Marat

Decisions to go to war are usually based on qualitative reasoning, but what if we apply rational cost-benefit analysis to the War on Terrorism? Has anyone ever calculated whether resources are more rationally spent on protecting the homeland from attack through expenditures on police and intelligence capacities than through invading terrorist bases abroad, or how much would be gained by increasing police resources at the expense of military investments? Prima facie it seems that foreign invasions are highly cost-inefficient, since huge expenditures for logistics, for the military's supporting bureaucracy, for propping up local puppet governments, for building local infrastructure, and for fighting the local population who would never have been terrorists, but who are just resisting a foreign invader, all absorb resources not directly related to preventing terrorist attacks on the U.S. In contrast, money spent on policing and intelligence-gathering would waste comparatively little through the unavoidable diversion of funding to projects irrelevant to the central mission. Another issue in the War on Terrorism which has to be quantitatively assessed is how much territory does an enemy need to occupy to organize, support, and fund a significant terrorist attack on the U.S.? Since countless nations around the world could provide alternative bases for terrorist groups to flee to if squeezed out of any one place, the U.S. would have to block terrorist access to the entire potentially terrorist-supporting world in order to prevent future attacks. So it is important to know how much territory has to be controlled in potentially terrorist-friendly areas to prevent terrorists from moving there and setting up a base of sufficient size to mount another 9/11 attack. If the area required is sufficiently small, say 100 square miles, then the terrorists could easily hide out in the mountains of West Pakistan forever, where geopolitical factors would make them unattackable by anything but relatively ineffective U.S. drones. If small patches of land like this are sufficient to support a significant terrorist attack on the U.S., and the U.S., for reasons of logistics, geopolitics, and cost could never manage to occupy them all, then it makes no sense to devote so many resources to foreign invasions rather than domestic policing to control terrorism.

While I don't doubt that Obama is a 'natural born citizen' of the U.S., there is an interesting legal question about what would now have to be done if it were discovered that he was not. Bills become law only after passed by Congress and signed by the President, so all these laws would be arguably invalid. However, when it was discovered that all the laws of Manitoba, Canada, were invalid because they had not been passed in French and English, the Canadian Supreme Court ruled in 1985 that the need to preserve the rule of law trumped the need to have all valid statutes in both official languages, and so it validated all the invalid statutes to preserve the integrity of the legal system. The province was required to prepare the required French translations, but the laws were still valid pending that translation. I don't doubt that the U.S. Supreme Court would reach some similar solution. Similar questions about the eligibility of George Romney, the father of former Governor Romney of Massachusetts, to become President were raised in 1964 because of his purported birth to American Mormons hiding out from U.S. anti-polygamy laws in Mexico. Romney's candidacy never got far enough for the issue to be tested, however.

One reason for the current doctor shortage in Canada is that various provincial governments in the early 1990s took at look at spiraling healthcare costs projected for the future and stupidly thought that the best way to control them was to limit the number of new physicians being trained. But since the demand for healthcare is relatively inelastic, because healthcare is not a consumer good people can forego if there are insufficient suppliers, the result was an extreme doctor shortage. Another problem is that the medical societies, just to keep the profits of their members high, severely restrict the number of new physicians being trained, and this causes further shortages. The final problem is that the taxpayers want excellent healthcare with no waiting lists for treatment but they don't want to vote to provide enough money to fund what they want. Thus the U.S. spends 17% of its GNP to provide 84% of its population with healthcare, while Canada spends just 10% of its GNP to cover 100% of its population. That works out to the U.S. spending about twice as much per capita on healthcare as Canada does, so when people compare the poor standard of care and the long waiting lists in Canada with the better results in the U.S., they should keep in mind that this is not a fair comparison of socialist healthcare with private healthcare, but just of underfunded healthcare with well-funded healthcare. The greatest advantage of the Canadian system is that you never have to worry that a sudden, catastrophic illness is going to bankrupt you and your family and destroy all the financial security you have been able to establish over a lifetime of working. The care is lower standard and the provision of care is extremely slow, but at least there are no user fees. Since it is funded out of general taxation, the effect of catastrophic illness expenses is that some multi-millionarie has to forego his golf vacation in the Bahamas this summer, rather than that some middle class family loses its savings, its ability to send the children to college, and its house.

I don't see anything in your data to make me change my views that the gains in life expectancy in the modern world were due to factors having nothing to do with advanced medical science. Improved hygiene, better nutrition, clearing of swamps and the decline of malaria, reduction in infant mortality and puerperal fever, were the truly significant causes of today's improved lifespans. The data you provide on the lifespan at various ages in the Roman Empire confirm rather than refute my hypothesis, since they show that in Ancient Rome people who made it to 70 were likely to live to be 75, those living to 65 were likely to make it to 73, those living to 60 were likely to survive to 70, and those making it to 55 were also likely to live to 70. This shows that once infant mortality, early infections, and childbirth-associated deaths were taken out of the equation, the life expectancies reached without any advanced medicine were close to those found today, suggesting that modern medicine has not achieved very much.

There are two brands of liberalism, ordinary and militant. According to ordinary liberalism, everyone should be free to act as he pleases, unless he actually harms someone else. According to militant liberalism, no one may do anything which harms or threatens liberal values. The first sort of liberailsm is epitomized in the U.S., the second sort is found in France, Germany, and Canada. Thus in Germany it is illegal to establish a political party which threatens liberal values, such as Nazism, but in the U.S., freedom means being free even to found a Nazi Party. In the U.S., short of libel and shouting fire in a crowded theater, you can say what you like, but in Canada, you can't say anything that would promote hate against an identifiable group, since that would harm the atmosphere of liberal tolerance. Forbidding women to wear an outfit that implies the denial of their human dignity is typical of militant liberalism. Generally, ordinary liberalism is preferable, since once the government gets in the business of deciding whose exercise of freedom is threatening to what liberal value, the exercise of that power easily becomes unfair, unreasonable, and simply expresses the government's dislike for some activities and approval of others.

There are two ways to use the Bible as a source of information. One is as the revealed truth of God about the world, which is not how I am using it here. The other is as an archaeological record of what people at the time believed was normal about human physiology -- here, with respect to life expectancy. Assuming that the authors of the book would not want to fill their document with statements about what was natural for humans with obvious inaccuracies, since this would undermine the credibility of the whole tale, I take what they say about the natural lifespan as more or less accurate for the time, since the authors could gain nothing by lying. Thus I am reading the Bible here much as archaeologists look at a piece of pottery in an ancient granary marked with the word for 'corn' and take that as evidence that the granary once stored corn.

The most commonly made mistake in all perception of anomalous things is to leap from the undeniable fact of the unexplainable perception to the assumption that what was perceived corresponds to the predominant theory of what causes such perceptions. For example, some people report seeing what look like dead people moving around, and then everyone leaps to the conclusion that this must prove the immortality of the soul since spirits live on after their lives are over. But the underlying ontology of whatever was perceived could be anything: e.g., an optical illusion, a schizophrenic fantasy, some unknown form of ESP, some strange ability of the mind to project actual objects from itself, illusions of existing dead people created by the Devil (as was believed in the Middle Ages), or actual living spirits of the dead. The anomalous perception itself, however, does not permit a clear inference to what the perception signifies. The same is true of UFO perceptions. Some people think they are time travellers, others that they are other dimensions coinciding with ours, still others that they are just illusions. The most that can be said is that something which you cannot explain appeared to you, be it what it may.

Of course hygiene has some scientific elements, but the progress in hygiene, and its life-saving effect, is heavily concentrated at the very bottom of the 'scientific' spectrum, whereas what we usually mean by 'medical progress' is heavily concentrated at the very top of the scientific spectrum, involving reliance on high-tech innovations to cure disease and extend the lifespan. It seems counterintuitive to classify hand-washing as a breakthrough in medical science rather than just the attainment of a higher degree of social organization. In using ancient source materials as an indication of the average span of life long ago, it would be foolish to count the extreme examples, such as that of the 800-year-old Methuselah or the miraculously long-lived Moses, since this is just superstition to enliven the tale and says nothing about nomral life expectancy at the time. These long lives were supposed to impress contemporaries as astonishing, so they say nothing about what was normal at the time. But it is quite different with the phrase in Psalms 90:10, where the Bible says "The days of our years are three score and ten," for this is stating what is regarded as the normal time allotted for human life. It would only discredit the tale in the eyes of its contemporary audience if 70 years were known to them as a life expectancy which was not ordinary.

Of course unrealistically optimistic families are often the comatose or senile patient's worst enemy when they have control over the care delivered, which can amount to torturing the patient uselessly just to keep the unrealistic expectations of the family from being disappointed too soon. The sense of my original post was to criticize those physicians who, just because they are physicians, believe that they know all they need to know about medical ethics, even though they lack all but the most rudimentary education in the subtleties of the kind of moral, philosophical, legal, psychological, and social decisions to be made in medical ethics. Obviously on committees with a balance of expertise this would not be a problem. But what is most unfortunate is that the general public, the media, governments when making important policy decisions, and universities when filling appointments often assume that the acquisition of the technical knowledge involved in medical decision-making is sufficient to make someone a qualified medical ethicist.

Although you can technically say that hygiene is part of medicine, in fact huge gains in health and life expectancy can be achieved with improvements in hygiene which are utterly primitive and nearly totally pre-scientific, like hand-washing, defecating in water only downstream from where you wash your hands, getting enough sunlight, not eating out of the same pot that you urinate in, etc. So while you might count those commonsense, primitive public health measures as still part of 'medicine,' they make no positive comment on the state of modern medical science as a progressive discipline. The fact that the Old Testament speaks of the allotted lifespan of man as three score and ten suggests that this was a typical life expectancy at the time. If so, then the average life expectancy of 78 now -- a gain of only 8 years after 3300 years of work and who knows how many trillions of dollars of research efforts -- represents a pitiful degree of progress among those making it past the huge infant mortality cull in primitive societies.

I think you can legitimately infer from the extreme lack of moral sensitivity among physicians in the examples I cite that the average degree of ethical insight for the entire group is fairly low. This should not be surprising, given their education from a very early age in purely technological rather than humanistic matters. I once took a course from a British institution which gives degrees in medical ethics primarily for physicians, and the intellectual level in that group was astonishingly low. As a foreign student at a German medical faculty in the 1980s, I was surprised to find that the medical ethics course had only four students instead of the 300 who were usually present at the hard science courses. I then noticed that all the other students in the medical ethics class were, like me, foreigners, and that we had all made the same 'mistake,' which was to attend a non-required course.

Since there would still be many, conservative, risk-averse patients who would only want to use drugs that had completed all four phases of the FDA certification process, it would still be worthwhile for drug companies to go through the entire process, even if patients could still access these drugs earlier. The irrationality of the FDA rules is that while they might be scientific they are not existentially sensible for people who are certain to die unless they try some desperate and profoundly risky experiment which might work. If somone is in the last stages of terminal cancer, and some new and unproven drug claims to be able to rescue patients even at this stage, it would be absurd for that patient not to try it, but the FDA will still often fight that patient to prevent him from getting the drug. That is not just irrational, it is downright lunatic, and totally inconsistent with American traditions of individual liberty.

You can confirm these data from any good medical history book, such as Singer's famous text. Now you can probably also confirm this information from internet sources.

I worked at a dialysis clinic for a number of years where I saw a woman in her 80s brought in from the nursing home three times a week for treatments which caused her to scream her lungs out. She was utterly senile and had no idea what was happening to her or why, but the 'wise doctors' had decided for her that it was their medical duty to keep her alive by continuing the treatments. At that same clinic, a very bright 18-year-old girl was told by the transplant supervisor that she would not be put on the waiting list for a transplant because in the utterly subjective opinion of the supervisor, "You don't seem mature enough." This turned out to be a death sentence for the girl, who had severe hypotension on dialysis, but no criminal charge could be brought, because doctors get to play god, as everyone knows. When working in another clinic I saw an old man weeping after both of his feet had been amputated. The attending physician screamed at him that "We have given you enough morphine to kill a horse, so what are you crying about?!" The old patient said, "It's not the pain," to which the wise and kindly doctor replied, "Then what the f- are you crying about?" The notion that someone might weep on waking up to find himself without feet could not get through the thick skull of someone who had been nothing but a technocrat with no human or humanistic skill-development all his life. For anyone who needs any more convincing that physicians know nothing about medical ethics, I have ten thousand more stories like that from my personal experience. You can read similar cases in Mendelsohn's book, 'Confessions of a Medical Heretic.'

It is not easy to get into a clinical trial of an experimental treatment, but most importantly, you have no autonomous right to participate in that treatment, and you can only get the drug if someone else -- the physicians and scientists directing the experiment -- let you. That is hardly medical liberty. But if some drug or treatment doesn't happen to be enrolling subjects into an experiment when you need it, or if you are not accepted into the trial, then the FDA will exercise the full power of the federal criminal law to stop you from accessing the therapy, which is inconsistent with the American philosophy of individual liberty. Benjamin Rush, a physician and a major force in the American Revolution, actually wrote that medical liberty -- the free access by the individual to any form of treatment he wants -- is the most essential liberty of all, and Thomas Jefferson wrote statements in agreement with him. But that was before America was taken over by monied interests, and Big Pharma has no interest in letting sick people escape the plantation on which it holds them and drains their money away for expensive treatments, nor does Establishment Medicine want people being able to access drugs without paying doctors first to get a prescription. If you want to take Laetrile or undergo Ardenne treatment for cancer, have an autologous stem cell transplant for your chronic and otherwise incurable disease, or have fresh cell injections for their rejuvenative effects, the 'freest country on Earth' forbids you to do this, and your only option is to become a medical refugee from America and seek the greater medical liberty available in Europe and South America to exercise your right to manage the medical treatment of your own body as you see fit. If you look at the case of Abagail Alliance v. von Eschenbach you will see how mightily the FDA struggles against Americans having the right to treat their own diseases as they choose. (You can find this case online.)

You could even say that rocket technology is just the applied science version of Newton's discoveries in mechanics 350 years ago, but other areas of technology, such as computers, show much more important advances over the past 50 to 80 years than medicine has achieved. The great advances in human life expectancy were achieved through improvements in public health, not medical science. Cleaner living conditions, better water purification, and improved diet are the main reasons that the average life expectancy in developed countries today is entering the eighties. If you look at the odds of a 60 year old in 1900 living to 80, you will find very little difference from what they are today, which speaks against medicine as the motive force behind these gains. What really made the difference was the high infant mortality rate in earlier historical periods. People always make the mistake of thinking that because average life expectancy was 40 in a certain historical period that means that people in their late 30s then were old because medicine was not as good. But in fact, it was just that babies under 5 were dying like flies from inadequate nutrition and infectious disease, and that new mothers were dying from mineral loss and puerperal fever, which can be avoided by simple cleanliness. The Old Testament, written about 1300 B.C., speaks of people naturally living for 'three score and ten,' or 70 years, so what has 2300 years of medicine achieved since then -- an additional 8 years?! Recently life expectancy among males has actually leveled off or is declining slightly in some areas of the developed world -- for the first time ever, because medicine cannot make any progress against cancer, diabetes, autoimmune disease, athero- and arteriosclerosis, etc. And what benefit is it to most people to live past 75? The typical person is functionally dead at that age, since the intellect is going or gone, and another decade of existence spent in mounting confusion, incontinence, and crippling arthritis is hardly 'life.'

I think that the explanation is in large measure cultural rather than biological, and so has to be addressed for humans separately from animals. For humans in third world countries, children are often a kind of social security system, since the more children there are, the bigger the family is, and the bigger the family is, the more the healthy and successful members can support those who are afflicted with disease and misfortune. So overpopulation in this context is an artifact of social organization in countries where the government has no social support system to care for its people, with the result that each family has to expand to take care of itself.

I am not saying that there is anything like an organized conspiracy which causes all the public information you hear about medical progress and disease prognosis to be so profoundly optimistic, while all the technical information you read in medical textbooks is so profoundly pessimistic. I am merely suggesting that the same general social and economic forces operate to produce this enormous disconnect between public and professional disease information, and that these probably are the need for Big Pharma and the Medical Establishment to induce the public to tolerate their social power and insistence on enormous remuneration for their inadequate performance. I am not saying that there hasn't been any medical progress since 1800. But compare the progress in other areas of science with medical progress and you will notice that medicine is lagging badly. In 1944 the first military jet plane was developed and now we are more than 30 years past having sent men to the Moon and back. In 1944 the first renal dialysis machine was developed but it was found to produce a hideous lifestyle for patients and to provide them only with a very short lifespan. Today, 66 years later, although the dialysis machines and treatments are better, the same basic problems of hideous patient lifestyle and extremely shortened lifespan remain. In 1922 Banting and Best discovered insulin injections as a way to correct the metabolic abnormalities of diabetes, but the inability of insulin injections to imitate the natural functions of the pancreas meant that patients often suffered poor quality of life and died early. Today, 88 years laster, those same problems with insulin therapy of diabetes remain, though life expectancies have improved. But contrast the situation in 1922 in diabetology and aeronautics with that today: Insulin was discovered 5 years before Lindberg made history by flying over the Atlantic, and now we can send space probes to Jupiter. Or compare the advances in computer technology: the fastest way to calculate in 1922 was with an adding machine, but now a pocket calculator can solve quadratic equations; there is nothing in medicine that can compare with this degree of progress.

I think most people are quite risk-averse, so even if there were no FDA the typical citizen would not take any drugs which were not approved by traditional medical advice. Many countries don't have anything like the FDA and yet masses of people don't die from dangerous medical experimentation on themselves, just as they did not die in the U.S. prior to the existence of such regulatory bodies. I would not ban the FDA, since its provision of advice to people on the risks and benefits of various treatments would still be useful. But I would deny it the legal power to prevent people from trying whatever treatments they wanted according to their own judgment. After all, it is now legal to eat high-cholesterol foods every day, intoxicate yourself with alcohol, go motorcycle racing, work in a dangerous coal mine, and smoke constantly, and all this you are allowed to do purely for your own profit or entertainment, so why shouldn't you be able to try an unproven medicine to save your life?

While most medical schools offer courses in medical ethics, they are philosophically primitive to say the least, relying completely on such simple, introductory texts as Beauchamp's or Gillon's and nothing more, for example. Even then, they are usually elective courses, and in the high-pressured environment of medical school, no rational student can afford to waste ten seconds of time on an optional course. Of course a medical ethicist should know the technical aspects of the medical issue he or she is dealing with, and most of them do. The same is true with courts which have to deal with such issues, for which the judges rely on expert medical advisors or testimony. But while humanistically trained medical ethicists and judges can be helped to understand the technical issues involved, purely technically trained physicians seem never to be able to summon the subtle skills of humanistic judgment required to deal with problems in medical ethics in any sophisticated way.

At many universities and on various hospital ethical committees, you will find that the resident 'medical ethicists,' who have to have an extremely sophisticated understanding of the legal, philosophical, psychological, and social issues involved in the ethical problems arising in medicine, have training only in medicine. While they may have the technical expertise from their training to know what can be done and what can't be done with the available medical technology, it is typically the case that years of purely technical training -- memorizing biochemic pathways rather than thinking creatively, devoting all their energies to competing fanatically to get into medical school when other undergraduates were busy growing up; and then thinking they know everything about medical ethics because they have extensive experience in the arrogant, uncritical, careless way ethical issues are dealt with in hospitals and clinics -- have combined to make them utterly naive with respect to sophisticated ethical decisionmaking. Asking a doctor to give advice on medical ethics is like asking an electrician who should be executed for murder at a criminal trial, since after all, the electrician knows more than the judge and jury do about how the electric chair works.

If you ask the typical layperson, he or she will say that medicine is doing wonders today. But the FDA published a 'panic bulletin' in 2008 noting that the number of new drug approval requests had declined for the first time since the approval process was established, and the typical patent attorney will tell you that the drug patenting laws are now inappropriate because they were designed to protect major therapeutic breakthroughs which are no longer happening. The death rates for many forms of cancer have not improved significantly for decades, the unsolved problems in diabetes and renal failure remain what they were a half century ago, and the last disease removed as a public health problem was polio nearly 60 years ago. In short, medicine is stagnating, but the public is being told the opposite. If you look at any websites where doctors, hospitals, public health officers, drug companies, and the government 'inform' patients and the public about various diseases, you will find that the fatuously over-optimistic information about the disease and its prognosis provided bears no resemblance whatsoever to the negative picture presented of the disease in any medical book. The same misleading optimism characterizes all the patient forum websites, where anyone posting honest, medically accurate, but negative information is instantly banned. So why does society feel compelled to hide the truth about the failures of modern medicine and the unmet challenges of disease? Perhaps because if the public knew how bad the reality of disease was, this would have a revolutionary impact. People would refuse passively to keep paying the outrageous prices demanded by Big Pharma for its products; they would demand that their legislators stop providing such generous patent protection to Big Pharma's drugs; they would decline to support the inflated salaries of doctors; and they would rebel against regulatory agencies like the FDA and the AMA. In short, a lot of powerful interests would feel the heat from the public if the news got out that their social power, prestige, and wealth were based on inadequate performance.

The FDA can and does ban supplements just as easily as it bans medicines -- e.g., vitamin B17, also known as laetrile. The Clinton administration had to pass legislation to try to slow down the ravenous attempt of the FDA to swallow up and forbid nearly the whole supplement industry, which it hates in its role as the agent of Big Pharma and the Medical Establishment, which profit most from more expensive prescription drugs. As one FDA official once quipped, "If coffee were a newly introduced substance today, you would have to get a prescription before you could have a cup of it." The worst problem is that if anyone, even someone not associated with the manufacture of a supplement, claims that it can cure disease, then the FDA can re-classify it as a drug and ban it. The FDA even banned poor old Dr. Reich's wooden 'Orgone Boxes' and put him in federal prison for selling them, even though they were totally harmless -- just because they were ineffective and curative claims had been made for them. Before you dash into a burning building to save your family from death, you don't know whether your action will be safe and effective, but you have every right to make your own judgment about whether to do it or not. The same is true of countless other risks people take every day. So if you are dying of an incurable disease and you would prefer to risk death or the worsening of your condition by taking an unproven remedy to continuing on with things as they are, then that should be your own business, not the decision of a state bureaucrat. Many people who were otherwise certain to die of a presently incurable illness would quite sensibly prefer to accept a 50% chance that they would make their condition worse or more painful by taking an unproven drug that offered them a 1% chance of cure. Yet as things are now, the federal government will step in with all its might to stop them from trying to save their lives as they see fit, and unfortunately, the courts, which usually roll over and play stupid when confronted with Medical Science, almost always give into them. See the decision in Abagail Alliance v. von Eschenbach.

What if the FDA only had the authority to label all medications with the results of its safety and effectiveness tests in both medically technical terminology and layman's terminology? Then the public would be put on notice about the potential risks, but they would remain free to take those risks or not as they saw fit. Perhaps the requirement for some particularly toxic medicines could be even more stringent, such as insisting on a 15-minute talk with a pharmacist before the patient could obtain the drug. For drugs for which there was not yet sufficient information to determine whether they were safe and effective or not, there would be a requirement that this lack of data be brought to the consumer's attention before the consumer could purchase them, but still, the decision would ultimately rest with the patient. This would be more consistent with America's claim to be 'the freest country on earth' than its present restrictive practices, which make many drugs less readily available in the U.S. than they are in supposedly less free countries in Europe and South America. If it is legal for Evil Knieval to ride his motorcycle over a gorge with a high risk of death just for a stunt, then it makes no sense that it is illegal to take adrenalin without a prescription because the state decides for its citizens that it is not safe enough to use without a doctor's written permission.

While you can get some 'medicines' which have now fallen under the classification of 'foods' or 'supplements,' this is far from being the case with many drugs. Interestingly, the restrictions on patients' access to medicines are highly culture-dependent, which argues against their being rational, since the human body is the same everywhere in the world. Thus in Germany you can get without a prescription a noradrenalin ampule for injection which you could never get near to under the paternalistic healthcare restrictions of the United States. But in contrast, Austrian culture is so suffocatingly paternalistic that you practically need a letter of permission from the health ministry to get an aspirin -- even though it was one country with Germany until 1945. What counts as 'knowing' that a medicine is safe and effective for use for ordinary rationality is profoundly different from what counts as knowing this for purposes of FDA approval. Dr. Denise Faustman at Massachusetts General Hospital has recently been forced to waste two years and tens of millions of dollars proving that BCG is a safe and effective drug for treating autoimmune diabetes, but BCG has been in regular use for decades in medicine for other purposes where there was no question of its safety and effectivenes. The motives for the FDA (or 'foot-dragging administration' as it is called among medical researchers) deliberately blocking medical progress are well-known. Like most federal regulators, the FDA is in bed with the institutions it is supposed to regulate, and since the big pharmaceutical companies hate competition, the FDA helps them by making the testing and approval process for new drugs so prohibitively long and expensive that nothing ever emerges to challenge the existing monopoly of the drug companies.