Tag Archives: Medicine

Hide Death?

By Robin Hanson · January 31, 2010 6:30 pm · Comments (23)

Kübler-Ross took a job as an assistant professor of psychiatry at the University of Chicago. … She began a series of seminars, interviewing patients about what it felt like to die. … Many of Kübler-Ross’s peers at the hospital felt that the seminars were exploitative and cruel, ghoulishly forcing patients to contemplate their own deaths. At the time, doctors believed that people didn’t want or need to know how ill they were. They couched the truth in euphemisms, or told the bad news only to the family. Kübler-Ross saw this indirection as a form of cowardice that ran counter to the basic humanity a doctor owed his patients. ….

Kübler-Ross began to work on a book … It came out in 1969, and, shortly afterward, Life published an article about one of her seminars. … Angered by the article and its focus on death, the hospital administrators did not renew her contract. But it didn’t matter. Her book, “On Death and Dying,” became a best-seller. …

Her argument was that patients often knew that they were dying, and preferred to have others acknowledge their situation: “The patient is in the process of losing everything and everybody he loves. If he is allowed to express his sorrow he will find a final acceptance much easier.” And she posited that the dying underwent five stages: denial, anger, bargaining, depression, and acceptance. … Today, Kübler-Ross’s theory is taken as the definitive account of how we grieve.

More here.  Pause to see things from those old docs’ point of view.  While we usually prefer to be honest and forthcoming, we make exceptions.  Some of our reasons are selfish, but we also say that telling people some truths only makes them feel bad, without actually helping much to make decisions.

So isn’t imminent death a great examples of a truth that makes folks feel very bad without much helping decisions?  Look how fiercely people avoid thinking about death when it is only a slight possibility, and how more anxious they get as death becomes a larger possibility.

Sure, most folks say they want to be told the truth about imminent death.  But most folks also say they want to know if their partner is cheating, if their career is tanking, if their neighbors hate them, etc.  If you asked folks straight out, most would even say they want the truth on “do I look fat in this.” So if you are going to hide some type of truth from people for their own good, you must do so in the face of the fact that most folks say they want to be told.

Yes, we may like the closure of taking their time in saying goodbye to folks, but don’t similar modestly useful actions correspond to most truths we think of hiding from folks?  Does this gain so obviously outweigh the terror of knowing you will die soon?  I want to be told about my death, but I’m weird and want the truth on most everything.  What is a better example than imminent death of a truth we’d consider hiding from folks?

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Prefer Fem Babes?

By Robin Hanson · January 27, 2010 1:00 pm · Comments (32)

People often talk as if they are extremely concerned about health, and would give up a great deal of everything else to get just a bit more health.  “When you’ve got your health, you’ve got just about everything.” This sort of justification is often offered for spending vast sums on apparently ineffective end-of-life medicine.

So I think it important to ponder our strong disinterest in big ways we could improve health.  For example, women very consistently live longer than men.  In the US, Australia, Japan, Spain, etc. they live 4-7 years longer; studies that control for many other factors typically find males dying about twice as often.

Yet we see almost no interest in preferring female children on the basis that they will live longer.  We see parents prefer to gender balance their kids, and in some cultures parents prefer males.  Do parents not care how long their kids live, do they think male lives are worth more per year, to compensate for fewer years, or what?

See also Bryan on gender imbalances less harmful than supposed.

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School Is Not Healthy

By Robin Hanson · January 25, 2010 4:10 pm · Comments (9)

Better educated folks are healthier, but they would be just as healthy with less school:

There is a strong, positive and well-documented correlation between education and health outcomes. There is much less evidence on the extent to which this correlation reflects the causal effect of education on health – the parameter of interest for policy. … Our approach exploits two changes to British compulsory schooling laws that generated sharp differences in educational attainment among individuals born just months apart. … We confirm that the cohorts just affected by these changes completed significantly more education than slightly older cohorts subject to the old laws. However, we find little evidence that this additional education improved health outcomes or changed health behaviors.

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Food Not Med

By Robin Hanson · January 22, 2010 5:20 pm · Comments (15)

Listening to the radio this morning to reporters visiting the epicenter of the Haitian quake, I heard locals complaining that no one had come to help them.  Locals said they need food, water, and shelter; when rains come they will get cold.  The reporters, however, seemed obsessed with noting that locals need medicine.  They also focused on local efforts to dig out and bury their dead.

Given their desperate need for food, water, and shelter, it seems unlikely to me that medicine is such a priority.  Furthermore, experts say, dead bodies are just not a problem:

Corpses do not represent a public health threat. When death is due to the initial impact of the event and not because of disease, dead bodies have not been associated with outbreaks.

I’m not sure to what extent we are seeing a bias in Haitians, in the reporters, or in their US audience.  But surely epicenter Haitians have more important worries than medicine and dead bodies.

Added:  The contrast between the oh so visible US concern and US planes flying around Haiti with loudspeakers warning locals not to try to boat it to the US is quite striking.  Clearly at some level US folks realize they could help Haitians most by letting them immigrate.  If we (thought we) cared less and were instead eager to gain migrant farm workers and household servants, we might end up helping Haitians more.

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Two Anecdotes

By Robin Hanson · January 17, 2010 2:00 pm · Comments (17)
In December 2008, two seemingly unrelated events occurred. The first was the release of Stephen Greenspan’s book, Annals of Gullibility: Why We Get Duped and How to Avoid It. Greenspan, a professor of psychology, … discussed gullibility in fields including finance, academia, and the law. … The second was the exposure of the greatest Ponzi scheme in history, run by Bernard Madoff, which cost its unsuspecting investors in excess of $60 billion. … The irony is that Greenspan, who is bright and well regarded, lost 30 percent of his retirement savings in Madoff’s Ponzi scheme.
…
At conference dealing with spine surgery, a surgeon presented the case of a female patient with a herniated disc in her neck and pain that was caused by a pinched nerve. She had already failed typical conservative treatments such as physical therapy, medication, and waiting it out.
The surgeon asked the [doc] audience to vote on a couple of choices for surgery. The first was the newer anterior approach, where the surgeon removes the entire disc, replaces it with a bone plug, aim fuses the discs. The vast majority of the hands shot up. The second choice was the older posterior approach, where the surgeon removes only the portion of the disc that is compressing the nerve. No fusion is required because the procedure leaves most of the disc intact. Only a few audience members raised their hands.
The speaker then asked the audience, which was almost entirely male, “What if this patient is your wife?” The show of hands was reversed for the same two choices. The main reason is that the amount surgeons are paid for the newer and more complicated procedure is typically several times what they’d receive for the older procedure.

On the impotence of book learning:

In December 2008, two seemingly unrelated events occurred. The first was the release of Stephen Greenspan’s book, Annals of Gullibility: Why We Get Duped and How to Avoid It. Greenspan, a professor of psychology, … discussed gullibility in fields including finance, academia, and the law. … The second was the exposure of the greatest Ponzi scheme in history, run by Bernard Madoff, which cost its unsuspecting investors in excess of $60 billion. … The irony is that Greenspan, who is bright and well regarded, lost 30 percent of his retirement savings in Madoff’s Ponzi scheme.

On distorted doc incentives:

At conference dealing with spine surgery, a surgeon presented the case of a female patient with a herniated disc in her neck and pain that was caused by a pinched nerve. She had already failed typical conservative treatments such as physical therapy, medication, and waiting it out.

The surgeon asked the [doc] audience to vote on a couple of choices for surgery. The first was the newer anterior approach, where the surgeon removes the entire disc, replaces it with a bone plug, aim fuses the discs. The vast majority of the hands shot up. The second choice was the older posterior approach, where the surgeon removes only the portion of the disc that is compressing the nerve. …

The speaker then asked the audience, which was almost entirely male, “What if this patient is your wife?” The show of hands was reversed for the same two choices. The main reason is that the amount surgeons are paid for the newer and more complicated procedure is typically several times what they’d receive for the older procedure.

More here.  I’m actually surprised by this doc story; I’ve heard that docs over-consume med like everyone else.
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Keeping Us “Safe”

By Robin Hanson · January 7, 2010 1:30 pm · Comments (19)

Since 2001, airline passengers — regular people without weapons or training — have helped thwart terrorist attacks aboard at least five different commercial airplanes. It happened again on Christmas Day. …

And yet our collective response to this legacy of ass-kicking is puzzling. Each time, we build a slapdash pedestal for the heroes. Then we go back to blaming the government for failing to keep us safe, and the government goes back to treating us like children. … Since regular people will always be first on the scene of terrorist attacks, we should perhaps prioritize the public’s antiterrorism capability. …

President Obama: “The American people should be assured that we are doing everything in our power to keep you and your family safe.” …  Obama … did not call for Congress to cut spending on homeland-security pork and instead double the budget of Citizen Corps — the volunteer emergency-preparedness service. …  He did not demand that the government be more open with us about the threats we face.

More here.  This is indeed puzzling, but it seems related to our medical over-insurance.  We know we could save on average by paying less less up front, and then making more last minute decisions on which med treatment is worth the cost.  And perhaps we even know we wouldn’t be any less healthy in this scenario.  But we don’t want to make such stressful decisions; we like putting it out of our mind and paying high status docs huge sums to affiliate with us and deal with it.

Similarly maybe we prefer to pay our high status leaders to inefficiently deal with terrorism for us, rather than facing the stress of thinking we each may have to deal with a terrorist ourselves, even if that would work better, and even if that’s what really happens anyway.  See also our neglecting to support ordinary folks’ discouraging of auto accidents.

Fear of (thinking about) death is a very powerful thing.

Added 3p: Justin Fox:

If all the various elements of the intelligence community had simply Tweeted their findings, the hive mind of the Internet (or, more specifically, some 14-year-old in his bedroom in Bakersfield) would have blown the whistle on Abdulmutallab weeks ago. … And what’s the best mechanism known for sharing and weighing dispersed information? A market. … [Yet] in all the public discussion of what went wrong in the Abdulmutallab case, I have seen not a single mention of the Policy Analysis Market, as the Pentagon called its project, or the terrorism futures market, as everybody else called it. Hanson hasn’t even brought it up lately on his blog. So I figured it was time to rectify that.

Big government agencies hate to change how they do things, especially changes that threaten their autonomy.  So they won’t change unless the public cares much more about outcomes than the appearance of “doing something.”  At the moment, the public hardly cares about either.

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Docs vs MBAs

By Robin Hanson · December 29, 2009 12:00 pm · Comments (22)

In a Florida operating room … there’s an anesthesiologist alternating with a nurse anesthetist, an X-ray technician and a circulating nurse; … there’s the surgeon, a middle-aged orthopedist who has never performed this type of operation before.  And, at the foot of the operating table, there’s Chuck Bates, a guy who studied biology in college. … Come up one centimeter and make your incision there, Bates tells the surgeon. …

The job wholesaling hot dogs enabled Bates to get an MBA … which led to employment with Kyphon, a manufacturer of medical devices.  … Bates was the salesman in the operating room. … Sales representatives … in operating rooms … serve as simple reminders that medicine is a business, with all the potential that entails to promote efficiency, boost sales and extract profit.  But should they be there at all?  In an age of rapidly proliferating technologies, the salesmen may know more about their products than the doctors who use them do. … They speed procedures along, making time for more. …

Many medical devices could not be used — or used safely — without sales reps. … Richmond gynecologist Catherine A. Matthews said that’s a frightening argument.  “They’re not in any way motivated to recommend what might be the best thing for the patient,” Matthews said. “They’re there to sell their product.”  Doctors shouldn’t have to depend on reps for expertise, she added. … The presence of the salesman in the operating room has long raised concerns that it can put the interests of manufacturers before those of patients.

More here.  Can’t you feel the shame?  You pick a prestigious doctor to solve your problem, and instead he’s taking orders from some lowly MBA!  Horrors.  Such low status folks might, gasp, recommend things to make money, not like surgeons, who are far too high status and “professional” to care about such lowly things as money.  Riiiight.

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Animal Smoking Studies

By Robin Hanson · December 27, 2009 4:30 pm · Comments (25)

Some seem to think experiments show smoking causes cancer in animals.  Not so, for mice or rats:

I review the results of a representative selection of chronic inhalation studies with rats and mice exposed to mainstream cigarette smoke. … Smoke-induced epithelial hypertrophy, hyperplasia, and squamous metaplasia were reported in the conducting airways in most of the studies, along with increased numbers of intra-alveolar macrophages that were occasionally associated with alveolar metaplasia. Lung adenomas and adenocarcinomas were reported in only a few of the studies. No statistically significant increase in the incidence of malignant lung tumors was seen. …

The 14 studies reviewed … [showed] significant increases in the numbers of malignant tumors were not produced in the respiratory tracts of rats or mice exposed chronically by inhalation to cigarette smoke.  The studies clearly involved the inhalation of very large amounts of smoke (usually from unfiltered, high-tar cigarettes) …  The results of this work clearly indicate that maximal amounts of smoke were inhaled into the lungs of the animals (blood COHb concentrations very close to those associated with lethality) daily for up to 2 yr with no carcinogenic effect noted.

Nor for hamsters, dogs, or primates:

This paper makes an identical evaluation as before, but, restricting the species being evaluated to representative studies of smoke-exposed hamsters, dogs (both by tracheostomy and by direct inhalation), and nonhuman primates. As was seen previously, no statistically significant increase in the incidence of malignant tumors of the respiratory tract was found in any of the 3 species, even though very long exposures and high doses of smoke were used.

Now the number of animals in these studies is a few thousand at most, and their duration is less than decades, but experimenters did have complete control over making animals smoke heavily.  Yes this review author works for a tobacco firm, but his papers seem professional.

Searching for “animal smoking experiments,” I found many sources admitting we haven’t found much evidence smoking hurts animals, and none saying the opposite.  Here is a ‘97 Scientific American article “Animal Research is Wasteful and Misleading”: Continue Reading "Animal Smoking Studies" »

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Smoking Trials Again

By Robin Hanson · December 25, 2009 11:45 pm · Comments (37)

Recently I talked about checking on smoking skeptics.  I described three studies:

  1. A randomized trial of 1400 high risk smokers.  After 10 years one half had half the smoking rate of the other, and after 20 years it had an insignificant 7% lower mortality (13% less heart disease, 11% less lung cancer).
  2. MRFIT randomized multifactor trial of 8000 smokers.  After 6 years one half quit 49% (vs. 29%), and after 16 years had an insignificant 6% lower mortality (11% less heart disease, and -15% less lung cancer).
  3. A randomized multifactor trial of 1200 high risk men.  After five years one half reduced smoking by 3/8 (vs 2/9), but had twice the mortality (10 vs. 5 count).

I’ve now had time to look over seven more studies:

  1. A randomized trial of 6000 smokers with “asymptomatic airway obstruction”, i.e., weak lungs. (HT Karl.)  After 5 years in two-thirds, 22% (vs 5%) stopped smoking, and after 14.5 years they died a (3% level significant) 15% less (20% less of heart disease, 15% less of lung cancer, and 50% less of “respiratory disease other than cancer.”) (More details here, which I don’t have.)
  2. WHO collaborative multifactor randomized trial of 61,000 men.  After six years one half had 2% fewer smokers, 7% among highest risk men, giving an insignificant 5% lower mortality (7% in heart disease).
  3. Gotenborg multifactor randomized trial of 30,000 men.  After ten years one third had 9% fewer smokers (32.5 vs. 35.4%) than the other two thirds, and an insignificant 2% lower mortality (0% heart disease, 15% cancer).
  4. Norwegian multifactor randomized trial of 1200 men.  After five years one side had 1/8 less smoking, and after 28 years it had 46% more mortality (95 vs 65 count).
  5. Oslo mulitfactor randomized trial of 1200 men.  After 8.5 years one side had 45%(?) less smoking, and 40% less mortality (19 vs. 31 count).  (This just from abstract; anyone have the paper?)
  6. A non-randomized study of 1600 men over 26 years. Initial lung quality was unrelated to mortality for non-smokers, but high smokers with initially bad lungs died 62% more than initially good lungs.
  7. A non-randomized AER ‘06 study of WWII vetrans.  Its key “identifying assumption is that cohort and age effects in the smoking equation are the same for men and women” and that the entire increased mortality of WWII veterans is due to their smoking more. (HT Alex T.)  It finds “a nonveteran average annual mortality rate of 13.1 per 1,000 men and a veteran … rate of 16.6″ (1.2 vs. 2.2 for lung cancer), suggesting “36 to 79 percent of the excess veteran deaths due to heart disease and lung cancer are attributable to military-induced smoking”.  Since heart disease and lunch cancer were 38% of deaths, this suggests ~4-12% higher smoking mortality.

OK, so how best to summarize this evidence?  Based on study #4, I tentatively estimate smoking raises mortality for folks with bad lungs, about 10 to 25% of folks, by 50-100%.  (This affect appears to not work mainly via lung cancer.)  This is supported by study #9 and could explain a 5-25% overall smoking mortality increase.

In the rest of the studies, if we assume the entire effect seen was from smoking, we can collect smoking mortality affect estimates.  Setting aside #8, as I haven’t read the paper, #1 had the biggest change in smoking rates, and suggests a ~20% mortality.  The next biggest change was #2, and suggests ~30% mortality.  Study #6 had the next less change, and suggests ~22% mortality.  The rest were all across the map, as expected from their small count and change.

So, we seem to see a 50-100% smoking mortality increase on bad lungs, which predicts a 5-25% overall smoking mortality increase.  If we attribute to smoking the full benefit seen in our three most relevant multifactor randomized trials, we get crude smoking harm estimates of 20,22,30%.  And if, from study #10, we attribute the entire higher mortality of WWII veterans to their smoking more we get ~4-12% mortality effect.

Bottom line:  a randomized trial suggests a large smoking harm on bad lungs, which can explain the entire apparently average smoking harm seen elsewhere.  My best guess: smokers die ~10-30% more on average, living about 2-6 months less, but there’s much less net harm to strong lung folks.

Added 10a: Wikipedia says

Male and female smokers lose an average of 13.2 and 14.5 years of life, respectively. .. The risk of dying from lung cancer before age 85 is 22.1% for a male smoker and 11.9% for a female current smoker, in the absence of competing causes of death. The corresponding estimates for lifelong nonsmokers are a 1.1% probability [20 times less] of dying from lung cancer before age 85 for a man of European descent, and a 0.8% probability [15 times less] for a woman.

Other sources mention risk factors of 15, 23 or 100. Such figures are common and, it seems, rather misleading. The above studies clearly suggest that the causal effect of smoking on mortality, even for lung cancer, is much less than the factors of 15+ often thrown around.

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Random Smoking Trials

By Robin Hanson · December 14, 2009 2:10 pm · Comments (66)

Hal Finney recently commented:

[Johnstone & Finch's] Scientific Scandal of Antismoking … makes the case that smoking is not bad for your health. … [It has] the superficial appearance of referencing scientific studies and claiming the the mainstream misrepresents the results.

Yes, they are superficially credible.  Their New Scientist letter:

WHO … claims … “an epidemic of chronic illnesses … could be prevented through simple changes in diet, by being more active and by not smoking.” … There have been a number of such studies, with various combinations of these three lifestyle factors, including the WHO collaborative trial (60,881 subjects, 6 years), the Goteborg trial (30,022 subjects, 11.8 years) and the Multiple Risk Factor Intervention trial (12,866 subjects, 7 years).  These and another eight trials were conducted over three decades, one of the most expensive and sustained series of biological experiments in the history of medical science. … None showed any improvement in life expectancy and two showed a significant reduction in life expectancy in the test group.

So I dug further; bottom line:  Johnstone & Finch are right.  We usually see strong correlations between death and smoking, and we see those same correlations within each random arm (i.e., group) of a randomized trial.  Nevertheless, we see no significant net death differences between control arms and arms induced to smoke less.

So we don’t have clear evidence that smoking kills on net; it could be that most or all of the death-smoking correlation is due to selection effects, and not smoking causing death.  Experts say there is a substantial causal component, and for now I’m accepting that claim, but this lack of clear evidence is suspicious, and disturbing.  Now for some details. Continue Reading "Random Smoking Trials" »

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