Scott’s earlier work was awesome. He changed the way I saw the world. For five years, probably more, the quality had deteriorated. This is a new low. Such a shame. Anyway. This is a good piece and a good response.
This is also my impression, but I don't think Scott has gotten worse. I think we've just assimilated his most important insights, and, ironically, the marginal value of his more recent insights of the last five years aren't as high for us as the first ones we encountered.
I don't think this is just ordering effects either; I would bet that someone demographically similar to us who encountered Scott's work for the first time in ACX would not find it as impressive as his earlier stuff from SSC.
Sorry, I guess my second paragraph means Scott's work has gotten worse. But I think it's not because he doesn't put in as much care, I think it's just: he doesn't have as many world-changing insights anymore. That said, I think he hasn't gotten worse, in the sense that the earlier insights still structure what he writes today.
The majority of the confusion here is that Hanson characterized marginal health spending as "near zero" as in not statistically discernable. Scott noted that the RCTs don't have that much statistical power and that therefore it is a stretch to take it as proven that additional marginal medical spending has next to no effect. Rhetorically characterizing this as "saying medicine doesn't work" isn't a stretch and in fact Scott does specifically note that Hanson is arguing marginal effects
It is a reasonable prior to think that the marginal effect should be positive, though not necessarily valuable, since the given studies can't tell us. Missing out that the Obamacare study reported only the cohort with a significant effect is a real error but not fundamentally different from not noticing that the RCTs don't have statistical power
It's an interesting discussion and I look forward to it continuing!
That is my impression as well, which is really disappointing. This last essay really had me scratching my head and wondering what he was talking about.
Scott now ranges from peddling experimental out-of-FDA's scope drugs from companies his wife and friends are involved with (brushing away the conflict of interest as irrelevant), to contrived apologetics for the EA cult
Surprising and a bit disappointing from Scott who I usually expect to go very deep into a topic. This seems like he only skimmed for the prep. Or he probably could have just asked.
Not really sure what his motivation is unless he’s just trying to release as many words as possible and this one seemed easy.
Oh nice, a rare moment where I can almost fully agree with Robin. Medicine is in fact, a cesspool whose most likely outcomes are commonly the following two: 1) Nothing much happens. and 2) Things get worse(ultimately). That's medicine, in a nutshell. Some fields of medicine are worse than others(Psychiatry being the worst offender by far-- uh oh... a conflict of interest is already coming into view...).
What I can criticize is how Scott and Robin engaged in debating the subject. Both people, basically get lost in the details. Which is a main critique I have towards people in the "Rationalist" community-- I believe they are pathologically pragmatic, care about specifics and details and precision (which is fine to care about, but not if it's almost all you care about or how you fundamentally and philosophically structure your representation of reality).
They get lost in the details of certain studies, they get lost on certain points, all of this is utterly narrow and myopic as usual. How would I approach this? I'd start with just stating the facts of why medicine is actually a shit show: 1) Bad incentives. The whole thing, is structured as a business, for the most part, where the goal is ultimately, making money, not making people better. When everyone's healthy, you can't make money. Uh Oh! (See how this big picture stuff really has a beautiful simplicity to it?)
2) Bad people(Humans are bad in general(with loads of narratives and beliefs about them being good, or how the question itself is wrong), which is why they get confused about almost everything they do(the bugs are features, for humans). When they can use medicine to wage war or dominate each other, or dominate the bottom rungs of their hierarchy so they can more easily wage war with other hierarchies, they will do so. Like how psychiatry has historically been used and almost certainly remains today as tool of profit and social engineering in a more sophisticated form rather than anything genuinely therapeutic(There's that conflict of interest again. Hey is the CIA still doing booths at the APA's big events?)
3) Remember that detail orientation problem rationalists have? Where they miss the forest for the trees? Well that entire approach, which I like to call "autistic" with a big emphasis that I am not using this description in a pejorative sense, have nothing but well wishes for autistic people, and just find to be useful to describe a style of thinking that obsessives over precision, quantity, can be robotic, cold, and so glued to a ground-level, to superficiality, that it misses the point in a tragic way. Virtually anyone involved in a "rationalist" space will show symptoms of this flawed way of thinking, myself included.
The problem is-- this exact pathology a major foundation of the approach to Western pharmacology and most treatment approaches. This is slowly changing because we can't help but understand things slightly less superficially and narrowly with time, but we're still very dense. Let's get into the details for once. Take a skin condition. Let's say a bacteria or fungi causes it. What does Western medicine have to say? Oh, easy-- a topical antibacterial or a topical antifungal can do the trick. Of course, no one fucking asked, "Hey, why does this condition come up in the first place beyond mere appearances?" That's just not seen as very "medical". Instead, it's this autistic Cause->Effect superficial bullshit. What happens? Symptoms may reduce, but return again(Big picture problem never addressed). What also happens? The company that makes the anti-bacterial/anti-fungal makes more money. We need more ointment! What also happens? Selection pressure towards the pathogen, making it stronger. Are you... seeing the problem yet?
This is not going to perfectly represent all medical failure, but this little analogy represents an overwhelming amount of it if you understood the fundamental problem and don't get lost in the details(Zoom out for once in your life), and that is only the slightest introduction as to why medicine currently, is a cesspool.
I have previously describe the basic facts of why "medicine is actually a shit show". But here I was responding to particular critiques by a particular person.
I ought to stop joking around about Little Wayne of Uproar and Mark Cuban of Cost Plus Drugs Tweets https://twitter.com/mcuban/status/1526281168928350210... Bambooz could upend the KiNobody Clothing firm... one day maybe even Under Armour, Gymnasium Shark, Adidas, and Nike if we get ahead of ourselves.
Okay good, I'm honestly not familiar with your particular position here, I don't even remember the points you said you made in the book. But if someone approached me on any position I have, I would always just state the fundamental facts when my opponent is picking at minutia. You never win the minutia game, it has no end(And that is why almost the entire field of Philosophy is a shit show , while we're on the subject )
This is such a bad take. It does nothing to answer the question of whether medicine is a shitshow or not because all these arguments are incredibly weak. Fundamentally, while simplicity can be illuminating, that’s not true when your simplicity is a function of narrative and vibe, not data. I write this to dissuade people reading from taking this comment seriously.
Re 1: it’s nice you can explain all human behavior with your pet theory about incentives. And I can explain the world by saying “God made it so” (see how this big picture stuff really has a beautiful simplicity to it?)
Re 2: isolated demand for rigor. It’s true psychiatry is unable to address the systemic issues that give rise to depression, and instead focuses on treating it. I think that criticism can be levied at any industry that doesn’t grapple with every aspect of a complex problem in the ways you prefer. If you are really saying there is some sinister organized plot to medicate people into apathy, that’s simply conspiracy thinking (everything becomes so simple when you blame conspiracy, who would have thought!)
Re 3: if it took you two seconds into contemplating medicine to wonder why nobody is thinking of root causes, I guarantee you it took about two seconds into medical school for every doctor to ask the same question, they’re really not that dumb. Instead of applauding your superior intelligence, consider that perhaps people have looked into this far more than you have, and the reasons why root causes aren’t always addressed are actually complex and persist despite a lot of smart people working on this issue.
Im sorry the world isn’t as simple as you’d like it to be with your best narrative. I’m sure Robin Hanson’s actual work is millions of times more robust than your comment.
General practise, psychology, sleep neurology, and psychiatry can all be quite beneficial for patients. Recently on my web log, I have been harsh against psychiatrists. People can consult on various lifestyle decisions, habits, multimicronutrients, etc. I learned many useful things from one particular practitioner and also felt somewhat cared about by a friendly psychologist at Caltech when I was an undergraduate.
Nothing much happens is the part people don't seem to understand.
As far as I can tell, *most* (but not quite all) of death is explained by the fact that young people have a 10^-5 chance of dying in any year which grows to a 50% chance as they age. Essentially, this more or less explains the deaths of everyone 65+. Sure cause of death might get listed as cancer, but if you cured cancer they'd just die of something else. Maybe they would have lived a little longer on average, but not much.
I don't really see *how* medicine could extend life expectancy except by curing terminal illnesses amongst young people.
> As far as I can tell, *most* (but not quite all) of death is explained by the fact that young people have a 10^-5 chance of dying in any year which grows to a 50% chance as they age. Essentially, this more or less explains the deaths of everyone 65+.
What? No it doesn't, and there's no world where this type of probability actually can be representative of the species or say anything meaningful. Young people *where*? In Norway? In Bangladesh? New York City?(The person on food stamps, or the trust fund kid with his own condo at 21?)
Not only does it not explain the death, it doesn't even give a probability that is useful. It's just bad, and that's because again, to get anything meaningful or true, you need depth. You need nuance. You won't get that with a statistic like that, you'll just get superficial bullshit, and from superficial bullshit only confusion follows.
Let me ask you a question: if there were no diseases other than aging, how long do you think humans would live (just aim for the right ballpark, obviously details would depend on a lot of stupid BS)?
Yes, this was an uncharacteristically weak post from Scott. I wish he had engaged with your actual arguments and applied his usual level of rigour to the evidence, rather than fighting a straw man.
I find myself sympathetic to Robin's view on the entirely flimsy basis that most medical treatment I have received have been useless. There are exceptions such as antibiotic treatment for an e. coli infection of my kidneys (very nasty and almost fatal!), some dental work (I suspect much is a waste of money), and probably flu and other vaccines to an extent (not so much Covid). I have had two spine problems for which experts provided zero help, just scans, sonograms, and worthless pain killers. I have doctor-caused damage to my left sciatic nerve which is never going to get any better (barring major new developments). I have for decades had chronic and too often really awful phlegm problems which remain unchanged despite trying probably a dozen sprays and pills and other treatments. I also continue to age without a single effective intervention.
> I find myself sympathetic to Robin's view on the entirely flimsy basis that most medical treatment I have received have been useless.
I never mentioned that in my post but yes, same here. It really helps to have been in the medical system and experienced its failure to attempt to diagnose and treat an assortment of health problems, and then it will be clear to almost anyone. Whoever lacks this experience is just going to be confused. And it's not that some people are just unlucky and end up biased-- it really just becomes transparent that this is typical of the system, and the reasons for why it's typical(money, incompetence, bad incentives, utility for social engineering/warfare, the existence of placebo, etc) are not some deep mystery. One basically has to either a) lack experience, b) be totally naive, or c) be an idiot, or some combination, to miss the fact that Western medicine is at best laughably broken and at worst deeply sinister.
Obstetrics is a good example of this. The USA is suffering from too much medical care. Countries that use midwives get better outcomes. We get too many unnecessary c-sections because that makes the doctor more money. It’s been a few years since I’ve looked at the research but of my memory is correct, the often cited stat that black women have worse outcomes is a result (in part) of increased rates of Medicaid. Doctors are more likely to over-treat Medicaid patients because they pay per service while a private insurance company will decline to pay for unnecessary procedures. Episiotomies are an excellent example, they are harmful and no study has ever found a positive effect. They should never be done. But Medicaid pays for it and private insurance won’t.
My first child was taken to the NICU for 4 days even though there was nothing wrong with her. The doctor kept giving us bs reasons that she had to stay, and even when she gained weight and did all the things he wanted, he insisted she stay. When the doctor changed out we were sent straight home. My private insurance found it unnecessary and refused to pay for the NICU stay at all.
I am glad you wrote up this response. I was really struggling to understand Scott's position since every time I had spoken with you or heard you speak on the matter your position had pretty consistently been "Some medicine is good, but most is a combination of useless, harmful, or generally the cost is greater than the benefit." I can see how the casino example is confusing if one doesn't know quite what your arguments have been over all, but having an inkling of those it seemed like a strange case to latch on to. Unless one assumes you had a significant stroke or something that wildly changed your position in a strange way.
I think this is an explained variance problem. Variance in medical care use explains negligible variance in health outcomes between individuals, but that doesn't mean that it doesn't have an effect in the aggregate.
Apparently he's fighting a straw argument because you once made a certain claim and he's afraid lots of people are going to stand by that decontextualized claim.
The claim "medicine doesn't work" is obviously false, but is likely a straw man argument.
There are several reasons to believe that a large part of approved therapies today, either don't work at all or don't work as they claim they do.
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author Scott Alexander Apr 24 Author
The problem is, Robin makes a specific claim I think is false, and if I don't refute it, then other people start thinking it's true and repeating the claim. It's not a straw man argument if it's the literal position a lot of people are making! I can refute that argument without necessarily refuting some other argument that other people on vaguely the same side should have made.
"Imagine someone claimed that casinos produce, not just entertainment, but also money. I would reply that while some people have indeed walked away from casinos with more money than they arrived with, it is very rare for anyone to be able to reasonably expect this result. There may well be a few such people, but there are severe barriers to creating regular social practices wherein large groups of people can reasonably expect to make money from casinos. We have data suggesting such barriers exist, and we have reasonable theories of what could cause such barriers. Regarding medicine (the stuff doctors do), my claims are similar."
In this quote, you explicitly say your claim is similar to saying doctors may help some people, but they on the whole take away health (because a casino takes away money on the whole).
You can certainly say this quote was ill-conceived and that the quotes you provide in your rebuttal reflect your actual beliefs, but you must acknowledge that you have at least made this claim in this quote.
I'm pretty against analogies in argumentation, and you're nicely demonstrating why: you can make an analogy to imply something, and then when called on it retreat to saying not to take every feature of the analogy literally. This is a very effective rhetorical technique for communicating baileys while feeling justified in defending yourself by saying you were only communicating the motte, but it's also intellectually dishonest.
He is the king of the motte and bailey. Makes utterly absurd implications about medicine being useless, and then when someone criticizes these statements, retreat to the claim that more medicine just isn’t extremely effective. Then, in the comments, return to saying that medicine is terrible.
If "other people" are standing by "decontextualised claims", then he ought to be able to quote those other people directly and respond to them, rather than responding to Robin, no?
If these other people are purely hypothetical, then the value in attacking their imagined arguments seems a bit unclear.
Thanks for the detailed response. I broadly agree with the stochastic concept of aging/dying. I have also often wondered how much of the (substantial) effect of say exercise on longevity is in fact genetic. That said, implicit in that very model is there is a certain rate of decay of our bodies. Based on almost every system we have ever seen we should be able to accelerate or slow down that rate, which is exactly what for example smoking and drinking, on one hand, and exercise and sauna with ice baths on the other, appear to do.
Accordingly, I do not follow quite how you go from that hypothesis to what appears to be a conclusion that there is nothing else to be done but wait and die. Some specific comments:
1. You appear not to value healthspan as opposed to lifespan. I think both are important.
2. I assume that you agree that exercise affects the shape of the curve? I agree that observational results from exercise are likely confounded in part with genetics, but it is a very strong claim that all of it is. I would see the burden of evidence there being on you not the rest of the world.
3. The role of vaccines in this is complicated. One can hypothesise a world in which, had the vaccines I mentioned not existed, we would have evolved to be resistant (in some ways a “better” species, except that not necessarily on the axes that we are most interested in such as fertility or intelligence). But that is pure supposition. Much more likely, and indeed consistent with the data we see (some of which you cite!) those vaccines effectively push the stochastic curve out to the right, if not its end point. That seems like a win for medical science.
4. I kinda do agree with regard to most cancers, flu, etc, because by and large these are the symptoms of a degraded metabolism. But that implies my point 1. It also implies that specific treatments to alleviate these degraded metabolisms (i.e. semaglutide, metformin, insulin) are in fact useful at moving the curve to the right.
5. It seems very hard to disagree with the effectiveness of A&E medicine: lots of people have accidents that would kill them or significantly shorten their lifespans, let alone health-spans, and are restored to nearly original function thanks to effective medical interventions. These may not increase total lifespan, but it does push the curve out to the right again.
I am certainly skeptical about medicine but I am even more skeptical about dramatic absolute claims.
Referring to you dismissively as someone "nobody listens to" is really surprising. I've always admired Scott as somebody who rises above petty rhetoric like that.
I've said this before, but your single minded focus on years of life when it comes to this issue is bizarre. Medical care has at least two other very important goals and these sometimes trade off with life extension.
The first is reduction in pain, and in discomfort broadly construed. Your link to the piece about prescription drug deaths is telling. It notes that some of the biggest killers are pain medications including NSAIDs.
Well maybe if you live with chronic pain, a shorter lifespan plus relief of your pain is worth it. Same goes for the deaths from falling later in life due to antidepressants.
Another aim of medicine is the provision of information that people want. They want to know if they have cancer, even if the cancer isn't treatable. A lot of medicine works to provide this benefit.
How old are Scott's infant twins? As someone barely able to do my job in the midst of the chronic sleep deprivation and distraction imposed my by own two babies, that's where my head goes.
Scott’s earlier work was awesome. He changed the way I saw the world. For five years, probably more, the quality had deteriorated. This is a new low. Such a shame. Anyway. This is a good piece and a good response.
This is also my impression, but I don't think Scott has gotten worse. I think we've just assimilated his most important insights, and, ironically, the marginal value of his more recent insights of the last five years aren't as high for us as the first ones we encountered.
I don't think this is just ordering effects either; I would bet that someone demographically similar to us who encountered Scott's work for the first time in ACX would not find it as impressive as his earlier stuff from SSC.
Sorry, I guess my second paragraph means Scott's work has gotten worse. But I think it's not because he doesn't put in as much care, I think it's just: he doesn't have as many world-changing insights anymore. That said, I think he hasn't gotten worse, in the sense that the earlier insights still structure what he writes today.
The majority of the confusion here is that Hanson characterized marginal health spending as "near zero" as in not statistically discernable. Scott noted that the RCTs don't have that much statistical power and that therefore it is a stretch to take it as proven that additional marginal medical spending has next to no effect. Rhetorically characterizing this as "saying medicine doesn't work" isn't a stretch and in fact Scott does specifically note that Hanson is arguing marginal effects
It is a reasonable prior to think that the marginal effect should be positive, though not necessarily valuable, since the given studies can't tell us. Missing out that the Obamacare study reported only the cohort with a significant effect is a real error but not fundamentally different from not noticing that the RCTs don't have statistical power
It's an interesting discussion and I look forward to it continuing!
That is my impression as well, which is really disappointing. This last essay really had me scratching my head and wondering what he was talking about.
Scott now ranges from peddling experimental out-of-FDA's scope drugs from companies his wife and friends are involved with (brushing away the conflict of interest as irrelevant), to contrived apologetics for the EA cult
Surprising and a bit disappointing from Scott who I usually expect to go very deep into a topic. This seems like he only skimmed for the prep. Or he probably could have just asked.
Not really sure what his motivation is unless he’s just trying to release as many words as possible and this one seemed easy.
Sometimes I wonder if Scott employs ghost writers and researchers. This was definitely one of those times.
Oh nice, a rare moment where I can almost fully agree with Robin. Medicine is in fact, a cesspool whose most likely outcomes are commonly the following two: 1) Nothing much happens. and 2) Things get worse(ultimately). That's medicine, in a nutshell. Some fields of medicine are worse than others(Psychiatry being the worst offender by far-- uh oh... a conflict of interest is already coming into view...).
What I can criticize is how Scott and Robin engaged in debating the subject. Both people, basically get lost in the details. Which is a main critique I have towards people in the "Rationalist" community-- I believe they are pathologically pragmatic, care about specifics and details and precision (which is fine to care about, but not if it's almost all you care about or how you fundamentally and philosophically structure your representation of reality).
They get lost in the details of certain studies, they get lost on certain points, all of this is utterly narrow and myopic as usual. How would I approach this? I'd start with just stating the facts of why medicine is actually a shit show: 1) Bad incentives. The whole thing, is structured as a business, for the most part, where the goal is ultimately, making money, not making people better. When everyone's healthy, you can't make money. Uh Oh! (See how this big picture stuff really has a beautiful simplicity to it?)
2) Bad people(Humans are bad in general(with loads of narratives and beliefs about them being good, or how the question itself is wrong), which is why they get confused about almost everything they do(the bugs are features, for humans). When they can use medicine to wage war or dominate each other, or dominate the bottom rungs of their hierarchy so they can more easily wage war with other hierarchies, they will do so. Like how psychiatry has historically been used and almost certainly remains today as tool of profit and social engineering in a more sophisticated form rather than anything genuinely therapeutic(There's that conflict of interest again. Hey is the CIA still doing booths at the APA's big events?)
3) Remember that detail orientation problem rationalists have? Where they miss the forest for the trees? Well that entire approach, which I like to call "autistic" with a big emphasis that I am not using this description in a pejorative sense, have nothing but well wishes for autistic people, and just find to be useful to describe a style of thinking that obsessives over precision, quantity, can be robotic, cold, and so glued to a ground-level, to superficiality, that it misses the point in a tragic way. Virtually anyone involved in a "rationalist" space will show symptoms of this flawed way of thinking, myself included.
The problem is-- this exact pathology a major foundation of the approach to Western pharmacology and most treatment approaches. This is slowly changing because we can't help but understand things slightly less superficially and narrowly with time, but we're still very dense. Let's get into the details for once. Take a skin condition. Let's say a bacteria or fungi causes it. What does Western medicine have to say? Oh, easy-- a topical antibacterial or a topical antifungal can do the trick. Of course, no one fucking asked, "Hey, why does this condition come up in the first place beyond mere appearances?" That's just not seen as very "medical". Instead, it's this autistic Cause->Effect superficial bullshit. What happens? Symptoms may reduce, but return again(Big picture problem never addressed). What also happens? The company that makes the anti-bacterial/anti-fungal makes more money. We need more ointment! What also happens? Selection pressure towards the pathogen, making it stronger. Are you... seeing the problem yet?
This is not going to perfectly represent all medical failure, but this little analogy represents an overwhelming amount of it if you understood the fundamental problem and don't get lost in the details(Zoom out for once in your life), and that is only the slightest introduction as to why medicine currently, is a cesspool.
I have previously describe the basic facts of why "medicine is actually a shit show". But here I was responding to particular critiques by a particular person.
I ought to stop joking around about Little Wayne of Uproar and Mark Cuban of Cost Plus Drugs Tweets https://twitter.com/mcuban/status/1526281168928350210... Bambooz could upend the KiNobody Clothing firm... one day maybe even Under Armour, Gymnasium Shark, Adidas, and Nike if we get ahead of ourselves.
where did you do this?
The book cited in the post, for one.
Lmao, literally motte and bailey.
Okay good, I'm honestly not familiar with your particular position here, I don't even remember the points you said you made in the book. But if someone approached me on any position I have, I would always just state the fundamental facts when my opponent is picking at minutia. You never win the minutia game, it has no end(And that is why almost the entire field of Philosophy is a shit show , while we're on the subject )
This is such a bad take. It does nothing to answer the question of whether medicine is a shitshow or not because all these arguments are incredibly weak. Fundamentally, while simplicity can be illuminating, that’s not true when your simplicity is a function of narrative and vibe, not data. I write this to dissuade people reading from taking this comment seriously.
Re 1: it’s nice you can explain all human behavior with your pet theory about incentives. And I can explain the world by saying “God made it so” (see how this big picture stuff really has a beautiful simplicity to it?)
Re 2: isolated demand for rigor. It’s true psychiatry is unable to address the systemic issues that give rise to depression, and instead focuses on treating it. I think that criticism can be levied at any industry that doesn’t grapple with every aspect of a complex problem in the ways you prefer. If you are really saying there is some sinister organized plot to medicate people into apathy, that’s simply conspiracy thinking (everything becomes so simple when you blame conspiracy, who would have thought!)
Re 3: if it took you two seconds into contemplating medicine to wonder why nobody is thinking of root causes, I guarantee you it took about two seconds into medical school for every doctor to ask the same question, they’re really not that dumb. Instead of applauding your superior intelligence, consider that perhaps people have looked into this far more than you have, and the reasons why root causes aren’t always addressed are actually complex and persist despite a lot of smart people working on this issue.
Im sorry the world isn’t as simple as you’d like it to be with your best narrative. I’m sure Robin Hanson’s actual work is millions of times more robust than your comment.
General practise, psychology, sleep neurology, and psychiatry can all be quite beneficial for patients. Recently on my web log, I have been harsh against psychiatrists. People can consult on various lifestyle decisions, habits, multimicronutrients, etc. I learned many useful things from one particular practitioner and also felt somewhat cared about by a friendly psychologist at Caltech when I was an undergraduate.
"People don't care how much you know, but they know how much you care"
Nothing much happens is the part people don't seem to understand.
As far as I can tell, *most* (but not quite all) of death is explained by the fact that young people have a 10^-5 chance of dying in any year which grows to a 50% chance as they age. Essentially, this more or less explains the deaths of everyone 65+. Sure cause of death might get listed as cancer, but if you cured cancer they'd just die of something else. Maybe they would have lived a little longer on average, but not much.
I don't really see *how* medicine could extend life expectancy except by curing terminal illnesses amongst young people.
> As far as I can tell, *most* (but not quite all) of death is explained by the fact that young people have a 10^-5 chance of dying in any year which grows to a 50% chance as they age. Essentially, this more or less explains the deaths of everyone 65+.
What? No it doesn't, and there's no world where this type of probability actually can be representative of the species or say anything meaningful. Young people *where*? In Norway? In Bangladesh? New York City?(The person on food stamps, or the trust fund kid with his own condo at 21?)
Not only does it not explain the death, it doesn't even give a probability that is useful. It's just bad, and that's because again, to get anything meaningful or true, you need depth. You need nuance. You won't get that with a statistic like that, you'll just get superficial bullshit, and from superficial bullshit only confusion follows.
Calm down pal.
Let me ask you a question: if there were no diseases other than aging, how long do you think humans would live (just aim for the right ballpark, obviously details would depend on a lot of stupid BS)?
Yes, this was an uncharacteristically weak post from Scott. I wish he had engaged with your actual arguments and applied his usual level of rigour to the evidence, rather than fighting a straw man.
I find myself sympathetic to Robin's view on the entirely flimsy basis that most medical treatment I have received have been useless. There are exceptions such as antibiotic treatment for an e. coli infection of my kidneys (very nasty and almost fatal!), some dental work (I suspect much is a waste of money), and probably flu and other vaccines to an extent (not so much Covid). I have had two spine problems for which experts provided zero help, just scans, sonograms, and worthless pain killers. I have doctor-caused damage to my left sciatic nerve which is never going to get any better (barring major new developments). I have for decades had chronic and too often really awful phlegm problems which remain unchanged despite trying probably a dozen sprays and pills and other treatments. I also continue to age without a single effective intervention.
Sorry to hear, Max. You LOOK crazy health of course.
> I find myself sympathetic to Robin's view on the entirely flimsy basis that most medical treatment I have received have been useless.
I never mentioned that in my post but yes, same here. It really helps to have been in the medical system and experienced its failure to attempt to diagnose and treat an assortment of health problems, and then it will be clear to almost anyone. Whoever lacks this experience is just going to be confused. And it's not that some people are just unlucky and end up biased-- it really just becomes transparent that this is typical of the system, and the reasons for why it's typical(money, incompetence, bad incentives, utility for social engineering/warfare, the existence of placebo, etc) are not some deep mystery. One basically has to either a) lack experience, b) be totally naive, or c) be an idiot, or some combination, to miss the fact that Western medicine is at best laughably broken and at worst deeply sinister.
>I also continue to age without a single effective intervention.
The cure for that is DMSO and a nice cold bath.
Obstetrics is a good example of this. The USA is suffering from too much medical care. Countries that use midwives get better outcomes. We get too many unnecessary c-sections because that makes the doctor more money. It’s been a few years since I’ve looked at the research but of my memory is correct, the often cited stat that black women have worse outcomes is a result (in part) of increased rates of Medicaid. Doctors are more likely to over-treat Medicaid patients because they pay per service while a private insurance company will decline to pay for unnecessary procedures. Episiotomies are an excellent example, they are harmful and no study has ever found a positive effect. They should never be done. But Medicaid pays for it and private insurance won’t.
My first child was taken to the NICU for 4 days even though there was nothing wrong with her. The doctor kept giving us bs reasons that she had to stay, and even when she gained weight and did all the things he wanted, he insisted she stay. When the doctor changed out we were sent straight home. My private insurance found it unnecessary and refused to pay for the NICU stay at all.
I am glad you wrote up this response. I was really struggling to understand Scott's position since every time I had spoken with you or heard you speak on the matter your position had pretty consistently been "Some medicine is good, but most is a combination of useless, harmful, or generally the cost is greater than the benefit." I can see how the casino example is confusing if one doesn't know quite what your arguments have been over all, but having an inkling of those it seemed like a strange case to latch on to. Unless one assumes you had a significant stroke or something that wildly changed your position in a strange way.
All I got away was that medicine is effective conditional on one actually needing it. And a bunch of stuff about insurance
No, even if you need help, medicine might not give you help, and could even make you worse off.
I think this is an explained variance problem. Variance in medical care use explains negligible variance in health outcomes between individuals, but that doesn't mean that it doesn't have an effect in the aggregate.
That's why my whole focus is on studies of the aggregate
According to these article, prescription drugs are not that helpful:
https://brownstone.org/articles/prescription-drugs-are-the-leading-cause-of-death/
...
Also I like very much some pertinent articles from https://www.midwesterndoctor.com/, like osteoporosis, statins, antidepressants...
Apparently he's fighting a straw argument because you once made a certain claim and he's afraid lots of people are going to stand by that decontextualized claim.
Which claim?
Lorenzo Ferro Odyssey of Buridasinus Apr 24
The claim "medicine doesn't work" is obviously false, but is likely a straw man argument.
There are several reasons to believe that a large part of approved therapies today, either don't work at all or don't work as they claim they do.
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author Scott Alexander Apr 24 Author
The problem is, Robin makes a specific claim I think is false, and if I don't refute it, then other people start thinking it's true and repeating the claim. It's not a straw man argument if it's the literal position a lot of people are making! I can refute that argument without necessarily refuting some other argument that other people on vaguely the same side should have made.
It seems you don't have a quote of a particular claim of mine, and are just accepting Scott's claim that I made the claim he attributes to me.
"Imagine someone claimed that casinos produce, not just entertainment, but also money. I would reply that while some people have indeed walked away from casinos with more money than they arrived with, it is very rare for anyone to be able to reasonably expect this result. There may well be a few such people, but there are severe barriers to creating regular social practices wherein large groups of people can reasonably expect to make money from casinos. We have data suggesting such barriers exist, and we have reasonable theories of what could cause such barriers. Regarding medicine (the stuff doctors do), my claims are similar."
In this quote, you explicitly say your claim is similar to saying doctors may help some people, but they on the whole take away health (because a casino takes away money on the whole).
You can certainly say this quote was ill-conceived and that the quotes you provide in your rebuttal reflect your actual beliefs, but you must acknowledge that you have at least made this claim in this quote.
"similar" /= "exactly the same"
I'm pretty against analogies in argumentation, and you're nicely demonstrating why: you can make an analogy to imply something, and then when called on it retreat to saying not to take every feature of the analogy literally. This is a very effective rhetorical technique for communicating baileys while feeling justified in defending yourself by saying you were only communicating the motte, but it's also intellectually dishonest.
He is the king of the motte and bailey. Makes utterly absurd implications about medicine being useless, and then when someone criticizes these statements, retreat to the claim that more medicine just isn’t extremely effective. Then, in the comments, return to saying that medicine is terrible.
No.
It seems like he's wasting time to counter an argument you never made.
And you're wasting time to counter his straw man argument.
And I'm wasting time looking for some interesting argument in this discussion.
This is the actual link to those comments:
https://www.astralcodexten.com/p/contra-hanson-on-medical-effectiveness/comment/54682376
If "other people" are standing by "decontextualised claims", then he ought to be able to quote those other people directly and respond to them, rather than responding to Robin, no?
If these other people are purely hypothetical, then the value in attacking their imagined arguments seems a bit unclear.
Agree. As written in another comment, this whole debate is a waste of time.
Robin could well have written a tweet along the lines of "This guy misunderstands and misrepresents my position". End.
Apart from getting older, Scott has also gotten noticeably more cowardly since his real identity was revealed.
Thanks for the detailed response. I broadly agree with the stochastic concept of aging/dying. I have also often wondered how much of the (substantial) effect of say exercise on longevity is in fact genetic. That said, implicit in that very model is there is a certain rate of decay of our bodies. Based on almost every system we have ever seen we should be able to accelerate or slow down that rate, which is exactly what for example smoking and drinking, on one hand, and exercise and sauna with ice baths on the other, appear to do.
Accordingly, I do not follow quite how you go from that hypothesis to what appears to be a conclusion that there is nothing else to be done but wait and die. Some specific comments:
1. You appear not to value healthspan as opposed to lifespan. I think both are important.
2. I assume that you agree that exercise affects the shape of the curve? I agree that observational results from exercise are likely confounded in part with genetics, but it is a very strong claim that all of it is. I would see the burden of evidence there being on you not the rest of the world.
3. The role of vaccines in this is complicated. One can hypothesise a world in which, had the vaccines I mentioned not existed, we would have evolved to be resistant (in some ways a “better” species, except that not necessarily on the axes that we are most interested in such as fertility or intelligence). But that is pure supposition. Much more likely, and indeed consistent with the data we see (some of which you cite!) those vaccines effectively push the stochastic curve out to the right, if not its end point. That seems like a win for medical science.
4. I kinda do agree with regard to most cancers, flu, etc, because by and large these are the symptoms of a degraded metabolism. But that implies my point 1. It also implies that specific treatments to alleviate these degraded metabolisms (i.e. semaglutide, metformin, insulin) are in fact useful at moving the curve to the right.
5. It seems very hard to disagree with the effectiveness of A&E medicine: lots of people have accidents that would kill them or significantly shorten their lifespans, let alone health-spans, and are restored to nearly original function thanks to effective medical interventions. These may not increase total lifespan, but it does push the curve out to the right again.
I am certainly skeptical about medicine but I am even more skeptical about dramatic absolute claims.
Referring to you dismissively as someone "nobody listens to" is really surprising. I've always admired Scott as somebody who rises above petty rhetoric like that.
I've said this before, but your single minded focus on years of life when it comes to this issue is bizarre. Medical care has at least two other very important goals and these sometimes trade off with life extension.
The first is reduction in pain, and in discomfort broadly construed. Your link to the piece about prescription drug deaths is telling. It notes that some of the biggest killers are pain medications including NSAIDs.
Well maybe if you live with chronic pain, a shorter lifespan plus relief of your pain is worth it. Same goes for the deaths from falling later in life due to antidepressants.
Another aim of medicine is the provision of information that people want. They want to know if they have cancer, even if the cancer isn't treatable. A lot of medicine works to provide this benefit.
The RAND experiment, on which I've focused the most over the years, didn't look at deaths, but did look at pain and other health metrics.
Ah my bad, I didn't realize that about the RAND thing.
How old are Scott's infant twins? As someone barely able to do my job in the midst of the chronic sleep deprivation and distraction imposed my by own two babies, that's where my head goes.