Reason Magazine - Topics > Medicine

Medicare Fraud: Big League Faking It

mriggs@reason.com (Mike Riggs) — Fri, 13 Jun 2008 10:53:00 EDT

How much more common would this problem be under a universal healthcare system?

Rita Campos Ramirez orchestrated what prosecutors call the largest health-care fraud by one person. Over nearly four years, she electronically submitted more than 140,000 Medicare claims for unnecessary equipment and services. She used the proceeds to finance big-ticket purchases, including two condominiums and a Mercedes-Benz....
Employees review fewer than 5 percent of the nearly 1 billion claims filed each year. The vast majority of claims shuttle through computer systems that are tweaked when authorities notice fraud patterns.

And how do the Medicare and Medicaid authorities respond to these crooks?

This year, [Centers for Medicare & Medicaid Services] is working to finalize a rule that would prevent convicted felons from obtaining Medicare billing numbers.

Looks like even a universal program would leave a few people high and dry.

Senior Editor Jacob Sullum with more Medicare madness. Senior Editor Radley Balko on Medicaid Fraud and the 4th Amendment.

Triumph of the Pill

jsamuel@reason.com (Juliet Samuel) — Tue, 03 Jun 2008 07:00:00 EDT

This past January, the prestigious science journal Nature conducted an online survey asking how many of its readers (who are primarily scientists and academics) had ever used "cognition-enhancing drugs," or brain dope. Perhaps unsurprisingly, the informal survey of 1,400 readers found that "one in five respondents said they had used drugs for non-medical reasons to stimulate their focus, concentration or memory." Moreover, Nature found that "a high four-fifths thought that healthy adults should be able to take the drugs if they want to."

In the absence of any large-scale studies measuring illicit prescription drug use among professionals, these results provide a highly suggestive counterpoint to the increasing hysteria over the abuse of "study drugs" by college students. After all, if some professors are doping up before hitting the books, why shouldn't undergrads do the same?

In fact, over the past decade, prescription stimulants such as Adderall and Ritalin—which are typically used to treat Attention Deficit Disorder (ADD)—have become increasingly available on college campuses. While studies disagree on the prevalence of stimulant "abuse" (that is, non-prescription use) among college students, the numbers suggest that anywhere between five and 15 percent of undergraduates have illicitly used such drugs to improve their academic performance. And while college health officials and various government scolds decry this trend as evidence of "drug abuse" by America's best and brightest, the reality is far from alarming.

Part of the growing concern about stimulants comes from the explosion in legal prescriptions doled out to kids. Between 1993 and 2003 the number of children's doctor's visits resulting in a stimulant prescription jumped from 2.7 million to 6.6 million. Over 10 percent of 10-year-old boys in America are now prescribed some kind of drug to control their unruly behavior, and the average starting age is getting lower. Parents are increasingly told that doping their little ones will make the children happy and successful. In 2000, psychiatrist Peter Breggin testified before Congress that, "Teachers, school psychologists, and administrators commonly make dire threats about their inability to teach children without medicating them." This trend is certainly worrying, not least because the long-term effects of regularly administered stimulants are as yet little understood.

So there are legitimate reasons to be concerned about child doping, particularly given the growing frequency of ADD diagnoses. But what about the strategic use of the same drugs by consenting adults, particularly college students? As usual, the law gets it backwards: While it is perfectly legal to feed—even force feed—Ritalin to a child, unsupervised use by knowledgeable grownups is a crime.

At the same time, it is remarkably easy to score prescription brain drugs at many of America's most prominent universities. A quick survey I conducted of stimulant-using students at Harvard reveals that it's possible to obtain a Ritalin prescription after one 20-minute consultation with a psychiatrist. One student, a sophomore who wishes to remain anonymous, obtained a script for amphetamine salts after just two appointments. He's pretty sure he doesn't have ADD, and he definitely never lied about or exaggerated his symptoms, which featured insomnia more prominently than the ADD hallmark of distractibility. Yet his psychiatrist readily prescribed the drugs. "It's not as if there's some medical authority making this decision for you," he told me afterwards. "Any reasonably capable person could walk out of there with just about whatever [drug]."

Still, there is widespread alarm about the possible health problems arising from unsupervised dosing. "Put the pills in the wrong hands and the results can be dangerous," NBC News warned. Henry Chung, Director of the New York University Student Health Center has warned that, "Students may have some kind of manic reaction or a seizure that could occur from taking these medications." For high doses, Chung is correct. But today's performance-enhancing undergraduates exhibit more responsibility than Chung realizes. One NYU senior I spoke to says it's mainly a case of "every now and again for finals. I don't know anyone who abuses Adderall or Ritalin." Moreover, "because they're prescription you can find out so much about them so you know how you can take it safely."

There is also the claim that student dopers—like testosterone-injecting athletes—are cheating because college is a competitive environment in which participants are obliged to play fair. Of course, this argument ignores the fact that most of the abilities being enhanced by such drugs are already unequally distributed (due to a mixture of biological and socioeconomic factors). Why is doping to achieve "normal" functionality a permissible act for ADD sufferers, but wrong for those seeking better grades or greater knowledge?

As the Nature survey suggests, responsible and successful adults dope up for a variety of professional reasons. There is no evidence that student doping is more dangerous or widespread than that done by their professors. Yet many university authorities are nonetheless determined to close Pandora's box. Unlike their Harvard counterparts, for example, students at the University of Michigan typically have to go through $1000 worth of psychometric tests before psychiatrists are willing to prescribe them any neuro-enhancing drugs. And doctors, of course, are loath to relinquish their power over patients.

It's time for such authority figures to admit that performance-enhancing drugs are already part of everyday life for a great many rational, healthy adults and that their use can no longer be dismissed under the title of "abuse" or "cheating."

Juliet Samuel is a writer living in Boston.

Where in the World Can We Do the Most Good?

rbailey@reason.com (Ronald Bailey) — Mon, 26 May 2008 12:00:00 EDT

Copenhagen, May 25—The opening press conference for the Copenhagen Consensus Center's 2008 conference took place in one of the gilt-edged ballrooms at the Moltkes Palace. The action unfolded beneath a bas-relief depicting heroic Danish burghers in top hats carrying a banner supplemented by bas-reliefs on pilasters portraying such everyday tools as hammers, pliers, squares, and drawing compasses. The PowerPoint question displayed on the screen behind the head table of notables was, "Where can we do the most good for the world?" Danish Prime Minister Anders Fogh Rasmussen began, "The Copenhagen Consensus is a simple but powerful idea. The world faces a number of serious challenges. We only have limited means to solve them, so where do we start?"

That's the question that the Copenhagen Consensus Center conference for 2008 (CC08) will try to answer this week. The Copenhagen Consensus Center is the brainchild of "skeptical environmentalist" Bjorn Lomborg. Headquartered at the Copenhagen Business School, the CC08 is convening leading economic experts with the aim of ranking 10 of the world's biggest problems. The expert panel is supposed to figure out which ones should receive priority and which should be bumped further down the queue. To make the exercise concrete, the experts are notionally deciding what challenges should be allocated an "extra" $75 billion in foreign aid over the next four years.

Among the experts are Nobel Prize winners in economics Vernon Smith, Thomas Schelling, Douglass North, Robert Mundell, and Finn Kydland. Other expert panelists include economists Nancy Stokey from the University of Chicago, Jagdish Bhagwati from Columbia University, and Francois Bourguignon from the University of Paris. The experts are considering detailed reports by prominent international researchers regarding ten challenges, including air pollution, armed conflicts, diseases, education, global warming, malnutrition and hunger, sanitation and access to clean water, subsidies and trade barriers, terrorism, and women and development. In each area, the researchers define the problem, suggest options for solving the problem[*], and assign a benefit-to-cost ratio (BCR) to each solution. The higher the BCR, the more cost-effective the solution is.

Prime Minister Rasmussen concretized the value of the CC08 exercise by referring to the earlier version in 2004. He noted that in 2004, CC04 participants put controlling the HIV/AIDS epidemic in developing countries at the top of the list. Consequently, the Danish government began to devote a higher proportion of its overseas development aid to combating that disease, doubling the aid from $100 to $200 million per year by 2010.

Rasmussen got ahead of the 2008 deliberations a bit when he turned to the subject of climate change. He argued that the case for action is strong, and that the world needed to cut its greenhouse gas emissions. To address the problem, Rasmussen called for "a new Green industrial revolution and a new Green world economy." Interestingly, the 2004 Copenhagen Consensus report ranked measures to address climate change at the very bottom, finding that proposals for carbon taxes and implementing the Kyoto Protocol would have costs that "were likely to exceed the benefits."

Of course, the prime minister is likely making politic noises as he gears up to host the 2009 United Nations Climate Change Conference. At that meeting in Copenhagen, governments are expected to adopt a comprehensive new global warming treaty on climate change. Lomborg opposes stringent limits on greenhouse gas emissions as not being cost effective when it comes to helping poor people. At the end of the week, we'll see what the experts say this time.

Lomborg followed the prime minister, claiming that the Copenhagen Consensus is not about doing what's fashionable, but instead focuses on doing what's rational. He pointed out that politicians and activists often argue that we should solve all problems. But the fact is that in a world of scarce resources, a couple of big issues will get the bulk of the available resources. Trade-offs have to be made. When Lomborg is speaking of resources, he is basically talking about foreign development aid. What the Copenhagen Consensus hopes to do is help donors, both public and private, to spend their money is ways that solve the most urgent problems.

To illustrate how issues might be ranked, Lomborg cited some findings from a paper dealing with the challenge of disease. Spending $1 billion on controlling tuberculosis would save 1 million lives and result in estimated benefits of $30 billion for a benefit-cost ratio of 30 to 1. Spending $200 million on treating heart disease in poor countries (which accounts for 25 percent of deaths in those countries) with an inexpensive "polypill" combining aspirin and statins would produce $5 billion benefits implying a 25 to 1 benefit-cost ratio. And a $1 billion spent on malaria produces a benefit-cost ratio of 20 to 1.

During the question and answer period, I noted that the CC08 process looks to shower money on problems, but does not address many of the institutional impediments for making sure that the money would actually be spent effectively. In fact, I suggested, the reason poor countries are poor is because they do not have effective governance and economic institutions. Lomborg responded that of course institutions are important, but the Copenhagen Consensus was focusing chiefly on "what can money do to help." He pointed out that the Copenhagen Consensus conference in 2004 considered corruption as an issue, but couldn't figure out how spending money would be able to help fix that problem. Earlier Prime Minister Rasmussen correctly observed, "No problem has ever been solved only by throwing money at it. We must prioritize." Unfortunately, as New York University development economist William Easterly has documented, the West has thrown $2.3 trillion dollars in aid to poor countries during the past five decades without much to show for it.

Lomborg further suggested that institutional analysis could be implicit in deciding how to prioritize the challenges. For example, if the experts decide that corruption or lack of private property rights would get in the way of effectively deploying money to solve a specific problem, they could give it a lower priority.

The deliberations of the expert panel are private, but all of the research papers and respondents to them will present their work to a forum of 80 young people drawn from 37 different countries during the week. These presentations are public and I will be reporting on their findings in daily dispatches from Copenhagen.

Ronald Bailey is reason's science correspondent. His book Liberation Biology: The Scientific and Moral Case for the Biotech Revolution is now available from Prometheus Books.

Disclosure: Danish taxpayers are paying my travel expenses to attend CC08. There are no conditions placed upon my reporting.

For live webcasts from CC08, go here.

[*]: Corrected from an earlier version that, due to an editing error, implied only two options were suggested.

Salty Fears

jsullum@reason.com (Jacob Sullum) — Thu, 22 May 2008 11:46:00 EDT

A new analysis of data from the National Health and Nutrition Examination Survey (NHANES) finds that high salt consumption is not associated with an increased risk of cardiovascular disease. In fact, the subjects who consumed the least salt (but who were not on special low-salt diets because of pre-existing conditions) were 80 percent more likely to die from cardiovascular disease than the subjects who consumed the most salt. "Our findings suggest that for the general adult population, higher sodium is very unlikely to be independently associated with higher risk of death from CVD or all other causes of death," says the lead author. These results, which are consistent with earlier analyses of NHANES data, further undermine the recommendation from government health agencies that everyone should strive to reduce salt intake.

By contrast, a 2007 study found that patients who reduced their salt consumption substantially (by 25 to 35 percent) were 25 percent less likely to develop cardiovascular problems than a control group that did not cut back on salt. But these subjects all had "high-normal" blood pressure, which is consistent with the idea that salt reduction is beneficial only for a subset of the population with pre-existing risk factors. Although the weight of the evidence after decades of research supports this understanding of the relationship between salt intake and cardiovascular disease, public health officials and activists (and the doctors and journalists who parrot them) continue to insist that salt is Bad for You, no matter who you are or what your medical condition is.

I noted the Center for Science in the Public Interest's demonization of salt in my 2003 reason story about the group. Gary Taubes reviewed the long-running controversy over salt's health effects in a classic 1998 Science article.

A Pill a Day Keeps the Doctor Away?

kmw@reason.com (Katherine Mangu-Ward) — Wed, 14 May 2008 10:58:00 EDT

More than half of Americans now take prescription meds to treat chronic health problems, according to a new study out today. The study is being played as bad news, with the wire services quoting doctors proclaiming that "things will get worse instead of getting better" and chalking the problem up to our "couch potato culture."

But digging deeper into the study reveals that much of the increase is the result of good preventive treatment for diseases that were once debilitating or fatal, like the use of allergy medication and steroid treatments to prevent asthma flareups in kids, and higher rates of antidepressant use, especially among young women.

(For more on the latter topic, re-read reason contributor Will Wilkinson's excellent article on whether an epidemic of depressive disorder is sweeping America. Answer: Not really)

There's no doubt Americans have brought many cases of diabetes and hypertension on themselves by being lazy fatties. Chronic medication use is growing fastest among young people, but the real heavywights continue to be the oldsters. Drug use grows steadily because as we live longer the ol' bod just starts to experience wear and tear, as in the case of arthritis.

Plus, we aren't just a nation of unreflective pill poppers: Rates of use for hormone replacements fell by half in 2007 when news broke about potential side effects. People are, at least in many cases, educated consumers of all those meds.

One doctor, at least, saw a "silver lining": "People are receiving treatment which can prevent more serious health problems down the road."

Aussie Doc Proposes $47,000 per Donated Kidney to Relieve Chronic Shortages

gillespie@reason.com (Nick Gillespie) — Mon, 05 May 2008 07:37:00 EDT

An Australian doctor has proposed that the government pay up to $47,000 for kidney donations to overcome a chronic shortage.
The suggestion has touched off debate around the country on the idea, which critics say will end in the poor selling their organs to the rich.
Kidney specialist Gavin Carney says allowing the sale of organs would save thousands of lives and billions of dollars in care for patients on transplant waiting lists.
He also says it would stop people from buying organs on the black market in developing countries, where they pursue risky, unregulated surgeries.

And the predictable response from the Aussie medical establishment, despite the country's low rate of donation? Don't even think about it: "The idea was dismissed by Health Minister Nicola Roxon, who said Australians would not be allowed to market their organs.

A few weeks ago, reason.tv host Drew Carey looked at how open markets in human organs would make everybody involved much better off.

Check it—and a ton of relevant resources—here.

Opening Up the Dental Market Is Like Pulling Teeth

jsullum@reason.com (Jacob Sullum) — Fri, 02 May 2008 11:44:00 EDT

Years ago I wrote an article for reason (not available online) that explored the cost-controlling potential of allowing nurse practitioners, physician assistants, and other non-M.D.s to offer services traditionally performed by doctors. Not surprisingly, organized medicine tends to resist these inroads, especially when it comes to operating independently and prescribing drugs. But judging from a recent New York Times story, dentists have been even more effective at fighting off competition from people who have less than the conventional seven or eight years of post-secondary education. The Times reports that "dental therapists," who undergo two years of intensive training after high school, can do basic dental work such as filling cavities and extracting teeth, serving people who otherwise might not get dental care at all. If you've never heard of dental therapists, that's not surprising: Although research indicates their work is just as competent as the average dentist's, they are permitted to operate only in Alaska, under a federally funded program serving people in sparsely populated areas.

Even this limited experiment has drawn fierce opposition from the Alaska Dental Society and the American Dental Association, which say dental therapists threaten ~~dentists'~~ ~~income~~ patients' welfare:

The opposition to therapists follows decades of efforts by state dental boards, which are dominated by dentists, to block hygienists from providing care without being supervised by dentists.
The dental associations say they simply want to be sure that patients do not receive substandard care. But some dentists in public health programs contend that dentists in private practice consider therapists low-cost competition. In Alaska, the federally financed program that supplies care to Alaska Natives pays therapists about $60,000 a year, one-half to one-third of what dentists typically earn....
The American Dental Association...says it does not fear lower-cost competition but instead wants to protect patients from inadequately trained therapists, who may not be able to handle the emergencies, like uncontrolled bleeding, that sometimes occur during routine procedures.

So it's better for someone with a bad cavity to suffer constant pain or yank his own tooth than it is to run the risk of "uncontrolled bleeding" during a visit to a dental therapist. The other argument against dental therapists is even more blatantly paternalistic:

In the long run, the only way to improve dental health is encourage people to take better care of their teeth, Dr. [Amid] Ismail [an ADA consultant] said.
"I'm not in favor of training just to fill teeth, because a solution of filling teeth is not going to reduce disease," he said. "The patients will go home, and they will drink six cans of soda a day, and they will come back with more cavities."

But if the government forces them to suffer with unfilled cavities by blocking access to low-cost dental care, maybe they'll learn to lay off the soda and brush and floss regularly. They'll be better off in the long run!

More DNA Day Fun: To Test, Or Not to Test?

kmw@reason.com (Katherine Mangu-Ward) — Fri, 25 Apr 2008 12:19:00 EDT

In honor of DNA day:

Congress reached an agreement clearing the way for a bill to prohibit discrimination by employers and health insurers on the basis of genetic tests...
[The bill] would make it illegal for health insurers to raise premiums or deny coverage based on genetic information, and would prohibit employers from using such information for decisions on hiring, firing, promotions or job assignments.

Everybody's favorite fillibusterin' Republican Tom Coburn of Oklahoma has been delaying the bill, but it looks like it's about to shake loose. Coburn says he was worried about a new lawsuit boom as people with genetic conditions sued employers, insurers, or any body who looked at them cross-eyed. Some additional legal protections for employers have been added to the bill in the form of a "firewall" between insurer and employer sections of the bill, so it will mostly affect people looking to get individual health insurance plans.

We're bound to see more debate in this area as the science improves and the price of genetic testing comes down--this particular legislation took 13 years to make it through Congress. On one hand, people are afraid to do (potentially lifesaving) genetic tests right now because they're worried about future insurabiity--surely a suboptimal state of affairs. On the other hand, employers will discriminate on certain conditions, no matter what the law says, and in many cases, they ought to be able to. Why should we demand, for example, that a company invest in training an employee that it knows will likely to be out of commission due to illness in the near future?

And then there's this slippery slope:

[The bill] does not prohibit discrimination once someone already has a disease, and some experts said such protection would have to be the next step.
“You don’t want to be denied health insurance when you are at risk for breast cancer,” said Sonia M. Suter, an associate professor at George Washington University Law School. “But it seems to me you really don’t want to be denied health insurance when you have breast cancer.”

Our insurance system is pretty broken at this point, but layering on legislation requiring insurers and employers to ignore the information made available by quickly evolving science and medicine doesn't seem likely to help much.

Charles Nelson Reilly Has a Tax-Induced Headache

gillespie@reason.com (Nick Gillespie) — Tue, 15 Apr 2008 11:57:00 EDT

Want to know the true barbarity of tax state? Check out this old Excedrin ad in which Charles Nelson Reilly (!?!?) is reduced to a stammering heap of jelly during a tax audit for claiming that a fur coat he bought for "a m-m-model" is a "legitimate business expense." He "owns a dress line," fer chrissakes.

Everyone feels like a criminal on tax day!

Does Leviathan know no bounds? And does Excedrin really have four (count 'em) ingredients, including an anti-depressant?

Both Sides Now—and We Hate That

jsullum@reason.com (Jacob Sullum) — Mon, 14 Apr 2008 11:19:00 EDT

Over at The Huffington Post, reason contributor Maia Szalavitz notes that Kansas physician Stephen Schneider and his wife, Linda, who are accused of drug trafficking through improper painkiller prescriptions, have managed to get their side of the story out with the help of the Pain Relief Network. The usual practice in cases like this is to convict the defendant in the press, which typically depicts his practice as nothing but a "pill mill" and rarely covers patients who are grateful for desperately needed pain relief. In the Schneiders' case, Szalavitz writes, "The AP has covered the story as one with two sides—including the legitimate need for access to pain relief, not just focusing on the prosecution's storyline of evil doctors pushing patients into addiction." Federal prosecutors have responded by seeking a gag order that would not only prevent the Schneiders and their lawyers from publicly discussing the case but silence Pain Relief Network President Siobhan Reynolds as well. Shouldn't they also have asked the judge to prevent people from talking about the gag order?

Szalavitz on pain doctor prosecutions here. More reason coverage of the subject here.

Now Playing at Reason.tv: Drew Carey on Human Organ Markets

Tue, 18 Mar 2008 07:00:00 EDT

In his most controversial segment yet, reason.tv host Drew Carey offers a startling solution to the critical shortage in kidneys available for transplant: Pay people to donate their kidneys.

Featuring former reason editor—and organ donor—Virginia Postrel.

Click on the image below to watch "Organ Transplants: Kidneys for Sale."

Like Taking Air From Fogies

kmw@reason.com (Katherine Mangu-Ward) — Tue, 04 Mar 2008 13:27:00 EST

The Bush administration has suggested to Congress that it cut Medicare home oxygen reimbursements by $6.8 billion over 10 years to help fund the annual Farm Bill, according to a Department of Agriculture letter sent to lawmakers March 2.

Right now, wheezers are entitled to 36 months of O2 after getting out of the hospital. The letter suggests trimming that to 13 months.

This is bound to be a real publicity coup for Bush and for the farm lobby--something that House Agricultural Committee Chair Collin Peterson (D-MN) noted in his speech to the farm lobby in Las Vegas on Monday:

When it comes to the oxygen cuts, he suggested the idea was not politically astute, according to a recording of his speech posted at www.agri-pulse.com.
“Some of our critics would probably have a field day if we are taking payments away from people on oxygen and they would say we are giving it to wealthy farmers, probably,” Peterson said.

The quotes (and links) above are from InsideHealthPolicy.com, behind the subscription wall. You can see another writeup here.

Shouting "Screw You" At Prozac

bdoherty@reason.com (Brian Doherty) — Fri, 29 Feb 2008 20:35:00 EST

Found via Kevin Drum at the Washington Monthly, an interesting new metastudy written up in the UK Guardian that casts doubt on the effectiveness of such SSRIs and SSNIs commonly prescribed for depression as Prozac and Effexor.

An excerpt from the Guardian account:

The study examined all available data on the drugs, including results from clinical trials that the manufacturers chose not to publish at the time. The trials compared the effect on patients taking the drugs with those given a placebo or sugar pill.
When all the data was pulled together, it appeared that patients had improved - but those on placebo improved just as much as those on the drugs.
The only exception is in the most severely depressed patients, according to the authors - Prof Irving Kirsch from the department of psychology at Hull University and colleagues in the US and Canada. But that is probably because the placebo stopped working so well, they say, rather than the drugs having worked better.
"Given these results, there seems little reason to prescribe antidepressant medication to any but the most severely depressed patients, unless alternative treatments have failed," says Kirsch.
The paper, published today in the journal PLoS (Public Library of Science) Medicine, is likely to have a significant impact on the prescribing of the drugs.
.........
The pattern they saw from the trial results of fluoxetine (Prozac), paroxetine (Seroxat), venlafaxine (Effexor) and nefazodone (Serzone) was consistent. "Using complete data sets (including unpublished data) and a substantially larger data set of this type than has been previously reported, we find the overall effect of new-generation antidepressant medication is below recommended criteria for clinical significance," they write.

From my own perspective on the rolling juggernaut of psychatric medicine, I somehow doubt the optimistic "likely to have a significant impact" bit. Especially given Kevin Drum's observation on how little play this has gotten in American media, which still seems to be the case.

Drum's comment thread is very interesting and worth at least skimming for those who care about this topic. Lots of people jousting with the results, some of them of the level of intellectual sophistication of those who note that, damn, that horoscope that day really described exactly what I was going through; others raise the notion that the study might be misleading for either conflating some drugs that work with others and dragging down the working drugs average, or for mixing subjects who really are depressed with a bevy of people to whom the drugs were misprescribed and thus don't work.

The full study, from the open-access Public Library of Science.

Ronald Bailey wrote back in July 2007 for reason on the fascinating world of public access open source scientific journals such as Public Library of Science.

This July 2007 reason feature by me touches on some of the things that psychiatric medical science can't quite tell us.

And see this July 2000 reason interview with psychiatric critic Thomas Szasz, conducted by Jacob Sullum.

Your Computer Is Smarter Than Your Doctor

kmw@reason.com (Katherine Mangu-Ward) — Mon, 25 Feb 2008 15:09:00 EST

Screw Deep Blue, the computer on which you're reading this blog post can diagnose Alzheimer's--better than a doctor.

From a new study in the scientific journal Brain.

Experts taught a standard computer how to diagnose Alzheimer's from brain scans, and got a 96% success rate.
The accuracy of diagnosis from standard scans, blood tests and interviews carried out by a clinician is 85%.

reason pits man vs. machine here and here.

Israel Stiffens Defenses

gillespie@reason.com (Nick Gillespie) — Thu, 07 Feb 2008 18:00:00 EST

It might harm their reputation, but Israel's air force is considering giving its combat pilots Viagra to improve their performance in the air.
A recent study conducted by Israeli doctors among mountain climbers in Africa found a link between erectile dysfunction drugs and improved performance in high altitudes, the mass-selling Yediot Aharonot reported.

More here.

Via Dan Gifford.

Nonaddictive Morphine?

jsullum@reason.com (Jacob Sullum) — Thu, 31 Jan 2008 13:18:00 EST

University of California at San Francisco researchers say they've genetically engineered mice that can receive morphine on a regular basis without developing tolerance or physical dependence. They believe the success of their genetic manipulation may point the way to developing a strong painkiller that patients can take over an extended period without increasing the dose to maintain effectiveness or worrying about withdrawal symptoms. Those certainly would be welcome improvements for patients in pain, but it would not, contrary to the UCSF press release about the research, "block dependency" or eliminate the possibility of addiction.

Both the university press office and the researchers themselves seem to be equating addiction with tolerance (the need for escalating doses to achieve the same effect) and physical dependence (the adaptation that results in withdrawal symptoms when a drug is suddenly withdrawn). Anyone who takes narcotics long enough and regularly enough will develop tolerance and physical dependence, but addiction requires a persistent desire to use the drug for its psychoactive effects. According to the American Psychiatric Association, tolerance and withdrawal are neither necessary nor sufficient for a diagnosis of drug dependence, and this is one of the rare occasions when I agree with the APA.

Otherwise, we'd have to say that everyone who regularly uses narcotics for pain becomes addicted to them, even though only a small percentage end up using such drugs for nonmedical reasons. We'd also have to go back to saying that drugs such as nicotine and cocaine (use of which does not lead to the clear, predictable tolerance and withdrawal associated with narcotics) are not truly addictive but merely habit-forming, a distinction without a difference. And if addiction were defined as tolerance plus withdrawal, it would not be meaningful to speak of addiction to things other than drugs that provide pleasure or relieve stress, such as gambling, sex, or shopping. Addiction is a pattern of behavior, not a chemical reaction; in the case of drugs, it resides in the person's relationship with the substance, not the substance itself.

Still, it's true that you don't often hear of addiction to aspirin or ibuprofen. If a drug company could produce a painkiller as strong as morphine that had no psychoactive effects, it would not be attractive to people seeking to get high or soothe their unhappiness. Then it would make sense to call the drug nonaddictive.

[Thanks to CK for the tip.]

Will Britney Spears Place a Call to Thomas Szasz?

gillespie@reason.com (Nick Gillespie) — Thu, 31 Jan 2008 07:26:00 EST

Pop diva (whatever that means!) Britney Spears is back in the hospital, this time apparently committed for psychological evaluation by her doctor and/or family:

Los Angeles Police officers physically removed pop star Britney Spears from her home early today, placing the troubled celebrity on a "mental health evaluation hold," authorites said....
This is the second time in a month that Spears has been placed on a 72-hour welfare hold. The first occurred on Jan. 3, when Spears declined to give up custody of her children to ex-husband Kevin Federline.

More here.

I am curious as to what Hit & Run readers--and the wide, wide world, too, of course--think generally about the topic of involuntary commitment. Is it ever justified? If so, when? And if so, shouldn't Britney have been committed at some point before or at the very latest during her infamous Video Music Awards number?

reason on the topic here.

Brian Doherty on the chilling catalog of mental-health industry abuses Mad in America here.

Jacob Sullum interviewed contributing editor and arch-critic of the "medicalization" of American life, Tom Szasz, in 2000. Whether you agree with Szasz in part or whole or not at all, that Q&A is well worth reading.

Rocketship Rudy Sets His Sights on Mars!

kleinp@spectator.org (Philip Klein) — Tue, 29 Jan 2008 17:00:00 EST

Tampa, Florida--"I hate pandering... have all my life," Rudy Giuliani once told Newsmax. "It's one of the worst characteristics that politicians have--pandering to people...There's a dishonesty in that that really offends me."

That was in 2006. This year, the former mayor of New York City is trying to win an election. With his national lead eroded and his presidential candidacy on the brink, Giuliani has staked everything on winning today's Florida primary. In the process, he has developed a strange new appreciation of the space program and the perils of the homeowner's insurance market.

"We're going to get to Mars before anyone else gets there," Giuliani boasted at a rally on Monday by the Orlando Sanford International Airport. "And we're going to reestablish our space program and eliminate that gap, so we can get our people up to the space station ourselves. That's something I learned about here in Florida, and I am committed to doing it."

Beyond supporting an industry that is an important part of the state's economy, Giuliani's main gambit to win votes and influence people in the Sunshine State has been getting behind something called the National Catastrophic Fund. Under this proposal, the federal government would help in the event of a major natural disaster, which would spread risk and thus allow insurers to offer more affordable homeowner's polices to residents of hurricane-prone Florida.

"The idea is to be there with a backstop that will allow a private market to work so that people who have risk will pay more but at least they'll have insurance that [isn't] excessive," Giuliani explained last week.

Contrary to Giuliani's assertion, the private market in Florida is functioning quite efficiently, because it is sending homeowners the signal that it'll cost them if they choose to live in an area in which there is a high risk of a hurricane. To artificially lower insurance rates would only encourage more people to move to the state, meaning more costly storms in the future. Giuliani's response to critics is that the federal government ends up stepping in anyway, so being proactive is actually the more fiscally conservative thing to do.

At every campaign stop "America's Mayor" has been touting the fact that he is the only Republican in the race that supports the National Catastrophic Fund, and he took out a television ad educating voters on his position. During last Thursday's debate, when Giuliani had the opportunity to ask a question to one of his rivals, the former prosecutor grilled former Massachusetts Gov. Mitt Romney on his lack of enthusiasm for the giveaway.

Yet Giuliani has received very little in return for taking such a strong stand on the fund and the desperate need for a publicly funded Mars expedition. His poll numbers have continued to dwindle in the state, and Florida's GOP Gov. Charlie Crist, a leading proponent of the idea, ended up endorsing Sen. John McCain, who said no to the fund.

To be sure, not all economic pandering is created equal. While Giuliani doesn't have much to show for his efforts, Mitt Romney's latest incarnation as a born-again John Edwards has paid enormous dividends.

After defeats in Iowa and New Hampshire, where he had spent tens of millions of dollars, Romney's chances of capturing the Republican nomination seemed slim. But in Michigan, he won by promising to save the auto industry and fight for every job, and he has continued to echo populist themes in Florida. At campaign stops here, Romney talks about the "economic squeeze" and "help[ing] middle class families make ends meet."

After spending most of last year running away from his Massachusetts health care plan, Romney now fully embraces it, defending the various mandates that are part of the program. He has been promising that as president, he'll work to get every American insured.

Not only is Romney pushing the idea of universal health care, but according to a report in the Politico, his campaign has attempted to woo senior citizen voters in Florida with robo calls attacking the frontrunner McCain for voting against "the AARP-backed Medicare prescription drug program."

That multi-trillion-dollar entitlement program has served as a monument to President Bush's betrayal of limited government principles, and the AARP has been the biggest obstacle to achieving entitlement reform because of its use of scare tactics directed at its elderly members. The idea that Romney, who is trying to portray himself as an economic conservative, would employ similar scare tactics to assail a rival for opposing the boondoggle is staggering. Yet many conservatives have concluded that Romney is their last hope of stopping McCain, whom they dislike on immigration, campaign-finance reform, and other issues. So they are giving the former Massachusetts governor a free pass on his dash to the left on economic issues.

In the primaries so far, McCain himself has avoided the type of economic pandering that his rivals have engaged in, and it has been greeted with mixed results. He had a better-than-expected showing in Iowa despite his opposition to ethanol subsidies. And his refusal to endorse the idea of a catastrophic fund didn't cost him the endorsement of Gov. Crist. In the span of a few weeks, he improbably went from also-ran to the head of the GOP pack, both in Florida and nationally.

Which isn't to say he hasn't paid a price in the campaign.

"We went to Michigan, and we told them the truth," McCain recounted at a Tampa rally Monday night, referring to his acknowledgement that auto industry jobs leaving Detroit weren't coming back. He then joked, "They didn't like it much."

Philip Klein is a reporter for The American Spectator.

Discuss this story at reason's Hit & Run blog.

The Pharmacy of the Future and You

rbailey@reason.com (Ronald Bailey) — Wed, 23 Jan 2008 12:30:00 EST

One of the perennial concerns of conservative bioethicists like Leon Kass and Francis Fukuyama is that some portion of humanity will rush to adopt various biotech enhancements to their detriment. In his essay "Disenchantment," from Philosophers Without Gods: Meditations on Atheism and the Secular Life, University of Sheffield philosopher David Owens worries about the problems that future neuro-enhancements will pose.

Owens posits this case: You have developed some nagging doubts about your partner's fidelity. Although you sometimes think your doubts are irrational, you remember certain lingering looks at parties, and your happiness is spoiled. You're not the sort to hire a private detective, but you have heard of a new pharmaceutical, the anti-doubt pill, Credon. Credon lulls your suspicious nature, but doesn't make you gullible to car sales people. It works only in the context of intimate relationships. The manufacturer does warn that Credon has sometimes generated excessive trust between lovers. So off you go to "The Pharmacy of the Future" for Credon.

Once there, the conscientious pharmacist confirms that Credon does usually work, but asks if you've considered alternative treatments. For example, why not take the new anti-possessiveness pill Libermine? Patients using Libermine don't care if their partners have an occasional fling. Or why be a couple at all? Solox, the emotional independence pill, enables patients to have a wide and emotionally satisfying circle of friends but liberates them from the tedium of having only one intimate partner. Owens then posits that the price of Credon is about as much as for a candy bar, while Libermine and Solox costs as much as good bottle of wine. So on what grounds do you choose among these options?

Owens suggests that one response might be that it's "normal" to want to be in relationship. The pharmacist reminds you that people born with extra Solox in their brains are just as "natural" as people without it. Surely you would agree that such free spirits should not be regarded as somehow inadequate. Another response is that taking Libermine would so change you that you wouldn't be you anymore. Of course, the whole point of taking Credon is to change you so that you, in some respects, aren't you anymore.

So why not flip a coin? Would that mean that the choice doesn't matter any more to you than choosing between two brands of coffee? Surely one's emotional state and the state of one's most intimate relationship should matter more than choosing between Bustelo and Starbucks.

Let me now quote Owens at length:

"For Trotsky, the better we understand how human beings work, the freer we shall be. But The Pharmacy of the Future suggests that the more we learn about ourselves, the less free we will be. A scientific understanding of man is a threat to our freedom because it undermines our capacity to govern our own lives by making decisions. If man is just a bag of chemicals, once we know what these chemicals are, we can re-mix them at will. And by re-mixing them at will, we can give ourselves whatever character we like. But if we can choose a character at random, our current needs and interests lose their authority as grounds for making any decision. And what other grounds for making decisions are there?"

What other grounds might people use to justify their decisions? "In Western Europe, religious belief used to be the source of those fixed points that make decision making possible," writes Owens. "In the rest of the world, it still is." Owens laments that scientific disenchantment is undercutting the authority of religious belief.

The "fixed points" supplied by religious belief may have been useful guides in earlier, less prosperous times. Before the 20th century, most women who bore children out of wedlock could not earn enough to support them, so religion sanctioned stoning and honor killing to discourage fornication. Another previously "fixed point" in Western Europe was that divorce was not permitted. With prosperity and the advent of effective birth control pills and pharmaceutical abortions, the "fixed points" of religiously sanctioned stoning and marriage-for-life were overthrown. Americans and other modern societies are still working out how the pill and burgeoning prosperity have shifted the battle lines in the immemorial war between the sexes, but stoning as a punishment for fornication is still condoned only in some backwards regions of the world. That will change as the 21st century progresses. So even some guides long-established by religion are not "fixed." (On the other hand, given everyone's interest in the preservation of their bodies, one point that is fixed is that murder is wrong.)

Owens' larger concern seems to be an anxiety about authenticity. Are you the real you? But what is the real you? Were you, you, when you 10 years old? 20? 45? Were you the real you before you had graduated college? Were married? Were a parent? Were you more real when you were shy before you "came out of your shell" after joining the basketball or debate team? Are you the real you when you drink coffee to boost your concentration in order to finish that new sales report? Or are the real you when you take Viagra to boost your sexual performance? Turn the question around: are people who choose to use Viagra, cosmetic surgery, hair-coloring, propranolol to overcome stage fright, fakes? A strong case can be made that people who take advantage modern technologies are seeking to become more authentically who they believe themselves to be. Demands for authenticity turn out to be just a way for other people to impose their views of your proper social status on you.

Owens concludes that religious "beliefs may all be delusions but, as technology advances, the need for such fixed points becomes more, not less pressing." However, as we've seen, such "fixed points" don't really exist. Owens wants to liken the human journey to following the signposts of a well-marked Rand-McNally atlas. Instead, humanity is a team of explorers who constantly push forward into undiscovered territories. With many false starts and dead ends, we chart the map of the future as we go along. Like all analogies, the map analogy is inexact—we not only make the map, we also create the landscape of human possibilities through which we travel.

Another way to think of it is that we are not following a pre-determined blueprint as we build our societies. We are constructing the scaffolding and the edifice as we go along. Sometimes whole wings which housed us for a long time must be dismantled and rebuilt to fulfill our new requirements.

Just as humanity is still learning how to use the contraceptive pill and to handle divorce, so too will we engage in a process of trial-and-error social learning about how to use (or not) new psycho-pharmaceuticals. Not only is that as it should be, it's as it has always been. Nothing could be more human.

Ronald Bailey is reason's science correspondent. His most recent book, Liberation Biology: The Scientific and Moral Case for the Biotech Revolution, is available from Prometheus Books.

Ohio Court to Decide Who Owns Your Body Parts?

gillespie@reason.com (Nick Gillespie) — Wed, 23 Jan 2008 08:20:00 EST

Potentially big case brewing in the Buckeye State:

During an autopsy, the Hamilton County coroner removed Christopher Albrecht's brain and never put it back - a common practice for coroners.
But when Albrecht's parents learned years later that they had buried him without a brain, they filed a lawsuit that raises ethical, moral and religious questions about the treatment of one's body after death.
The case, to be argued Wednesday before the Ohio Supreme Court, has drawn international attention for its ramifications to coroners, crime investigators, EMTs, funeral directors and followers of religions that espouse the importance of burying the whole body.
The Albrechts argue that they had a right under the Ohio Constitution to their son's brain, and a right under the U.S. Constitution to reclaim the brain before it was destroyed. The lawsuit is a class action suit against coroners and commissioners in 87 of Ohio's 88 counties covering cases dating to 1991.
Under Ohio law, brains, hearts and other body parts and fluids removed during an autopsy are classified as medical waste, which generally means they are incinerated after use.

More info here.

reason readers know that there's a huge after-market in human tissue and other remains--a market that benefits just about everybody except the donor body. Read "Who Owns Your Body Parts?" And read the case for openly selling human organs.

And Don't Get Me Started About Doctors...

jsullum@reason.com (Jacob Sullum) — Fri, 11 Jan 2008 11:50:00 EST

On Wednesday the Massachusetts Public Health Council approved plans by CVS to open 25 to 30 "MinuteClinics" at stores in the Boston area. The limited-service clinics are aimed at providing quick, convenient treatment for minor illnesses. Boston Mayor Thomas Menino was outraged:

In a statement, the mayor said the decision yesterday by the state Public Health Council "jeopardizes patient safety. Limited service medical clinics run by merchants in for-profits corporations will seriously compromise quality of care and hygiene. Allowing retailers to make money off of sick people is wrong."

Evidently Menino not only wants to prevent the clinics from opening; he wants to abolish CVS and every other pharmacy.

[Thanks to an anonymous reader for the tip.]

Too Much Money for AIDS

jsullum@reason.com (Jacob Sullum) — Thu, 03 Jan 2008 12:28:00 EST

Here is something you don't see every day: an AIDS researcher calling for less spending on AIDS. In a New York Times op-ed piece, Daniel Halperin, a senior research scientist at the Harvard School of Public Health, suggests that politicians who criticize President Bush for seeking "only" $30 billion over five years to fight AIDS don't know what they're talking about:

Even the current $15 billion in spending represents an unprecedented amount of money aimed mainly at a single disease.
Meanwhile, many other public health needs in developing countries are being ignored.

Halperin argues that more lives could be saved by reallocating money earmarked for AIDS to less fashionable causes, such as prevention and treatment of the diarrheal diseases that are a major cause of mortality in Africa. The "rigid focus on AIDS," he says, has led to a deadly waste of resources:

This year [Botswana] will receive about $300 million to fight AIDS—in addition to the hundreds of millions already granted by drug companies, private foundations and other donors. While in that sparsely populated country last month, I learned that much of its AIDS money remains unspent, as even its state-of-the-art H.I.V. clinics cannot absorb such a large influx of cash.
As the United States Agency for International Development's H.I.V. prevention adviser in southern Africa in 2005 and 2006, I visited villages in poor countries like Lesotho, where clinics could not afford to stock basic medicines but often maintained an inventory of expensive AIDS drugs and sophisticated monitoring equipment for their H.I.V. patients. H.I.V.-infected children are offered exemplary treatment, while children suffering from much simpler-to-treat diseases are left untreated, sometimes to die.

The Buck Keeps Moving

jsullum@reason.com (Jacob Sullum) — Wed, 02 Jan 2008 06:57:00 EST

Critics of OxyContin manufacturer Purdue Pharma blame it for promoting abuse of the painkiller by encouraging family doctors to prescribe it. "As a result of the expanded access," said a recent New York Times story, summarizing the rap against the company, "OxyContin wound up in the high schools and street corners of rural America, where curious teenagers crushed the pill, defeating the time-release formula, and ended up addicts or, in some cases, dead."

Miraculous as OxyContin may seem to people suffering from severe chronic pain, it does not have the ability to crush itself and leap up the noses of innocent bystanders. No one "ends up" an addict without repeatedly choosing to seek out and consume a drug for the pleasure or emotional relief it provides. Drug treatment data indicate that regular OxyContin users are typically experienced illicit drug consumers who have undergone treatment before, not "curious teenagers."

Purdue Pharma, which pleaded guilty in May to "misbranding," may have misled doctors by telling them OxyContin was less subject to abuse than other opioids. But depicting OxyContin addicts as innocent victims of corporate greed is equally misleading, ignoring the decisions by which they determined their own fates.

There was no shortage of such responsibility-deflecting narratives in 2007. A few more highlights:

Kentucky Fried Lawsuit. Arthur Hoyte, a retired physician from Rockville, Maryland, sued KFC after discovering what he portrayed as the fast food chain's deadly secret: It fried its chicken in partially hydrogenated vegetable oil. (It has since switched to a trans-fat-free oil.) "If I had known that KFC uses an unnatural frying oil, and that the food was so high in trans fat, I would have reconsidered my choices," Hoyte said.

But the evidence Hoyte cited to back up his class action, which was supported by the Center for Science in the Public Interest, consisted largely of information KFC itself disseminated through its website and point-of-sale posters. In May a federal judge dismissed the suit.

Deadly Drinking. Last spring, after a fraternity initiation rite, Gary DeVercelly Jr., an 18-year-old freshman at Rider University in Lawrenceville, New Jersey, was pronounced dead at a Trenton hospital. He had a blood alcohol concentration of 0.43 percent. In August local prosecutors responded by charging three students and two university officials with "aggravated hazing," which carries a penalty of up to 18 months in prison.

Unless the administrators were at DeVercelly's side shouting "drink, drink," charging them seems like a stretch, even if you accept the premise that anyone should be held criminally liable for an adult's decision to consume three-quarters of a bottle of vodka in less than half an hour. Although the charges against the Rider officials were later dropped, last week DeVercelly's parents sued the university.

San Francisco Tiger. So far the story about the fatal Christmas Day attack at the San Francisco Zoo has focused primarily on the question of what the zoo should have done to prevent the tiger from escaping, the main criticism being that the wall around the enclosure was not tall enough. But the experts seem to agree that a Siberian tiger does not leap a 33-foot moat and scale a 12½-foot wall without provocation. "There had to have been a tremendous stimulus that made the tiger react the way she did," one told the San Francisco Chronicle.

The teenager who was killed, Carlos Sousa Jr., reportedly saved his friends, 19-year-old Amritpal Dhaliwal and his 23-year-old brother, Kulbir, by luring the tiger away from them. The brothers were hostile to the police, at first refusing even to give their names, and have yet to provide a public account of what happened.

Police found a shoeprint on top of the railing outside the enclosure, and the Chronicle reported that "pinecones and sticks that were found in the moat might have been thrown at the animal." Whatever role the Dhaliwal brothers played in the attack, you can be sure it will be further obscured by their inevitable lawsuit.

A $2.5 Million Misdiagnosis

bdoherty@reason.com (Brian Doherty) — Mon, 17 Dec 2007 09:31:00 EST

A woman misdiagnosed with AIDS and made ill by the medicines prescribed to her for 9 years wins $2.5 million in court. Some details from AP:

[Audrey] Serrano's attorney, David Angueira, said Dr. Kwan Lai, who treated his client at the University of Massachusetts Medical Center in Worcester's HIV clinic, repeatedly failed to order definitive tests even after monitoring of Serrano's treatment did not show the presence of HIV in her blood.
"It is one of the clearest cases of misdiagnosis that I have ever seen and it's based in part on a presumption that people who engage in certain types of conduct are more likely to have HIV and AIDS than other people without really listening to the patient," Angueira said after the verdict.
Lai testified last week that Serrano told her she had worked as a prostitute, her partner had AIDS, and that she had suffered three bouts of a type of pneumonia typically associated with those infected by the virus.
Serrano has denied she had ever been a prostitute. She confirmed that her former boyfriend tested positive for HIV/AIDS, but disputed the claim that she told the doctor that she had suffered bouts of Pneumocystis pneumonia.

Michael Moynihan blogged last month on millions of other people (mostly theoretical, still...) who were said to have AIDS but don't really.

4.5[*] Doctors Out of 10 Didn't Report Bum Peers

gillespie@reason.com (Nick Gillespie) — Tue, 04 Dec 2007 07:41:00 EST

Doctors still get high marks for professionalism and ethics in most surveys, but a new poll of MDs finds:

While 96% of respondents said doctors should always report impaired or incompetent colleagues, only 55% of those with direct personal knowledge of such doctors in the past three years said they always did so.
And while 93% of respondents said doctors should always alert authorities when they observe serious medical errors, only 54% of those who had such information in the past three years said they always did so.
"I think human beings always fall short of their aspirations," senior author David Blumenthal says. "The intent of the paper was not to criticize but to ... highlight the areas for improvement."

More here.

[*]: Early-morning, pre-coffee, elementary math mistake corrected thanks to reader MR.