Monday, May 31, 2004

Paternalism In Medicine - Part III: The War On Drugs 

This is Part III of my series "Paternalism in Medicine." See previous installments:

In my first installment in this series, I argued that physicians should yield their status as gatekeepers for prescription drugs, as it infringes on patients' liberties by requiring permission from doctors to buy life-improving drugs, and the empirical evidence indicates that this policy does not infer any safety to the general population. I alluded to the fact that the gatekeeper status was a leg holding up the table where drug warriors eat - the two policies are hard to justify without the presence of the other.

What does the War on Drugs have to do with paternalism in medicine? Well, as I stated in my introduction, paternalism in health matters is not the domain of health professionals alone, but increasingly the government as well. The War on Drugs is unique in that in combines the paternalistic actions of both. And when all is said and done, both gain from this paternalistic policy. I would stop short of accusing health professionals of supporting the War on Drugs because they gain from it, but it certainly contributes to the inertia of support for policy change that is called for by the evidence I shall present.

The Drug Enforcement Agency has this to say about drug prohibition:
We've been fighting it for 120 years. In 1880, many drugs, including opium and cocaine, were legal. We didn't know their harms, but we soon learned. We saw the highest level of drug use ever in our nation, per capita. There were over 400,000 opium addicts in our nation. That's twice as many per capita as there are today. And like today, we saw rising crime with that drug abuse. But we fought those problems by passing and enforcing tough laws and by educating the public about the dangers of these drugs. And this vigilance worked - by World War II, drug use was reduced to the very margins of society. And that's just where we want to keep it. With a 95 percent success rate - bolstered by an effective, three-pronged strategy combining education/prevention, enforcement, and treatment - we shouldn't give up now.
They make a lot of claims here, most of which will be addressed in short order.

The American Medical Association takes the following view of drug prohibition:
(The AMA) encourages the undertaking of comprehensive research into the potential effects, both positive and adverse, of relaxing existing drug prohibitions and controls and, that, until the findings of such research can be adequately assessed, the AMA reaffirm its opposition to drug legalization.
To be honest, this stated policy is more open-minded than I expected to find from the AMA when I researched this article. So for present and future members of the AMA who have not had the privilege of seeing the evidence, allow me the honors.

I think it is important to look at drug prohibition from a historical perspective. At the turn of the century, according to USC law professor Charles Whitebread, it is believed that between two and five percent of the US population was addicted to what are considered today to be illicit drugs. That's the number cited today for people who use illicit drugs. That's amazing. Certainly drug prohibition has had a much greater impact on drug use than I am proposing. Not so fast. When you look deeper into why this was so, you understand that these people were becoming addicted because they did not know what they were taking. Most "medicines" of the day were simply various concoctions of opium/morphine and alcohol. These were marketed as cures for every ailment under the sun.

In 1906, along came the Food and Drug Act which essentially created the FDA. This act required product labels on these medicines to inform the user what they were taking. What happened? Most people who preferred not to be addicted to morphine stopped taking the medicines. As professor Whitebread states, "The Pure Food and Drug Act of 1906, not a criminal law, did more to reduce the level of addiction than any other single statute we have passed in all of the times from then to now."

Then came the Harrison Narcotics Control Act of 1914 which set a high tax on the non-medicinal sale of narcotics. It was the fist federal law to criminalize drug use, but not in the way we do it today. It placed a prohibitively high tax on opium, so that to buy it without paying the tax, you were breaking the law - tax evasion. Indeed, this law was federally enforced by the Department of Treasury. It is important to remember that this was a time where federalism was well-respected and "states rights" was protected. Thus, a federal criminal prohibition was not held to be constitutional. And so in a matter of a few years, when Congress wanted to ban alcohol, they had the courtesy not to abuse their powers and actually change the US Constitution (how the federal drug laws are constitutional today and not then is beyond me).

The 18th Amendment, ratified in 1917 and taking effect in 1920, set the stage for America's first experiment with drug prohibition. It's history has been chronicled before and in great detail, so I won't go through it again. Needless to say, use declined modestly, crime rates exploded, we all got the point, and the experiment ended in 1933. But to say we learned our lesson for good would be laughable.

Marijuana was targeted federally in 1937, but had been subject to numerous state bans years before that. But the 1937 legislation has a fascinating history chronicled by professor Whitebread here. I won't go into it in depth, but it involved all of two hours of testimony from Congressmen who labeled marijuana "an addictive drug," spokesmen from hemp-using industries rope, resins, and bird-seed, and a representative of the AMA who claimed "The American Medical Association knows of no evidence that marihuana is a dangerous drug." There you have it. Marijuana was criminalized and its never really been back.

All of these events culminated in the broad prohibition of drugs that occurred in the 60's and 70's. Presidents Johnson and Nixon initiated the War on Drugs as we have come to know it with the passing of the Drug Abuse control Amendment of 1965, the Comprehensive Drug Abuse Prevention and Control Act of 1970, and the formation of the Drug Enforcement Agency in 1973. From there we have come to a point in time where we expend in excess of $30 billion per year, and many other indirect expenditures, to fund illicit drug prohibition.

What I find most interesting in this history is how the justifications for prohibition have evolved. Today it is for reasons of health and crime, but in times past different reasons were articulated. The present justifications were sometimes mentioned, but the two main reasons were puritanical moralism and overt racism. The moral justification is pretty straightforward, so let me focus on the racist.

Almost every law enacted in the century-long history of prohibition can be credibly linked to persecution of racial minorities and fears of racial miscegenation. Many of the state and federal opium laws (including Harrison's) used overt anti-Chinese propaganda to rally support. According to prohibitionists, the opium was being used as a tool by the Chinese to lure white women into sex. It just so happened that this group was a source of cheap labor taking American jobs. This scenario was mirrored by movements against cocaine use (a popular drug used at the time by many) with regard to Southern blacks. According to the Drug Policy Alliance, "The New York Times published a story that alleged 'most of the attacks upon white women of the South are the direct result of the 'cocaine-crazed' Negro brain.' The story asserted that 'Negro cocaine fiends are now a known Southern menace'." And once again, marijuana prohibition garnered much support, documented in legislative records, by parlaying fears of Mexicans. It's telling that many of these, and other, laws were justified on racist grounds. It leads to me to wonder if yesterday's explicit justifications are today's implicit ones.

But while racist roots are a good reason to be skeptical of today's drug policies, it is not definitive evidence of bad policy. To examine that further, we must now look at what empirical evidence has to say.

Just this month, Boston University economist and drug war economics expert Jeffrey Miron published "Drug War Crimes," a short elegant analysis of drug prohibition policy. With a simple direct argument, he states the underlying assumption with regard to the Drug War and presents the empirical evidence (his own and the work of others) relevant to these assumptions. In the end he examines the collateral effects of prohibition and wraps it all up with a normative analysis of the costs and benefits to conclude that legalization should be favored by a large margin over prohibition.

To start, Miron gives us empirical evidence that the decrease in drug use due to the War on Drugs is most likely a very modest one. His main pieces of evidence regard data from alcohol prohibition of the 1920's and 30's and international statistics from other Western countries, many of whom have liberalized drug laws. His data, while admittedly not the strongest, indicate that across-the-board legalization of illegal drugs would cause an increase in use from 0-50% (most likely much closer to 0). Far less, he claims, than the orders of magnitude threatened by drug warriors. He concludes, "And since other alleged benefits of prohibition, such as reduced crime, improved productivity, or better health, depend on the decrease in consumption, these benefits are likely modest as well." His stance on this point is bolstered by many researchers cited whose data indicate similar findings. In addition, he suggests, quite rightly I believe, that prohibition curtails the use of the most modest users, those least likely to be violent or use otherwise irresponsibly. The bottom line is that it is really hard to tease the truth from this historical experiment, but the weight of the evidence support Miron and others over the drug warriors.

Next Miron moves to the violence associated with drug use. As stated above, one of the underlying assumptions of the drug war is that drug use causes violence and prohibition decreases this violence. In what I think is the most damning evidence against our prohibition policy, Miron shows that it most likely increases violence, and that this amount of violence varies directly to the level of enforcement. There are two main reasons why this is so. Removing a drug dealer from the market causes the remaining dealers to violently compete for the vacuum left behind. And enforcement against non-violent drug use takes resources away from combating violent non-drug-related crime. According to his numbers, the changes in homicide rates in the US over the past century almost perfectly match the changes in expenditure for drug and alcohol prohibition. Now Miron quickly points out that one could make a plausible argument that the causation could go either way: either increased enforcement causes increased violence, or increased violence causes more enforcement. Three pieces of evidence give great weight to Miron's side, though. First, the homicide rate jumps drastically following alcohol prohibition and fall back to the baseline directly following its repeal. Second, a look at the data shows that a vast majority, around 85%, or "drug-related" homicides were not perpetrated while either actor was under the influence. Most of these events occur due to the disputes arising from a black market. Last, a look at across-country data reveal that countries with similar drug use rates compared to the US, but with much lower levels of enforcement, have much lower homicide rate (by an order of magnitude).

None of which to say is definitive evidence. However, as Miron asserts:
...The exact degree to which prohibition induces violence is difficult to pin down. But the standard defense of prohibition assumes enforcement reduces (emphasis his) violence, in stark contrast to these results. Thus, whatever its limitations, the evidence provides no support for prohibition.
From here Miron jumps into his normative analysis of the drug war and he examines the collateral costs and benefits of drug prohibition. First he differentiates between rational and irrational drug use. Rational use is defined as that which is responsibly done and which brings pleasure to the user, much like millions do with regard to alcohol. He states that while the reduction in use described above would be considered by many to be a benefit of prohibition, the elimination of rational use, regardless of how big one thinks that amount is, would actually have to be regarded honestly as a cost. Indeed if something brings pleasure to an individual at no cost to society, its disappearance is most certainly a negative thing. On the other hand, irrational use is what we imagine when we talk about drug use. Miron describes the irrationality of drug use consisting of two variables: the addictiveness of drugs and the amount of harm to the users health. I'll get into this later, but Miron and others have provided data that indicate drug warriors, with the help of physicians and public health experts, have overstated these effects.

Second, Miron discusses the externalities of drug use that many often bring up in debate. These include: those injured in driving and work-related accidents committed by those under the influence and unborn babies harmed by abusing mothers. Some of these effects are not as large, according to data that he presents, as some have led us to believe. But more importantly, these externalities can occur from legal substances also, and their presence per se does not constitute a valid argument for prohibition. Indeed, many of these can be handled via legal avenues that traditionally punish or compensate for unjust harm to innocents.

Last, the War on Drugs has led to some extremely negative collateral damage. It has negative health effects, namely the undertreatment of pain and contributing to the spread of HIV in IV drug users. It has negative economic effects because it costs $33 billion per year. It has negative diplomatic effects by causing the US to interfere in the domestic policies of other nations. It has contributed to the racial divide here in the United States. It has led to vast amounts of corruption in government and law enforcement agencies. It has supported terrorism by driving drug prices up and giving an economic boon to terrorist organizations. It has led to the erosion of civil liberties by lending incentive for unconstitutional searches and seizures. And it has eroded liberty in general, by solidifying the erroneous idea that the government can tell us what we can and can not put into our own bodies.

From all this, Miron comes to the overwhelming conclusion that the War on Drugs is awful policy, and I have to say I agree. In fact, it continues to baffle me how so few people can come to the same conclusion. I applaud Miron on his intelligent efforts in this cause.

I find this persuasive, yet most people, including physicians, would never be able to get their brains around the fact that drugs are addictive and unhealthy. Indeed they are, but these qualities apply to many substances and behaviors in this world that are not prohibited. So these facts alone do not justify present drug policy. Many would argue, however, that these effects are so much greater with current illegal drugs, that they require special legal attention.

The most damning statement ever made about a drug has been "it's so addictive, that you can become hooked after using it just once." This has been applied to many drugs, including heroin, cocaine, and amphetamines among others. I have heard it spoken within the walls of my own medical school by respectable physicians. And it is utterly false. It relies on a theory of pharmacological action and physical dependence that physicians would not believe when applied to any other drug or medicine. So why are they so credulous to the claims about illicit drugs? This is an important question because health professionals has played the largest role in spreading these myths that support government policy.

A look at the data, summarized by Jacob Sullum in his book "Saying Yes: In Defense of Drug Use," sheds light on the truth. The National Household Survey on Drug Abuse found that out of 3 million American who have ever used heroin, 15% had used it the past year, 4% in the last month, and presumably much less use it on a daily basis. Hardly indicative of an instantaneously addictive drug. Likewise, of the people who have tried crack cocaine, 1.1% had used in the last year, 0.3% in the last month. Sullum writes, "In other words, 93 percent of the people who have tried a drug said to be instantly addictive were not using it even as often as once a month." Finally, of the people who reported to ever have used methamphetamine, 6% claimed use in the past month. What is striking about all these figures is the fact they are not out of line with the numbers cited for cigarette and alcohol use. An the fact that every one of these substances has been tagged with the infamous title "Most Addictive Substance Known To Man" is indicative of how disingenuous researchers (almost always government funded) and policy makers are when they discuss this issue.

Aside from the addictive nature of the drugs, health professionals also often exaggerate their adverse health effects. Marijuana fries your brain and reduces your intelligence. Stimulants will cause your heart to explode. Steroids will give you liver cancer. PCP will send you into violent uncontrollable rages. All of these drugs (like all other drugs) have harmful pharmacological characteristics. And none of these would be confused with, say, and apple a day. Yet again, a look through the medical literature leads one to the conclusion that many of these "facts" are based on anecdotal evidence and less-than-optimally modeled experiments. Statistics pulled form autopsy reports are often used to show the number of people whose death is associated with drug X. But many of these quoted statistics ignore that they often are huge doses of drug X, and more importantly are mixed with drugs Y, Z, A, B, and C. And we can't ignore that some of the adverse health effects are caused by prohibition. Impurities and improper dosing resulting from products sold in a black market. AIDS and hepatitis spread through sharing of illegal needles. Injecting, itself a risky procedure, is produced by the incentive to get "more bang for your buck" when using artificially expensive drugs. But again, even the true adverse health effects don't justify their prohibition when seen in light of the fact that legal recreational drugs, namely tobacco and alcohol, are as unhealthy if not more so.

Why do physicians allow the wool to be pulled over their eyes? Some, indeed, truly believe these statements. Yet others perpetuate these myths without so much as a critical thought. One answer is that physicians are no different from the general population in their fears of illegal drugs. They fear their social dangers, they fear their children growing up lured into a world of crime and addiction. These are legitimate fears, even if I believe them to be based on false premises.

Yet physicians are in a privileged position to understand the truth, and a cynical person (who would be me on some days) might wonder if they have something to gain from willful ignorance. I can think of three reasons why this could happen. First, physicians being who they are, value health over most things and value health more than the average person. This in and of itself is not scandalous or even controversial. It's a simple fact of human nature that a person will value the central facets of his life more than other things and more than the average person will. Fashion designers value clothes and fashion more than the average person. Teachers value education more. So it goes without saying that physicians would support discontinuing the use of substances with potentially harmful effects. I don't even have a problem with that - my problem arises when they support a harmful prohibition of said substances.

The other two reasons are a tad more sinister. I have discussed previously the status of gatekeepers for prescription drugs that physicians presently hold. Economically, this is profitable for them because it increases the demand for their services. It goes without saying that an across-the-board legalization of illegal drugs would call into question this legal gatekeeper status. How could one justify allowing heroin to be sold legally but requiring a prescription for lipitor? Similarly, the banning of certain drugs, used by people to treat their own depression, anxiety, and pain, forces those people, if they do not want to break the law, to seek the help of a physician to treat these with legal substances (not sold over-the-counter). Indeed the ever-increasing use of drugs (especially by psychiatrists) to treat behavioral and mental "disease" has blurred the distinction between "medicinal" drugs and "recreational" drugs. And even if the drugs used by physicians are considered safer than the illicit kind, it is insulting to patient autonomy to deny them access to drugs that may actually work better for them. Sullum writes:
Psychiatrists have been defining an ever-lengthening list of mental states as disorders to be treated with psychoactive substances. The medical excuse for drug use is so powerful that it can justify giving stimulants to inattentive schoolboys, tranquilizers to anxious travelers, and happy pills to melancholy teenagers - provided an MD approves. Taking MDMA to overcome shyness is drug abuse, but prescribing Paxil to treat "social anxiety disorder" is good medicine. Legally, the distinction between medical and nonmedical is clear. Conceptually, it has never been blurrier.
All of this makes me wary of motives, but is understandable given the culture we live in. However, I am insulted by some of the attitudes I see around the hospital I work. People complain about "drug-seekers," those demonic heathens who are forced (understandably) to be less-than-forward about their intentions for visiting the doctor. I am sure it is frustrating to be a practicing physician and have to spend time dealing with this, when you trained for so long to deal with more interesting medical problems. But there is a solution - and it does not involve more interference from the DEA. Relinquish complete control of the substances these people are seeking - and they'll stop coming to your office. I find it a little hypocritical when some physicians complain about the phenomenon that is a direct consequence of a policy many support and from which they directly benefit.

I can't get through a whole one of these without talking about personal liberty. When you get down to it, doesn't it strike anyone as unjust that we can force someone from putting a substance into their own body, and then throw them in jail if they do? An isn't it hypocritical that two people can go to a party and talk about the evils and immorality of drug use while partaking of a few drinks? And isn't in shameful that we have gotten to this point after a history of racism, misinformation, puritanism, and abuse of power?

I will repeat something I have said before - the War On Drugs is the biggest civil rights violation imposed on the citizens of the United States since the last Jim Crow law was repealed. Its injustice knows no boundary of race, sex, religion, etc. It affects us all, either directly or indirectly. The one thing I would feel I can accomplish with this is to begin to persuade members of the AMA and fellow health professionals to realize the harm our drug policies cause and lead the charge for their repeal. Do it for justice. Do it for liberty. Do it for our health.

Stay tuned for later installments of this series:
  • Part IV: Physician Licensing
  • Part V: HIPAA
  • Part VI: Public Health
  • Part VII: Food and Drug Administration
  • Part VIII: Physician-Assisted Suicide
  • Part IX: Organ Donation
  • Part X: CLIA
  • Part XI: Socialized Medicine
If anyone has a particular interest in these (or other) topics and would like to collaborate or submit their own entry, contact me.

Update: Blogborygmi has some thoughts.

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Hittin' the Big Time 

Check out PT favorite Nick Genes in his piece for the Worcester Telegram and Gazette.
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Saturday, May 29, 2004

Send Good Vibes 

Cameron at 2md is taking Step I as we speak. I didn't know he was taking it today - it makes me feel a little guilty harrassing him all week. Anyway, everyone send out good thoughts. Step I is a bitch, and the test is rather exhausting. I can't wait to see his drunken post about 3:00 AM tonight.
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Friday, May 28, 2004

Who Will Be the Next Vice-President of the United States? 

Here are the top 20 choices.
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The Day After Tomorrow: Free-Market Style 

Don Boudreaux has this inspired pitch for the plot of a movie, inspired by a new movie about global warming, that sees a liberal socialist state bring down society as we know it in 48 hours:
A ten-cent increase in the federal minimum wage casts millions of blacks and Hispanics into permanent unemployment and despair; all of these unemployed women scrape up pennies by offering themselves as prostitutes, while all of the unemployed men swarm to the suburbs to rape soccer-moms and then riot so violently in the cities that the Empire State building, the U.S. Capitol, the Sears Tower, and the Bank of America building all crash violently to the ground, killing tens of thousands of innocent civilians, including a kindly book-peddler specializing in works by and about Ayn Rand.
Can't wait for the previews.

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Thursday, May 27, 2004

Please Make It Stop 

I am quickly growing tired of the debate, partly because it has gone on long enough, partly because I am tired of having my positions restated in incorrect and intellectually dishonest ways. So I'll end with a challenge to Cameron:

Lord Page you have just been granted the title of supreme leader of the United States (or the world if you want). You quickly (and probably after executing your economist advisers) implement a health care system of your choice (national, social, whatever). To fund it and pay for the health care of 40 million uninsured Americans, you must tax the insured Americans $X (probably around $1,000, but the number is not important) to pay for it. You justify this by appealing to their morals. But you run into a problem - a young smart-ass pathologist objects slightly. He states that he will willingly give up his $1,000, but he says instead he will send it to Bangladesh to pay for their health care. He adds that if that means that a person making minimum wage has to go without some of his health care this year, that's just too bad.

Do you allow this person to proceed with his plan, or is the young pathologist going to find himself on the wrong end of an autopsy?

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Wednesday, May 26, 2004

Calling My Bluff 

I have to say I was surprised (or a better word would be shocked) to read this at 2md:
The reason healthcare is a moral issue has to do with the proximity of the uninsured to abundance. And by proximity I don't necessarily mean geographic, I mean cultural and social. When it's your fellow citizens who are dying for lack of medical care, that does demand greater outrage than an equivalent number of Chinese deaths.
I have thought about this for a good hour (just today) and probably hours on end before that. And I just can't get it through my thick head why I should be more compassionate, more interested, or more outraged by the plight of someone from Arizona who I have never met over someone from China who I have never met. How could something so abritrary, like a national border, carry so much weight? I'll repeat the line from Steve Landsburg because I like the words he uses:
You might or might not believe that we come into this world with an implicit moral obligation to feed the poor, but it is both repulsive and ridiculous (emphasis added) to imagine that the strength of that moral obligation could vary with the national origin of the recipient.
Repulsive and ridiculous. I like those words. I like Cameron, and I appreciate his willingness to argue with me. I always look forward to the back and forth. But that in my mind is repulsive. Morals are absolute - they are not affected by things as arbitrary as national boundaries. And somebody's right to health care does not vary by the distance from abundance. That's ridiculous.

I feel like the point I was making was pretty clear, but my argument was made into a characterture of itself, so I'll try again. Most in favor of socialized health care claim the moral high ground because they are "helping people." We should give to those in this country who are less fortunate. But I find this morally repulsive for reasons stated before. You can then retreat and talk about political practicality or being uncomfortable having to see the inequalities living on the same street, but now your making something other than a moral argument. And the view changes a bit when you have to vacate that high ground. It's OK to argure for socialized care - there may be valid arguments for it. But moral superiority is not one of them.

Make no mistake. I am not bringing up this abstract philosophical point to obscure the debate, as Cameron seems to contend. I'm doing the exact opposite. I'm bringing it up to focus the debate.

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Tuesday, May 25, 2004

Ignorance 1, Knowledge 0 

Most everyone who comes to this site has probably already seen this story on other medblogger sites; but just in case, I'm providing a link because I think it's exceedingly important.

In Maryland, a 53-year-old man suffering from prostate cancer has been awarded $1 million against the University of Maryland Family Practice Department. It appears that the resident discussed with the patient the pros and cons of undergoing a PSA blood test for prostate cancer. The man refused and such was documented. (These facts are not disputed). Current standard-of-care maintains that the PSA test is not good enough (correction: appropriate) to screen the general population (patients without symptoms). This is the consensus of all relevant medical professional groups and, indeed, the United States government. The man went on to develop prostate cancer detected by PSA two years later.

In the trial, the plaintiff's lawyer "urged the jury to return a verdict to teach residencies not to send any more residents on the street believing in (evidence-based medicine)." This should be infuriating to doctors, but also to believers in information, reason, and science. It is a victory for ignorance over knowledge, and it makes me wonder what type of judge or jury could allow this to happen.

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Sunday, May 23, 2004

Health Care For All (Americans) 

Our favorite health communist has been on a roll lately, thanks in part to the good folks at the National Board of Medical Examiners. He managed to slip this one past me, but I am now free from the shackles of OB/Gyn. In the aforementioned post, he drops his usual bankrupt empirical support for socialized health care, and instead returns to the basis for his support of this policy: namely, that we're all in this together and are morally bound to help each other out. An excerpt:
A few weeks ago I boiled the healthcare debate down to two choices: continuing to deny that we are all linked, or accepting that our fate is collective and embracing a universal system (whatever that might be).
So Cameron and I can argue the merits of various health care policies and their economic and health outcomes until we're blue in the face. The simple fact is that those don't matter. Regardless of who would win that admittedly empirical argument, in the end "health care for all" would win out because of our moral responsibility to provide health care for those who can't provide it for themselves.

The questions I have for Cameron are these: Is it fair to characterize your position that it is proper to essentially tax and redistribute wealth and income from the richest to the poorest for the purpose of providing for the bare necessities of health care? Do you consider this a moral absolute? If this is so, would you support a truly "universal" (or at least "global") health care system - not just one that was "national."

Here's what I'm getting at. This call for support of socialized health care is just another in the line of calls for welfare of various types. It's not an appeal to reason or science, it's an appeal to morality. But it's morally bankrupt, at least in the sense that most modern liberals apply it. They can't really believe it, or else that would be particularly disgusting to confine that morally mandated charity to stop at the US border.

I can hear the reply, that such a global system would be ideal, but is not practically possible. No - we're talking about moral imperatives here. Practicalities never trump moral imperatives.

Let's have a look at the numbers courtesy of David Henderson and Charley Hooper:
On the other end today are 3.5 billion of the world's 6.1 billion who live in countries whose per capita GNP is less than $760. The poorest of the poor, more than 1.2 billion, live on less than $1 a day. Now that's poverty.

The poor in the United States, by contrast, live on up to $23.50 a day.
Never mind for a moment that the poorest Americans already get free care via Medicaid - the uninsured Americans who Cameron would have us cover are the working poor who make in excess of $50/day.

The frequently quoted number of the uninsured is more than 40 million and the average cost of health care per person in the US is ~ $4,000/year. Allowing for a lot of error, that would cost us between 100 and 200 billion dollars per year in new taxes (or redirected taxes for other uses - still the same money no matter how you slice it). That's an insane amount of money for a group of people who live long and relatively wealthy lives. Can anybody guess how much more marginal health improvement that could buy those truly poor living on $1/day. Now I am not advocating necessarily that we do the latter, all I am saying is that if you
  • have the courage of your convictions,
  • want to make a moral argument and take that argument seriously,
  • and were faced with limited resources,
you would certainly choose the latter over the former. In addition, one could make an argument that the former (the American poor without health care) should pay taxes to buy health care for the latter (the world poor).

In his book "Fair Play", Steve Landsburg argues against the liberal version of the welfare state (the theory of an implied social contract put forth by John Rawls) with logic that applies here, I think:
If there's one thing the unborn soul would want to insure against, it's being born in the wrong country - Cuba, or Albania, or Mali instead of Canada, or Luxembourg, or the United Arab Emirates. The US tax code does exactly nothing to provide that kind of insurance. All it does is shuffle money around among some of the luckiest people on earth - those who have the great good fortune to be born in the United States of America.

Even the poorest Americans have wealth and opportunities that would dazzle the poorest Indonesian (or for that matter, the average Sudanese). So if social insurance is supposed to compensate the least fortunate, we should be sending welfare payments no to East Los Angeles but to East Timor. You might or might not believe that we come into this world with an implicit moral obligation to feed the poor, but it is both repulsive and ridiculous (emphasis added) to imagine that the strength of that moral obligation could vary with the national origin of the recipient.

...But my government compels me to donate a substantial portion of my income to those same relatively affluent Americans. That policy is not the fulfillment of any plausible implicit contract. According to the agreements we'd have signed before birth, the typical "impoverished" American should be sending welfare payments to Tajikstan, not collecting them from his countrymen
I find that argument particularly compelling, and I am waiting for those who want universal health care to start talking about truly universal health care.

The call for socialized health care in the US is an empirical argument, not a moral one.

Good luck on boards, Cameron.

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George Bush the Liberal 

If you really want to piss your left-wing friends off (and I mean really piss them off), follow Jacob Levy's lead and point out how liberal George Bush's policies have been:
Anytime I make any reference to the fact that George W. Bush has been pursuing some objectively liberal policies, I get slammed in the blogosphere, and also get hostile email denying that anything W. has done could be construed as liberal. What I mean by objectively liberal is simply that if the same policy was pursued by, say, a Gore Administration, it would win praise from liberals. Some obvious examples that come to mind are (1) the new Medicare drug entitlement; (2) the massive increase in federal education spending; (3) increased funding (proposed) for the National Endowment for the Arts; (4) the general huge increase in discretionary federal spending, including spending on infrastructure projects (what Bill Clinton called "investment"); (5) close attention to affirmative action concerns in excecutive appointments. Imagine that Al Gore, facing a Republican Senate and House, had managed to enact any of these policies. Is there any significant doubt that while liberals may have found these policies imperfect in various ways (e.g., the drug program doesn't include price controls), they would be praising his political acumen in winning these victories for Progressivism? And at least some liberals would also be praising Bush's protectionism, though among them would not be the more clever liberal bloggers.
Levy is right, and I think this is precisely why labels such as liberal, conservative, etc. are, for lack of a better word, stupid. 95% of the time these words are simple proxies for political affiliation, which are based on something other than principled beliefs of how the world should work.

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Drug War Crimes 

After several months, I'm finally reading something new. Look to the right sidebar to find a link to Jeffrey Miron's "Drug War Crimes," an economic analysis of the War on Drugs. It simply, yet elegantly, indicts American drug policy by empirically analyzing its effects on drug use and violence. It also delves somewhat into the collateral costs of the drug war, such as corruption, fostering racist attitudes, and adverse health effects.

I plan on submitting a more detailed outline and review in an upcoming installment of my "Paternalism in Medicine" series. Stay tuned.

Order this book on Amazon through the link to your right. It costs eleven bucks, you can read the whole book in the matter of three hours, and you will be extremely enlightened by the experience.

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Friday, May 14, 2004

Change the World 

Apparently the British are going to start offering statins over-the-counter:
In a bid to prevent heart attacks and strokes, Britain will be the first country to permit nonprescription sales of a cholesterol-lowering drug, the government said Wednesday.

Some expert groups welcomed the decision, but others said people taking such drugs needed supervision and an assessments of risks.

Health officials said a low-dose version of simvastatin, marketed as Zocor by Merck & Co. of Whitehouse Station, N.J., will be available without a prescription at pharmacies across the country starting later this year. No date was announced.

Simvastatin belongs to a class of drugs called statins, considered a powerful weapon against the buildup of fat deposits that clogs arteries, leading to heart attacks and strokes.

Pharmacists will ask people a series of questions and, if needed, will offer a range of optional health tests to ensure it is safe to take the drug, said Health Secretary John Reid. Pharmacists will have the power to refuse to sell the drug.

The Royal College of General Practitioners and the British Medical Association raised concerns.

The drugs still are available only by prescription in the United States.
Do you think they have been reading the Proximal Tubule?

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Wednesday, May 12, 2004

I Import My Free Trade Posts From Catallarchy 

Brian Doss at Catallarchy asks "has anyone free-traded themselves into poverty:"
I know of plenty of cases where the erection of barriers to capital, goods, and even labor flow have impoverished a country with phenomenal natural resource wealth (Russia) and an industrious population (East Germany, Czechland), and plenty of cases where free trading countries have become fabulously wealthy even without any resources and far too many people per square foot (see also Hong Kong)- but I don’t have many in my “free trade left me in the poorhouse” file.
The guys over there have been hammering this home with tremendous wit and wisdom the last few days. Go check it out.

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Smoke 'Em If Ya Got 'Em 

Do smokers react to market constraints just like everyone else? Or are they powerless in the face of their addiction? These are generally opposite views - it's hard to beleive both at the same time. But modern anti-smoking crusaders do. Jacob Sullum has more:
"It is not at all surprising," an anti-smoking activist told the Times. "This is what we said all along would happen if you sharply raised the cost of smoking." But they've also said all along that government intervention is justified because nicotine addiction prevents people from freely choosing whether to smoke. Whatever you think of using financial penalties to encourage healthier habits, the fact that smokers respond to them demonstrates the error of equating addiction with slavery. The problem is not that smokers cannot choose; it's that other people don't like their choices.
Two thoughts:
  • If smokers react to higher prices just like other consumers, enough with all the junk about needing to help people drop their addictions - it's is a choice to smoke.
  • If smokers are such slaves to addiction, then these outrageous taxes are pure plays by government to secure more revenue. And further, since the average smoker is poorer than the average non-smoker, this tax reaches into the pockets of those who can least afford to pay. (And for those who think these taxes are needed to offset the cost of health care for smokers - it's been shown in several economic studies that since smoking results in premature deaths, it's a net gain for the state due to a decrease in social security payments larger than the increase in medicare/medicaid payments)
Elsewhere, Sidney Smith comments on the "study" that reported a nearly 50% reduction of heart attacks in area hospitals after Helena, Montana banned public smoking:
It's quite a stretch to look at the data from Helena and conclude that thirty minutes of second hand smoke exposure will kill your heart. It's just too small a sample to make such sweeping conclusions. If banning public smoking really reduced heart attack rates by forty-percent, wouldn't New York city cardiologists have noticed by now? A forty-percent decrease in business is hard to overlook. And wouldn't the city's health department, which believes strongly in the benefits of smoking bans, have noticed, too?

Smoking is bad and smoking around non-smokers without their permission is rude. But exaggerating the dangers that smokers pose to non-smokers is not wise. For one thing, it undermines the credibility of the medical profession. For another, it promotes an attitude of intolerance that should give us pause in a free society. The way things are going, it will be only a matter of time before a smoker is charged with manslaughter for his co-worker's heart attack.
I don't smoke, and I detest being anywhere near smoking. However, I am willing to defend smoking from puritanical crusaders and junk science, and I am glad that intelligent people like Sullum and Smith are around to keep those forces honest.

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Sunday, May 09, 2004

Cause For A Big Fat Celebration 

I am planning on getting around to the med student debate on obesity, since Cameron laid the gauntlet specifically for me, it seems. But it will be a little time, unless people stop reproducing really soon.

In the meantime, I'll link to this post by Nick Gillespie over at Hit & Run. Nick, unlike most everyone else, can see the bright side to our worldwide obesity epidemic:
Let's not mince words: There's something worth celebrating about a world in which even poor people have so much to eat that they can become fat.
Amen to that, Nick.

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Saturday, May 08, 2004

Wired and Tired 

It's 3:00 on the labor hall, I'm about to fall asleep standing up, and I just finished a 32 oz. Mountain Dew. I have this strange joint sensation of fatigue and edginess. I feel like everything is a hallucination (am I really blogging this?). Make it stop.

While I am here delivering babies of teenage mothers, I thought I'd link to Educated Guesswork's post about the FDA denying approval for "Plan B" sale over-the-counter. Readers may recall my previous thoughts on OTC approval, and Plan B specifically. Good job, guys. It's good work you're doin' there.

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Thursday, May 06, 2004

Be a Humanitarian, Support Sweatshop Labor 

Micha Ghertner over at Catallarchy, has this:
Luckily, when it comes to issues like sweatshop labor, there is something we, as private individuals, can actively do to solve the problem. Instead of boycotting products made with sweatshop labor as some would propose, we should purchase as many of these products as humanly possible.
Go read the whole thing.

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Wednesday, May 05, 2004

In Sheep's Clothing 

Bjorn Lomborg is heading has teamed up with a handful of Nobel laureate economists along with The Economist to start the Copenhagen Consensus. Supposedly they "will create a prioritized list of opportunities to solve the 10 greatest challenges facing humanity, as we see them.":
The economists will examine the costs and benefits of solutions to each challenge. An example of a solution (to the challenge of communicable diseases) could be to provide free mosquito nets to areas affected by malaria. The result will be perhaps the grandest "To Do" list the world has seen, showing us how to spend our money the most efficiently. The list will be concrete, outlining tangible opportunities that can be done today.
Don Boudreaux at Cafe Hayek isn't so sure:
The ultimate goal is to decentralize decision-making power as much as possible down to individuals. It's at the individual level that cost-benefit calculations are most accurately made; it is at the individual level that the most important "to do" lists are formulated, pursued, adjusted, and achieved.
The whole point for economists who are convinced of the power and value of free markets is that they allow individuals to make decisions based on their local expertise, and that the outcomes of these decisions, on balance, are better for all. Economists correctly criticized communism on this premise. I don't know much about Lomborg and his group, but I understand that they would support what I have just said. So how come what they are trying to accomplish sounds so much like an elite centralized authority whose purpose is to find the "most central truths" to the human condition? Didn't FA Hayek teach us anything?

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Monday, May 03, 2004

Competitive Balance 

Last week, Rob Neyer wrote that the "problem" of competitive balance may not be such a problem after all:
If by "competitive balance" we mean that a significant number of teams have a fighting chance to win the World Series, then we're probably at an all-time high. In any given season since 1994, roughly four out of every 10 teams finished the schedule within five games of either a division title or the wild card, and that's a lot of teams.

And yet, the Commissioner continues to prattle on about "competitive balance" and, even more cloyingly, "hope and faith." Well, he and his fellow owners solved the "problem" 10 years ago when they created two new divisions and four new postseason berths. In the face of the evidence I've presented above, I'm led to one of two conclusions: that the Commissioner won't be happy until 1) MLB is like the NHL and the NBA, with more than half the teams not only having the chance to make the playoffs, but actually making the playoffs, or 2) the Commissioner's own team, which hasn't played a postseason game since 1982, actually makes the playoffs.

Then again, maybe those two things are one and the same. All I know is that among all the other things that make this the greatest time to be a baseball fan, is the fact that most baseball fans this winter could reasonably harbor high hopes for their team in 2004. Almost everybody is happy, or will be soon.
When developing playoff formats, there is a trade-off that is difficult to get around. You try to accomplish two goals, but they are often at odds with each other:
  • You want the best teams to win the playoffs. This makes the regular season actually mean something and it celebrates excellence. The less teams in the playoffs, the greater the chances of this occurring.
  • You want to create the most interest among the highest number of fans and you want to give teams the incentive to compete their hardest throughout the year. The more teams in the playoffs, the greater the chances of this occurring.
Baseball has traditionally traded the second for the first (unlike the other team sports), because in baseball there is the least distribution of winning percentage. If you allowed all baseball teams in to a postseason tournament, there is an unacceptable chance that an average team would come out on top and the best team would not. In all other sports, half the teams are in the playoffs, yet the best team seems to win a good portion of the time. They have managed the trade-off well.

Well, I think there is a way to manage this trade-off in baseball, still give the best teams the best chance of winning, and include all, yes - all, teams into the playoffs. Here's how it works:
  • First, let's assume two teams are added (even though this is not necessary, just makes the model easier to describe.)
  • Seed the teams in each league 1 through 16 (however you choose to do so - by record, weighted to division standing, etc.).
  • This would give five rounds of playoffs. All rounds would be best-of-seven.
  • In the first round, the highest seeded team gets a 3-game advantage, starting the series leading 3-0.
  • In the second round, the higher seed would get a 2-0 advantage.
  • In the third round (of eight) the higher seed would start 1-0.
  • In the league championship series and World Series, series' would be best-of-seven with no advantage.
  • Of course, this would require shortening of the season, but not by as much as you would think. If earlier rounds are played without a lot of days off, this would make up for the revenue of games lost during the season.
  • If the number of teams are kept at 30, then the top seeds could get a first-round bye.
This system most certainly would never happen, but it has certain advantages:
  • It gives every team a legitimate shot every year.
  • If the worst team happened to beat the best team, it would be against such long odds that it would not harm the integrity of the playoffs.
  • This system is stacked in favor of the 4 best teams in any given year (actually this is more so than exists know, where the 7th or 8th best teams have taken advantage of short series' to win the World Series without much advantage being given to the better teams over the course of the season - home field advantage doesn't mean much in baseball)
  • Imagine the competition for the middle seeds, where the winner gets a 3-game advantage over the loser.
Any thoughts?

Update: I just realized that this may bring to a halt all the trading that goes on in season (especially at the trading deadline). Is this necessarily a bad thing? Does it actually add integrity to the regular season.

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Sunday, May 02, 2004

Don't Be Afraid To Say It 

Last month I tried to start the national health care debate for the 8,000-th time.

Two weeks ago I asked, "When we're all paying for one anothers health care, should we be interested in how each other uses our bodies?"

The other day I discussed the "obesity epidemic."

Now read this post from the comments section over at MedRants. He makes my point for me:
We're not in a "moral panic about obesity." We live in a society in which one person's problems have a way of becoming everyone's problem. Fat people have greater health costs than fit people, and the government pays for roughly half of health care in this country, so when you are fat, it costs me.
Does anybody see a problem here?

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