Wednesday, March 31, 2004

Readers React To "Gatekeepers" 

Got a lot of good debate going and some crticism that I want to respond to. First I feel the need, to clear up any confusion, to concisely state my thesis in no uncertain terms:
  • Prescription only regulation restrict liberty by mandating that consumers seek the guidance and permission of physicians for pharmaceuticals.
  • The regulation is legally unique in that it gives some citizens authoritative powers over others. Also the current state of affairs is contradictory to the stated intentions of those who passed the regulation.
  • Because of this, those who want to restrict this freedom carry the burden of proof that this is necessary and beneficial.
  • People assume that it is true that this regulation is beneficial, but I was wanting to step back and examine the arguments and evidence.
  • Economically, this regulation definitely raises the cost of the drugs. This really can't be seriously disputed.
  • Medically, what littel evidence of study that exists claims that it is not beneficial in general, and is just as likely to harm patients has to help them.
  • Thus, I conclude that the burden of proof has not been met, and the health care system has to answer for this.
A lot of people take issue with my use of the word paternalism. Many claim that all paternalism is not bad, some patients want paternalism, and that my use of the term was sloppy.

Well, first let me explain my use of the word. To me it means using an unbalanced relationship to meet assumed beneficial and protective ends. A father uses his authority over his child to raise a child properly. A doctor uses his authority to prescribe drugs to guide exactly what a patient takes and when. Now these are good things. But I reject that a doctor should be granted legal authority to take these actions. In addition while some, indeed most, pateints definitely do want the doctor to act peternalistically, they can still choose to work under that relationship without it being legally mandated. If you actually read my paper, you see that I claim, supported by the research I cited, that this does not change when prescription-only status is dropped. Suprise, suprise; people actually are smart enough to fugure out that doctors know more about how to get healthy than the average person.

I also, maybe sloppily, use paternalism as the title of this series because it loosely ties together all the things I plan to write about. In addition, my series is going to deal with several seemingly different issues, all involving getting the government out of health care - this one, socailized health care, public health, etc. The one common thread I could see in all these was paternalism, whether physician or governmental. Now this isn't definitely the definition that medical people are used to, but that is how I've used it. I take responsibilty for the confusion of the language I've used, but I really don't think it matters that much. I'll change the title of the series if it will stop people from picking nits. I think the arguments I present stand alone from the title on their own merits. Any suggestion for new titles?

Now on to substantive criticsim.

Several people claimed that some drugs are too dangerous for pateints to take wthout medical assistance. Medpundit writes:
There are some drugs, like prescription allergy medication, and ulcer medication which are fairly harmless and don't really need monitoring or the help of a doctor to decide whether or not they're needed. But there are others - heart medications, cancer drugs, blood pressure drugs, etc. that either need the expertise of a physician to make the correct diagnosis for their appropriate use or that need to monitored closely for potential side effects. Even drugs as seemingly benign as blood pressure drugs need to be monitored periodically to make sure they aren't having adverse effects on the kidneys or, in some cases, the heart or the balance of the body's electrolytes. That isn't being paternalistic, just responsible.
Medrants adds:
If you have congestive heart failure, I have a complex drug regimen to prescribe. Adjusting these medications requires repeated visits. I must understand the side-effects of each medicine, alone and in combination. I must consider your renal function, and your electrolytes. Finally, I must prescribe the medications with an understanding of your other medical problems (and few patients have CHF alone).
Finally, Cut to Cure writes:
Tamoxifen: This is a medication that has a wide variety of side effects such as thromboembolism, endometrial cancer, and cataracts. One use of Tamoxifen is the prevention of breast cancer in selected high-risk women. A woman who was not at high risk may have such a fear of cancer that she may take the medication if offered over the counter, needlessly exposing herself to risks.

Coumadin: A medicine that is hard even for experienced physicians to manage. The therapeutic range is narrow and can be affected my so many variables (diet, other drugs) . A patient may be going on a plane trip and wants to avoid "economy class syndrome" and takes some OTC Coumadin. Suppose this patient has protein C or S deficiency?

Thyroid hormone: With the recent ban on ephedra, patients could achieve the same results with OTC Synthroid.
Now here's the thing - I agree. No right-minded individual would start taking these drugs without consulting a doctor. But they should have the liberty to do so if they desire. Many people don't seem to think you should have the freedom to make mistakes like this, but if you only have freedom to make good decisions about your health, then it is not freedom. It's paternalistic (or whatever word you wnat to use) to make these decisions for others by legal mandate instead of letting them make them for themselves.

I think Educated Guesswork may have said it better, so I'll quote him:
Both of these responses seem to me to miss the point. Sure, one should generally have a professional diagnose one's medical problems and control one's drugs. But one would also probably be better off if one let a professional work on your car transmission, do your taxes, o, to draw an example closer to my heart, hiring a professional to design your computer security system rather than trying to do it oneself. Certainly 99% of the time the professional would do a better job, but only the customer can decide whether that justifies the inconvenience and expense of seeking a professional.

What's paternalistic is that in the medical field--as opposed to computer security or auto repair, the professionals have managed to lobby to make it illegal for people to serve themselves. There are lots of fields that are so complicated that one could argue that consumers would be better off to hire a professional--in fact this is the standard argument that guilds have used to justify legislated monopolies for centuries. Neither DB nor Medpundit seems to me to have made a particularly good argument for why they should be able to use the force of law to maintain that monopoly.
Several commenters acted like they had not even read my paper, assuming that welfare was definitely increased by this regulation: I likened it to evidence-based medicine in one reply:
You operate from the assumption that general wellfare would be harmed by removing these regulations. Well, I just stepped back from that assumption and tried to look and see if it were really true. There is not much evidence out there, but all there is says that that assumption is false. Think of it like EBM for medical policy. I liken it (though loosely) to the history of antiarrhythmic therapy. People assumed it was true that these drugs saved lives and so they used them. When they actually looked at the evidence, they found they were actually killing patients. Well, here we're working from the assumption that this regulation saves lives. But I've shown some evidence that it might actually be neutral or harmful. So the question is are you ready to examine this further and see what the evidence says, or do you want to just keep working on assumptions?
I then draw a parallel to the switching of ibuprofen:
One day in 1984 (I think it was) ibuprofen became legal to sell OTC. The day before, it wasn't. Now what changed on that day? Did ibuprofen become a different drug? Did the fundamental laws that rule the universe change? No. It was a buraeucratic decision just as it was a bureaucratic decision to make it prescription-only. Now, one of those polar opposites decisions was wrong. And once you realize that, you realize they may be wrong about others. So, do you want to require prescriptions for ibuprofen, or do you want to sell others OTC. To have the same answer for both questions is most likely inconsistent. And do people claim that none of the drugs currently taken by prescription-only might need to be OTC? Or are people willing to accept that maybe we're wrong about some of them?
Finally, Carey at Glorfindel says:
The practical consequences of removing the physician as gatekeeper to medications might be, in the short term, disastrous. The reason is that the current regulatory regime has induced a widespread belief among the public that OTC medications are, by and large, safe. Libertarians might not like this, but it's a fact, and a fact that extends to virtually the entire consumer market. Caveat emptor died two or three generations ago. Any changes in the law ought to be (as usual) done with a lot of forewarning.
My reply:
You are right here to the extent that in any deregulation that is on balance a good thing, the costs are usually payed up front and the benefits accrue later. These are the ugly transaction costs, of course. But here's the thing - transaction costs are a finite value, where as benefits (like the ones I describe in this debate) occur every year into infintiy (or until the US collapses or the sun implodes - whichever happens first). I think we can safely assume the present value of those benefits are greater than the transaction costs. Thus, generally, I find transition costs arguments, while to be taken into account when formulating the transition, are not persuasive when arguing the merits of the transition when it in total is beneficial. So how do we do it? I don't know, but peolpe with some imagination could probably figure a way. Maybe switching drugs slowly so patients get used to the liberty and the responsibilty that comes with it.
I would add that you have to imagine how the world would be different if this regulation had never existed. Would patients take more responsibity for their health? Would they be able to understand drug toxicities, interactions, and proper useage better? Would be have to spend so much time educating everyone?

Let me state this clearly: My conclusion is that overall this practice harms patients, and that doctors, a group I am about to become a part of, profit from it. Now, further studies may show that no harm is caused, but isn't it worth checking (instead on working on to now unsupported assumptions)?

Thanks to everyone for the spirited debate. This debate has alos touched slightly on the War on Drugs and medical licensure, so I imagine I will start writing on those next.

Additional thoughts: With regard to toxic medicines - those who disagree with me say that some meds, say something really toxic like digoxin (or something else you guys find to toxic to be OTC) are too toxic to risk patients taking them without supervision. But you most surely agree that some, like say Tylenol, are not. Here is where our two viewpoints differ. On the continuum of risk/benefit ratios of OTC use, if you claim a line has to drawn, you have to draw it somewhere between Tylenol and digoxin. Where do you draw the line? Is there some magic tipping point of risk-benefit raio that is measurable in between there? You have to be able to answer these questions to support your point with anything resembling intellectual honesty. It's easy for me, because I say lets not draw the line. Give patients the freedom to decide for themselves and then treat the ones who decide to seek your advice.

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Monday, March 29, 2004

Paternalism In Medicine - Part II: Gatekeepers 

This is Part II of my series, Paternalism in Medicine. See previous installments:

Any claim that paternalism is an artifact of medicine's past is simply wrong. Even though the culture has improved recently, it still lives with us today and it has no appearances of going away anytime soon. In other industries, service models revolve around a customer who hires someone to serve her needs. In medicine, doctors, with an assist from the federal government, have a dominant position with regard to the patient and have a unique amount of control over their paying customers. Many people may disagree with this characterization, but I fail to see anything different in spite of recent efforts to change this relationship. Patient autonomy does not exist in any way like it should.

In no area is this more apparent than in the prescription-only status of most medicines. It always amazes me that this fact is never called into question, especially among my medical school colleagues. There is no shortage of debate in and about medicine on just about any other topic, but we accept this culture of the gatekeeper almost without question. You would think just once you would here somebody say, "Doesn't anybody find it odd that it is illegal for this patient to by this drug unless I write it down on a little piece of paper and then sign it." Maybe I lack imagination, but I can't think of another aspect of the human experience where one set of people, not members of the government, wield that amount of power over others.

But so it goes, consuming up some of the doctors' and patients' days, scribbling on a pad and turning crime into commerce. Should it be this way? And is there an alternative? Before we answer those questions, we should consider how we got here in the first place.

Economists Alex Tabarrok and Daniel Klein have a wonderful website FDAReview.org where they give a detailed history of the laws passed by Congress and their effects on the FDA's power. In it they write:
Prior to 1938, consumers could buy any non-narcotic drug without first obtaining a doctor's prescription. Consumers often obtained prescriptions or at least sought the advice of physicians before self-medicating, but were under no legal compulsion to do so.¹
But in 1938, Congress passed the Food, Drug, and Cosmetic Act which gave Congress broad new powers to regulate drugs through the FDA. A lesser provision of the act stated that some must be labeled "Caution: To be used only by or on the prescription of a physician." Before this, pharmaceutical companies decided whether to sell drugs over-the-counter or by prescription when they began marketing a drug. However, if the FDA later deemed that an OTC drug should have had the previous label, under the FDC Act they could deem a drug "mislabelled" and the company was liable for any harm that stemmed from its use. Now that the FDA had this power, drug companies would have been foolish to sell anything but the most harmless drugs OTC.

Very quickly, the market for medicines changed drastically and drugs were restricted, even though lawmakers claimed that was something they were trying to avoid. The House committee at the time stated, "This bill is not intended to restrict in any way the availability of drugs for self-medication. On the contrary, it is intended to make self-medication safer and more effective.¹" Regardless of their stated or real intentions, the obvious effect was to restrict the market for OTC drugs.

This power was further magnified by the Durham-Humphrey Amendment of 1951, which "drew a clearer legal distinction between prescription-only and OTC drugs, and authorized the FDA to classify drugs accordingly,¹" write Tabarrok and Klein. The previous legislation just gave drug companies an incentive to adopt a de facto prescription requirement. The D-H Amendment codified it into law.

And so it has existed for 50+ years since then that a new class of illegal drugs (with an asterisk) was created. There must be some sound arguments for this practice, otherwise it would not have been adopted and would not have persisted. So what were they? The three most common that come to mind:
  • The most obvious is safety. This, of course, is the proposed justification for most legislation, especially in the realm of health care. The assumption is that unknowing consumers must be protected from harmful drugs that, if taken without physician guidance and permission, would lead to adverse outcomes.
  • In addition, with the war on drugs that is currently being waged, nobody would dare suggest that certain classes of prescription drugs should be available over the counter. Benzodiazepines, narcotics, barbiturates, etc. would be cheaper to obtain and would have much greater potential for abuse.
  • With antibiotic resistance becoming a greater problem, OTC antibiotics would be used for non-bacterial illnesses and would quickly become less efficacious.

As a matter of fact, the prescription-only status for drugs is a prescription of our liberty. The idea that physicians and lawmakers can tell citizens what they can't put into their bodies violates the spirit of human freedom and the moral fact that we as individuals own our own bodies. Indeed, the federal government has gained this power only through a very broad interpretation of constitutional powers. I really don't think anybody would dispute these statements. The dispute arises on whether the arguments stated above justify restricting human liberty with regard to medicine. I will try to show that there is no justification.

It's considered a forgone conclusion that medicines in the hands of unsupervised patients are definitely harmful. During the recent debate to switch Claritin to OTC status, a letter to the New York Times read:
Your May 7 editorial praising the switch of Claritin from prescription to over-the-counter status does not mention the effects such switches have on patients seeking medical attention for serious illnesses.

Americans have a tendency to self-medicate rather than seek expert advice if possible. Allergies are serious illnesses, and, especially coupled with asthma, they can kill. Moreover, many individuals benefit from therapies other than antihistamines, but only doctors can properly advise them.

The current debate about whether to allow emergency contraception over the counter also illustrates the fact that Americans would choose not to go to a doctor if they could receive medications without one -- a testament to the inability of Americans to see doctors quickly and affordably, and a serious deficiency in our health care system.²
But is this necessarily so? It's sure sounds true, but let's be skeptical. Fortunately, there are economists who study the effects of gatekeeping regulation. University of Chicago's Sam Peltzman is one of the preeminent researchers in the effects of regulation. In a 1987 paper entitled "The Health Effects of Mandatory Prescriptions," he investigated this very issue. While acknowledging that by its nature government regulation is difficult to study in a controlled fashion, he tried to answer the following questions: how has compulsory prescription regulation affected health outcomes across countries with different laws? How have mortality rates from accidental poisonings changed in the US over the 1900's? And what has been the "rate of decrease in infectious disease mortality since 1950³" in different countries?

His results were striking. First, he found that the rate of accidental poisoning/overdoses and mortality from poisoning fell steadily from 1900 to 1940 only to begin rising again after 1940 - precisely the time that prescription-only regulation was being introduced to keep such things from occurring. He concluded that such regulation yielded to the common problem of moral hazard - "the phenomenon that drug consumption in these (regulated) countries switches to more potent drugs." "The regulation may lower the risk-cost per-pill, but this shifts consumption toward riskier pills.³" Now the rise in drug discovery during this same period could explain some of the rise in accidental mortality, but this just supports Peltzman's conclusion that consumers are willing to take a given level of risk for drug rewards. And regulation has either no or negative effect on those risks while not increasing the reward.

In addition he found "no additional favorable effect" on infectious disease mortality rates "from enforcement of compulsory prescription regulation - that is, no evidence that consumers with a given income and access to doctors were better informed about the life-saving potential of drugs in countries where prescription is required for purchase of antibiotics." He concluded that "consumers are able to understand the value of a doctor's advice even if they are not required to seek it.³" This should alleviate fears that switching drugs to OTC would lead to increased mortality from self-diagnosis. I, as does Peltzman, concede that there is great limitation to this study. However, it does not support the idea that gatekeeping improves safety. And more importantly, there is no similar study to find such support.

But there is intuitive evidence to support the idea that prescription-only regulation actually has other harmful effects. By creating this large barrier to obtaining necessary drugs, patients are put at risk for not having drugs they need for periods of time. Countless times have I seen patients in clinic who came in after running out of medications and needing only new prescriptions. Now some would say that this has little effect, and others might reply that patients can just call in for prescription renewals. But just because they could call in, does not mean that they do call in. This does have to be considered when trying to justify this regulation. And any argument over the magnitude of this phenomenon ignores the fact that its effect, if it exists, is negative.

A specific argument that definitely falls into the category of "negative" is the prescription status of birth control pills. It's no mystery that this fact causes a lot of people who need birth control to not obtain it. I don't have the data, but until shown otherwise, I will assume that the risks of underage (or any) pregnancy are greater than the small risks of thrombosis, malignant hypertension, or cancer. Actually, the university of Washington is conducting a study to experimentally allow OTC birth control pills. However, unfortunately this study simply transfers the gatekeeper status from physician to pharmacist, which still has its own problems. This is a small step in the right direction, but still far from optimal.

Most importantly, these regulations increase the cost of all drugs by requiring the patient to expend time in the office, money for the visit, and value of missed work and transportation. Indeed, MIT's Peter Temin, another expert in this field, found that switching drugs from prescription to OTC (with regard to many cold medications) yielded a consumer surplus in the billions of dollars. He did state that this might not apply to all drugs, and every class needed to be looked at individually°. But we should operate under the assumption that this regulation imposes costs to all drugs, and then be forced to prove it is necessary. Literally, this regulation is costing consumers an outrageous amount of money, and there is no measured benefit in the form of safety. Where is this money going? (More on that later.)

Moving on to the argument dealing with controlled substances, I must first state that one does not have to be opposed to the War on Drugs (even though I am) to still see the logic of the previous arguments. However, there still is a deficiency in the current system with regard to controlled substances and their prescription status. It drives a wedge between the physician-patient relationship like no other. Patients who are in pain or have anxiety are at the mercy of the doctor, who must decipher whether the patient is being honest. Patients in pain sometimes suffer because they are under-treated due to the current atmosphere of government scrutinization. Patients who are drug-seeking take up physician time and health care resources better spent on real health problems. I will tackle drug prohibition (and especially its effect on health care and paternalism) later in this series.

With regard to antibiotics and the specter of resistance, here lies the one and only one justification I see for any drugs to be available by prescription only. This issue has gained importance over the last few decades as medicine has witnessed the rise of new drug-resistant bacteria that were previously easily handled by antibiotics. The reasons for this are too numerous to mention here, but one cause is the wide availability and improper use of antibiotics in poorer foreign countries. As Stuart Levy writes in "The Antibiotic Paradox:"
...antibiotics are available through the pharmacy without a prescription or they can be bought through the black market. To some extent, the ease of procuring antibiotics relieves some of the problems created by the paucity of medical personnel for these people. Still, a safe balance between the health needs of the people and the efficacy of antibiotics must somehow be realized.

While over-the-counter sales have been one solution to the problem of too few doctors, the situation has created menacing results. The easy availability has contributed to the emergence and spread of resistant strains so that readily accessible drugs no longer cure common infections. Yet antibiotics continue to be used. Consequently, rather than kill off the disease-causing agent, they enable them to thrive in the patient and spread easily to others.ˆ
Clearly there is legitimate argument to be made here for restrictions.

To switch gears, let's look at two recent examples of drugs that switched to OTC status to much fanfare. In 2003, the heartburn medication Prilosec was granted OTC status. Its price quickly fell from $4 to $1 per pill. In 2002 the allergy medication Claritin underwent the same transformation with a similar fall in price. It amazes me that I have actually heard some physicians say they didn't understand why. When the gatekeeper was removed, supply was no longer artificially restricted and the price was bound to fall. (Claritin was complicated by the fact its patent was set to expire. However, its price fell independent of its patent expiration.)

(Sidebar: As an example of the perverse incentives of health insurance, while the price of the medicines fell, the price the patients had to pay out-of-pocket actually increased because OTC meds are not covered by health insurance plans or Medicare. So patients had the incentive to buy the more expensive medicines, increasing the costs for everyone.)

But it is important to realize that the increased price due to prescription-only status does not entail the entire increase cost of this regulation. As discussed before, this issue burdens patients with other financial and non-financial costs that they should not have to pay.

Gatekeeping increases the cost of health care, perpetuates paternalistic medicine and infringes on patient autonomy, drives a wedge between the patient-physician relationship, and violates the human moral of self-ownership. In exchange for this, there has been no measurable increase in safety and evidence exists that it is harmful to patient health. I don't know, Monte, I'd like to see what's behind door number three.

That's a pretty raw deal. But if patients lose, who gains? The benefits have to accrue somewhere. And they accrue right into the lap of physicians. Under the pretenses of patient safety, we have supported a system that restricts access to drugs so that patients will be more reliant on our care. By placing ourselves at the top of the drug information hierarchy, with the government's blessing, we have created a system that artificially increases demand for our services (thus increasing fees), stresses the service capability of the health care system, and very possibly causes harm to patients.

The government sees gain in this system, too. They gain power by being able to mandate the circumstances under which patients can purchases certain products. And it further increases their control over certain substances they deem "harmful" (i.e. narcotics) in an attempt to regulate human behavior. The unspoken truth of the War on Drugs and compulsory prescription status is that neither can exist with out the other, as they have similar justification. If one loses its justification, the other has a very tenuous hold on that same justification.

As Tabarrok and Klein write:
Licensed doctors, therefore, became deputies and spoilsmen in the growing system of controls. Consumers had to pay for the drug and a visit to the doctor. These new privileges for doctors were the bounty of the government's regimentation of the drug industry and assault on consumers' freedom to self-medicate. Dependence on doctors was further institutionalized and legitimated by making it difficult for consumers to gain information, in particular by the labeling and advertising controls that prohibited information or mandated unintelligibility. Thus, licensed doctors gained wealth and relative status by stripping others of freedom and by dumbing down consumers.¹
My purpose in writing this is to get health care personnel, especially medical students, to think about it. It is not something that is ever discussed, but it no doubt should be. We must come to terms that this is a violation of liberty, and then ask ourselves two questions. Is this violation justified? And can we look ourselves in the mirror if it is not?

1. http://www.FDAReview.org
2. Basu, Nina. 2002. Letter to the editor. New York Times. May 12, 2003.
3. Peltzman, Sam. 1987. The Health Effects of Mandatory Prescription. Journal of Law and Economics 30, no. 2: 207-38.
0. Temin, Peter. 1992. Realized Benefits from Switching Drugs. Journal of Law and Economics vol. 35: 351-69.
ˆ Levy, Stuart. 2002. The Antibiotics Paradox. pp 286-7.

I would like to thank Jessica Shah and Dr. Alex Tabarrok for their help.

Update: See what Educational Guesswork has to say here, here, and here. Read Medpundit's thoughts here. Carey at Glorfindel responds here. And the chief surgeon of the blogosphere has this.

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Sunday, March 28, 2004

Paternalism In Medicine - Part I: Introduction 

The practice of medicine has changed in ways during the last three decades that I am sure I could never fully comprehend or imagine. Common medicines and procedures that are staples today did not exist. I doubt that health care was so politically charged (but I could be wrong about that). Hell, some diseases (AIDS) didn't even exist. But such scientific and economic variables don't represent all the change. The "society" of medicine is drastically different, too. We're taught in medical school that in the old days patients would seek the all-knowing doctors to cure their ailments. The doctors would balance what they knew about the patients to determine what was best for them. Physicians would make their prescriptions and patients would follow them if they knew what was good for them.

But now things are very different. Patients are more educated about what is wrong with them and what needs to be done. Doctors work with (or for) patients to find out both what the patient want and what the patient needs. The doctor and patient become a team that determines the prescriptions together. In short, the days of paternalism are long over.

Don't believe it. Certainly things are better today than days before. Patients are expected to be educated and responsible, and doctors are expected to yield to patients' desires and work on an even level with them. But the difference is in degree, not in kind. The current practice of medicine is still fundamentally paternalistic, and it will continue to be so.

Some will disagree - I mean, what do I now? I'm just a medial student with no real world experience. I have no authority to truly know of which I speak. But I am well-educated and I am part of the health care establishment, so what I say should carry a little bit of weight. What I would ask those who may disagree is this? How could you say that medicine today is not paternalistic? When doctors are granted powers to act as a phamaceutical gatekeeper. When our health care financing systems gives patients little incentive to be healthy or play an active role in their care. When the federal government and public health establishment are so interested with interfering with our health choices and the substances we put into out bodies. And when that same government has the power to mandate certain health practices. Some would argue that paternalism is what patients want, and to an extent that's is true. But we have government supported and mandated paternalism and that is a bad thing. Now patients sign a little form that says they acknowledge they could die in surgery and we kid ourselves into thinking that paternalism has disappeared. Well I'm going to stop kidding myself.

Over the next few months I'm going to write a series of essays regarding ways to relieve the paternalistic nature of our medical society. I will highlights ways to remove doctors from their authoritative positions over the patient, to change the health care finance system to give patients incentive to truly take control of their health care decisions, and, most importantly, to remove government and regulatory bureaucracy from medicine so that the health care market can grow and improve.

I would like to invite other bloggers, health care personnel, economists, and other parties interested in these same goals to join the debates. If anyone is interested in contributing to a particular issue by writing an essay, I would thoroughly appreciate and enjoy that. Contact me and we can work out the details. Please read my first installment this week regarding the physician status of gatekeeper to most drugs.

Addendum: Some of my views are quite radical and might seem very impractical. Please ignore that. I don't want to receive mail or comments saying, "I agree, but that will never happen." The point of this series is to argue the issues on their merits, regardless of the situation at hand.

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Saturday, March 27, 2004

Evidence-Based Medicine 

A lot of energy is expended citing the virtues of evidence-based medicine in my medical education. Professors love to tell students the virtues of this newfangled EBM that came onto the scene in the late 80's/early 90's and became all the rage. For the uninitiated, EBM is defined by the EBM Working Group as "an approach to practicing medicine in which the clinician is aware of the evidence in support of clinical practice, and the strength of that evidence." "the process involves...converting information needs into focused questions, efficiently tracking down the best evidence with which to answer the question, critically appraising the evidence for validity and clinical usefulness, applying the results in clinical practice, and evaluating performance of the evidence in clinical application."

Well, if you ask me, I'm a little skeptical. But not because I do not see the virtue of EBM. It's just that I fear a little plagiarism is going on. It seems that the definition and description of EBM sounds suspiciously like the scientific method. Those shifty doctors - finally adopting the practice of science after centuries and then trying to rename it something else and claim its new. It's a shame nobody has a patent on science because they would have a case.

In all seriousness, the reliance on science is not foolproof. As Steven Milloy and Sydney Smith (and even myself) have repeatedly shown, there is plenty of bad science out there masquerading as "evidence." But DB of Medrants does his best, and I would certainly agree, to argue that EBM is beneficial. And finally, Nick Genes at Blogborygmi takes it to its logical conclusion and tries to find the evidence for evidenced-based medicine.

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Marginal Revolution 

One of my favorite sites, The Motley Fool, has this article about another favorite, The Marginal Revolution.

The Motley Fool was started by brothers Tom and David Gardner in the early 90's and is dedicated to teaching individual investors how to take charge of your own finances and how to understand the financial markets. Their books, which are both wonderful information sources and literary works, include You have More Than You Think, The Motley Fool Investment Guide, Rule Makers, Rule Breakers, and What To Do With Your Money Now.

The Marginal Revolution is written by George Mason University economics professors Tyler Cowen and Alex Tabarrok. Examples of their work include Cowen's Creative Destruction and What Price Fame? and Tabarrok's Entrepreneurial Economics. These two have daily provocative and educational posts. Recently they have featured guest blogger Russell Roberts. Roberts latest effort is this post on the obesity epidemic.

I digress, but you hear many of the same old arguments about why we have gotten so fat so fast. Super-sized meals. Too many commercials. Not enough education. None of these strike me as adequate due to the fact that little evidence exists to their effects. I agree with Dr Roberts in the link above - we're fat because we want to be. A similar argument was put forth last year in this Slate article by Steven Landsburg. His bottom line: when you decrease the price of something, consumers want more of it. In the 90's medical advances were made in heart disease and cholesterol medications that decreased the price of becoming fat. Thus, who should be that surprised that we got more of it?

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Friday, March 26, 2004

Master Of My Domain 

You can now go to www.proximaltubule.com and you will be redirected to this site. Those with links to this site can change them to this address.
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I Think I Need A Prozac 

Over at Reason, Jacob Sullivan takes on the FDA's new suggested warning that antidepressants are linked to increase risk of suicide attempts. I think that Sullum makes one mistake in that from what I understand, this is a general advisory and is not a mandated warning to be put on the drugs themselves. However, it probably will down the road, and anyway, his general point still rings true: there is no definitive scientific evidence to support this move. Repeat: no definitive scientific evidence:
The FDA's decisions are not supposed to be based on anecdotes, which are emotionally compelling but scientifically unreliable. Instead the agency prides itself on demanding evidence from controlled, randomized, double-blind clinical trials. Such studies provide no evidence of an association between antidepressants and suicide in adults and only weak evidence of such a connection in children and teenagers.
I feel that I am wasting my time in medical school learning about all this science business and evidence-based medicine junk. I mean if we really don't have to use it to make claims such as these, what is it worth? Oh, I see - I have to use it but the FDA does not. What's going to happen is this will open the doors to a new round of litigation against doctors, and patients (especially poor ones) will be the ones to eventually foot the bill in the form of decreased access to care.

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The Beginning of the End 

Well, bad news folks. The UN wants to get involved with world internet government. The same internet that has become a staple in most of our lives and is the last frontier of pure freedom. It was fun while it lasted. You can read the article, but I thought I'd mention this one nugget:
As far back as 1999, a U.N. agency proposed taxing all e-mail messages to pay for development aid. "There is an urgent need to find the resources to fund the global communications revolution to ensure that it is truly global," the 1999 report said. "The costs for users would be negligible: Sending 100 e-mails a day, each containing a 10-kilobyte document (a very long one), would raise a tax of just 1 cent."

The United Nations hastily backed away from that proposal, however, after prominent members of the Congress slammed it as a "bureaucracy looking to get its greedy mitts on the Internet through new taxes."
Which Congress were they talking about here? Congress, Arizona? They're not possibly talking about the same 538 guys who never met a bureaucracy they didn't like, are they? How wonderful they finally have learned the error of their ways. ; )

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Thursday, March 25, 2004

New Changes 

A few small changes to the site. I have "Trackback" capabilities and an RSS feed. Soon I would like to have a google search field for this blog if anyone can direct me to the code. Also, I am in the process of acquiring www.proximaltubule.com. Let you know when it's up and running.

Just entered "proximal tubule" in Google, and this site is at the very top of the list. I'm sure all the nephrologists will be pissed to be surpassed by an upstart.

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This Week's Top Five 

1. Jacob Levy has this outstanding post about the Pledge of Allegiance
2. Read Timothy Lynch's viewpoint on the Dudley Hiibel case currently being argued at the Supreme Court. Go here to see the video of the events in question.
3. Arnold Kling examines the market for health care. Read a related article by him here.
4. Virginia Postrel has many interesting posts on naming strategies for married couples. (see here, here, here, and here)
5. David Bernstein and "Juan Non-Volokh" have an interesting discussion of anti-trust law here and here.

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Wednesday, March 24, 2004

Big Day 

First big news, welcome to Stephanie Berrong who joins The Proximal Tubule. Maybe she'll actually write something.

But such good news is trumped only by the birth of PT niece, Sophia Elizabeth Stinnett at 2:00 this morning.

To commemorate this day, here are the stories and events of March 24, 2004:
  • A 16-year-old Palestinian with a suicide bomb vest strapped to his body was caught at a crowded West Bank checkpoint Wednesday, setting off a tense encounter with Israeli soldiers whom the army said he was sent to kill.
  • The European Union slapped Microsoft Corp. with a $613 million fine Wednesday for abusively wielding its Windows software monopoly and ordered sanctions that go well beyond the U.S. antitrust settlement — setting up what could be another lengthy court battle.
  • Kobe Bryant's accuser testified about her sex life for more than three hours Wednesday during a closed-door hearing that will determine whether any of the information can be introduced at the NBA star's rape trial.
  • The Bush White House scaled back the struggle against al-Qaida after taking office in 2001 and spurned suggestions that it retaliate for the bombing of a U.S. warship "because it happened on the Clinton administration's watch," a former top terrorism adviser testified Wednesday.
With so much bad news, its lucky that Sophie arrived to save the day. For some additional news:
  • 16 college basketball teams who have survived the first weekend are still battling for the NCAA championship.
  • Cubs' star pitcher Mark Prior will open the season on the DL.
  • In light of the recent gay marriage debate, an Oregon county has placed a moratorium on all marriages.
  • Celbrity birthdays for today include: Harry Houdini, Steve McQueen, Peyton Manning, and Kelly LeBrock.
Today I spent the day seeing patients at the UK internal medicine clinic for my 3rd year of medical school. Tonight I studied for a test I must manage to concentrate on while waiting to meet you.

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Monday, March 22, 2004

Random Variation? 

I know I promised no more steroids but I couldn't resist. Hall of Fame pitcher Jim Palmer made waves in the baseball world last week by scrutinizing fellow Oriole Brady Anderson's fluky year in 1996:
The latest outbreak in a spring filled with daily accusations came Monday, when comments by former Baltimore Orioles pitcher and Hall of Famer Jim Palmer to a radio station found their way into print, suggesting former Orioles outfielder Brady Anderson had used steroids when he hit 50 home runs in 1996.

"I like Brady, and it doesn't mean he's a bad guy because he took steroids," Palmer, a television commentator on Orioles telecasts, told Baltimore radio station WIYY-FM in an interview that was broadcast Sunday. "But I'm sure he wanted to enhance his performance." The comments were printed in the Baltimore Sun in Tuesday's editions.
Here is Anderson's reply:
"Because I only hit 50 home runs once, it was, in fact, an aberration. However, it was not a fluke," he told The Sun yesterday. "Nothing can be considered a fluke that takes six months to accomplish. Rather it was a culmination of all my athleticism and baseball skills and years of training peaking simultaneously. This was my athletic opus.

"Hitting in front of [Roberto] Alomar, [Rafael] Palmeiro, [Bobby] Bonilla and [Cal] Ripken didn't hurt, either."
Anderson is well known for having one of the flukiest power seasons in the history of baseball. Here are his HR and OPS for 1994-1998:


Another player not immune to steroid accusations is the one and only Barry Bonds. Lets look at his numbers surrounding his historic 2001 season, the one which brought the first accusations of steroid use:


The one striking thing about these samples from a non-power hitter with a fluke season and a power hitter with a fluke season - they both went up by large amounts but then returned to their own historical norms almost perfectly.

Steroids are performance enhancers because they allow the athlete to work-out longer and harder with less time to rest in between workouts. Thus, you build muscle and keep it. My question is this: Wouldn't a steroid user's power production go up and stay up, or at least gradually return to normal with aging? Or, wouldn't this be the case if the steroids were actually causing the jump? Are we getting worked up over random fluctuations? Here's Bret Boone, who as well has been the target of accusations:


Here we see someone who jumped their power production and stayed in the rarified air. What does all this mean? Not much. Steroids are most likely being used and are responsible to some extent for the increased power numbers of the last 10 years. Players who had a conspicuous jump in power and stayed there could possibly be open to steroid accusations. However, the great years that have been ridiculed with accusations should still be celebrated as truly unique historical occurences, because it is also most likely that steroids had little to do with them. And people who have no proof should shut their mouths.

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With objectivity that only Fox News could love, Yasir Arafat thinks The Passion is not anti-Semetic. Phew! Glad we got that controversy out of the way. (Thanks to Eugene Volokh)

Also at the VC, Jacob Levy has some thoughts on Lou Dobbs and other rabid protectionists.

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Sunday, March 21, 2004

Bad Day 

UAB 76, Kentucky 75. As Bill Simmons would say, I just threw up in my mouth.
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Saturday, March 20, 2004


Read this Reason article about the tribulations of James Yee.

And things in Canada are going to shit. The highly-touted health care system is unsustainable and research on human cloning for therapeutic purposes (along with the obvious reproductive purposes) has been outlawed. All those people who say they want to move to Canada for the health care may be changing their tunes.

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The Downfall Of A Journalist 

The danger in calling out the actions of others and claiming moral superiority (at least by default) is, unless you are truly without sin, the stones you throw can behave like boomerangs. Such is the peril of the life of Sports Illustrated's Rick Reilly. I used to be a big fan. He is a good writer - creative, funny, clever, and sarcastic. A killer combination. Most of the time he would write about inspiring sports figures, especially the kind of athletes who are not normally found on the front sports pages, but who nonetheless who overcome great odds to accomplish great things. But sometimes he liked to cross over into the land of hero deconstruction. This poses two problems: sometimes the hero has done no wrong, and sometimes the writer has done the same wrong that he derides.

A warning sign came in 2001 in this scathing article about Barry Bonds. His point seemed to be that Barry was an awful teammate who wouldn't lift a finger for the other guys on the team. To prove this he quoted Bonds' teammate Jeff Kent who diplomatically proclaimed in a national publication that he nor anybody else liked having Barry Bonds on the team. In true hypocritical fashion, Reilly railed agaist one poor teammate (who he did not quote as tearing down a teammate) while appearing to hold up another as a model (who he did). The point is not that Bonds was a great guy or great teammate, the point is that the article was terribly unbalanced and misleading in many regards.

The following year, Reilly approached baseball star and suspected steroid used (the two could be synonymous) Sammy Sosa with a scheme that would have Sosa test his urine for steroids at a Chicago area lab. With no warning, after a game Reilly questioned Sosa about steroids and suggested Sosa would have to get tested to prove his innocence. A heated exchange then took place and for the next few days Reilly was on every sports news TV and radio talk show. He had ceased to report and comment on the news and had actually become the news. In the course of events Reilly had unfailry ambushed Sosa, indirectly made accusations without proof, and had injected himself into the story. At best this is questionably ethical journalism.

This year, Reilly has been involved inreporting on the recruiting sex scandal at the University of Colorado footbal team. Reilly broke the story that former CU female placekicker Katie Hnida had been raped by her former teammates. Coach Gary Barnett reacted by stating that Hnida was not a good kicker. Reilly wrote and commented on TV that any coach that unknowingly let this go on under his watch was pretty much the same as one who willfully allowed this to happen. (Note: I find the coach's behavior and comments in this situation reprehensible.) This attitude, while not altogether wrong, is a little debatable.

Well I have been directed to this story in The Denver Post which claims that a high scholl friend of Reilly's daugter was sexually assautled at a party at Reilly's home while Reilly was not there. It seems that he is guilty of the same neglect with which he (rightly) accuses Barnett. PT favorite Scott Lange of The Northside Lounge has this outstanding satire of Reilly's present situation in the form of his ambush of Sosa:
"You've said if someone is unaware of things like sexual assaults occurring under their watch, they must be hellbent on not knowing, right?" I asked him in his office yesterday. "And a fourteen year-old girl says she was raped in your home, right? Well why wait to prove your innocence?" I then provided the name and phone number of Mike Marnell at Alverson & Associates, a private polygraph administrator in Denver, a short drive from his Cherry Creek home. I told him what Marnell had told me: If any person wants evidence that they are telling the truth, all he has to do is make an appointment and take a polygraph."
The only question remains, when will that day come when I will be guilty of the same hypocrisy I deride? I spend a lot of time on this blog noting others who are hypocritical or flat-out wrong. That does not make me immune to being wrong or a hypocrite. And I hope Scott Lange will be there to parody this article on that one un-fine day when I will be.

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Thursday, March 18, 2004


Congrats and wishes of luck go to PT's own Jessica Shah, who matched today as an Internal Medicine intern at University of Texas-Southwestern in Dallas. All the hard work paid off. This is officially a shout-out.
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Of Interest 

Via Craig Newmark, here's a list of the 100 most mispronounced words. Some favorites:
  • dialate should be dilate - "The [i] in this word is so long there is time for another vowel but don't succumb to the temptation."
  • herb should be pronounced with the h - "Does, "My friend Herb grows 'erbs," sound right to you? This is a US oddity generated by the melting pot (mixed dialects). Initial [h] is always pronounced outside America and should be in all dialects of English."
  • often is pronounced without the t - "We have mastered the spelling of this word so well, its spelling influences the pronunciation: DON'T pronounce the [t]! This is an exception to the rule that spelling helps pronunciation."
Read this article about how to care for your introvert. Some excerpts:
  • I am here to tell you what you need to know in order to respond sensitively and supportively to your own introverted family members, friends, and colleagues. Remember, someone you know, respect, and interact with every day is an introvert, and you are probably driving this person nuts.
  • My own formula is roughly two hours alone for every hour of socializing. This isn't antisocial. It isn't a sign of depression. It does not call for medication. For introverts, to be alone with our thoughts is as restorative as sleeping, as nourishing as eating. Our motto: "I'm okay, you're okay—in small doses."
  • Extroverts have little or no grasp of introversion. They assume that company, especially their own, is always welcome. They cannot imagine why someone would need to be alone; indeed, they often take umbrage at the suggestion. As often as I have tried to explain the matter to extroverts, I have never sensed that any of them really understood. They listen for a moment and then go back to barking and yipping.
  • The only thing a true introvert dislikes more than talking about himself is repeating himself.
  • Also, it is probably due to our lack of small talk, a lack that extroverts often mistake for disdain. We tend to think before talking, whereas extroverts tend to think by talking, which is why their meetings never last less than six hours.
  • How can I let the introvert in my life know that I support him and respect his choice? First, recognize that it's not a choice. It's not a lifestyle. It's an orientation. Second, when you see an introvert lost in thought, don't say "What's the matter?" or "Are you all right?" Third, don't say anything else, either.
And Jacob Levy writes of a Tennessee county trying to outlaw homosexuality:
Rhea County commissioners unanimously voted to ask state lawmakers to introduce legislation amending Tennessee's criminal code so the county can charge homosexuals with crimes against nature.

"We need to keep them out of here," said Commissioner J.C. Fugate, who introduced the motion.

County Attorney Gary Fritts also was asked by Fugate to find the best way to enact a local law banning homosexuals from living in Rhea County.
Hopefully Ron Lewis will get his way so this one will go through without a hitch.

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Wednesday, March 17, 2004

Ron Lewis Update 

Eugene Volokh comments on this case:
I'm pretty sure that this is unconstitutional, under current legal doctrine. Of course, if Congress enacts this and then stares down the Supreme Court when the Court strikes it down -- for instance, if a majority of the public will be on its side -- perhaps Congress will win, and current doctrine will thus be changed. I doubt, though, that this will ever be enacted, or that the people will side with Congress rather than the Court here (setting aside whether they should).

But I want to ask a different question: Let's say that this does indeed get enacted and validated -- for instance, assume for the sake of argument that it's implemented as a constitutional amendment. How does Congress expect even obedient judges to abide by its "revers[als]"?

Assume that the Court strikes down an abortion ban, based on some legal argument and legal precedents that the Justices would find persuasive (e.g., the right to privacy, and Casey). Congress reverses the judgment. The judgment will thus no longer be effective; the parties to the case would be free of it. But then someone else files a similar though not identical challenge to the same law.

Presumably the Justices would still find persuasive the same argument and precedents they found persuasive in the first case. True, the first decision was reversed -- but the arguments underlying it and the precedents supporting it still remain. The right of privacy, as defined by Casey, still leads the Court to think that the abortion ban is inconsistent with that precedent. Why should the Court do anything but strike the law down, at least so long as there's any conceivable distinction between this case and the preceding one (for instance, this challenge is an as-applied challenge applied to different facts, or this challenge is brought by a litigant who has a subtly different interest, and so on)? After all, the Congressional veto didn't purport to wipe off the books the preexisting precedents; it only reversed one particular Supreme Court judgment. So the Congressional veto might not be terribly effective -- again, even if the Justices really do want to obey the veto process.

Ah, you might say, the Court should defer to the Congressional judgment as a precedent itself, albeit one set by Congress and not the Court, and say "We won't strike the law down, because of this new precedent set by Congress." But, at least these days, courts don't just view the result of a case as a precedent; they apply the reasoning of the case.

The Congressional reversal includes no reasoning; it's doubtless based on legislators' reasoning, but the reasoning doesn't appear in the Congressional action (or at least nothing in this proposed statute suggests that it would). Did the Congress reverse the decision because it thought all abortion bans were permissible? Just this particular abortion ban? Just this particular abortion ban as applied to this particular litigant? The Court would have no clear way of telling this, except through guesswork. The Justices really couldn't apply the Congress's decision as a precedent even if they wanted to. (There is one potential analogy here: When the Court had a practice of summarily affirming lower court decisions without opinions, the theory was that lower courts at least should abide by that result in logically indistinguishable cases, but weren't bound by it otherwise; but that also proved not to be very helpful to courts, and the Supreme Court itself felt much less bound by its past summary affirmances than it was by its past reasoned opinions.)
Dahlia Lithwick writes at Slate:
So who is HR 3920 really going after? The nine justices on the Supreme Court, who "were not elected and are serving life terms" and who should not have the final word on what "the American people must do and not do." The bill serves as a warning that the court had better vote for majoritarian values or risk becoming irrelevant.
And the man of the hour himself in his own press release:
“The recent actions taken by courts in Massachusetts and elsewhere are demonstrative of a single branch of government taking upon itself the singular ability to legislate. These actions usurp the will of the governed by allowing a select few to conclusively rule on issues that are radically reshaping our nation’s traditions.”
The recent actions taken by members of the US House of Representatives are demonstrative of a single branch of government taking it upon itself the singular ability to legislate. These actions usurp the natural rights of the governed by allowing a select few to conclusively rule on issues that are radically reshaping our nations traditions.

In the presence of judicial review, Congress has a terrible record with regard to passing constitutional laws. How would that record be without it? For some reason I fear that the tyrrany of the majority may not be the wonderful thing Ron Lewis makes it out to be.

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Kentucky Representative Wants To Rip Up Constitution 

Here's some news from the Louisville Courier-Journal. Kentucky representative Ron Lewis has introduced a bill in the US House that would:
...let lawmakers reverse Supreme Court decisions if the court rules that laws passed by Congress are unconstitutional.

Under the measure, two-thirds of the House and Senate would have to agree to the override.
Well this is obviously unconstitutional, but wait there's more:
Lewis said he would pursue a constitutional amendment if his measure failed. About a dozen Republicans are sponsoring the bill.
No word on when Rep. Lewis would appoint himself supreme ruler of the US after his bill passed. I mean, checks and balances are so 18th century.

Are you kidding me? When did the LCJ start picking up stories from The Onion? Nick Genes at Blogborygmi has the line of the day:
I'm no authority on constitutional law, or astrophysics, for that matter. But it's a safe bet that if this bill were to pass, and the Supreme Court ruled it unconstitutional, something significant would happen to the fabric of space-time.
Is it too much to ask Mr. Lewis to remove himself from office for being such an embarrassment to his state? I mean most other congressmen just want to ignore the constitution, they don't actually want to throw it away.

Update: David Boaz alerts me to Article III, section 2, of the Constitution which states:
Clause 2: In all Cases affecting Ambassadors, other public Ministers and Consuls, and those in which a State shall be Party, the supreme Court shall have original Jurisdiction. In all the other Cases before mentioned, the supreme Court shall have appellate Jurisdiction, both as to Law and Fact, with such Exceptions, and under such Regulations as the Congress shall make.
Does anybody have any knowledge of this and would like to enlighten me? Any history where Congress has tried to regulate the SC's power? What kind of "Regulations" are we talking about here?

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Tuesday, March 16, 2004

Are You Pure? 

Bryan Caplan has this libertarian purity test. Go to this site to see where you rank among certain bloggers. Check me out at 95, which means "You have entered the heady realm of hard-core libertarianism. Now doesn't that make you feel worse that you didn't get a perfect score?" Also see the Political Compass, the Political Survey, and the World's Smallest Political Quiz. They're all badly-worded biased tests, but they beat the shit out of reading about diabetes.
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How's This For Influence? 

I have previously posted about Blogrunner's 200 most influential bloggers list. Yesterday UCLA's Eugene Volokh (#6) posted that the State Dept. had issued a publication that opposes the individual rights view of the 2nd amendment. Read his expert critique here. Well, today the original publication has been temporarily removed from the web. Coincidence?
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And A Step Back 

Apparently, according to the Houston Chronicle, the government is taking steps to reinstitute forms of a military draft. Cato explains why that is a bad thing, as if such explanation is even necessary.
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A Step In the Right Direction 

Good news, via Virginia Postrel, that we may be moving ever so closer to over-the-counter birth control pills. The AP reports that women in a U of Washington study can get the meds at a pharmacy after a survey, blood pressure check, and $25. Now, it's good that somebody is at least thinking out there, but this news is tempered by the fact that the gatekeeper status is just shifted from doctors to pharmacists. There should be no gatekeeper. (PT readers, in about two weeks I will have a long essay on this issue with regard to all drugs.)

Additional thoughts: Reasons cited in the story as to why this is a good idea are a) health benefits that slightly outweigh the risks, and b) population control. Are you kidding me? Are those supposed to persuade anybody? How about liberty? Isn't that a good enough reason in and of itself? The notion that freedom and liberty is ever a valid argument in these issues has totally evaporated. A vast majority of Americans don't consider it at all when arguing their positions on anything. I am going to write a column on the value of freedom as a good unto itself in the next few weeks. If anybody would like to contribute their thoughts, bring 'em on.

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Monday, March 15, 2004

Top Bloggers 

Blogrunner has a listing of the top 200 most influential bloggers as measured by unique web references in the past 60 days. PT favorites on the list include:Read this article by Matt Welch on the future of blogging. Most of the people on the Blogrunner list were actual mainstream journalists from the NYT, Washington Post, etc. But many aren't.

Congratulations to the people above who have important ideas and who influence a large amount of people. You sure have influenced me.

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The Baby 

That is what some people want to throw out when they eliminate the outsourcing bathwater. As The Wall Street Journal points out (via Cato), that may not be a good idea when insourcing is greater than outsourcing (when measured in dollars). Of course this is nothing new, as alluded to before at The Marginal Revolution. While outsourcing is greater than insourcing when measured in number of jobs, the gap has been narrowing for quite some time.

Update: Here's a cautionary tale.

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Today's Top Five 

Hope to start an ongoing weekly feature here at The Proximal Tubule - the Top Five. Today's top 5 outrageous items from around the web (mostly from Reason - they had a big day in the outrageous department):

1. When asked if the government ought to ban fatty and unhealthy foods in schools in an effort to fire a shot in the War on Obesity, Secretary of the HHS, Tommy Thompson, had this response:
"I don't want to start banning things," Thompson said. "Prohibition has never worked."
Really? Can't wait for HHS and public health to join that drug policy reform campaign.

2. Don't be surprised when Thompson is fired for saying something that, while obviously true, directly or indirectly doubts White House policy. Richard Foster, the chief analyst for Medicare costs at the Dept. for HHS, had his job threatened if he were to provide lawmakers with is analysis of the true costs of last years Medicare bill. Even though the news later came out that the original official government estimate was under by more than $100 billion, at least that was after the bill had passed.

3. And just to be fair, John Kerry, in the middle of a presidential campaign, tells a questioner that it is "none of your business," when asked what foreign leaders have told him they want Kerry as the next president. I always complain about politicians saying the same old things in interviews, debates, and town meetings, but I have not heard that one before.

4. This is old news, but still outrageous. The Senate passed a bill allowing the FCC to fine indecent broadcasters up to half a million dollars. The only thing I can think to say is - ffffuck.

5. Finally, as Michael Fumento reports, the Lancet has retracted a 1998 article showing evidence linking vaccines and autism. The scientists who sold their souls for money, the lawyers who bought those souls, and their many uncritical followers all have blood on their hands.

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Economists Fail To Predict Unprecedented Phenomenon 

Over at TCS last week, Arnold Kling explains that if economists would drop their political affiliations, the dialogue regarding jobs and growth in the past few years would be different:
Give an economist the actual output growth of 7.8 percent over three years (roughly 2.5 percent per year) and ask the economist to "predict" the breakdown between growth in employment and growth in output per person. Almost any economist would have said something like "Well, the output growth sounds pretty close to trend. So, assuming that trend productivity growth is about 1.5 to 2 percent per year, I figure 5 or 6 percent total productivity growth and 2 or 3 percent total employment growth."

No economist in his or her right mind would have predicted that we would have gotten 7.8 percent growth in output with 11.3 percent growth in productivity and a loss of 3.1 percent in employment. That is completely outside the experience of history.

By attacking the Administration's credibility in forecasting employment, Krugman and others are implicitly criticizing its failure to forecast the unprecedented burst in productivity. In fact, Krugman's tone all but suggests that the Administration knew about the coming productivity miracle and was engaging in a cover-up!
And then adds this for that great tax-cutter and man of the people George W Bush:
If you gave me a blindfold and asked for my analysis of the Bush tax cuts, I would say that they trouble me in the context of the Administration's failure to address entitlement spending. Because the President has not touched the long-term Medicare and Social Security deficits -- other than to add to them with the prescription drug benefit -- I find it quite offensive that he wishes to claim credit for cutting taxes. Long term, he has done no such thing.

A President who has only added to future entitlement obligations ought to be judged as having acted to increase taxes. To call this Administration a tax cutter is like taking a spoiled kid who does not touch dinner but takes a double portion of chocolate cake for dessert a "good eater."
So if the democrats complain about Bush's tax policy, and that policy actually increases taxes, then they should be promising to decrease taxes. Now there is a candidate I can get behind.

Update: Alex Tabarrok adds some useful information.

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Sunday, March 14, 2004

1998 All Over Again 

The Cats (UK Wildcats for you feriners who come to this site) are going to repeat their '98 romp through San Antonio and The Final Four. There will be dancing in the street at Woodland and Euclid.

Joining UK deep in the heart of Texas will be Oklahoma St from the East, Duke from the South, and UConn from the West. Dickie V is picking the Cats to go all the way - I've gotta feeling, baby!

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Last Call For Steroids 

This will hopefully be my last post about steroids in baseball. As a huge fan I have been hearing about this for a long time and frankly I'm tired of it. So relish these final words...

Nick Schultz has an interesting point that I have made to my friends before:
More importantly, The New Atlantis has its new issue out with a strong piece from Charles Rubin on "Man or Machine." Interesting outtake:
The possibility of harmful side effects from enhancement technologies will always be worrisome. But the deeper dilemma is not simply the regulatory question of what is safe but more fundamental questions about the proper shape of a human life. Some danger, after all, is central to noble activity. The pursuit of excellence in one area of life will inevitably create distortions in others. The question is how far such distortions can go before the quest for excellence becomes destructive of the very humanity of the one undertaking it.
This is the problem with the discussion -- or absence of discussion -- about the steroid controversy today. Most players taking them probably think this way (although they won't admit it in court). Yes, steroids pose some sort of risk, but players feel they take plenty of risks as it is, so steroid use is a question of degree, not kind.
Steroids are on a continuum of risks and rewards and an arbitrary line has been drawn saying that both are too great with steroids.

But still there are those that say it is cheating and illegal and thus wrong. Well, it hasn't been cheating by the rules of Major League Baseball until this year (note: last year it was technically cheating but it was a experimental period for the new rules and there were no punishments). So any past steroid use was not cheating - any future use will be cheating and I will recognize it as such. And, as I have argued before, the laws against steroids (as any other drug) are immoral and unconstitutional and thus the players are not morally bound to follow them.

Which brings me to this. You have to ask yourself - "Who are the interested parties in this matter and what should be their motivations regarding steroids?
  • The media? Due to all the hysteria, it's most likely they just like the controversy and the stories that follow. Steroids give them an audience for their pontification.
  • The fans? Even with all the indignation and the appeal to the sanctity of past records, one can't deny that the "steroids era" has coincided with an attendance boom. Steroids brought them to the park.
  • Management? See above.
  • The players? Now here's the interesting thing. As mentioned before by Nick Schultz and The Marginal Revolution, players should all agree to ban steroids. If every single player takes them, they get no net benefit but bare all the risks. So if the players don't want to ban them, well so what?
In actuality, the players have used all the ridiculous hysterics by management, the fans, the media, and government to their advantage. They turned a favorable policy into a "concession" to be collectively bargained. Gotta hand it to the union.

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Saturday, March 13, 2004

Some People's Definition of Compassion 

Via Reason, here's a story detailing reason #54,399 why the War on Drugs is the biggest civil rights violation since slavery was abolished and maybe since women got the right to vote.

The evidence in question is the law denying federal financial aid for higher education to those convicted of a drug offense. Putting aside for a moment the problem with federally funded aid for higher education, if it exists it should not discriminate against drug offenders. Especially when those offenses occurred in the past:

Given that she had been thrown out of the house by 13 for declaring herself a lesbian, spent her teenage years sleeping on subway trains and rotting piers and yet still managed to get her G.E.D., Laura Melendez figured she had kept her nose pretty clean.

Sure, there had been a few arrests for smoking marijuana, but after an entire adolescence spent on the streets, with far more visits by the police than by her parents, what did those offenses really amount to?

"It means I'll be denied an education," said Ms. Melendez, who is from the Bronx, now 22 and applying to college.

If Ms. Melendez had been an armed robber, a rapist, even a murderer, she would not be in the same predicament. Once out of prison, she would have been entitled to government grants and loans, no questions asked.

But under a contentious provision of federal law, tens of thousands of would-be college students have been denied financial aid because of drug offenses, even though the crimes may have been committed long ago and the sentences already served.
So, certainly the author of this law has proper justifiction for this travesty:

"It is absurd on the face of it," said Representative Mark Souder, Republican of Indiana.

Mr. Souder, who wrote the law, says the Clinton and Bush administrations have both turned it on its head, taking a penalty meant to discourage current students from experimenting with drugs and using it to punish people trying to get their lives back on track.

"I am an evangelic Christian who believes in repentance, so why would I have supported that?" he said. "Why would any of us in Congress?"
Or, in other words, "Oops, my bad! Next time I'll take my power as a lawmaker seriously and I'll think about the consequences of our actions."

In true politician fashion, he tries to pass the buck to the presidential administrations of both Clinton and Bush, even though both professed the desire to crack down on drug use and both are just acting on what the law says. If someone says they're going to shoot your mother, don't complain about the results when you hand them a gun.

Meanwhile, back in the real world, people's lives are being ruined, not due to the drugs themselves, but due to the war waged on them:

On the other hand, there is the case of Marisa Garcia, a junior at California State University, Fullerton. A few weeks before her freshman year began, Ms. Garcia received a ticket for having a small marijuana pipe in her car. (It had some ashes in it, she admits.)

That was her first and only offense. Accordingly, she paid a $415 fine. But she also lost her federal grants and loans for a year, amounting to thousands of dollars. Under the revised rules, her penalty would be no different.

"It doesn't make sense," Ms. Garcia said. "To punish someone by taking away their education? It's counterproductive."

The law does allow students to win back their aid by going through drug treatment. But when Ms. Garcia looked into that option, all she could find was residential counseling that cost as much as her tuition.

"If I couldn't afford to pay for school," she said, "then how was I supposed to pay for these programs?"
I hope there is a day, before I die, where we will all look back on this illegal, immoral, counterproductive, destructive, and reprehensible policy and wonder what we are all thinking. We will be ashamed, but hopefully at least we will gain the wisdom that nothing of its sort should happen again.

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Monday, March 08, 2004

Steroids, con't 

Nicholas Genes at blogborygmi (damn it, that one should've been mine) adds his thoughts to my earlier post regarding steroids:
As more people are free to join the pursuit of excellence, the bounds of what's necessary to compete move farther and farther from what's mainstream. And even, what's healthy. It's easy to sit and the sidelines and shake one's head at the spectacle: female skaters and gymnasts with stunted development, or biathletes with cardiomegaly that will kill them in their fifties.

And the fact that many of these athletes have freakish traits and proportions to begin with doesn't seem fair, either.

But using this to justify steroids for pro athletes is a big leap. To be fair, the folks at the Proximal Tubule don't explicitly make the case for steroids or hormones. They're just pointing out that media coverage is pretty slanted, steroids aren't all harmful, and the issue is more nuanced than what's being reported.

They're right on those counts. But on the issue of whether it's cheating, there's no contest. I think what confuses a lot of people is the mixing of athlete's goals with those of the audience and the organizers. The athletes want to win, so they train hard and feel the urge to bend the rules. The public, on the other hand, wants to see who's the best. So they make rules about eligibility for competing, just as they make rules about triple axels and free throws. No one in the audience wants to see a team win because the officials blew a call, but I think the athletes would say they trained hard, the other team got breaks too, and a win is a win. I think athletes make similar excuses about steroids.

TPT points out the dichotomy between 'natural' and 'unnatural' is artificial -- and they're right. But the designated hitter rule for half of Major League Baseball is kind of arbitrary, too. If the media reports on steroids with on a scolding, superior tone, it's because dozens of baseball's best players are, be definition, cheating. They're entitled to be critical: they're disappointed, too. It's no different than Sammy's corked bat.
Here is my reply in his "comments" section:
I wrote that post way too quickly and I wonder if it made sense or if it was stream of consciousness. With a chance for re-direct I would break the argument down thusly:

Should steroids be legal for the average Joe? For pro athletes? My answer to the first question is an unequivocal yes and to the second is a definite maybe. Basically pro sports should be able to make their own rules either way. Leading to:

Are steroids cheating? Should they be considered cheating? Again the answer to the first is yes and the second is "I don't know." I personally believe, based on my post, that calling steroids illegal and other things legal is arbitrary. And a good debate would begin by ending all the damned hysteria.
There are good arguments for making steroids against the rules. There are good arguments for allowing steroids (like, if you can equalize the natural unfair disadvantage of genetics, then the player who works harder gets the rewards). All I ask is that one of those groups of arguments not be granted moral superiority.

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Fat People of the Nation Unite! 

Nick Gillespie stands up for the not-so-little guy.

How about combining the worst tax ever placed upon American citizens, the poll tax, with the worst tax being considered for the near future, the fat tax. Scales at every voting booth. Body Mass Index > 25? See ya next November!

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Give Me A Break 

Gotta take this opportunity to plug John Stossel's new book - Give Me A Break: How I Exposed Cheats, Hucksters, and Scam Artists and Became the Scourge of the Liberal Media. Read an excerpt here. Also read these reviews from Tim Cavanaugh and Michael Fumento.

The book briefly chronicles Stossels career from local reporter, to media watchdog, to media contrarian, before moving on to the author's experiences investigating the abuses of big government. It's a wonderfully entertaining collection of tales regarding Stossel's exposure of bullying governemnt agents, hypocritical activists, and corporate parasites. Many of the stories involve transcripted segments from his trademark "Give Me A Break" portion of 20/20.

The best and most refreshing thing about the book was his candid admission that as a memeber of the media elite claiming to "fight for the little guy," he was often a part of the problem instead of part of the solution. He takes the reader through his intellectual journey that turned his world viewpoint upside-down. Many may be scared away by the title eluding to "the liberal media," which I can understand - I think it is an unfortunate title. But, as Tim Cavanaugh pointed out in his review:
"...anybody expecting another wheezing Philippic in the manner of Bernard Goldberg's Bias or Ann Coulter's Slander -- books in which the new media elite hurl invective, Animal Farm-style, at the old media elite -- will be disappointed. Without a doubt, Stossel is part of the media elite. He's just honest enough to admit it."
Go out and read this book today. It's a quick read, it's funny, and you won't be able to put it down.

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Sunday, March 07, 2004


As a sports fan, you can't help but noticing the unbalanced view held by the leagues, fans, and mostly the media regarding the steroid "problem." The conventional wisdom holds that steroids are 100% bad, they are cheating, they are unnatural, and they should be illegal and wholly and unequivocally banned.

The arguments for banning performance-enhancing drugs are generally:
  • They are unnatural (even though they are identical to natural products and "natural" vs. "unnatural" is a false dichotomy)
  • They are unfair because they trump given talent (even though the distribution of genetic athletic spoils is unfair)
  • They force otherwise clean athletes to undertake unhealthy measures to keep up (even though the "natural" measures to become a world-class athlete are just as unhealthy - do you think becoming a 300-pound NFL lineman or dedicating your life to one solitary thing is healthy?)
  • They are dangerous (even though the medical evidence is uncertain in this regard and it is currently illegal to do the proper scientific studies to know the truth)
Here are three articles by incredibly balanced journalists who try to take a look at the world of world-class athletes and performance-enhancing drugs in an objective manner. The first is by The New Yorker's Malcolm Gladwell. The second is by Reason's Dayn Perry. Lastly this article appearing in TCS by Patrick Cox, an exercise physiologist. Also, Nick Schulz has an interesting discussion on his sports technology blog. Finally, the guys over at The Marginal Revolution discuss what economic theory predicts with regard to sports leagues and how they should handle this issue.

On a note of personal disclosure, I am and have always been a small and thin guy. I am a decent athlete, having played a wide variety of sports, and always had to manage my size disadvantage. One semester in college, I underwent a diet and exercise regimen that entailed a 4000-5000 calorie per day diet and religious weight training for four months. I gained 10 pounds and was marginally stronger. This took quite a commitment and I had disparate results to show for it. If I had the option to seek medical advice to obtain legal means to enhance the rewards of my work, I would have at least considered it. It could have boosted my confidence and made me a better athlete so I could enjoy the sports I loved even more. But this is the body I was given and to tamper with that would have been unnatural. Right?

Update: The Miami Herald's Dan Lebatard becomes the first major newspaper reporter I have seen break from the mob hysteria among major sportswriters.

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