Monthly Archives: May 2011

Who Killed Autopsies?

By Robin Hanson · May 17, 2011 10:40 am · Comments (45)

What if the airline industry lobbied to end the practice of routinely investigating the cause of each airline crash? After all, if there is no investigation, it will be hard to show an airline was at fault. You might imagine there’d be a public outcry. But in 1970 the US medical profession did essentially the same thing, and few complained:

Today, hospitals perform autopsies on only about 5 percent of patients who die, down from roughly 50 percent in the 1960s. … Autopsies play a critical role in helping to advance understanding of the progress of a disease and the effectiveness of various treatments. At the same time, they may identify medical conditions that clinicians and high-tech imaging miss or misdiagnose. …

In 1998 the Journal of the American Medical Association reported that autopsy results showed that clinicians misdiagnosed the cause of death up to 40 percent of the time. … Until 1970, hospitals had to autopsy at least 20 percent of their patients in order to remain accredited. Once that requirement was dropped, autopsy rates began to fall, due to lack of direct funding, fear of litigation and increasing reliance on technology as a diagnostic tool, among other reasons. … Today, about 40 percent of hospitals don’t perform autopsies at all. (more)

The idea that we could afford autopsies before 1970, but now they are too expensive to afford is pretty crazy. In 1970 the US spent 75B$ on medicine (7% of GDP); we now spend 2500B$ (18% of GDP). A pretty obvious explanation for fewer autopsies: docs don’t like being proven wrong. Such dislike can lead to lawsuits, and generally make docs look bad. This can explain doc “fear of litigation”, dislike for autopsies that might disagree with tech diagnoses, and lobbying to cut accreditation rules requiring autopsy funding.

Could there be any clearer evidence that docs care more about getting paid than about healing patients, yet the public can’t bring itself to imagine docs are that selfish?

Added 20May: More detail on the transition:

For most of the postwar period up to 1970, hospitals generally paid it, essentially because they had to: the Joint Commission on Accreditation of Healthcare Organizations required hospitals to maintain autopsy rates of at least 20 percent (25 percent for teaching hospitals), which, then and now, is the rate most advocates say is the minimum for monitoring diagnostic and hospital error. The commission eliminated that requirement in 1970. Lundberg says that this happened because hospitals, which had already allowed the rate to drop to close to 20 percent since its 1950′s high of about 50 percent, wanted to let it drop further and pressured the commission. The commission’s current president, Dr. Dennis S. O’Leary, says it eliminated the standard because too many hospitals were doing poor autopsies — and often only the cheapest, simplest ones — just to make the quota. (more)

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Conscription Is Slavery

By Robin Hanson · May 16, 2011 10:20 am · Comments (83)

Bryan Caplan:

Slavery is involuntary servitude; conscription is involuntary military servitude; therefore not only is conscription slavery; it’s a particularly heinous form of slavery that often ends in maiming and death. Yet most people disagree – and so did the U.S. Supreme Court back in 1918. … I think I finally figured out what most people are thinking. Namely: They implicitly regard slavery not as mere involuntary servitude, but as low-status involuntary servitude. … conscripts have high status – and therefore can’t be slaves.

Comments there give many reasons conscription is not slavery:

  • “The key difference is the idea of … `servitude for the public benefit’.”
  • “Cannot sell its conscripted soldiers … conscription offers pay.”
  • “Slavery as an institution appears to cause a lot more social harm than limited conscription powers.”
  • “People hate slavery because it is malicious and exploitative.”
  • “Conscripted soldiers are not owned by a private person. This is the same reason that we don’t consider taxes theft”
  • “Conscripts still have civil rights, slaves did not. Conscripts were paid, slaves were not. Conscripts could own property, especially real property,and wait for it, conscripts could VOTE.”
  • “If the ‘slaves’ could neither be bought nor sold, then they would just be serfs.”
  • “Slavery … is a permanent condition and [conscription] is not. One can apply to anyone, the other only to a specific cohort.”
  • “The connotation attached to conscription and slavery evokes different emotions … positive for conscription and negative for slavery.”

Consider that “comfort women,” forced to serve as prostitutes for the Japanese military during World War II, are often called “sex slaves.” Would they not be slaves they were paid, served only for a limited time, could own property and vote, could not be bought or sold, and were seen by the Japanese public as serving their benefit and evoking positive emotions? Would such conditions also imply comfort women were not “raped”?

It is hard to believe that one must argue this point. OF COURSE conscripts are slaves. Conscription may be a good form of slavery – I for one do not accept a moral axiom that slavery must always be bad. But surely it is slavery. And Bryan is probably right – we don’t call conscripts slaves, but do call comfort women slaves, because the first is high status and the second low.

Added 10a: On reflection, the main effect here is probably that many people take “slavery is bad” to be part of the definition of slavery. So therefore by definition anything good cannot be slavery. For what other words do we take value to be part of the definition? Democracy? Rape?

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Two Recent Talks

By Robin Hanson · May 15, 2011 12:00 pm · Comments (5)
  1. On April 27, I talked at Harvard Business School on information accounting: audio, slides.
  2. On May 5, I talked in Geneva on the economics of artificial intelligence: audio, slides.
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The Mysterious Desert

By Robin Hanson · May 14, 2011 10:30 pm · Comments (8)

How bright is our future? That depends greatly on how feasible is interstellar travel. And we don’t really know that, because we are still pretty ignorant about what lies between the stars. Oh it all looks pretty empty, but looks could be deceiving. If you look at a logarithmic map of the universe, the scales on which we seem the most ignorant (below 10Bly) are the three orders of magnitude between the furthest planets and the nearest stars. Now we see clues that unexpected and powerful things happen there:

Between May 2009 and May 2010, IceCube detected 32 billion cosmic-ray muons, with a median energy of about 20 TeV. These muons revealed, with extremely high statistical significance, a southern sky with some regions of excess cosmic rays (“hotspots”) and others with a deficit of cosmic rays (“cold” spots).

Over the past two years, a similar pattern has been seen over the northern skies by the Milagro observatory in Los Alamos, New Mexico, and the Tibet Air Shower array in Yangbajain. … It’s a mystery because the hotspots must be produced within about 0.03 light years of Earth. Further out, galactic magnetic fields should deflect the particles so much that the hotspots would be smeared out across the sky. But no such sources are known to exist.

One of the hotspots seen by IceCube points in the direction of the Vela supernova remnant … almost 1000 light years away. Cosmic rays coming from such large distances should be constantly buffeted and deflected by galactic magnetic fields on route, and should thus have lost all directionality by the time they reach Earth. …

There could be a “tube” of magnetic field lines extending between the source and our solar system, funnelling the cosmic rays towards us. … [This] theory is highly speculative. … Others have proposed that … solar magnetic field lines cross and rearrange, converting magnetic energy to kinetic energy – could be accelerating local cosmic rays … creating the observed hotspots. … “That’s also crazy, but it is at least less crazy than other explanations.” (more)

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The People’s Romance

By Robin Hanson · May 12, 2011 11:00 am · Comments (16)

Diplomacy is the art of letting someone else have your way. Daniele Vare

I recently heard several presentations on the ethics of using computers to do things previously done by humans. Across many diverse examples, the method stayed the same: imagine specific scenarios in which bad things might happen with a computer in charge, and then declare “more controls are needed.” There were no attempts to determine if harmful scenarios were common or rare, or how often similar harmful scenarios happen when people instead do things.

Regarding firms having incentives to institute controls for such risks, most said we can’t trust firms because they are loyal to shareholders not us. But these same folks seemed happy if any government had controls, not just their own government, even though other governments were not loyal to them. Apparently they considered most governments more trustworthy than most firms.

It happened that the main audience for these presentations was diplomats and spies, and I realized that diplomats seem to most folks the most respected profession of liars and deceivers. To the extent that we think of salesmen, politicians, executives, ad-men, pickup artists, etc. as deceivers, we tend to think of them as bad. But diplomats (and even spies) seem to be widely considered good respectable people, even when they represent foreign nations.

Both of these seem to me examples of what Dan Klein calls the People’s Romance – where governments and the things they do and the people who help them do them are generally considered more legitimate and respectable.

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Regulatory Bias

By Robin Hanson · May 11, 2011 2:50 pm · Comments (57)

Restaurants are held to a higher standards of food preparation than individuals. Few rules constrain your holiday meal for twenty, but if you served ten folks for lunch in a tiny diner, a huge rule book applies.

In Europe, firms are also held to a higher privacy standards than individuals. Firms must be careful to store your emails to them very carefully, to ensure a very low risk they might be stolen. But individuals can be very sloppy in how they store emails.

There are many such apparent regulatory “biases,” i.e., ways that regulations hold some things to higher standards than others, even when the relevant consequences seem similar. For example we seem to prefer:

  • Individuals over firms
  • Non-money over money exchange.
  • Natural over artificial chemicals
  • Old over new practices
  • Human over machine control
  • Locals over foreigners
  • Non- over for-profit organizations.
  • What else?

Now I’m sure clever folks can think up justifications for such preferences. But as with the common preference to redistribute money but not grades, I expect few folks could quickly come up with those reasons, even though most embrace such preferences. This again suggests that the clever reasons some can offer are not the main reasons most folks support such biases. And the obvious reasons that might drive most folks to support such biases do not suggest these are biases worth keeping.

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The Hypocrisy Curtain

By Robin Hanson · May 10, 2011 12:50 pm · Comments (27)

More evidence for the hypothesis that human brains are huge mainly to hypocritically evade rules: cultural barriers often consist in advantages locals get by knowing which rules they can safely break:

Tim Wu grew up in Canada with a white mother and a Taiwanese father, which allows him an interesting perspective on how whites and Asians perceive each other. … “There is this automatic assumption in any legal environment that Asians will have a particular talent for bitter labor,” …

By contrast, the white lawyers he encountered had a knack for portraying themselves as above all that. “White people have this instinct that is really important: to give off the impression that they’re only going to do the really important work. You’re a quarterback. It’s a kind of arrogance that Asians are trained not to have. Someone told me not long after I moved to New York that in order to succeed, you have to understand which rules you’re supposed to break. If you break the wrong rules, you’re finished. And so the easiest thing to do is follow all the rules. But then you consign yourself to a lower status. The real trick is understanding what rules are not meant for you.”

This idea of a kind of rule-governed rule-breaking—where the rule book was unwritten but passed along in an innate cultural sense—is perhaps the best explanation I have heard of how the Bamboo Ceiling functions in practice. (more; HT John Wilson)

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Strange Salt

By Robin Hanson · May 9, 2011 10:25 pm · Comments (48)

A new JAMA study finds a strong correlation: the third of folks who eat the least salt die over three times as often as the third of folks who eat the most salt. Yet other studies almost as big find contrary effects. I find it quite disturbing that such big studies can show such different results; something is very wrong in big diet correlation study land. Details:

Among 3681 participants followed up for a median 7.9 years, [heart attack] deaths decreased across increasing tertiles of 24-hour sodium excretion, from 50 deaths in the low, 24 in the medium, and 10 in the high excretion group (P < .001). … In multivariable-adjusted analyses, this inverse association retained significance (P=.02): the [hazard ratio] in the low tertile was 1.56 (95% CI, 1.02-2.36; P=.04). Baseline sodium excretion predicted neither total mortality (P = .10) [though 118, 64, 37 total deaths for low, medium, high tertiles sure looks significant to RH]. … All hazard ratios were adjusted for study population, sex, and baseline variables: age, body mass index, systolic blood pressure, 24-hour urinary potassium excretion, antihypertensive drug treatment, smoking and drinking alcohol, diabetes, total cholesterol, and educational attainment. …

Our current observations on cardiovascular mortality are consistent with several other reports. The National Health and Nutrition Examination Surveys (NHANES) I and II demonstrated an inverse association of cardiovascular and total mortality with salt intake as assessed from dietary recall with a similar trend in NHANES III. Alderman and colleagues followed up for 3.5 years 2937 patients with mild to moderate hypertension. There was an inverse association between the incidence of myocardial infarction and 24-hour urinary sodium excretion at baseline for the total population and for men, but not women. …

At variance with our current findings, other prospective studies suggested that a high-salt intake may lead to a worse outcome. … Cook and colleagues analyzed the long-term results of dietary sodium restriction on cardiovascular outcomes by combining 10 to 15 years of follow-up of 744 and 2382 participants randomized in the Trials of Hypertension Prevention, phases 1 and 2. Net sodium reductions during the intervention period (from 18 to 48 months) were 44 mmol and 33 mmol per day, respectively. … With adjustments applied for trial, clinical site, race, sex, and age, the [hazard ratios] for intervention vs control were 0.80 (95% CI, 0.51-1.26; P = .34) for total mortality. … In a 19-year follow-up study of 3126 Fins, the multivariable- adjusted [hazard ratios] associated with a 100- mmol increase in 24-hour urinary sodium were 1.26 (95% CI, 1.06-1.50) for total mortality, 1.45 (95% CI, 1.14- 1.84) for CVD, and 1.51 (95% CI, 1.14- 2.00) for coronary heart disease. (more)

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Some Good News

By Robin Hanson · May 9, 2011 3:25 pm · Comments (21)

It has been a long time since I read something that made me this hopeful about the future:

Fully 42 percent of seniors say greed and speculation are behind higher gas prices, compared with just 13 percent of adults aged 18 to 29. Young adults are twice as likely as seniors to say economic factors and overseas developments are the primary causes. (more)

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Medical Wealth Effects

By Robin Hanson · May 8, 2011 10:45 am · Comments (28)

Imagine being a cash-poor college student who likes expensive sports cars. While you intend to buy one someday, for now you focus on paying for tuition, books, etc. Then your rich uncle dies and, knowing your car passion, leaves you a sports car in his will. While you might sell it to pay off $30,000 in students loans, you might also keep it – you are now richer, and can perhaps afford this luxury.

Does this mean that it is usually economically efficient for college students to buy expensive sports cars? No – the fact that students would not ordinarily take out a loan to buy a sports car strongly suggests such cars are not worth the price. The fact that they might buy one later when they are richer does not change that conclusion.

Oddly, some people think differently about medicine. When people have more medical insurance, they consume more medicine. And many attribute this to the fact that insured folks don’t pay the full price of their medicine. But John Nyman argues that if medical insurance were to pay out in cash like auto insurance does now, so that patients had the option to take cash instead of treatment, up to 70% of the extra medicine that insured folks consume, beyond what uninsured folks consume, would still be chosen by patients. Nyman thinks this implies that such treatment is economically efficient, and Austin Frakt and Mark Thoma agree.

Arnold Kling is skeptical:

If Nyman were to debate Robin Hanson on the empirical realism of this, my money would be on Hanson.

My argument, however, is mostly theoretical. If uninsured patients and their families would not be willing to take out loans, or sell valued possessions, to pay for some expensive treatment, that strongly suggests they don’t see such treatment as worth its price. Yes, before a problem arises people might want to arrange to make themselves financially richer in the states of the world where problems arise. And yes, market failures might prevent people from borrowing or selling quickly and efficiently. But these don’t seem to be the main effects here.

It bugs me that even economists mostly consider alternate more efficient institutions as ways to argue for their favored versions of our inefficient institutions. I say let’s try to actually give patients the choice to take cash instead of treatment. Even Nyman should agree that would reduce waste.  And if you think market failures in borrowing really prevent folks from buying good medicine, why not push for government loans to help the uninsured pay for medicine, instead of forcing everyone to be insured? If you worry that hospitals price discriminate against folks who show up without insurance at the last minute, why not help them pre-negotiate for lower prices?  Could it be that some folks don’t actually want more economically efficient medicine?

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