Category: Medicine

Euthanasia and bargaining power within the family

Let’s say more of the world moves to a Netherlands-style euthanasia law.  While euthanasia is at first based on individual consent, it usually evolves into a “in unclear cases your spouse or guardian has the actual say.”

How will this affect bargaining power within the family?  Here are a few options:

1. Family members will be much nicer to each other, ex ante, so they will be kept around for longer if they come down sick.

1b. Because of time consistency problems, family members won’t be much nicer with each other.

1c. You fear that family members aren’t willing enough to pull the plug on you, so you become actively less nice.

2. Family members will be much more anxious with each other, because they will so often be wondering how the others will wish to dispose of them, and when.

3. Some family members will make explicit ex ante deals, such as: “You can send me to my doom when the time comes, with a clear conscience, but on Tuesday nights we’re going to watch my game shows, not your reality TV.”

4. “It stresses me out that you are stressed out over my dying, so I will apply for euthanasia right here and now, even though I still have nine months to live with my cancer.  Except I will tell you that I just don’t want to live any longer, so you don’t feel bad about why I am doing this.”

5. You have no family and given your illness you are a net revenue drain on your nursing home.  If you go back to live out your final days, you’ll end up with the worst room and less spicy food and no private TV.  You agree to euthanasia, granted that they send $20,000 to your favorite charity.  You leave this earth with a warm glow, feeling that 20k probably saved at least one life.  In reality, with p = 0.68 it subsidized someone’s overhead.

What else?

Sex Redistribution and Disability

I am surprised that the subject of sex and disability has not arisen in the controversy surrounding Robin Hanson’s and Ross Douthat’s remarks on sex redistribution. The subject is one of active debate in the literature on medical ethics. Bioethicist Jacob Appel writing in the Journal of Medical Ethics in 2010 argued:

If sexual pleasure is a fundamental right, as this author believes, then jurisdictions that prohibit prostitution should carve out narrow exceptions for individuals whose physical or mental disabilities make sexual relationships with non compensated adults either impossible or high unlikely.

…A second area in which reform is desperately needed is the ‘no sex’ policies that exist in American nursing facilities, mental hospitals and group homes. Many such facilities require the doors of patients’ rooms to be open at all times, making intimacy all but impossible. The assumption underlying these restrictions is that anything short of clearly expressed wishes by a fully competent and rational individual does not fulfil a minimum standard to consent to sexual relations. The principle advanced by this approach is that institutionalised individuals require a higher degree of protection than those living outside of institutions. In many matters, this is certainly the case. However, in regard to sexual relations, this ‘higher’ standard often serves as an obstacle to meeting both the wishes and interests of individuals who cannot conform to ‘real world’ standards of consent.

More challenging than a ‘negative rights’ conception of sexual liberty is one that also embraces a ‘positive right’ to sexual pleasure for the disabled–either for those individuals who are too impaired to find mates and/or those who are so physically incapacitated that they are incapable of pleasuring themselves. Several European nations, including Germany, The Netherlands, Denmark and Switzerland, allow limited ‘touching’ services for the severely disabled through non-profit organisations.

In the UK charities exist to help match sex workers with the disabled. Similar services are available in Denmark and in the Netherlands and in those countries (limited) taxpayer funds can be used to pay for sexual disability services. The Green party has proposed such services elsewhere:

A German politician has sparked controversy by suggesting people with severe disabilities could receive “sexual assistance” paid for by the state.

The Green party’s spokeswoman for age and care policy, Elisabeth Scharfenberg, said the government could “provide grants” for sexual services to disabled people who cannot achieve satisfaction by any other means.

Such a system is currently operating in Denmark and the Netherlands, where certified “sexual assistants” with special training conduct visits to disabled people who cannot afford to pay themselves.

Regardless of the answers one gives, I think these are legitimate questions of profound and deep importance to the people involved. It’s unfortunate and wrong that someone who brings these issues to the public forum is denounced and called creepy. We can and should do better.

One estimate of the rate of return on pharma

…return on investment in pharma R&D is already below the cost of capital, and projected to hit zero within just 2 or 3 years. And this despite all efforts by the industry to fix R&D and reverse the trend.

That is from Kelvin Stott.  Keep in mind this is during a time when global demand has been growing, which suggests the supply side is all the more constipated.

Equality is a mediocre goal, aim for progress

That is the title of my latest Bloomberg column, here is one excerpt:

Take this all a step further and imagine that the next 30 years brings an enormous blossoming of medical innovation, outpacing the general rate of economic growth. Government revenue then might not grow rapidly enough to cover all or even most of these new medical miracles, some of which will be quite expensive, especially in their early stages. Governments will decline to cover more and more care.

This fiscal crunch is all the more likely if people live much longer but cannot work enough longer to fund their newly extended retirement spans.

To date, so much of the health care debate has been about whom to cover. Over time, it may be more and more about what to cover. It could be that all the citizens will have nominally the same insurance coverage, whether subsidized or guaranteed, but many medical and mental-health conditions will fall outside this coverage —  leading to rampant inequalities in access.

It’s the best problem to have. It means that medical innovation has arrived at a very high rate. If we enter the future being able to cover most medical treatments with reasonable equality, that would be a sign we failed at the task of progress. In other words, successful futures are likely to be highly unequal futures, again because medical innovation will have outpaced government revenue. (Innovations that extend working years would ameliorate this effect by adding to government revenue.)

Do read the whole thing.

My Conversation with Balaji Srinivasan

Here is the transcript and audio, and this is the intro:

Marc Andreessen has described Balaji as the man who has more good ideas per minute than anyone else in the Bay Area. He is the CEO of Earn.com, where we’re sitting right now, a board partner at Andreessen Horowitz, formerly a general partner. He has cofounded the company Counsyl in addition to many other achievements.

Here is one excerpt:

COWEN: Why is the venture capital model so geographically clustered? So much of it is out here in the Bay Area. It’s spreading to other parts of the country. Around the world, you see Israel, in some ways, as being number two, per capita number one. But that’s a very small country. Why is it so hard to get venture capital off the ground in so many areas?

SRINIVASAN: That’s actually now changed with the advent of ICOs and Ethereum and crypto. Historically, the reason for it was companies would come to Sand Hill Road. One maybe slightly less appreciated aspect is, if you come to Sand Hill Road and you get VC financing, the VC who invests in your company typically takes a board seat. A VC does not want to fly 6,000 miles for every board seat if they’ve got 10 board seats and four board meetings a year per company.

What a VC would like in general, all else being equal, is for you to be within driving distance. Not only does that VC like it, so does the next VC in the B round and the next VC in the C round. That factor is actually one of the big things that constrains people to the Bay Area, is VC driving distance, [laughs] because VCs don’t want to do investments that are an entire world away.

With the advent of Ethereum and ICOs, we have finally begun to decentralize the last piece, which was funding. Now, that regulatory environment needs to be worked out. It’s going to be worked out in different ways in different countries.

But the old era where you had to come to Sand Hill to get your company funded and then go to Wall Street to exit is over. That’s something where it’s going to increasingly decentralize. It already has decentralized worldwide, and that’s going to continue.

COWEN: With or without a board seat, doesn’t funding require a face-to-face relationship? It’s common for VC companies to even want the people they’re funding to move their endeavor to the Bay Area in some way, not only for the board meeting. They want to spend time with those people.

We’re doing this podcast face to face. We could have done it over Skype. There’s something significant about actually having an emotionally vivid connection with someone right there in the room. How much can we get around that as a basic constraint?

And here is another:

COWEN: Right now, I pay financial fees to my mutual funds, to Merrill Lynch, all over. Anytime I save money, I’m paying a fee to someone. Which of those fees will go away?

SRINIVASAN: Good question. Maybe all of them.

And:

COWEN: Drones?

SRINIVASAN: Underrated.

COWEN: Why? What will they do that we haven’t thought of?

SRINIVASAN: Construction. There’s different kinds of drones. They’re not just flying drones. There’s swimming drones and there’s walking drones and so on.

Like the example I mentioned where you can teleport into a robot and then control that, Skype into a robot and control that on other side of the world. That’s going to be something where maybe you’re going to have it in drone mode so it walks to the destination. You’ll be asleep and then you wake up and it’s at the destination.

Drones are going to be a very big deal. There’s this interesting movie called Surrogates, which actually talks about what a really big drone/telepresence future would look like. People never leave their homes because, instead, they just Skype into a really good-looking drone/telepresent version of themselves, and they walk around in that.

If they’re hit by a car, it doesn’t matter because they can just rejuvenate and create a new one. I think drones are very, very underrated in terms of what they’re going to do. 

Do read or listen to the whole thing.

Let the boy Brexit!

Pope Francis has been praying for the British toddler Alfie Evans — and the Italian government has granted the child Italian citizenship and lined up a transportation plan that could swiftly bring the sick little boy to a Vatican hospital.

But Alfie’s doctors say he cannot be healed, and shouldn’t make the trip at all.

On Tuesday, according to lawyers representing Alfie’s family, a British judge sided with the doctors, saying that the family cannot accept the offer to take Alfie to the Vatican for treatment.

Here is the full story.  The boy’s situation is dire, but he has not even received a definitive diagnosis from the British doctors.

Why are so many graduate students depressed?

PhD and master’s students worldwide report rates of depression and anxiety that are six times higher than those in the general public (T. M. Evans et al. Nature Biotech. 36, 282–284; 2018). The report, based on the responses of 2,279 students in 26 nations, found that more than 40% of respondents had anxiety scores in the moderate to severe range, and that nearly 40% showed signs of moderate to severe depression.

That is from this summary statement.  Here is the original piece.  So what might be going on here?

1. The ordeal of studying and possibly finishing is extreme, and extreme ordeals depress people.  This seems inconsistent with other evidence, however, namely rising (reported) rates of depression in prosperous, comfortable societies.

2. The task of studying and possibly finishing is correlated with a kind of extreme lassitude, and that in turn is correlated with depression.

3. Graduate students become depressed as they realize they have chosen poor life paths.

4. Graduate students become depressed as they realize, a’la Caplan, that it is mostly about signaling.

5. Graduate students are undergoing a transformation of their personalities, and being turned into intellectual elites, but this process is traumatic in several regards, thus leading to frequent depression.  The chance of depression is part of the price of admission to a select club.

6. Our graduate institutions serve women poorly (women in graduate school experience depression at higher rates — 41% vs 35% for the men).

7. It’s all just sample bias, as depressed graduate students have nothing better to do than respond to this survey.

What else?  And how much should we regard these results are symptoms of a deeper malaise?  Or is the problem confined mainly to academic life?

How FDA-Approved Prescribing Information Lags Behind Real-World Clinical Practice

Once a drug has been approved for some use it can be legally prescribed for any use. New uses for old drugs are often discovered. When physicians learn of these new uses, prescribing practices move beyond the uses that the FDA has evaluated and permitted. In Outdated Prescription Drug Labeling, Shea et al. compare off-label uses for cancer drugs that are graded as “well-accepted” by the National Comprehensive Cancer Drugs & Biologics Compendium (NCCN) with the labelled, “FDA-approved” uses. What they find is that most drugs have multiple off-label uses that are significantly different from FDA approved uses.

Our analysis of the NCCN Compendium and FDA drug labels for 43 cancer drugs approved between 1999 and 2011 identified hundreds of off-label uses, most of which were strongly supported by NCCN expert panels.

…Additionally, of the 253 off-label uses, 165 (65.2%) were categorized as “new indications,” meaning they were in disease settings not represented on labels

In my work on off-label prescribing (and with Klein) I have emphasized that the off-label world offers a window on what the larger world would look like with much less FDA control over new drug approvals. Notice that even today it’s physicians and the private approval process, as represented by the compendia, that determine actual prescribing and payment.

We found that 4 of the 5 largest private payers, as well as Medicare, cover over 90% of uses listed on the NCCN Compendium (uses graded 1 and 2A), suggesting widespread acceptance of these uses by diverse stakeholders. While standards for FDA approval differ from standards for coverage determinations, these findings indicate that the gulf between labeled uses and covered uses may be needlessly wide.

To bring FDA labeling up to real-world practice the authors recommend “a collaboration between the FDA and the developers of clinical guidelines and drug compendia to evaluate existing evidence about approved drugs and suggest updates to labeling.” In other words, the decentralized, private approval system should be used to determine which new uses of old drugs are safe and effective and those determinations should then be adopted by the FDA. I agree. But if private practices can be used to approve new uses for old drugs, why shouldn’t similar procedures be used to approve new uses for new drugs?

Opioids are not mainly an economic phenomenon

Overall, our findings suggest that there is no simple causal relationship between economic conditions and the abuse of opioids. Therefore, while improving economic conditions in depressed areas is desirable for many reasons, it is unlikely to curb the opioid epidemic.

That is from Janet Currie, Jonas Y. Jin, and Molly Schnell in a new NBER working paper.

What should I ask Balaji Srinivasan?

I will be doing a Conversation with him, no associated public event.  Here is his home page, here is his bio:

Balaji S. Srinivasan is the CEO of Earn.com and a Board Partner at Andreessen Horowitz. Prior to taking the CEO role at Earn.com, Dr. Srinivasan was a General Partner at Andreessen Horowitz. Before joining a16z, he was the cofounder and CTO of Founders Fund-backed Counsyl, where he won the Wall Street Journal Innovation Award for Medicine and was named to the MIT TR35.

Dr. Srinivasan holds a BS, MS, and PhD in Electrical Engineering and an MS in Chemical Engineering from Stanford University. He also teaches the occasional class at Stanford, including an online MOOC in 2013 which reached 250,000+ students worldwide.

His latest Medium essay was on ICOs and tokens.  I thank you all in advance for your wise counsel.

Longevity FAQ

From Laura Deming, you will find it here, essential reading for our time.  Here is one bit:

Senescence

at a glance: a fraction of your cells get older than the others, so we’d like to eliminate them

As you get old, so do your cells. But some of your cells get old in a way that is much worse than the others. You may have heard of a thing called telomerase. If you remember correctly, it’s the thing that keeps the end of your DNA long enough that your cells can still divide. When one of your cells runs out of telomerase, it can’t make many more copies of itself. If the cell sticks around, refuses to die even when it stops working, and starts secreting signals to the immune system, we call that a ‘senescent cell‘.

What happens when you get rid of these cells? Some animals that age faster than normal have a lot of these ‘senescent cells’ and are good experimental models in which to ask that question. In 2011, a group from the Mayo Clinic cleared out many of the senescent cells in one of those animal models, and found that the resulting mice were healthier in old age (among other things, they did not get cataracts and bent spines, which typically emerge in old age). In 2016, the same investigators found that getting rid of senescent cells in normal mice made them live a longer healthy lifespan. Knocking out senescent cells is tricky, because they don’t have many unique identifiers. Companies are working to either find things empirically that kill senescent cells, or figure out specific mechanisms by which to try to destroy them.

It starts off like this:

Hi! I’m Laura Deming, and I run Longevity Fund. I spend a lot of time thinking about what could increase healthy human lifespan. This is my overview of the field for beginners.

Does it end with you living to 129?  I genuinely do not know.

My Conversation with Robin Hanson

I am honored to have been able to do this, here is the podcast and transcript.  The topics we covered included…the ideas of Robin, most of all: “With Robin, we go meta. Robin, if politics is not about policy, medicine is not about health, laughter is not about jokes, and food is not about nutrition, what are podcasts not about?”

Here is one exchange:

COWEN: Let’s say I’m an introvert, which by definition is someone who’s not so much out there. Why is that signaling? Isn’t that the opposite of signaling? If you’re enough of an introvert, it doesn’t even seem like countersignaling. There’s no one noticing you’re not there.

HANSON: I’ve sometimes been tempted to classify people as egg people and onion people. Onion people have layer after layer after layer. You peel it back, and there’s still more layers. You don’t really know what’s underneath. Whereas egg people, there’s a shell, and you get through it, and you see what’s on the inside.

In some sense, I think of introverts as going for the egg people strategy. They’re trying to show you, “This is who I am. There’s not much more hidden, and you get past my shell, and you can know me and trust me. And there’s a sense in which we can form a stronger bond because I’m not hiding that much more.”

And:

COWEN: Here’s another response to the notion that everything’s about signaling. You could say, “Well, that’s what people actually enjoy.” If signaling is 90 percent of whatever, surely it’s evolved into being parts of our utility functions. It makes us happy to signal. So signaling isn’t just wasteful resources.

What we really want to do is set up a world that caters to the elephant in our brain, so to speak. We just want all policies to pander to signaling as much as possible. Maybe make signals cheaper, but just signals everywhere now and forever. What says you?

HANSON: I think our audience needs a better summary of this thesis that I’m going to defend here. The Elephant in the Brain main thesis is that in many areas of life, perhaps even most, there’s a thing we say that we’re trying to do, like going to school to learn or going to the doctor to get well, and then what we’re really trying to do is often more typically something else that’s more selfish, and a lot of it is showing off.

If that’s true, then we are built to do that. That’s the thing we want to do, and in some sense it’s a great world when we get to do it.

My complaint isn’t really that most people don’t acknowledge this. I accept that people may be just fine leaving the elephant in their brain and not paying attention to it and continuing to pretend one thing while they’re doing another. That may be what makes them happy and that may be OK.

My stronger claim would be that policy analysts and social scientists who claim that they understand the social world well enough to make recommendations for changes—they should understand the elephant in the brain. They should have a better idea of hidden motives because they could think about which institutions that we might choose differently to have better outcomes.

And of course I asked:

COWEN: What offends you deep down? You see it out there. What offends you?

And why exactly does it work to invite your date up to “see my etchings”?  And where is “The Great Filter”?  And how much will we identify with our “Em” copies of ourselves?  There is also quantum computing, Robin on movies, and the limits of Effective Altruism.  On top of all that, the first audience question comes from Bryan Caplan.

You should all buy and read Robin’s new book, with Kevin Simler, The Elephant in the Brain: Hidden Motives in Everyday Life.

Toward a Jungian theory of Amish fertility?

At least in the Geauga, Ohio Amish settlements, the decline in fertility followed national fertility trends very closely. Here’s a fun fact: the Amish don’t use most forms of birth control or abortion.

Now, this doesn’t mean Amish fertility fell as low as U.S. general fertility; it simply means that Amish fertility fell as much as U.S. general fertility.

…Cuz what I’m seein’ is that Amish fertility is pretty well correlated with U.S. TFR on the whole.

Scroll down through this Lyman Stone essay to see the graphs of the data (which won’t reproduce for me here, alas).  Here are some pictures in tweet form, if you don’t like scrolling.

Is legal marijuana more potent?

Yes, here is Keith Humphreys from Wonkblog:

Although some people believe prohibiting drugs is what makes their potency increase, the potency of marijuana under legalization has disproved that idea. Potency rises in both legal and illegal markets for the simple reason that it conveys advantages to sellers. More potent drugs have more potential to addict customers, thereby turning them into reliable profit centers.

In other legal drug markets, regulators constrain potency. Legal alcohol beverage concentrations are regulated in a variety of ways, including through different levels of tax for products of different strengths as well as constraints on labeling and place of sale. In most states, for a beverage to be marketed and sold as “beer,” its alcohol content must fall within a specified range. Similarly, if wine is distilled to the point that its alcohol content rises too high, some states require it be sold as spirits (i.e., as “brandy”) and limit its sale locations.

As states have legalized marijuana, they have put no comparable potency restrictions in place, for example capping THC content or levying higher taxes on more potent marijuana strains. Sellers are doing the economic rational thing in response: ramping up potency.

How about the Netherlands?:

The study was conducted in the Netherlands, where marijuana is legally available through “coffee shops.” The researchers examined the level of delta-9-tetrahydrocannabinol (THC), the main intoxicant in marijuana, over a 16-year period. Marijuana potency more than doubled from 8.6 percent in 2000 to 20.3 percent in 2004, which was followed by a surge in the number of people seeking treatment for marijuana-related problems. When potency declined to 15.3 percent THC, marijuana treatment admissions fell thereafter. The researchers estimated that for every 3 percent increase in THC, roughly one more person per 100,000 in the population would seek marijuana use disorder treatment for the first time.

The Dutch findings are relevant to the United States because high THC marijuana products have proliferated in the wake of legalization. The average potency of legal marijuana products sold in the state of Washington, for example, is 20 percent THC, with some products being significantly higher.

I believe that marijuana legalization has moved rather rapidly into being an overrated idea.  To be clear, it is still an idea I favor.  It seems to me wrong and immoral to put people in jail for ingesting substances into their body, or for aiding others in doing so, at least provided fraud is absent in the transaction.  That said, IQ is so often what is truly scarce in society.  And voluntary consumption decisions that lower IQ are not something we should be regarding with equanimity.  Ideally I would like to see government discourage marijuana consumption by using the non-coercive tools at its disposal, for instance by making it harder for marijuana to have a prominent presence in the public sphere, or by discouraging more potent forms of the drug.  How about higher taxes and less public availability for more potent forms of pot, just as in many states beer and stronger forms of alcohol are not always treated equally under the law?