intellectually defensible belief that industrialization was a disaster for humanity did, and was so certified in a court of law. As far as I'm concerned, Ted is just a violent fanatic on behalf of reasonable ideas, whereas creationists are completely nuts. Update: Lest anyone misunderstand me, Kaczynski was convicted for his actions, but found insane by reason of his beliefs, and therefore spared the death penalty. You could look it up. His actions may have been insane, but his beliefs were not.

The point of all this rambling is that we need to equip more people with better critical thinking faculties. That ought to be the main point of education, and it's quite possibly the biggest and most important challenge we face as a species. We can't solve our problems if people refuse to understand them.

Water, water, not everywhere?

The editors of PLoS Medicine want to declare a basic human right to clean water. I buy this as a rhetorical strategy and in particular as an implicit critique of the neoliberal approach to global development which has caused such devastation in the world. Yes, yes, those neoconservatives were just awful weren't they, but they share a lot more with neoliberals than just the prefix.

Specifically, we have had a consensus in the capitalist capitals since the time of Ronald Reagan (and not, by the way, including Nixon) that the path out of poverty for the great mass of humanity went through shriveling of government investment in social welfare and human development, and turning loose the magic of private enterprise and free markets. You can read all about it here, thanks to Global Issues.

In the case of water, specifically, this meant alienation of the public domain -- handing over what had been provided freely by nature to private ownership -- and requiring people to pay money which hundreds of millions of them did not have to acquire one of life's most basic necessities. According to the WHO, providing clean water to everyone would prevent 6.3% of all deaths worldwide. As I have said here many times, "preventing deaths" is, in itself, a nonsensical metric because, well, we're all going to die, we're all going to die! Yes we are. However, deaths from contaminated water largely affect the young, in particular the very young. They are also the tip of the iceberg of an immense burden of disease -- 9.1% of the global burden, sayeth the WHO, including parastic diseases that destroy the productive potential of young adults.

But simply declaring water to be a "basic human right" doesn't accomplish anything. Rights are only effective when they place enforceable obligations on others. Institutions with the power to deliver clean water must actually be made to do so. This creates immensely complex problems including international conflicts over watercourses and lakes, and demands for infrastructure that poor nations cannot meet. Climate change, with accompanying drought and more rapid evaporation, just makes it harder.

So make sure this very big challenge is also on your list. Petroleum, phosphate, topsoil, water, seafood -- all going, going, gone because of the tragedy of privatizing the commons. We got it horribly wrong.

How we live

Long time readers know that I own property in Windham County, Connecticut where I plan to plant a pear orchard. Yesterday, while waiting for the Domicile Deepott to deliver kitchen appliances -- of course they never showed -- I cleared a corner of land to make way for an additional dozen trees or so. Yup, it's back to the land and the simple life and all that, if you happen to possess, as I do, a tractor with a front end loader, a brush cutter equipped with a circular saw blade, a Stihl Farm Boss chain saw for felling and a Poulan Woodshark chain saw for lopping and cleaning up the saplings, a hydraulic log splitter, and a wood chipper, both with Honda engines. To finally prepare the ground, I'll have to pull my tiller through it to rip out the small stumps, roots and rocks.

It was still quite a lot of hard work for me, but think about the Europeans who first planted orchards in Connecticut in the 19th Century. They had to chop out the brush with hand tools, fell the trees and take them apart with axes and hand saws, and plow the ground with a team of oxen. (Major muscle is needed to get a plow through raw forest soil full of tree roots.) Back then, very few men my age could have contributed much to that effort, those few who were lucky enough to be alive.

Food today is as much fossil fuel as it is biomass, not just to operate the equipment, but to build it in the first place, from mining the metal ore to forging and machining and assembling and shipping it; to manufacture synthetic fertilizer; and of course to ship the produce all around the world. Our dilemma is that it takes fossil fuel to produce biofuel, to manufacture wind turbines and solar panels. There's scarcely any net payoff to much of the technology that's being promoted today. The distance from here to a sustainable post-petroleum economy that could evenly come close to supporting the current human population seems nearly impossible to traverse.

After my father died, my sister happened to find a Mitchell's New Atlas of North America, dated 1867, in the back of a cabinet. The map of Massachusetts, Connecticut and Rhode Island shows a network of major roads, that more or less follow the routes of most of the present Interstate Highway network. I-95, for example, essentially duplicates U.S. Highway 1. Back then, however, the traffic on those roads was horses and horse-drawn conveyances. There were no highway bridges across the Thames or the Connecticut River; travelers on the Post Road took ferries. A journey by road from Boston to New York would have been a substantial undertaking. Most people never traveled farther than the nearest market town. (The New York, Providence and Boston railway opened in 1837.)

Our lives today are so strange, so radically unlike the circumstances under which we evolved, that it is astonishing how easily we seem to function. But it isn't going to last very long. Yet another very different world is coming, but no-one can see its shape, even vaguely.

Fear of an Enlightened Planet

As a member of SWA -- Sciencedorks With Attitude -- I'm not in the least surprised, but still plenty bent out of shape, by the latest Pew poll done in collaboration with the American Association for the Advancement of Science. Which helps explain my perpetual state of high curmudgeonliness. (Yes, I've finally attained the age where I get to be a curmudgeon.)

Of course, the people labeled as "scientists" aren't unanimous about anything, but 87% of them believe in evolution without any of that ID pishtosh (disappointingly low) and 84% believe that global warming is occurring due to human activity. (I'm willing to cut a little slack there, it's not something you have to be personally down with to study the Quantum Hall Effect.) And, as we already know, the public is approximately divided into thirds over the question of whether life evolved by natural processes; life evolved under divine guidance; or humans have always existed in their present form. Only 2% of "scientists" agree with the latter -- and scientists are not immune from dementia and mental illness, so that is to be expected.

No news here, but reason yet again to ponder the ugliness. It is ultimately our fault, as scientists, for thinking that it's enough for us to do what we do and know what we know. We get to talk our own secret language. We store our arcane lore in libraries you aren't allowed to enter and thousand-dollar-a-year journals you aren't allowed to read even if you could make any sense of them. We won't let your kids become initiates into our secret societies because you can't afford to pay for college and they don't score high enough on the SAT anyway. And when, as one would expect, you end up not believing our jive, we just call you a bunch of dumb hicks.

Here's what has to happen. Science must remake itself as a participatory, public enterprise. Ten percent of every NIH grant, on average (the appropriate amount depends on the type of research) should be allocated to public programs, including community based participatory research designs, public outreach and science education -- not just in school but everywhere people can be reached -- and the democratization of scientific infrastructure and enterprise. It is possible to do science in a whole different way that eliminates those walls between the research and teaching enterprise, and what has always been to scientists the "outside" world, i.e. humanity and society. This remoteness and outside perspective has even been affected by social scientists, which is a logical absurdity.

I have a lot of ideas about specific ways to do this. I'll bet that if we really changed, people would come around to understanding our point of view and agreeing with us about the stuff we're good at proving. And guess what -- we might learn a thing or two as well. More to come on this.

More stuff you probably didn't know

It appears I misunderstood the situation -- for so long as Michael Jackson remains dead, and Sarah Palin remains a narcissistic doofus, the public discourse will consist of nothing else. We are doomed to hear about these two individuals, the not-so-quick and the dead, relentlessly, and exclusively, until the extinction of humanity. So, I guess it's up to me to tell you some of the news that isn't fit to print.


Did you know that President Obama, on June 29, acted to abort a Bush administration initiative that could have led to the resumption of nuclear fuel reprocessing in the United States? The nuclear power controversy was big time in my youth but it has been quiet lately, so readers may need a brief review of the reprocessing issue. The Union of Concerned Scientists gives a primer, including a discussion of the now extinct GWB plans. Briefly, as the enriched uranium in nuclear reactors fissions to produce power, it's breakdown products include plutonium, as well as a whole lot of shorter-lived, highly radioactive species. In reprocessing, the plutonium and unburned uranium are chemically separated from the rest of the junk, the idea being that both can then be re-used in reactors.

The problems with this? You've got a whole lot of highly radioactive, very dangerous stuff being shipped around the planet -- the very dangerous spent fuel from reactor to reprocessing plant, and the plutonium heading back out to reactors. Unlike uranium, which requires elaborate technology to enrich from reactor to weapon grade, plutonium can be separated out chemically, by a smart college kid.

All of the stages in this cycle make excellent targets for attacks by depraved maniacs, whether to cause a disaster on the spot or to steal material for use in weapons. Terrorists aside, plain old accidents would be unacceptable. Furthermore the process generates a stream of highly radioactive liquid waste which is hard to dispose of. Reprocessing and other technologies to extend the nuclear fuel resource may become part of the global energy mix in the future, but that won't make sense until we have nuclear disarmament -- so the plutonium is not subject to diversion -- and a technological regime which can implement these processes safely and securely. We are nowhere close to that yet.

In other news apparently equally unfit to print, Obama appointed Eric Goosby, M.D., as U.S. Global AIDS Coordinator and the Senate confirmed him a couple of weeks ago. He was an HIV policy official in the Clinton administration and then head of the Pangaea Global AIDS Foundation. There is a lot going on in global AIDS policy right now, not least the evident failure of the universal treatment campaign -- we're actually rolling out treatment more slowly than the pace of new infections; the impact of the economic slowdown on AIDS prevention and treatment efforts in the poor countries; Obama's breaking his campaign promise to provide $1 billion a year in new funding for the President’s Emergency Plan for AIDS Relief; and PEPFAR's emphasis on abstinence and monogamy in HIV prevention, which is not effective with the people at highest risk, including married women who cannot control what their husbands do. Many of us are expecting positive changes.

I choose these two items because they are of particular interest to me, they are very important, and the corporate media have largely ignored them. I'll accept other nominations.

The back pages

Now that it's clear that Michael Jackson is going to stay dead and Sarah Palin is going to remain an incoherent ignoramus and pathological liar, I believe the nation can finally afford to pay attention to other issues, no doubt less important but still worthy of notice.

One you have undoubtedly not heard about is legislation which would reverse the effect of the 2008 Supreme Court ruling in Riegel v Medtronic. A summary of the issues is here, in a NEJM editorial. The Court's ultimate ruling was that the 1976 Medical Device Amendments to the Food, Drug and Cosmetic Act prohibit all lawsuits against medical device manufacturers by people who are injured by devices which have FDA approval. Of course, the 1976 legislation doesn't actually say any such thing: it just says that federal regulation pre-empts state law in this area, not tort actions. But you know, those activist judges, legislating from the bench . . .

Anyway, as we know, the FDA does not do an adequate job of establishing the safety of medical devices. In particular, they rely on trials run by the manufacturers, who have an obvious conflict of interest, and the agency does not adequately oversee these trials to ensure their integrity and the reliability of the results. Oh -- you don't have to take it from me. You can take it from George W. Bush's Inspector General of HHS. So, device manufacturers can slip shoddy science past the FDA, you can be injured by their products, and you can't sue them. Thus sayeth John Roberts.

You can read a summary and text of the House and Senate bills here, at the Library of Congress's "Thomas" service. Just click on the "bill number" radio button and then search for HR1346 or S 540. BTW the site has a lot of other great features, you can find out all about what's going on in Congress there. The bill, very simply, would restore the orginal intent of Congress and overturn the Supreme Court's judicial activist intervention by restoring your right to sue if you are injured due to a faulty medical device. Power to the People! Call your representative and senators and tell them to vote yes.

And let's stop appointing activist judges like Roberts, Alito, Scalia, and Thomas who don't respect the democratic process as reflected in the plain language of the law, and instead substitute their own judgment for that express will of Congress.

Occam's Razor

The chattering classes are all in a twitter over the reasons for Sarah Palin's bizarre resignation announcement. What is her ulterior, nefarious, elaborate plot or plan? Actually there is a very simple explanation: She's a blithering idiot.

Why is the death of a weirdo song and dance man the biggest news since Pearl Harbor? (Bigger by far, by far, than the president signing an agreement with the Russians to reduce nuclear arsenals by 25%) Simple: Everybody has heard of Michael Jackson and thinks they know something about him. Hardly anybody knows anything about the U.S. and Russian nuclear arsenals, including the international affairs reporters for the major TV news channels, so why should they be expected to talk about stuff they don't understand?

Why do self-righteous moralizing puritanical christian fundamentalists bluenoses keep getting caught in tawdry and often downright bizarre sex scandals? Projection.

Why do the ill-informed, frequently dishonest, bigoted and atavistic bloviators for a discredited, defeated political movement who are destined for the ash heap of history hog most of the air time on the teevee blather shows while the party that is actually in power and responsible for shoveling the mountains of shit they left behind can barely get a word in edgewise? Ahh, that one's not so easy.

Stay out of the clutches of doctors

That's not always possible, and it's not always good advice, but it's very important to put the entire enterprise in perspective, particularly as we consider restructuring our health care system. Specifically, I've come across two recent articles -- both subscription only -- that remind us that Ivan Illich had a point after all. In the July 1 JAMA, Charles Kilo and Eric Larson -- both of them well established on the Dark Side, holding M.D.s -- review the harmful effects of health care. They actually name That Which Can Not Be Named: "On balance, the data remain imprecise, and the benefits that U.S. health care currently deliver [sic] may not outweigh the aggregate health harm it imparts."

Uh oh. Now that would be a pretty serious waste of 17% of the U.S. economy. Direct physical harm from adverse effects of treatment is well known and justified as the inevitable consequence of placing bets where the odds are on your side but you will sometimes lose on the flop or the turn. However, the truth is that physicians very often do not have good information about the odds of benefit or harm associated with particular treatments. This is partly because adverse effects often emerge only after long experience, long after drugs are approved, viz Rofecoxib or a lesser known debacle, the Swan-Ganz pulmonary artery catheter which sold millions of units for billions of dollars for 35 years before it was ultimately found to be harmful.

However, as Kilo and Larson note, "[B]oth physicians and patients generally embrace techology enthusiastically -- implicitly trusting in its benefit before adequate assessment is made."

But there is also emotional harm, such as anxiety from false-positive test findings. One which they do not mention but which I have thought about a bit lately is the opposite effect -- the considerable distress patients often feel when doctors tell them that symptoms such as chronic pain, for which the doctor can find no physical cause, are of psychological origin. This can make people feel stigmatized, disbelieved, and devalued.

Then there is the opportunity cost. Every dollar spent on a useless or harmful treatment is a dollar not spent on something else, be it feeding a hungry child or improving public education. Either of the latter would do far more for the public health than medical intervention can do. "Although health care's objective should be to improve health, it's primary emphasis has been on producing services." We simply have no good measures of the overall impact of health care on population health.

Ian Scott in BMJ (also off limits to the rabble) discusses errors in clinical reasoning. His literature review includes the following highlights:

1. The correct diagnosis is missed in 5-14% of acute hospital admissions.


2. Autopsy studies find diagnosis error rates of 10-20%.


3. Even with the correct diagnosis, up to 45% of people do not receive the recommended evidence-based care.


4. From 20-30% of investigations and prescriptions are possibly unnecessary

His point is that a lot of this has to do with the ordinary human fallibility of physicians. Doctors suffer from the same biases in decision making and sometimes erroneous shortcuts in reasoning that plague us all. There are other structural and cultural causes of medical error, of course, which may be just as important. But it is salutary for physicians as well as patients to keep in mind always that they are engaged in an enterprise characterized by a great deal of uncertainty and potential for error, which nonetheless has a strong bias toward action.

Rather than producing more medicine, we need to produce somewhat less, but distribute it more equitably and wisely. This is one way of understanding the fundamental struggle that is going on in Washington right now. As the Washington Post reports (in the small window of opportunity remaining before it closes the impending sale of its newsroom to lobbyists), the health care industry is currently spending $1.4 million a day on lobbying. You read that correctly folks, that is $1,400,000 every day to buy the votes of Max Baucus and Joe Lieberman. And why are they doing this? As reporters Dan Eggen and Kimberly Kindy write, "The aim of the lobbying blitz is simple: to minimize the damage to insurers, hospitals and other major sectors while maximizing the potential of up to 46 million uninsured Americans as new customers."

Exactly. They want to get paid to provide services to 46 million more people, but they don't want to have to prove that they are actually doing those people any good. We need rationing. We want rationing. Rationing is good, rationing is wise, rationing will save you money, rationing will make you happier, rationing will make you healthier. Please bring on the rationing.

Bazz Fazz

I'm heading out to the poison ivy farm for a couple of days. Reflecting on the nation's birthday, I have to say I'm really torn between optimism and pessimism. The corporatist regime established after the collapse of the populist movement in the latter part of the 19th Century is seemingly as entrenched as ever. The peculiar pathologies of our culture seem equally enduring. These include radical individualism, and its strangely entwined, totally opposite identical twin, irrational cultism and militant conformity. Paradoxically, these largely co-exist in the same people, and the same cultural, media and political spaces.

We're in an economic crisis which I happen to think is much worse than the corporate media want us to believe. We're hurting everywhere but the good people of California are about to learn the hard way that in the end, you have to pay for what you get, and they're going to really going to miss what they refuse to pay for. The rest of us are going to learn it less abruptly, but we're still going to have to learn it. Over six decades, we've come to believe in eternally growing wealth and power as a law of nature. That's over now, for a long time to come. We're still a wealthy country and we can meet our people's needs with less than we have had in the past, but whether we have the wisdom and the generosity to do so is far from clear.

We are very far from truly accepting and confronting the world's multiple environmental crises. We're still hopelessly addicted to war and petroleum. Our mass media are shallow, corrupt, and cowardly. Yes, we have big problems.

But let's give ourselves some credit as well. We're in the midst of real social change. Gender inequality is still eroding, albeit slowly, and so is racism. (I'm not going to get involved in arguments over which is further along. I know we have a long, long way to go on both fronts, but you can't deny that there's real movement.) The pace of liberation for sexual minorities has been nothing less than astonishing.

Most important, the power of enlightened critical thinking in our discourse is growing. New information technology helps -- the corporate media find themselves having to answer for their sins, and we can even have these public conversations without them. We also have a much better understanding of the world than we used to, simply because science marches on and we just keep on learning and figuring stuff out. The planet is in crisis, but at least we are aware of it and have some ideas about what to do about it. More and more of us think of ourselves as planetary citizens and the claims of nationalism and tribalism are weakening in much of the world -- granted that they also benefit from a strengthening backlash elsewhere. And, nothing concentrates the mind like a hanging.

So, I believe we can overcome, even though we need to overcome a lot. La lucha continua.

Okay, you've convinced me

I was wrong, creating a publicly sponsored health insurance option for all Americans would be extremely dangerous. As this Health Affairs policy brief argues:

There's also worry that people with private insurance would transfer into a more attractive publicly funded health plan — a phenomenon known as “crowd-out.” As private plans then disappeared, that could lead to what opponents fear most: a “single payer” health care system in which government pays all the bills for health care.

A prospect so horrific they have to repeat it:

Finally, opponents are concerned that the increasing bargaining powers of a large government plan could destabilize the marketplace, controlling prices and choking competition. Economists call the phenomenon a “public monopsony.” As private plans were driven out of business, government could become the predominant payer. And if pressures mounted to subsidize public coverage, in effect the government might come to finance all health insurance — leading to what in effect would be a single-payer system.

Oh yeah: "Opposition to the notion of a public plan comes from health insurers’ leading trade association, America’s Health Insurance Plans (AHIP), as well as from some conservative Democrats and many Republicans." What it does not come from is the large majority of the American people. But who do you think Joe Lieberman and Max Baucus are listening to?

Update: You might be interested in seeing where Holy Joe gets his dough.

On liberty

The dictionary defines "power" and "liberty" in very different terms. Power is construed positively, as the ability to do or accomplish what one wishes; liberty is construed negatively, as the absence of constraint. On reflection, though, they are near synonyms, or at least overlap substantially in denotation. Liberty is a precondition for power, obviously; one way to lack power is to be constrained. But we are constrained as well by our inherent limitations: power is equally a condition for liberty. It is absurd to say that I am at liberty to play in the NBA, so long as I do not have the power. I could show up for a tryout, I suppose, but they wouldn't take me.

Power in general is not a zero sum game (or a constant pie, as the political scientists absurdly say). I can increase my power without reducing yours. Indeed, I can augment your power along with mine. For example, if I succeed in finding ways of making physician-patient collaboration more effective, you might end up feeling more powerful, even as I grow more capable in my field and perhaps better paid. (Just dreaming, of course.)

Where disputants often stumble is over not noticing that power over others is a special, and distinct case. Power's sibling liberty has precisely the same inflection point. It is an entirely distinct matter when one person's liberty infringes another's.

It is astonishing how often people miss the obvious in pondering the question of liberty. Homo sapiens derives its unprecedented power as a species precisely from its socio-cultural accomplishments: the accumulation and dissemination of knowledge and technology over generations, the immense achievements made possible by division of labor and organized enterprise, the availability of support and assistance in time of need. The powers which are preconditions for our liberties do not arise from us as individuals, but our created for us by society.

As a microcosmic example, when we go to the doctor, we want that doctor to be very powerful: highly intelligent, stuffed full of the latest information, equipped with special legal authority, resourced with high technology equipment and whole teams of specialists. We want the doctor to have all sorts of powers we do not have. At times, we surrender completely to the physician, allow her to render us unconscious, cut us open, dissect out body parts; bombard us with radiation; or pump our veins full of toxic chemicals. We depend on this extraordinarily powerful individual to preserve our own capacities and secure our own liberty to live independently, perhaps to work or pursue our relationships and avocations.

It can all go wrong, of course. We can end up feeling infantilized, be manipulated, exploited, abused, or just let down. The asymmetry of power can end up constraining our liberty, but it can also expand it. The only solution to that dilemma is to make rules and regulations: requirements for physician licensure, restrictions on the choices physicians can make, ethical norms for the practice of medicine. And that arguably restricts our own liberty to choose doctors who don't measure up and can't get or keep a license. It makes us pay more for physician services. But without such rules we would not be at liberty to surrender ourselves to the potentially empowering power of physicians with any confidence that our choice would succeed.

And here I think is the essential distinction between liberalism and libertarianism. We're all for "liberty," hence the shared etymology. But liberals understand that liberty is not the creation or possession of individuals. It is created and bestowed upon us by society. We need society, we need in fact constraints on our own liberty and that of others, in order to create and preserve the greatest possible measure of liberty, or any liberty at all for that matter. Society can also fail us in this regard, so liberals are deeply concerned with what kind of society we have, committed to using their own individual power and liberty to struggle toward a society that creates and defends liberty. Libertarians think they'll be free if society goes away. That is a fundamental, absolutely fatal error.

Deep thought?

The last few days I've found myself thinking about stuff that just takes too long to talk about to make a good blog post. The blogging form imposes a discipline, which is all to the good, but it can become procrustean at times. I really need to construct a long essay, and this just ain't the place for that.

So, I hope y'all won't begrudge me the day off -- from blogging anyway. And who knows, I might suddenly get inspired to do something later today anyway. But maybe not.

They're all wasted

Ari Hoffman and Steven Pearson, in Health Affairs, provide highlights of medical waste, by which they don't mean used needles, surgical sponges and ascending colons, but rather squandered resources. Distinguishing among the different kinds of waste is important to the political "discussion" we're having right now. The scare quotes are because it's mostly people in separate booths yelling past each other, with facts and logic often in short supply.

First, there's the kind they mention in passing but do not discuss, "excessive administrative costs, misused and wasted materiel, and inefficiencies such as duplicate testing and unnecessary physician visits generated by uncoordinated care." They say nothing further about this, but I will tell you right now that there is a simple, elegant solution that can eliminate almost all of this and has already done so just a a few feet away from Detroit: universal, comprehensive, single payer, national health care. But I digress.

Hoffman and Pearson are actually concerned about the kinds of waste Barack Obama is talking about when he discusses comparative effectiveness research, and Republicans are defending as essential to our freedom: medical interventions that might not be worth it but happen anyway. The subtlety is that they aren't all created equal. H&P identify 4 kinds of questionable interventions:

1. Inadequate evidence of comparative net benefit for any indication;


2. Use beyond boundaries of established net benefit;


3. Higher cost when established benefit is comparable to other options; and


4. Relatively high cost for incremental benefit compared to other options.

As to the first item on the list, it may surprise you to know that a lot of the drugs and medical devices that are widely sold, and surgical procedures that are commonly used, lack any scientific evidence for effectiveness whatsoever. Surgical procedures do not require FDA approval nor any evidence of benefit for doctors to use them, and medical devices can win approval on very flimsy evidence. But even drugs can be approved based on short-term comparison with placebos. They don't have to show that they are better than existing, cheaper drugs, nor that they provide any long-term benefit. That's just plain dumb, and the only reason we have that policy is so that drug companies can get patents on drugs for which there are cheap generic alternatives, without having to prove that their patented drugs are better, and then spend money on TV advertising and efforts to influence doctors so that the more expensive, and quite possibly worse, but new and exciting, drug gets prescribed.

The second item reflects a quirk in the law. Once a drug or device has FDA approval, doctors can prescribe or use it for any purpose whatsoever, which is called "off-label" prescribing. Companies aren't supposed to market drugs for off-label uses, but they do it anyway. Sometimes, the fines are just a worthwhile cost of doing business; more often the companies just get away with it because of lax enforcement.

While we might imagine that most people would readily agree that these practices ought to be curtailed, physicians as a class are against greater restrictions. They tend to see this as a question of professional autonomy and the right to exercise their clinical judgment, which they believe is more powerful than scientific evidence. Many consumers, I must admit, feel the same way. They flock to the GNC and buy mass quantities of stuff for which there is even less evidence of usefulness than there is for SSRIs -- and that's saying something. They trust decision rules (what we eggheads call heuristics) which are different from the ones used in clinical trials, and they expect their doctors to do the same.

The third and fourth categories are rather different. We know the stuff works, but either it costs more than something else that probably works almost as well, or it costs a huge amount and delivers what most people would consider a very small benefit. An example of the latter is paying tens of thousands of dollars for chemotherapy that can be expected to extend the life of a person with cancer by a few weeks. These are the kinds of issues that come up in the UK from time to time when the National Health Service refuses a treatment to some desperate person, and this is where the "rationing" rubber really hits the road.

If we could cut through the mass media tornado of trash talk and have a reasoned discussion, I expect most people would agree that we ought to try to have the best possible evidence for what works best under what circumstances, and we ought to stop mucking around with our bodies in ways that don't actually make us better, might make us worse, and cost a lot -- our God-given right to make choices that bankrupt and harm us is probably secondary, notwithstanding Betsey McAughey, John Stossel and Sam Brownback.

However, when it comes to the question of how much is worth spending to maybe benefit a sick person a little bit, the conversation does admittedly get more difficult. People have a glib reaction that "you can't put a value on human life" and the idea of accountants deciding that some necessarily largely arbitrary amount -- whether it be $10,000 or $50,000 or $10 million -- is too much to spend to "save a person's life" just doesn't sit right. The response ought to be obvious, but for some reason I can't quite grasp it is not to many people.

Note first of all that it is the very same people who are decrying the prospect of "rationing," in many instances, who are also insisting that we cannot afford the cost of providing universal health care. It is also very likely to be the same people who are opposed to environmental regulation, workplace safe and healthy regulation, and social welfare programs because they are "too expensive." We can't afford the economic cost of clean air, but it would be immoral to "ration" health care. These are positions which conservatives hold simultaneously, unapologetically, and apparently completely unaware of any contradiction.

Guest post from Les Izzmoor

Les may come around again from time to time. Clearly we need to hear from him. -- C

The new BMJ (i.e., British Medical Journal), which unfortunately gives the commoners only limited access to the stuff they are probably least inclined to read, has several items of interest to us colonists as we yell and scream about rationing and bureaucrats. The tea slurping decolonization monkeys think about these things rather differently than we do; their pinko doctors offer an instructive perspective.

1. Katy Bell et al find that routine monitoring of bone density in the first three years after post-menopausal women start on the anti-osteoporosis drug bisphosonate is useless and even misleading. Save money, don't do it.


2. CC Butler and a multitude find that there are big regional variations around Europe in the likelihood that adults with coughs will be prescribed antibiotics, but there is no association with better outcomes. Overprescribing of antitbiotics, as our faithful readers know, wastes money, causes adverse effects (for one thing, it can wipe out the endosymbionts in our throats and intestines, causing opportunistic infections), and of course promotes antibiotic resistance in pathogens. In Europe, of course, there tend to be bureaucrats who could get doctors to stop doing this. They should consider restricting people's personal freedom to waste money, harm themselves, and risk the doom of humanity.


3. According to SG Thompson and colleagues, routinely screening men age 65-74 for abdominal aortic aneurysm reduces the 10 year risk of death from .87% to .46%, so according to my calculations you could save a life by screening 243 men. They figure this will cost about 7 600 pounds sterling per avoided death, which they deem worth it. Of course, these guys are already getting on so they may not have long to go even if they avoid the aneurysm, but still. Of course, this doesn't save money, it costs money, but we still might want to do it. Rescreening the guys who were negative ten years later, however, is probably not worth it.


4. Joanna Moncrief and David Cohen argue -- entirely correctly as far as ol' Les is concerned -- that psychiatric drugs, specifically "antipsychotics" and "antidepressants" -- don't really target specific underlying disease processes. No, depression is not a serotonin deficiency and psychosis is not a disorder of dopamine processing. We don't really know what the heck they are. These drugs produce altered mental states which may just happen to make some people feel better, e.g. by suppressing affect they make people with psychosis calmer. That doesn't mean they are treating the disease, however. If patients understood this -- which would first require the drug companies to stop lying about it, although they don't mention that -- they would probably consume less of these drugs, save money, and avoid side effects.


5. New results in the Archive of Internal Medicine show that people with chronic kidney disease do just fine on lower doses of drugs that increase the red blood cell count. The manufacturers, by the way, have pushed for higher doses. Natch.


6. Iona Heath is a physician who declines her own doctor's recommendation that she have screening mammograms. She writes that "for every 2000 women invited to screening for 10 years one death from breast cancer will be avoided but that 10 healthy women will be "overdiagnosed" with cancer. This overdiagnosis is estimated to result in six extra tumorectomies and four extra mastectomies and in 200 women risking significant psychological harm relating to the anxiety triggered by the further investigation of mammographic abnormalities. The percentage of women surviving 10 years if they are not screened is 90.2%; it is 90.25% if they are screened. Is this enough of a difference to risk the possibility of significant harm? For me, it is not." If more women were given this information -- which is entirely accurate, by the way -- fewer might choose to be screened.

So we Americans need to clearly understand that meaningful choice requires accurate information. The freedom to choose to waste money and harm yourself out of ignorance is the opposite of freedom, as far as I'm concerned. People need to stop degrading and abusing the word freedom: it doesn't pertain exclusively to rapacious capitalists, it needs to be our common possession.

Clear Thinking

My post yesterday about a fairly prominent pontificator who is unencumbered by the thought process was like sweeping the beach. Our public discourse is mostly a farrago of well-crafted BS. Here is a useful guide to critical thinking, the provenance of which is not revealed to us but which, as far as I can tell, is entirely trustworthy.

Stossel's argument is an example of Circular Reasoning. If you think about it, you will realize that its essential form is "nobody spends somebody else’s money as wisely or as frugally as he spends his own, therefore nobody spends somebody else's money as wisely or as frugally as he spends his own specifically on health care." But that isn't an argument at all, it's just an assertion. And once you recognize that, it's obvious that it just isn't true. Stossel combines this fallacy with the equally fallacious Appeal to Authority. By citing the false premise as the pronouncement of a famous person, he seeks to forestall us from evaluating its truth.

There's another little trick here, which is the word "nobody." That makes this an assertion of non-existence. When we first read the statement, our inclination is to nod our head and think, "That's right, I certainly prefer to decide how to spend my own money," because we don't notice that it purports to be absolute and universal. But then Stossel hopes we won't notice when he universalizes the assertion to a realm in which it clearly does not apply.

In the debate over reforming our medical financing, there is far more fallacy than reason. This is not fundamentally a debate over values, about which we might differ, it is a debate between sense and nonsense. And there is a very good reason for that: most resistance to meaningful reform comes from a small minority of wealthy and powerful people who stand to lose some of their existing, undeserved privileges.

They obviously can't go around proclaiming their real motives, so they have to muddy the waters. They do this using the standard tool in the rhetorical arsenal of the economically advantaged, the Gospel According to Friedman, which purports to be scientific and logical and wise. Actually it's a vast edifice of fallacy which begins with its innumerable glib yet either false or essentially meaningless premises. The particular Friedman aphorism at issue here is entirely typical. Economists just make assertions, treat them as axioms, and off they go. Checking in with reality is for the naive and untutored, who are too limited to comprehend the ineluctable power of their faith.

Of course there are additional fallacious arguments available. Here Media Matters runs down an RNC ad for us:

Republicans want health care reform that reduces costs across the board.

Republicans believe every single American deserves quality health care.

Republicans also believe another government takeover would diminish health care choice and quality.

President Obama talks about a, quote, public option. When he says "public option," that means putting government bureaucrats in charge, instead of patients and their doctors. It's a bad idea.

Republicans want bipartisan health care reform, a responsible plan that we can afford, where people are free to choose the best care for their families - without a government takeover.

Tell President Obama to work with Republicans, and to stop rushing into another government takeover.

Saying that "Republicans believe" something obviously doesn't make it true. Labelling the president's proposal as a "government takeover" is just name calling. Presumably we're supposed to think that's bad, just because. But what has Obama really proposed, and what will it actually do? Does the "public option" put bureaucrats in charge of something that patients and doctors are in charge of today? What specifically is that? (Hint: It's nothing that Aetna and Blue Cross/Blue Shield bureaucrats aren't in charge of right now.) Would the purported "government takeover" mean that people aren't free to choose the "best" care for their families, compared with the freedom they have now? How would it do that?

On the contrary, of course, right now your freedom is limited to physicians and hospitals who accept your insurance. (And by the way, if you had Massachusetts Blue Cross Blue Shield, you would not have been free to come to my hospital or see my doctor a couple of months ago.) With a "government takeover," you would be free to go to any doctor, hospital, or other health care insitution in the country -- which you demonstrably are not free to do today, even if you're lucky enough to have insurance at all. But words like "freedom" and "bureaucrats" and the implied threat of communism have built-in resonance.

Painfully, however, all this bamboozlement is likely to be effective. All the reactionaries have to do is throw labels around and spout theological sophistry from economics textbooks. The reporters are either too ignorant or too cowardly to call them out on it, and the Democrats -- well I don't know what the heck their problem is. They just won't confront the BS head on, all they do is duck and cover. It's pathetic.