Astral Codex Ten

Medicine

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Medicine

Article

Medicine is a recurring concept in the Astral Codex Ten archive, appearing 2 times across 2 issues between November 23, 2021 and January 08, 2025. The archive places it in contexts such as ""Now the entire reputation of Medicine as a field is inextricably linked with the reputation of that government agency""; “He’s sullying Medicine itself”. It most often appears alongside DogeCoin, Alex Tabarrok, Andrew.

Metadata

  • Category: Concepts
  • Mention count: 2
  • Issue count: 2
  • First seen: November 23, 2021
  • Last seen: January 08, 2025

Appears In

Source Context

Recovered passages from the original issue text. When the raw archive preserved outbound links inside the source passage, they are listed directly under the quote.

Highlights From The Comments On The FDA And Paxlovid
November 23, 2021 · Original source
Note that this really only applies to new chemical entities; people have been manufacturing fluvoxamine for years and its probably well understood by now. Not always true though; we saw a worst-case situation recently with the ranitidine withdrawal: a medicine that some reasonably healthy people take every day of their lives was shown to be contaminated with small amounts of a nasty carcinogen. If Pfizer happened to have some gaps in their understanding for the Paxlovid process, the FDA might go easy on them as dying of Covid now is worse than a slightly increased risk of cancer in the future, but it takes time to review all of these risks and make a justified decision.
But more generally, it sounds a bit polemic to me to speculate that the FDA is concerned with its reputation. Maybe at stake is not the reputation of the FDA, but the reputation of the approval process? Assume the case a drug is approved "prematurely" and saves 30000 lives but completely unexpectedly kills 10000 patients (who would otherwise have survived). What sounds like a great net positive outcome might still be very negative on the long term: Many people might lose trust in approved medication or evidence bases medicine in general.
Maybe a better way of framing this is that we made a deal with the devil when we decided to ban all drugs until a centralized government agency said they were okay. Now the entire reputation of Medicine as a field is inextricably linked with the reputation of that government agency, and protecting that agency’s reputation is more important than saving lives, having reasonably-priced drugs, making reasonably-paced medical progress, or basically anything else. I acknowledge this behavior makes sense given that the deal exists, but I think we should be looking for ways to extricate ourselves from it.
On Priesthoods
January 08, 2025 · Original source
Society-wide: The marketplace of ideas! This is where everyone gets to have their say. New hypotheses get stress-tested, bounced off against each other, and only the strongest survive. This level also produces true learning - if only one idea survives the marketplace, then average spectators can easily pick it out (although of course it can still be wrong). Its disadvantage is that it’s impossible for several billion people to hold a true “discussion” among themselves. Also, many of these people are extremely stupid, their ideas are bad, and they fill the conversation with noise. Is there a useful group size in between these two? What about discussing ideas in a group made of only the most intelligent and knowledgeable people? This gives you the debate and collaboration functions that you only get in group conversation. But it’ll have a better signal-to-noise ratio than all of society, and it might be small enough to manage. Also, you can make people sign on to good discussion norms before they enter, and you can expel them if they screw up. The Boundary Against The Public From this formulation, it becomes clear that such a priesthood is only useful insofar as it has some kind of barrier between itself and the general public. The priesthoods don’t exactly hate the public. But they hate the idea of letting the public’s ideas mix with their own. It’s not just that they discount the public’s ideas insofar as the public is less sophisticated than themselves. Their whole identity comes from their separation from the public. Ideas that seem too similar to the public’s get actively penalized, the same way it would be hard to convince Democrats to accept a plan that Donald Trump proposed first, even if it otherwise fit with Democratic ideals. I recently reviewed Tom Wolfe’s From Bauhaus To Our House, on the architectural priesthood. It discusses the response when renegade architects would build things in styles favored by the public - for example, Edward Stone and the Kennedy Center: Stone and Saarinen, like Frank Lloyd Wright and Goff and Greene, were too American, which meant both too parochial (not part of the International Style) and too bourgeois. Somehow they actually catered to the hog-stomping Baroque exuberance of American civilization. When Stone designed the Kennedy Center in Washington with a lobby six stories high and six hundred and thirty feet long – so big, as one journalist pointed out, that Mickey Mantle’s mightiest home run would have been just another long fly ball – it was regarded as an obscenity. Stone was actually playing upto American megolomania. He was encouraging the barbaric yawps. He was glorifying The Client’s own grandiose sentiments. More generally: In a way, the very productivity of a man like Wright, Portman, or Stone counted against him, given the new mental atmosphere at the universities. Oh, it was easy enough, one supposed, to go out into the marketplace and wheedle and vamp and dance for clients and get buildings to do. But the brave soul was he who remained within the compound, stayed within the university orbit. Or, from the comments, this quote by architect Peter Eisenman: What I’m suggesting is that if we make people so comfortable in these nice little structures of yours, that we might lull them into thinking that everything’s all right, Jack, which it isn’t. And so the role of art or architecture might be just to remind people that everything wasn’t all right. I used to wonder why so many econ-bloggers I liked were at GMU. GMU only is only the 74th best economics department in the country, but more than half of the econbloggers I like are affiliated with it in some way (Tyler Cowen, Alex Tabarrok, Garett Jones, Robin Hanson, Bryan Caplan, Arnold Kling, Scott Sumner, Mark Koyama, sorry if I’m forgetting anyone!). Granted that some of this is because I lean libertarian and so do they - but I don’t think there’s a mountain of amazing and popular left-wing econbloggers who I’m ignoring. Part of this must be that Mercatus head Tyler Cowen is better at spotting and cultivating talent than others - but you’d still think the #73 ranked department would try to poach some of his hard work. When I asked academics about this, they didn’t find it mysterious at all. The average high-ranked economics department doesn’t care that you have a popular blog. They might even count it against you. Only your reputation within the priesthood matters. This is my experience too. I once got rejected from a psychiatry residency I wanted, partly because they saw I had a blog and thought it might cause trouble (though the less prestigious hospital that eventually accepted me did consider it a plus, for which I remain grateful). I wish I could say that the program which rejected me is kicking themselves right now - I’m probably one of the most-read psychiatrists in the world, and most of what I write is relatively orthodox and (I hope) reflects well on the field. But outside of my fantasies, they are doing nothing of the sort. At best, my blog has gone from a liability to being neutral or a very slight positive. Certainly it doesn’t make me as impressive as someone who went to a medical school one tier above mine. Consider how impressive a boundary this is - someone can have literally tens of thousands of fans for doing popular writing in a field, and the amount of extra status it gives them in the field is within a rounding error of zero. Only your reputation within the priesthood matters. Still, at least I’m a member in good standing. At least I’m higher than pond scum. The lowest-status doctor in the world - the guy who, if doctors were Maoist revolutionaries, would get his face on the “Criticize X, Criticize Y” posters - is Dr. Oz. This isn’t because Dr. Oz lacks medical skill. Back in the day, he was a professor of surgery at Columbia, and by all accounts quite good at it. But then he went on TV and started catering to the public. He told them their stupid miracle cures and $19.99 supplements were Real Medicine. Imagine a Catholic bishop declaring ex cathedra that The Da Vinci Code is 100% real. Authority bestowed to fight the heresies of a fallen world, instead used to prop up those heresies. Columbia recently “cut ties” with Oz in some vague way, but as far as the medical profession is concerned, it’s too little, too late. I think the profession’s hatred for Oz is justified - his claims are false and probably cause a lot of harm. But other doctors who say false harmful things get only a fraction of the hatred that Dr. Oz does. He’s not just defrauding and maybe killing the people who take his supplements. He’s sullying Medicine itself. This hard boundary - this contempt for two-way traffic with the public - might seem harsh to outsiders. But it’s an adaptive artifact produced by cultural evolution as it tries to breed priesthoods that can perform their epistemic function. The outside world is so much bigger than the priesthoods, so much richer, so full of delicious deposits of status waiting to be consumed - that any weaker border would soon be overrun, with all priesthood members trying to garner status with the public directly. Only the priesthoods that inculcated the most powerful contempt for the public survived to have good discussions and output trustworthy recommendations. The Boundary Against Capitalism Dr. Oz illustrates another point: power corrupts, and the priests (as people known to be more knowledgeable than the public) have the power to bless or damn interventions in their field. Without some boundary against capitalism, they would abuse that power to make money. Again, cultural evolution has produced such a boundary. A doctor who seems too mercenary loses status in the priesthood. My father - a much more orthodox (and hence higher-status) member of the medical priesthood than I will ever be - used to even get suspicious of concierge doctors. Was it really in keeping with the principles of medicine to care about the amount of money you got for your service? Shouldn’t the usual insurance payments (calculated behind the scenes, without you ever having to think about it) be enough for anybody? If you let doctors charge extra for their services, they might do bad medicine in order to increase profits. In the worst case scenario, they might flatter members of the public who wanted all-natural $19.99 supplements. This taboo has faded as insurance squeezes doctors harder; even my father eventually relented. But there’s still the sense that doctor is a calling in a way that used-car salesman isn’t. If you pursue money too aggressively, can we really be sure you’ve heard the call? Why doesn’t every doctor pursue their own $19.99 supplement business? Some of this is professional regulation - there’s a sense that probably the Medical Board will come down on you if you do something wrong (though most doctors are proudly ignorant of the exact limits of the Medical Board’s power - why should the pious worry about the exact boundaries of excommunicable offenses?) But most of the barrier comes from self-regulation based on social status. By the time you’re done with medical school and residency, all of your non-doctor friends have long since abandoned you, and all the old sources of status and approval that you used to crave have been excised and replaced with the all-seeing eye of the medical priesthood. If you sell out and start the supplement line, you might get a new Ferrari, but everyone whose opinion you respect will hold you in contempt. The public might think it’s cool that you have a Ferrari, but doctors know better: nobody with a supplement line has ever been cool. This doesn’t mean doctors are incorruptible. Plenty of them become pharma company shills. But that’s because being a pharma company shill doesn’t burn intra-priesthood respect the same way. For better or worse, pharma companies straddle the priesthood boundary. They may not be fellow priests, but they’re at least nuns or deacons or something. They won this by sacrificing certain capitalist parts of themselves (for example, becoming heavily regulated) and by agreeing to follow the norms of the medical priesthood (for example, communicating through papers published in medical journals with high-status doctors as lead authors). Through their sacrifice, they achieve ritual purity; now priests can interact with them guilt-free. Is ritual purity really the same as moral acceptability? Sounds like the kind of question a member of the public might ask! Communication Norms Within The Priesthoods Although priests talk normally when when they meet one another at the water cooler, ex cathedra communication must be performed in a ritually pure way. For the medical priesthood, that means papers published in a medical journal. Consider ritually impure communication - for example, Twitter. Someone may try to make a medical claim (“SSRIs are a great depression treatment!”). But one can’t even predict the genre the reply will take. It could be any of: Insult (“You’re just another a big pharma shill trying to poison us!”)
Inline links: recently reviewed, is only the 74th best, recently “cut ties” with Oz, too little, too late
Doctors know an extraordinary amount about medicine. They’re also well-coordinated. The phrases “scientific consensus” and “medical consensus” exist for a reason. Wider society sometimes reaches consenses on important questions - for example, after long debate, most Americans now agree that segregation was wrong. But priesthoods do it faster, and on more complicated issues.
The need to stay separate from the public, mixed with the desire to stay in touch with the public, creates a productive tension. Sometimes it inspires new forms of art. Other times it helps one faction of priests lead a coup against another - “your faction is out of touch, but mine is in touch”. In medicine, it mostly just causes a mind-numbing proliferation of Communication Skills classes and columns about the role of medicine in the Current Thing.