History, Model

Warriors and Soldiers

Epistemic Status: Full of sweeping generalizations because I don’t want to make it 10x longer by properly unpacking all the underlying complexity.

[9 minute read]

In 2006, Dr. Atul Gawande wrote an article in The New Yorker about maternal care entitled “How Childbirth Went Industrial“. It’s an excellent piece from an author who consistently produces excellent pieces. In it, Gawande charts the rise of the C-section, from its origin as technique so dangerous it was considered tantamount to murder (and consequently banned on living mothers), to its current place as one of the most common surgical procedures carried out in North American hospitals.

The C-section – and epidurals and induced labour – have become so common because obstetrics has become ruthlessly focused on maximizing the Apgar score of newborns. Along the way, the field ditched forceps (possibly better for the mother yet tricky to use or teach), a range of maneuvers for manually freeing trapped babies (likewise difficult), and general anesthetic (genuinely bad for infants, or at least for the Apgar scores of infants).

The C-section has taken the place of much of the specialized knowledge of obstetrics of old, not the least because it is easy to teach and easy for even relatively less skilled doctors to get right. When Gawande wrote the article, there was debate about offering women in their 39th week of pregnancy C-sections as an alternative to waiting for labour. Based on the stats, this hasn’t quite come to pass, but C-sections have become slightly more prevalent since the article was written.

I noticed two laments in the piece. First, Gawande wonders at the consequences of such an essential aspect of the human experience being increasingly (and based off of the studies that show forceps are just as good as C-sections, arguably unnecessarily) medicalized. Second, there’s a sense throughout the article that difficult and hard-won knowledge is being lost.

The question facing obstetrics was this: Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills—the Woods corkscrew maneuver for the baby with a shoulder stuck, the Lovset maneuver for the breech baby, the feel of a forceps for a baby whose head is too big. You do research to find new techniques. You accept that things will not always work out in everyone’s hands.

But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques. You notice the steady reports of terrible forceps injuries to babies and mothers, despite the training that clinicians have received. After Apgar, obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section.

Medicine would not be the first industry to industrialize. The quasi-mythical King Ludd that gave us the phrase “Luddite” was said to be a weaver, put out of business by the improved mechanical knitting machines. English programs turn out thousands of writers every year, all with an excellent technical command of the English language, but most with none of the emotive power of Gawande. Following the rules is good enough when you’re writing for a corporation that fears to offend, or for technical clarity. But the best writers don’t just know how to follow the rules. They know how and when to break them.

If Gawande was a student of military history, he’d have another metaphor for what is happening to medicine: warriors are being replaced by soldiers.

If you ever find yourself in possession of a spare hour and feel like being lectured breathlessly by a wide-eyed enthusiast, find your local military history buff (you can identify them by their collection of swords or antique guns) and ask them whether there’s any difference between soldiers and warriors.

You can go do this now, or I can fill in, having given this lecture many times myself.

Imagine your favourite (or least favourite) empire from history. You don’t get yourself an empire by collecting bottle caps. To create one, you need some kind of army. To staff your army, you have two options. Warriors, or soldiers.

(Of course, this choice isn’t made just by empires. Their neighbours must necessarily face the same conundrum.)

Warriors are the heroes of movies. They were almost always the product of training that starts at a young age and more often than not were members a special caste. Think medieval European Knights, Japanese Samurai, or the Hashashin fida’i. Warriors were notable for their eponymous mastery of war. A knight was expected to understand strategy and tactics, riding, shooting, fighting (both on foot and mounted), and wrestling. Warriors wanted to live up to their warrior ethos, which normally emphasized certain virtues, like courage and mercy (to other warriors, not to any common peasant drafted to fight them).

Soldiers were whichever conscripts or volunteers someone could get into a reasonable standard of military order. They knew only what they needed to complete their duties: perhaps one or two simple weapons, how to march in formation, how to cook, and how to repair some of their equipment [1]. Soldiers just wanted to make it through the next battle alive. In service to this, they were often brutally efficient in everything they did. Fighting wasn’t an art to them – it was simple butchery and the simpler and quicker the better. Classic examples of soldiers are the Roman Legionaries, Greek Hoplites, and Napoleon’s Grande Armée.

The techniques that soldiers learned were simple because they needed to be easy to teach to ignorant peasants on a mass scale in a short time. Warriors had their whole childhood for elaborate training.

(Or at least, that’s the standard line. In practice, things were never quite as clear cut as that – veteran soldiers might have been as skilled as any warrior, for example. The general point remains though; one on one, you would always have bet on a warrior over a soldier.)

But when you talk about armies, a funny thing happens. Soldiers dominated [2]. Individually, they might have been kind of crap at what they did. Taken as a whole though, they were well-coordinated. They looked out for each other. They fought as a team. They didn’t foolishly break ranks, or charge headlong into the enemy. When Germanic warriors came up against Roman soldiers, they were efficiently butchered. The Germans went into battle looking for honour and perhaps a glorious death. The Romans happily gave them the latter and so lived (mostly) to collect their pensions. Whichever empire you thought about above almost certainly employed soldiers, not warriors.

It turns out that discipline and common purpose have counted for rather a lot more in military history than simple strength of arms. Of this particular point, I can think of no better example than the rebellion that followed the Meiji restoration. The few rebel samurai, wonderfully trained and unholy terrors in single combat were easily slaughtered by the Imperial conscripts, who knew little more than which side of a musket to point at the enemy.

The very fact that the samurai didn’t embrace the firing line is a point against them. Their warrior code, which esteemed individual skill, left them no room to adopt this devastating new technology. And no one could command them to take it up, because they were mostly prima donnas where their honour was concerned.

I don’t want to be too hard on warriors. They were actually an efficient solution to the problem of national defence if a population was small and largely agrarian, lacked political cohesion or logistical ability, or was otherwise incapable of supporting a large army. Under these circumstances, polities could not afford to keep a large population under arms at all times. This gave them several choices: they could rely on temporary levies, who would be largely untrained. They could have a large professional army that paid for itself largely through raiding, or they could have a small, elite cadre of professional warriors.

All of these strategies had disadvantages. Levies tended to have very brittle morale, and calling up a large proportion of a population makes even a successfully prosecuted war economically devastating. Raiding tends to make your neighbours really hate you, leading to more conflicts. It can also be very bad for discipline and can backfire on your own population in lean times. Professional warriors will always be dwarfed in numbers by opponents using any other strategy.

Historically, it was never as simple as solely using just one strategy (e.g. European knights were augmented with and eventually supplanted by temporary levies), but there was a clear lean towards one strategy or another in most resource-limited historical polities. It took complex cultural technology and a well-differentiated economy to support a large force of full time soldiers and wherever these pre-conditions were lacking, you just had to make do with what you could get [3].

When conditions suddenly call for a struggle – whether that struggle is against a foreign adversary, to boost profits, or to cure disease, it is useful to look at how many societal resources are thrown at the fight. When resources are scarce, we should expect to see a few brilliant generalists, or many poorly trained conscripts. When resources are thick on the ground, the amount that can be spent on brilliant people is quickly saturated and the benefits of training your conscripts quickly accrue. From one direction or another, you’ll approach the concept of soldiers.

Doctors as soldiers, not as warriors is the concept Gawande is brushing up against in his essay. These new doctors will be more standardized, with less room for individual brilliance, but more affordances for working well in teams. The prima donnas will be banished (as they aren’t good team players, even when they’re brilliant). Dr. Gregory House may have been the model doctor in the Victorian Age, or maybe even in the fifties. But I doubt any hospital would want him now. It may be that this standardization is just the thing we need to overcome persistent medical errors, improve outcomes across the board, and make populations healthier. But I can sympathize with the position that it might be causing us to lose something beautiful.

In software development, where I work, a similar trend can be observed. Start-ups aggressively court ambitious generalists, for whom freedom to build things their way is more important than market rate compensation and is a better incentive than even the lottery that is stock-options. At start-ups, you’re likely to see languages that are “fun” to work with, often dynamically typed, even though these languages are often considered less inherently comprehensible than their more “enterprise-friendly” statically typed brethren.

It’s with languages like Java (or its Microsoft clone, C#) and C++ that companies like Google and Amazon build the underlying infrastructure that powers large tracts of the internet. Among the big pure software companies, Facebook is the odd one out for using PHP (and this choice required them to rewrite the code underlying the language from scratch to make it performant enough for their large load).

It’s also at larger companies where team work, design documents, and comprehensibility start to be very important (although there’s room for super-stars at all of the big “tech” companies still; it’s only in companies more removed from tech and therefore outside a lot of the competition for top talent where being a good team player and writing comprehensible code might top brilliance as a qualifier). This isn’t to say that no one hiring for top talent appreciates things like good documentation, or comprehensibility. Merely that it is easy for a culture that esteems individual brilliance to ignore these things are a mark of competence.

Here the logic goes that anyone smart enough for the job will be smart enough to untangle the code of their predecessors. As anyone who’s been involved in the untangling can tell you, there’s a big difference between “smart enough to untangle this mess” and “inclined to wade through this genius’s spaghetti code to get to the part that needs fixing”.

No doubt there exist countless other examples in fields I know nothing about.

The point of gathering all these examples and shoving them into my metaphor is this: I think there exist two important transitions that can occur when a society needs to focus a lot of energy on a problem. The transition from conscripts to soldiers isn’t very interesting, as it’s basically the outcome of a process of continuous improvement.

But the transition from warriors to soldiers is. It’s amazing that we can often get better results by replacing a few highly skilled generalists who apply a lot of hard fought decision making, with a veritable army of less well trained, but highly regimented and organized specialists. It’s a powerful testament to the usefulness of group intelligence. Of course, sometimes (e.g. Google, or the Mongols) you get both, but these are rare happy accidents.

Being able to understand where this transition is occurring helps you understand where we’re putting effort. Understanding when it’s happening within your own sphere of influence can help you weather it.

Also note that this transition doesn’t only go in one direction. As manufacturing becomes less and less prevalent in North America, we may return to the distant past, when manufacturing stuff was only undertaken by very skilled artisans making unique objects.

Footnotes:

[1] Note the past tense throughout much of this essay; when I speak about soldiers and warriors, I’m referring only to times before the 1900s. I know comparatively little about how modern armies are set up. ^

[2] Best of all were the Mongols, who combined the lifelong training of warriors with the discipline and organization of soldiers. When Mongols clashed with European knights in Hungary, their “dishonourable” tactics (feints, followed by feigned retreats and skirmishing) easily took the day. This was all possible through a system of signal flags that allowed Subutai to command the whole battle from a promontory. European leaders were expected to show their bravery by being in the thick of fighting, which gave them no overall control over their lines. ^

[3] Historically, professional armies with good logistical support could somewhat pay for themselves by expanding an empire, which brought in booty and slaves. This is distinct from raiding (which does not seek to incorporate other territories) and has its own disadvantages (rebellion, over-extension, corruption, massive unemployment among unskilled labourers, etc.). ^

Economics, Model, Politics

Minimum Standards or Broad Access?

[5-minute read]

There are two sides to every story. Zoning and maximum occupancy regulations are exclusionary and drive up the price of housing. They are also necessary to prevent exploitative landlords from leaving their tenants in squalor. Catastrophic health insurance plans leave patients uncovered for many of the services they might need. They’re also often the only plans that are rational for younger people to buy.

Where you come down on either of these – or any similar cases where there’s a clear trade-off between maximum access and minimum standards – is probably heavily dependent on your situation. If you’re an American millennial without an employer-provided or parental health care plan, you’re probably quite incensed about the lack of catastrophic health care insurance. For healthy young adults, those plans were an excellent deal.

Similarly, workaholics in the Bay Area sometimes want to be able to stuff a house full to the bursting to save on rent. If you’re never going to be home, regulations around the number of square feet per bed feel incredibly onerous.

I like to point out that regulation is a trade-off. Unfortunately (or perhaps fortunately), it’s a trade-off made at the middle. People in the long probability tails – those who are far from the median when it comes to income or risk-tolerance often feel left out by any of the trade-offs made by the majority. This is an almost inevitable side-effect of trade-offs that I rarely see mentioned.

If you have health problems for which Obamacare didn’t mandate coverage, then you might find yourself wishing that the coverage requirements were even more expansive. If you find yourself really hating the illegal AirBnB you’re living in with twelve other programmers, you might wish that the city’s rental enforcement unit was a bit more on their game.

Most articles about people on the extremes leave out the context and leave out the satisfied middle. They don’t say “this is the best trade-off we could get, but it’s still imperfect and it still hurts people”. They say breathlessly “look at this one person hurt by a policy, the policy hurts people and is bad; the people who advocate for it are evil.”

It’s understandable to leave out the middle in the search of a better story. The problem arises when you leave out the middle and then claim all advocates are evil for failing to care about the fringes. Because most of the time, no one is being evil.

The young people skipping out on coverage because it’s not worth it for them aren’t shirking a duty. They’re making the best of their limited finances, ravaged by a tough entry-level job market and expensive university education. The NIMBYs who fight against any change to local building codes that might make housing more affordable are over-leveraged on their houses and might end up underwater if prices fall at all.

Even appeals to principles don’t do much good in situations like this. You can say “no one should live in squalor”, but that might run right up against “everyone should be able to afford a place to live”. It can be that there simply isn’t enough housing supply in desirable cities to comfortably accommodate everyone who wants to live there – and the only way to change that involves higher direct or indirect taxes (here an indirect tax might be something like requiring 15% of new rental stock to be “affordable”, which raises the price of other rental stock to compensate), taxes that will exclude yet another group of people.

When it comes to healthcare in America, you can say “young people shouldn’t be priced out of the market”, but this really does compete with “old people shouldn’t be priced out of the market” or “pre-existing conditions shouldn’t be grounds for coverage to be denied”.

The non-American way of doing healthcare comes with its own country specific trade-offs. In Germany, if you switch from the public plan to a private plan it is very hard to get back on the public plan. This prevents people from gaming the system – holding cheaper private insurance while they’re young, healthy and earning money, then trying to switch back during their retirement, but it also can leave people out in the cold with no insurance.

In Canada, each province has a single, government-run insurance provider that charges non-actuarial premiums (premiums based on how much you make, not how likely you are to use healthcare services). This guarantees universal coverage, but also results in some services (especially those without empirical backing, or where the cost-benefit is too low) remaining uncovered. Canada also prohibits mixing of public and private funds, making private healthcare much more expensive.

Canadians aren’t spared hard choices, we just have to make different trade-offs than Americans. Here we must pick (and did pick) between “the government shouldn’t decide who lives and who dies” and “care should be universal”. This choice was no less wrenching then any of those faced by Obamacare’s drafters.

Municipalities face similar challenges around housing policy. San Francisco is trying to retain the character of the city and protect existing residents with rent control and strict zoning regulations. The Region of Waterloo, where I live, has gone the other way. Despite a much lower population and much less density, it has almost as much construction as San Francisco (16 cranes for Waterloo vs. 22 for SF).

This comes at a cost. Waterloo mandated that houses converted into rental properties cannot hold more than three unrelated tenants per unit, thereby producing guaranteed renters for all the new construction (and alleviating concerns about students living in squalid conditions). The region hopes that affordability will come through densification, but this cuts down on the options student renters have (and can make it more expensive for them to rent).

Toronto is going all out building (it has about as many cranes on its skyline as Seattle, Los Angeles, New York, San Francisco, Boston, Chicago, and Phoenix combined), at the cost of displacing residents in rooming houses. There’s the hope that eventually supply will bring down Toronto’s soaring house costs, but it might be that more formal monthly arrangements are out of the reach of current rooming house residents (especially given that rent control rules have resulted in a 35-year drought on new purpose-built rental units).

In all of these cases, it’s possible to carve out a sacred principle and defend it. But you’re going to run into two problems with your advocacy. First, there’s going to be resistance from the middle of society, who have probably settled on the current trade-off because it’s the least offensive to them. Second, you’re going to find people on the other underserved extreme, convinced all the problems they have with the trade-off can be alleviated by the exact opposite of what you’re advocating.

Obamacare looked like it would be impossible to defend without Democrats controlling at least one lever of government. Republicans voted more than 50 times to repeal Obamacare. Now that they control everything, there is serious doubt that they’ll be able to change it at all. Republicans got drunk on the complaints of people on the long tails, the people worst served by Obamacare. They didn’t realize it really was the best compromise that could be obtained under the circumstances, or just how unpopular any attempt to change that compromise would be.

(To be entirely fair to Republicans, it seems like many Americans, including many of those who opposed Obamacare up until Obama left office, also just realized it was the best possible compromise.)

This is going to be another one of those posts where I don’t have a clear prescription for fixing anything (except perhaps axing rent control aka “the best way to destroy a city’s rental stock short of bombing it”). I don’t actually want to convince people – especially people left out of major compromises – not to advocate for something different. It’s only through broad input that we get workable compromises at all. Pluralistic society is built on many legitimate competing interests. People are motivated by different terminal values and different moral foundations.

Somehow, despite it all, we manage to mostly not kill each other. Maybe my prescription is simply that we should keep trying to find workable compromises and keep trying not to kill each other. Perhaps we could stand to put more effort into understanding why people ask for what they do. And we could try and be kind to each other. I feel comfortable recommending that.

Epistemic Status: Model

Model, Politics

To have lobbyists on your side

There is perennial debate in Canada about whether we should allow a “two-tiered” healthcare system. The debate is a bit confusing – by many measures we already have a two-tiered system, with private clinics and private insurance – but ultimately hinges on the ability of doctors to mix fees. Currently it is illegal for a doctor to charge anything on top of the provincially mandated fee structure. If the province is willing to pay $3,000 for a procedure, you cannot charge $5,000 and ask your patients (or their insurance) to make up the difference.

Supporters of a mixed system argue that it will alleviate wait times for everyone. Detractors argue that it will create a cumbersome, unfair system and paradoxically increase wait times. It’s enough to convince me that I don’t know what the fuck a two-tier healthcare system would have as its first order effects.

But I oppose it because I’m pretty sure I know what the second order effects would be.

It is a truth universally acknowledged that an industry, temporarily in possession of good fortune, must be in want of a really good lobbyist to make that possession permeant.

This is how we end up with incredibly detailed tax and regulatory law. There are a whole bunch of exceptions and special cases, vigourously lobbied for by special interest groups. These make us all a bit worse off, but each exception makes a certain person or small group of people very much better off. They care far more about preserving their loophole or unfair advantage than we do about getting rid of it, so each petty annoyance persists. Except, the annoyances aren’t so petty anymore when there are hundreds or thousands of them.

I dearly don’t want to add any more “petty” annoyances to healthcare.

As soon as we allow doctors to mix public funding with direct payments from patients or insurance, we’ll unleash a storm of lobbying. Everything from favourable tax treatment for clinics (we don’t charge HST on provincial care, it’s unfair to charge it on their added fees!) to tax breaks for insurance, to inflated fees for private clinics to handle some public cases will be on the table.

If the lobbyists do their job well, the private system will perch like a mosquito on the public system, sucking tax dollars from the public purse and using them to subsidize private care. This offends me on a visceral level, sure. But it’s also bad policy. Healthcare costs are already outpacing general inflation; we should not risk throwing fuel on that fire. We might end up with having the same sort of cost disease as America.

If we can keep healthcare relatively simple, we can keep it relatively cheap. One of the most pernicious things about cost disease is that it mainly affects things the government pays for. Because of this, the government has to collect more and more tax dollars just to provide the same level of service. As long as healthcare, education, and real estate are getting more expensive in real (inflation adjusted terms), we have to choose between raising taxes or making do with less service. When there are two systems, it’s clear that the users of the private system (and their lobbyists) would prefer decreased public services to increased taxes.

When there is only the public system, we force the lion’s share of those who plan to lobby for better care to lobby for better care in the public system [1]. This is true not just in healthcare; private schools are uncommon in most Canadian provinces. Want better school for your children? Try and improve the public schools.

There is always option to lobby for subsidies for private systems, but this has generally been unproductive when the public system is effective and entrenched. Two-tiered healthcare is back in the news because of a court case, not because any provincial government is committing political suicide by suggesting it. When it comes to schools, offering to subsidize private schools may have played a role in dooming John Tory’s bid for the premiership of Ontario in 2007.

I wonder if there isn’t some sort of critical mass thing that can happen. When the public system (be it healthcare, education, or anything else) is generally good, all but the wealthiest will use it. The few who use private systems won’t have the lobbying clout to bring about any specific advantages for their system, so there will be a stable equilibrium. Most people will use the public system and oppose changes to it, while the few who don’t won’t waste their time lobbying for changes (given the lack of any appetite for changes among the broader public).

If the public system gets substantially worse, those with the means to will leave the public system for the private. This would explain why generally liberal B.C. (with its decade of nasty labour disputes between the government and teachers) has much higher enrollment in private schools than in conservative and free-market-worshipping Alberta (which has poured decades of oil money largesse into its schools) [2].

Of course, the more people that use the private system, the more lobbying clout it gains. This model would predict that B.C. will begin to see substantial government concessions to private schools (although this could be confounded if the recent regime change proves durable). This model would also predict that if we open even a small crack in the unified public healthcare system, we’ll quickly see a private system emerge which will immediately lobby to be underwritten with public dollars.

From this point of view, one of the best things about public systems is that they force the best off to lobby for the worst off. Catch-all public systems yoke the interests of broad parts of society together, increasing access to important services.

If this model is true, then getting healthcare and education right are just the table stakes. It is vitally important that the provinces institute uniform rules and subsidies for embryo selection and future genetic engineering technologies. Because if they don’t, then in the words of Professor Jennifer Doudna, we will “transcribe our societies’ financial inequality into our genetic code”.

Both IVF and genetic screening are becoming easier and quicker. According to Gwern, it’s already likely a net positive to screen embryos for traits associated with higher later earnings (he lists seven currently screenable traits: IQ, height, BMI, and lack of diabetes, ADHD, bipolar disorder, and schizophrenia), with a net lifetime payoff estimated at $14,653 [3]. Unfortunately, this payoff is only available to parents who can afford the IVF and the screening.

Recently, Ontario began covering one round of IVF for couples unable to conceive. This specifically doesn’t include any genetic testing or pre-implantation diagnosis, which means that if we see a drop in heritable genetic diseases in the next generation, that drop will only be among the better off. Hell, even though Ontario already “covers” one round of IVF, they don’t cover any of the necessary fertility drugs, which means that IVF costs about $5,000 out of pocket. This is already outside the reach of many Ontarians.

Not a lot of people are running analyses like Gwern’s. Yet. We still have time to fix the coverage gap for IVF and put in place a publicly funded embryo selection program. If we wait too long here, we’ll be caught flat footed. The most effective way for rich people to get the reproductive services they will want wouldl be by lobbying for tax breaks and help for their private system, not for the improvement of a good-enough public system.

There’s a risk here of course. IVF isn’t particularly fun. It might be that the people with the longest time horizons (who are perhaps likely to be advantaged in other ways) will be the only ones who would use a public embryo selection system. This would have the effect of subsidizing embryo selection for whichever groups have the longest time horizons and the most ability to endure short-term discomfort for long term payoff.

But anything less than a public option on embryo selection makes entrenching social divides as genetic divides almost inevitable. We could ban all non-medical embryo selection, which, as Gwern points out, would just move it to China. Or Singapore [4]. Or even America. This would shrink the problem, in that fewer people would have access to embryo selection, but wouldn’t stop it altogether.

Embryo selection is just the beginning here too. Soon enough, we’ll see treatments for genetic diseases using CRISPR. Hot on the heels of that, we’ll see enhancements. Well, we ostensibly won’t in Canada, at least without some amendments to the Assisted Human Reproduction Act [5], which bans changes to the DNA of germline cells. I say “ostensibly” because it’s the height of naivety to assume that you can end demand simply by banning something, but then, that’s Canada for you.

The advent of CRISPR should usher in a sudden surge in genetically engineered humans. Parents will optimize for intelligence, height, and lower disease risk/load. It will be legal somewhere and therefore some Canadians will do it. If we have a legal, public system in Canada, then it will be available to anyone who wants it. If we don’t, then it will become very hard for the children of normal Canadians to compete with the children of our elites.

Throughout this post, I’ve assumed cost is no object. That’s probably a bad assumption. We’re talking about horrendously expensive voluntary medical procedures here. Gwern gives the cost of an IVF cycle with embryo selection at $22,000. There are 393,000 babies born in Canada every year. If this technology was both subsidized and adopted by 10% of all parents seeking to conceive, the total cost would be something like $864 million, or an increase in total healthcare spending of about 0.4%. Given that healthcare spending is allowed to grow by 3% per year, this would eat up more than 10% of the total yearly increase.

I’m not holding my breath for that sort of new spending on reproductive medicine. A more practical system would probably be a lottery, with enough spots for 1% of prospective parents. That has a more reasonable price tag of $86.4 million. While they’re at it, the government could start paying surrogates, egg donors, and sperm donors and institute a similar lottery there. I can dream about Canada having a functional fertility services industry, right?

A lottery isn’t my preferred solutions. Wealthy people who put their name in and aren’t drawn will still go elsewhere. But it could help with the lobbying problem. A lottery establishes a plausible path towards a broader system, which people would at least consider lobbying to expand. It won’t capture everyone. It might not even capture a majority. But if an expanded public system is the most palatable system politically, it might just win in the long run.

If you take just one thing from this post, I want it to be “it’s really important to have good public systems, so that lobbying effort is focused on improving those systems”. If you have room in your mind for another, it should be “having a public embryo selection and genetic engineering program in place is very important if we don’t want to social stratification to become much more permanent”.

Epistemic Status: Model

Footnotes

[1] In this post, I’m talking about industries where there is either a clear need to serve the public good, a market failure, or both. In these cases, “use markets to lower prices and increase services” is an unappealing alternative. ^

[2] This would also predict that America, with its cluster-fuck of a public school system would have generally higher rates of private schooling than neighbouring (and better performing on standardized tests) Canada. This is true – ten percent of American children are in private schools, compared to eight percent of Canadians. I think there is a smaller gap between the two then there otherwise might be, due to the extreme heterogeneity of American schooling. That is to say that Canadian public schools might be better than American public schools on average, but everything I’ve heard suggests that the standard deviation is much higher in America. Well off students going to good public schools may account for why America’s private school enrollment isn’t higher. ^

[3] This number will get higher and higher as we better understand the genetic determinants of IQ. ^

[4] Singapore has a history of hosting the biotech advances the west finds distasteful^

[5] This bill could perhaps be more truthfully be called the No Assisted Human Reproduction Act. In addition to banning germline genetic engineering, it also bans any paid surrogacy, egg donation, or sperm donation. This had the predictable effect of inconveniencing the wealthy not at all, while making it impossible for anyone else to find any surrogates, egg donors, or anonymous sperm donors. With a side-helping of encouraging surrogacy in countries where surrogates have the fewest legal protection (remember, my whole thesis here is that if you don’t give people a good pro-social option, they often optimize for maximum personal gain). ^

Biology, Politics

Medicine, the Inside View, and Historical Context

If you don’t live in Southern Ontario or don’t hang out in the skeptic blogosphere, you will probably have never heard the stories I’m going to tell today. There are two of, both about young Ontarian girls. One story has a happier ending than the other.

First is Makayla Sault. She died two years ago, from complications of acute lymphoblastic leukemia. She was 11. Had she completed a full course of chemotherapy, there is a 75% chance that she would be alive today.

She did not complete a full course of chemotherapy.

Instead, after 12-weeks of therapy, she and her parents decided to seek so-called “holistic” treatment at the Hippocrates Health Institute in Florida, as well as traditional indigenous treatments. . This decision killed her. With chemotherapy, she had a good chance of surviving. Without it…

There is no traditional wisdom that offers anything against cancer. There is no diet that can cure cancer. The Hippocrates Health Institute offers services like Vitamin C IV drips, InfraRed Oxygen, and Lymphatic Stimulation. None of these will stop cancer. Against cancer all we have are radiation, chemotherapy, and the surgeon’s knife. We have ingenuity, science, and the blinded trial.

Anyone who tells you otherwise is lying to you. If they are profiting from the treatments they offer, then they are profiting from death as surely as if they were selling tobacco or bombs.

Makayla’s parents were swindled. They paid $18,000 to the Hippocrates Health Institute for treatments that did nothing. There is no epithet I possess suitable to apply to someone who would scam the parents of a young girl with cancer (and by doing so, kill the young girl).

There was another girl (her name is under a publication ban; I only know her by her initials, J.J.) whose parents withdrew her from chemotherapy around the same time as Makayla. She too went to the Hippocrates Health Institute. But when she suffered a relapse of cancer, her parents appear to have fallen out with Hippocrates. They returned to Canada and sought chemotherapy alongside traditional Haudenosaunee medicine. This is the part of the story with a happy ending. The chemotherapy saved J.J.’s life.

When J.J. left chemotherapy, her doctors at McMaster Children’s Hospital [1] sued the Children’s Aid Society of Brant. They wanted the Children’s Aid Society to remove J.J. from her parents so that she could complete her course of treatment. I understand why J.J.’s doctors did this. They knew that without chemotherapy she would die. While merely telling the Children’s Aid Society this fact discharged their legal duty [2], it did not discharge their ethical duty. They sued because the Children’s Aid Society refused to act in what they saw as the best interest of a child; they sued because they found this unconscionable.

The judge denied their lawsuit. He ruled that indigenous Canadians have a charter right to receive traditional medical care if they wish it [3].

Makayla died because she left chemotherapy. J.J. could have died had she and her parents not reversed their decision. But I’m glad the judge didn’t order J.J. back into chemotherapy.

To explain why I’m glad, I first want to talk about the difference between the inside view and the outside view. The inside view is what you get when you search for evidence from your own circumstances and experiences and then apply that to estimate how you will fare on a problem you are facing. The outside view is when you dispassionately look at how people similar to you have fared dealing with similar problems and assume you will fare approximately the same.

Dr. Daniel Kahneman gives the example of a textbook he worked on. After completing two chapters in a year, the team extrapolated and decided it would take them two more years to finish. Daniel asked Seymour (another team member) how long it normally took to write a text book. Surprised, Seymour explained that it normally took seven to ten years all told and that approximately 40% of teams failed. This caused some dismay, but ultimately everyone (including Seymour) decided to preserver (probably believing that they’d be the exception). Eight years later, the textbook was finished. The outside view was dead on.

From the inside view, the doctors were entirely correct to try and demand that J.J. complete her treatment. They were fairly sure that her parents were making a lot of the medical decisions and they didn’t want J.J. to be doomed to die because her parents had fallen for a charlatan.

From an outside view, the doctors were treading on thin ice. If you look at past groups of doctors (or other authority figures), intervening with (they believe) all due benevolence to force health interventions on Indigenous Canadians, you see a chilling litany of abuses.

This puts us in a bind. Chemotherapy doesn’t cease to work because people in the past did terrible things. Just because we have an outside view that suggest dire consequences doesn’t mean science stops working. But our outside view really strongly suggests dire consequences. How could the standard medical treatment lead to worse outcomes?

Let’s brainstorm for a second:

  • J. could have died regardless of chemotherapy. Had there been a court order, this would have further shaken indigenous Canadian faith in the medical establishment.
  • A court order could have undermined the right of minors in Ontario to consent to their own medical care, with far reaching effects on trans youth or teenagers seeking abortions.
  • The Children’s Aid society could have botched the execution of the court order, leading to dramatic footage of a young screaming indigenous girl (with cancer!) being separated from her weeping family. Indigenous Canadians would have been reminded strongly of the Sixties Scoop.
  • There could have been a stand-off when Children’s Aid arrived to collect J.J.. Knowing Canada, this is the sort of thing that could have escalated into something truly ugly, with blockades and an armed standoff with the OPP or the military.

The outside view doesn’t suggest that chemotherapy won’t work. It simply suggests that any decision around forcing indigenous Canadians to receive health care they don’t want is ripe with opportunities for unintended consequences. J.J.’s doctors may have been acting out of a desire to save her life. But they were acting in a way that showed profound ignorance of Canada’s political context and past.

I think this is a weakness of the scientific and medical establishment. They get so caught up on what is true that they forget the context for the truth. We live in a country where we have access to many lifesaving medicines. We also live in a country where many of those medicines were tested on children that had been stolen from their parents and placed in residential schools – tested in ways that spit on the concept of informed consent.

When we are reminded of the crimes committed in the name of science and medicine, it is tempting to say “that wasn’t us; it was those who came before, we are innocent” – to skip to the end of the apologies and reparations and find ourselves forgiven. Tempting and so, so unfair to those who suffered (and still do suffer) because of the actions of some “beneficent” doctors and scientists. Instead of wishing to jump ahead, we should pause and reflect. What things have we done and advocated for that will bring shame on our fields in the future?

Yes, indigenous Canadians sometimes opt out of the formal medical system. So do white hippies. At least indigenous Canadians have a reason. If trips to the hospital occasionally for people that looked like me, I’d be a lot warier of them myself.

Scientists and doctors can’t always rely on the courts and on civil society to save us from ourselves. At some point, we have to start taking responsibility for our own actions. We might even have to stop sneering at post-modernism (something I’ve been guilty of in the past) long enough to take seriously its claim that we have to be careful about how knowledge is constructed.

In the end, the story of J.J., unlike that of Makayla, had a happy ending. Best of all, by ending the way it did, J.J.’s story should act as an example, for the medical system and indigenous Canadians both, on how to achieve good outcomes together.

In the story of Pandora’s Box, all of the pestilence and disease of the world sprung as demons from a cursed box and humanity was doomed to endure them ever more. Well we aren’t doomed forever; modern medicine has begun to put the demons back inside the box. It has accomplished this by following one deceptively simple rule: “do what works”. Now the challenge is to extend what works beyond just the treatments doctors choose. Increasingly important is how diseases are treated. When doctors respect their patients, respect their lived experiences, and respect the historical contexts that might cause patients to be fearful of treatments, they’ll have far more success doing what it is they do best: curing people.

It was an abrogation of duty to go to the courts instead of respectfully dealing with J.J.’s family. It was reckless and it could have put years of careful outreach by other doctors at risk. Sometimes there are things more important than one life. That’s why I’m glad the judge didn’t order J.J. back into chemo.

Footnotes:

[1] I have a lot of fondness for McMaster, having had at least one surgery and many doctors’ appointments there. ^

[2] Doctors have a legal obligation to report any child abuse they see. Under subsection 37(2)e of the Child and Family Services Act (CFSA), this includes “the child requires medical treatment to cure, prevent or alleviate physical harm or suffering, and the child’s parent refuses to consent to treatment”. ^

[3] I’m not actually sure how relevant that is here – Brian Clement is no one’s idea of an expert in Indigenous medicine and it’s not clear that this ruling still sets any sort of precedent, given that the judge later amended his ruling to “make it clear that the interests of the child must be paramount” in cases like this. ^