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PaperclipPerfector  1yr ago (text post)   29947 thread views

Culture War Roundup for the week of June 24, 2024

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How Do We Stop Doctor Shopping

TLDR: If one is attempting to gatekeep a treatment, whether surgical or pharmaceutical, that is important for some patients but that other people may seek to access for reasons we find unacceptable, behind physicians and medical standards, how does one prevent doctor shopping? How does one prevent a sufficiently wealthy or connected individual from trying doctor after doctor until they get what they want?

My wife and I were discussing SCOTUS granting cert for USA v. SKRMETTI (link to petition, link to lower court decision here) a case in which the Justice Department is attempting to overturn a Tennessee law banning medical transition for minors. I commented that I saw no path forward for the case at SCOTUS, because they don't even bother in the petition to argue that Tennessee lacks the power to regulate medical care. The petition repeatedly cites WPATH standards, so recently discussed here, as though their existence writes itself into Tennessee law or the US constitution automatically. No matter how many times the petition uses the term "evidence based;" I'm left wondering where in the Constitution the legislature is required to act based on evidence. The core of their argument is around equal protection:

That is precisely how SB1 works: An adolescent assigned female at birth cannot receive puberty blockers or testosterone to live as a male, but an adolescent assigned male at birth can. And vice versa, an adolescent assigned male at birth cannot receive puberty blockers or estrogen to live as a female, but an adolescent assigned female at birth can. “Because [a] minor’s sex at birth determines whether or not the minor can receive certain types of medical care,” a ban on gender-affirming care necessarily “discriminates on the basis of sex.”

The decision from which they appealed concluded that:

There is a long tradition of permitting state governments to regulate medical treatments for adults and children. So long as a federal statute does not stand in the way and so long as an enumerated constitutional guarantee does not apply, the States may regulate or ban medical technologies they deem unsafe.

It seems to me that the state has the power to regulate medical treatments within its borders.

Being straight, as one occasionally must, I then listened to my wife bring up Kylie Jenner and her adventures in plastic surgery. I have to admit my wife has a point, the 26 year old woman looks at least 40. Her face is weirdly contoured, filler has wandered around, and her breasts are kinda detached from her body at some angles. Why, she asked, is it legal for her parents to get her plastic surgery, starting her on a path that has permanently altered and ruined her body; merely because those procedures were gender conforming? Because the weird "negroid-barbie-doll-centaur" Kardashian look is undoubtedly feminine rather than masculine, Kylie and her parents are unrestricted in making insane changes to her body?

I replied that it would make sense to ban plastic surgery for minors, and that Tennessee would certainly have the power to do so, and that I'd support a total ban except in cases of extreme deformities. How would you define extreme deformity, she shot back. Well, I guess you'd need a doctor to certify it. Gotcha, she said, that wouldn't stop Kylie or her parents for a second, they'd have crooked Armenian doctors on tap anywhere they needed them.

And it occurs to me that I have absolutely no idea what the next step in that process is. How do you gatekeep medical procedures against the well resourced?

In law school I knew lots of people who doctor shopped. First for a certification of "disability" that would grant them extra time on entrance exams, then for adderall prescriptions. ((I honestly felt they ought to piss-test before finals, addys were such a problem.)) They all fit the same criteria: well connected, wealthy families, people who often knew lots of doctors personally and had the resources and support to try multiple to get the diagnosis they were looking for to get what they wanted.

I've no doubt that if a diagnosis of "deformity" were required for cosmetic surgery, many women would suddenly be diagnosed with deformed breast tissue. I've already heard of plenty of use of creative diagnoses to get things covered by insurance policies.

Maybe it's lack of knowledge, but I'm at a loss as to how one fights this. A blanket ban on trying a different doctor seems like it would run dangerously close to banning second opinions, and I've seen many second opinions that massively improved on the first doctor's results. People should be free to keep trying if one doctor can't get results. But how do we distinguish the case of an individual trying to find help for a condition, from an individual without medical training settling on a pill they want to pop and trying doctors until they find one who will let them pop it?

This has obvious pharmaceutical implications. Adderall, Xanax, Oxy have all been abused. But what about things like TRT? Plastic surgery? And of course it comes back around to Transgender Kids: if somebody takes their kid to three doctors and they all say the kid isn't trans, but drags them on to a fourth doctor who says they are, is the kid trans or not?

I can't think of any good way to draw the line. At best we can rely on professional ethics, but, you know, lol. What's the strategy here?

There shouldn't be a strategy. Just make sure that doctors are liable when their willingness to go along with a patient's wishes crosses the line into malpractice, but other than that, it's worth the tradeoffs. The Covid response should have made that clear, especially around alternative treatment protocols (HCQ, ivermectin). Even if these were clearly not killing anyone (when prescribed and not taken by idiots who can't figure out dosage), and could conceivably have benefits, western government went above and beyond to stop people from taking them, or discredit doctors who prescribed them, not because of medical harm but because they needed to assert narrative control and that narrative was "No reasonable doctor believes in those treatments, don't even argue about it, shut up, stay at home and follow orders". If I recall they also in some places pressured pharmacists to not fulfill prescriptions for them. Governments will use and abuse any ability to insert themselves in the relationship between doctors and patients to the fullest, even if for political purposes and not medical purposes.

Because I believe in federalism as a way to achieve "laboratories of democracy", I support the ability of states like Tennessee to experiment with bans of various kind, regardless of whether I think the bans line up with good policy or not.

That said, I think it's a bit Quixotic to try to prevent all bad outcomes from a system. Law is always about trade offs.

There are a lot of traffic deaths in the United States every year, but it would be insane to limit the speed limit to 10 MPH on all roads, or to spend 100% of the national budget on reducing traffic deaths as much as is theoretically possible via human engineering. Instead, we make cars as safe as we can (within reason), make traffic laws as safe as we can (within reason), and build roads as safe as we can (within reason.) And then we accept that all of those decisions mean that a certain number of people still die in traffic every year.

I'm sure there's some level of regulation on trans medicine, cosmetic surgery, and abusable pharmaceuticals that makes a set of trade offs acceptable to most voters in a given area, but I doubt it would include many provisions for dealing with doctor shopping. I think you can get most of the "benefits" of such a law, by just making it illegal in the state, and not worrying about what rich people do to subvert the law.

Prediction markets could theoretically help both sides of this issue.

The issue is mandatory insurance / government money for "gender affirming" treatments. Plastic surgery isn't covered.

Very few parents have both the inclination and the money to trans their kid. If the courts weren't forcing government / insurers / parents to pay then their would be so few cases it wouldn't be seen as a problem the legislature needs to tackle.

You simply ban plastic surgery that could be reasonably expected to worsen the patient. Which includes worsening their aesthetics to a substantial enough degree. And then you revoke the licenses of doctors doing this. Of course you apply this to the trans issue too. This should apply in general. With sufficiently harmful procedures, you also criminally prosecute the people undertaking them for harming their patients.

So, if you are a rich guy, and even if not, and want to spend your money on hair transpant, trt, plastic surgery, you should be able to, provided that the operation will actually improve you. Or at least, not harm you. Although public funds should prioritize medical needs. With TRT the health side effects are such that it should be restricted until you reach people of sufficiently old age and low testosterone where it might be good for them.

So it should be allowed if it improves the patient and if rich people spend more on it, then that is fine.

If it worsens the patient, to an understandable degree, then it doesn't matter if they want it, and there is someone willing to provide it. It should not be allowed. Including restricting harmful drugs. Allowing some room for subjectivity and gray areas, and lack of knowledge though. Also, to take into consideration risk before surgery and whether if things go wrong is because it was foreseeable, or statistically it would happen over a large enough tries.

I replied that it would make sense to ban plastic surgery for minors, and that Tennessee would certainly have the power to do so, and that I'd support a total ban except in cases of extreme deformities. How would you define extreme deformity, she shot back. Well, I guess you'd need a doctor to certify it. Gotcha, she said, that wouldn't stop Kylie or her parents for a second, they'd have crooked Armenian doctors on tap anywhere they needed them.

I mostly agree.

The "it can't be stopped" is defeatist cope that can be applied on anything. The reality is that enforcement gains or loses ground and an attitude like this gives ground. It is the pro criminal fallacy that "if I don't do it, someone else will" of a corrupt society. In this case "If they don't do it, others will". The more people buy into this, the more you find your society captured by crooks.

Armenian doctors might be less likely to do such procedures than American doctors and if American doctors were unwilling to do this, then it is more likely that it might not have happened, or happened less.

Who's going to be the beauty police?

It isn't hard to see various plastic surgery transformations and to conclude that both the patient and plastic surgeons completely ruined the appearance of the patient.

There are also plenty examples that don't fit into this.

Some level of subjectivity is part and parcel of everything important that can be dictated by the law. There really isn't a way to escape from the necessity of having people make correct judgements in all such cases, which includes not interfering where they shouldn't.

Which if bad examples are used as deterrent, can be most of the time, including in cases where it is simply too subjective. Absent any control, you get a system with abuses. So there should be skepticism and accountability towards regulatory authorities, and opposition and demand to replace them if they get things wrong but this idea that no judgement is a good principle and letting plastic surgeons do as they please, won't work.

The most notorious case where this perspective breaks down is with mentally ill people who want surgical procedures which harm their bodies such as self mutilation. Like the people among others who think their actual limbs aren't there, and they should remove them.

I would trust plastic surgeons to use their professional judgment and follow the hippocratic oath to not do any surgery that makes a woman less hot!

Yeah, but some women actually do need breast reductions if they happen to be so large they interfere with being able to walk properly.

If that worked, you'd think that this would be the case today, but there seem to be fairly obvious counterexamples.

Fine, we'll appoint a board of supervisors. Harvey Weinstein can be its first head, with Joss Whedon as deputy.

Mastectomies probably don't need a subjective standard.

IIRC that one Oriental vizier-themed blog considers any breast reduction surgery a crime if it brings you below E cup, the ideal male preference.

A good Schelling fence is it ain't none of the government's business what's "good aesthetics". Looking back at history, would you really trust them with that? I don't.

I wonder if he's aware that his preference aligns with back problems and doesn't care, or if he's just never actually dated a skinny girl with E cups.

I do think there's a regulatory role for plastic surgery for minors, I think we can define major deformity pretty well. Something that would make shopping at Walmart difficult, though that's hardly a scientific test.

Well, I guess you'd need a doctor to certify it.

Instead of imposing prior restraint, simply use the court to punish them after the fact. Most doctors will be chilled from performing any borderline procedures, and the ones who go with it anyways can be hunted down by the AG. This is of course what the government does for its remaining plethora of onerous regulation, so there's no reason it won't work here.

How do you gatekeep medical procedures against the well resourced?

Well, first, you can't. But second, who cares?

I don't mean that in a dismissive way--I mean, has "but that law seems difficult to enforce" ever been a legible reason for striking down (or refusing to adopt) a law against something dangerous? There are countless laws against illicit drug use. Many of them are, at least arguably, stupid, but their stupidity is a political question, not a question for the courts. (At least until an activist court decides to get fancy with "arbitrariness," I suppose...) People use drugs, and it's bad for them, and explicit government disapproval of their activity does seem to actually reduce those harms (see: Oregon) even when it can't be said that the relevant harm can be eliminated entirely.

Ultimately, if enough people are down with transing the kids, the kids are gonna get transed. The threshold of "enough" is simply a question of power: if you've got a lot of money, then just knowing one willing (or venal) doctor will probably suffice. But if you're a middle class parent hoping to engage in a little light Munchausen's by Proxy for internet karma and GoFundMe credit, you're going to need some extra assistance via e.g. insurance, tax subsidies, and maybe some government bullying of recalcitrant health professionals. Conversely, simply making a law against transing the kids will suffice for 99% of the population, just like all the other laws that rich people so often find themselves free to disregard.

At best we can rely on professional ethics, but, you know, lol. What's the strategy here?

Sending a message. Having a government that doesn't directly contribute to harming children based on dubious pop culture trends and the elevation of mental illness to a virtue. Protecting children from abusive parents. "But they don't think it's abuse!" Fucking tough; I'm happy to outlaw genital mutilation (including male circumcision), too, because my conception of child abuse is unmoved by appeals to moral relativism. If states can't outlaw transing kids, then they can't outlaw the genital mutilation of infants, either--not in any principled way.

In addition to the natural law questions, outright banning circumcision pokes some very interesting (and difficult) questions of religious freedom. As a cultural practice for some groups, it long predates pretty much all written law.

While I'm against the practice generally, the thought of banning it (even just for minors) gives me pause.

This isn't directly on point, but I think the case against male circumcision has been overstated by advocates and adopted by guys who were circumcized as infants and wouldn't know the difference. A friend of mine nixed his foreskin at age 23 and said there was no real difference once he recovered from surgery. Contrast that with the experience of my mother, who spent 30 years as an outpatient surgery nurse and said the number of guys who come in for surgery do to recurring problems (usually UTIs), is enough for her to put the anti-circumcision crowd on the same level as anti-vaxxers.

While I'm skeptical of the uncutactivists -- and oh boy are they annoying in gay porn land -- my understanding of their thesis is that a lot of the impact comes during prepuberty or early puberty, or from the slow acclimatization over time. I think this has the separate problem of being unfalsifiable and depending on a lot of data that has too many alternative explanations, but it's not as overtly incoherent.

((Conversely, I do think the UTI risk is overstated. A lot of the studies for infants and younger kids are very streetlight-effect prone, in no small part because it's such a known impact; such a wide majority of UTIs clear up without medication that it seems likely to have underreporting among people who think they're immune. I've known more than a couple cut guys who only found out that they've been having repeated UTIs for the better part of a decade when they went to get tested for STIs.))

In the UK, where non-Jewish boys are not circumcised, they explicitly tell parents that they don't need to worry about UTIs in boys. It isn't a big risk. I did frequent urology clinics back in my mis-spent youth (I smashed up my dick in a cycling accident). Invariably I was the only man under 75in the waiting room.

A friend of mine nixed his foreskin at age 23 and said there was no real difference once he recovered from surgery.

I believe the common complaint is that your glans becomes less sensitive due to chafing in time, so presumably you wouldn't feel the difference right away.

Contrast that with the experience of my mother, who spent 30 years as an outpatient surgery nurse and said the number of guys who come in for surgery do to recurring problems (usually UTIs), is enough for her to put the anti-circumcision crowd on the same level as anti-vaxxers.

You're obviously going to get a lopsided picture if your job only brings you to contact with special cases.

I also had an adult circumcision. Sensitivity does definitely reduce over the long term.

...I think the case against male circumcision has been overstated by advocates and adopted by guys who were circumcized as infants and wouldn't know the difference.

It is certainly my belief that most, maybe all advocates are in the business of overstating their case, whether to make it seem more urgent, or to demand X in hopes of at minimum securing something less than X as a "compromise." In this particular case, botched circumcisions are sufficiently horrifying that the severity is difficult to overstate--but the incident rate is probably not.

This isn't directly on point...

Still, it's relevant. "Preventing children from having their properly functioning bodies interfered with, even when the adults in their lives are totally cool with it," is one of those things I think the law--judicial, legislative, and executive all--must be empowered to do, if it is empowered to do anything at all. If the law cannot protect the bodily integrity of minors, even against their own expressed wishes, much less the wishes of their parents, it's hard for me to imagine how the law can be permitted to paternalistically protect minors from anything at all.

And maybe that's the right answer, certainly I know some anarcho-libertarians who would bite that bullet. But despite the occasional temptation I have never really been able to get excited about governance quite that small.

Sure, there’s a natural law argument against circumcision. The petty annoyance of chafing against boxers and the risk of botching are both underrated. A man with normal hygiene has no real advantages from it. Etc, etc.

But it’s massively, massively overstated by advocates to the point of being an entirely different argument than the one reflected in reality, not merely exaggerated.

And I agree with you about circumcision- I don’t think it should be widely available. But that’s from natural law, not due to arguments about the disadvantages.

said there was no real difference once he recovered from surgery.

In Ancient Greece I am sure I could find at least one 12 year old boy who said he didn't feel worse off for being bummed by his mentor. Such a testinomy, given that it confirms that prejudices of its society, would be inherently problematic. Soeaking badly of some common practise, particurly a sexual one, is in all societies stigmatized and one is less likely to do is, even if one feels it to be wrong.

[anecdote about mother]

Every human rights is inalienable, causing minute harm in a some small fraction of those who exercise it, is no excuse to derogate. I am sure plenty of doctors or coroners have seen the consequences of people using the second amendment against themselves, people injured or killed by traveling by means faster than foot, people and gay men in particular suffering due to their promiscuity.

Edit: You may argue that you didn't argue making it illegal to posses intact male genitalia. However you made the comparison of vaccines v circumcision, and in many countries vaccines are mandatory.

The question about any surgery is whether the benefits outweigh the costs. If the worst thing about circumcision is that it violates some inalienable right to a foreskin then the argument against it falls flat. By that measure, tonsilectomies are also inhumane in that they aren't strictly medically necessary in most cases. My problem isn't so much with people who choose to forego the procedure but those who act like it's causing some great harm and should be prohibited in all but the most dire cases.

who spent 30 years as an outpatient surgery nurse and said the number of guys who come in for surgery do to recurring problems (usually UTIs), is enough for her to put the anti-circumcision crowd on the same level as anti-vaxxers.

I'll see your anti-vaxxer comparison, and raise your mom a "NO, U". If there was any truth to this you'd see a massive difference in UTIs between Europe and the US.

And you're assuming there aren't? The studies I've seen of circumcized vs. uncircumcised show a 10x increased risk among infants, 6x among children, and 4x among adults. I don't know what your definition of massive is, but these aren't numbers that can be waved off.

Yes. Last I checked (ages ago) the rates were essentially the same throughout the western world. I don't care about individual studies - population level data, or it didn't happen.

Is it perhaps driven by the population which doesn’t circumcise in America- I could well see hippies and/or Latinos having higher rates of UTI than the genpop.

Almost no one in Europe gets circumcised, though. When you have something between 50% (the number I recall from when I looked it up) to 30% (I believe the current rate), and a supposed 6x-10x advantage for circumcission, I'd say there's no way for it to not show up on the population level.

Yeah, that’s what I’m saying. It’s entirely possible that Latino or hippie parenting, or both, have some feature driving more UTI’s, and those are the main groups not circumcising in America.

I got the snip when I was just about old enough to remember it, maybe at the age of 6 or 7. It was intended as a medical intervention for phimosis, not that I remember it ever being an actual issue, in all likelihood, my parents were overzealous and it would have just gone away when I got a little older.

It makes little difference, the glans is probably less sensitive than it used to be, but I'll be damned if that matters, and there are some minor practical benefits anyway. Overall, my approach to circumcision is a resounding meh, I wouldn't get it done to my kids without a good reason, but there's not much reason for me to look at it and think that it ruins one's QOL or ability to enjoy sex. Just look at the TFR in most Islamic countries for one.

It honestly shouldn't be that big of an issue, I know lots of people on both sides of the snip. If anything you can last longer without a foreskin which increases sexual performance.

I'd rather live in a country where women merely expect me to wash my dick, not to have had plastic surgery on it. Seeing American anecdotes of women being creeped out by uncut dicks feels like the reverse of that thing where men want women to replicate hardcore porn acts and looks in bed.

I've never actually encountered one of those in the wild, I think at this point they're both the reverse of those men and equally mythical as most feminist strawmen.

I don’t think most people care, if they did exotic European guys would surely be considered unattractive in the US when often the opposite is true.

More comments

What about all the other countries in the world where it is a strange and abhorrent practice? If you're not a dirty retard you're not going to get a UTI from being uncircumcised, who is your mom interacting with? I take it you got clipped and have some motivated reasoning going on here.

Numbers I've seen show that the risk of UTI in uncircumcised infants is 10× that of circumcised infants. The numbers drop to 6× in childhood and 4× in adulthood. The infant number is what they're most worried about, though, since infants can't exactly communicate symptoms easily and untreated UTIs at that age can cause kidney damage and all sorts of other problems. I'm not that motivated on either side of things, but I'm irritated with the activists out there who act like circumcision is mutilation akin to sexual anesthesia. There are clear benefits, and whether those benefits outweigh the disadvantages is something to take into consideration, but the disadvantages are often overstated.

I know for my mother the risk of severe complications from the surgery (very rare approx 2-6/1000) was decisive in deciding against it.

Don't women get a lot more UTIs than men? I don't think it is as big a deal as many do, I know tons of people both circumcised and not, it hasn't impacted anyone's life that much. The ultra online people crazy about it are often damaged in a lot of other ways, and this is an easy thing to fixate on. Very Freudian really. You should see some of the crazy Propecia related ED forums, the insane corners of the internet are insane. But anti snip part of your peen off people are not in line with anti-vaxxers. The gripe they have is legit medically speaking, humans don't need to have their foreskin removed.

Maybe the most charitable way to interpret this is that since the well resourced have no problem overcoming laws; not having any at all levels the playing field.

They all fit the same criteria: well connected, wealthy families, people who often knew lots of doctors personally and had the resources and support to try multiple

I think you’re trying to legislate based on edge cases here. Even if we accept the hypothetical that “I know better than Kid X’s parent, how Kid X should be raised/medicated” AND “The optimum number of trans people is zero”, then refusing to accept a policy until such time as you achieve zero is making the perfect the enemy of the good. Restricting trans surgeries to the well-connected and wealthy people who have lots of doctors in their country club is very restrictive; that it probably won’t stop LITERALLY EVERY trans surgery is not policy disqualifying.

This isn't strictly an answer to your question, but it seems like health insurance (and its government regulators) has acquired at least a bit of a role of gatekeeping which procedures are actually worthwhile in terms of efficacy and reasonable expenditures. Honestly, I think there's probably a place for a more formal adversarial role in medicine asking whether any given intervention is the right choice, both for the patient and for the rest of us who bear the aggregate burden of paying for treatment (through taxes and insurance). But that would probably require a serious national discussion (we never really have those) about the massive cost and questionable benefit of a lot of primarily-end-of-life care -- "death panels." I think we already have a broad consensus that most elective cosmetic surgeries should be treated differently than reconstructive ones.

More practically, while I'm generally sympathetic to doctors and (adult) patients making their own decisions, there are examples where the government has seemingly-successfully cracked down on perceived excesses. The examples that come to mind are mostly Medicare/Medicaid fraud (see prescriptions for power wheelchairs about a decade ago) and the opioid crisis, where credentialed doctors have become much more reluctant to prescribe opioids, and have to jump through lots of hoops to track the prescriptions that are issued -- the last time I saw such a prescription issued, it involved time-sensitive two-factor authentication codes to write a electronic prescription for just a couple pills that ended up costing less than a dollar. Although I've heard anecdotes complaining that doctors are now too stingy with painkillers that I can't personally confirm. And that isn't even considering that "doctor shopping" in this context plausibly includes the "undocumented pharmacist" on the streetcorner depending on how you measure your outcomes.

I think the answer you're looking for is that if taxpayers voters have a sufficiently strong preference, the government can at least make it difficult for doctor shopping to be viable, although probably not impossible.

You can't. There will always be people with more power, access, and resources than others. There is no procedural way around this.

What did y’all think oligarchy meant? vibes? papers? essays? The doctors have this power because government gave it to them. Prescription requirements, medical certifications, doctor’s notes, these are active ingredients in the regulatory scheme. Power is delegated not to government agencies, but to medical associations. The AMA, APA, and their ilk decide what counts as a medical condition, what counts as an accepted treatment, and thus which medical procedures must be funded and never denied.

You can’t fix this without a complete overhaul of medical law. Band-aids prohibiting specific practices won’t work, as we see in the Idaho emergency abortion case.

I don't have an answer to the actual question you're asking besides you can't and probably shouldn't. People should be allowed to make decisions about their bodies and before they're old enough to consent to those decisions we can't do much better than relying on the parent's responsibility to act in their children's interests. Will some parents do irreparable harm in a failure of this responsibility? Absolutely. Does it mean that gating any treatment behind a doctor's evaluation is basically pointless for anything that could plausibly be granted? Also yes. But the alternatives seem worse. If we think a treatment is categorically wrong or wrong given objective criteria like age of recipient then we should write laws that do that. The fight is properly had on the ideological level and the motivation for such a procedure if it can't be won there then it ought not be won on these obscure proxy grounds.

I think it’s actually necessary in some cases. Things like surgery or drugs you don’t actually need can present lots of risks to patients. Surgeries can go wrong leading to infection or internal bleeding or the like. Drugs can be dangerous in themselves, especially if they have a low fatal dose or are highly addictive. This is actually how we got so many people hooked on opioids. Some people obviously need them, but at the same time, the drugs were so addictive that people would go to great lengths to get them including doctor shopping. There were “pain clinics” in some parts of rural America that were giving out more prescriptions than there were people in the town.

I think honestly the best approach isn’t to regulate patients, but doctors. If a doctor was on notice that over-prescription of scheduled medication would trigger an audit of his practice, he’s unlikely to be a pill pusher. If you’re going to get a similar audit for recommendations of surgery at rates far outside the norm for your specialty, then, again, you’re going to be a bit more careful about that sort of thing.

The problem I see with doing this on a one-size fits all legislative scale is that there will always be edge cases or extraordinary circumstances that can make the procedure necessary even if on paper the procedure can’t be done.

I just think I'm skeptical that this is realistically going to work on any topic that is at all ideological. Even with everyone basically agreeing that over prescribing opiates is very bad we get these pain clinics you mention. On subjects even a little bit controversial? Forget about it. It just becomes a matter of who is doing the auditing and an endless series of proxy wars around that and the judges and the people who decide what should trigger an audit on and on and on.

Just the thought of the amount of wasted human effort waging those wars makes me feel exhausted. Societies can't be run like this, we must actually come to some consensus on what reality is or split into small enough exclusive groups who can agree.

Things like surgery or drugs you don’t actually need can present lots of risks to patients.

So does life.

Surgeries can go wrong leading to infection or internal bleeding or the like.

So can playing football, or learning to use power tools, or white-water rafting, or cooking.

Drugs can be dangerous in themselves, especially if they have a low fatal dose or are highly addictive.

You can make the same claim about swimming pools.

If a doctor was on notice that over-prescription of scheduled medication would trigger an audit of his practice, he’s unlikely to be a pill pusher.

How large is the doctor-auditing agency you're planning to run, such that it has the capacity to evaluate any meaningful percentage of practicing doctors? And who's staffing it? Are line doctors going to be second-guessed by the type of people who currently disproportionately work in government jobs? Good luck with that.

And even this doesn't stop the problem - it just pushes the issue one step further up the chain. Now you're looking for doctors who are either willing to fake the books (increasing the danger to the people undergoing the procedure because black markets are incredibly unreliable) or who have political pull with the auditing agency. We already see this all over the place; the last head of the California Department of Alcoholic Beverage Control, which regulates and polices significant limitations on alcohol manufacture, wholesale, and marketing, resigned in order to take a job as...an alcoholic beverage control compliance specialist at a high-power law firm!!

You can't stop people from making shit decisions.

I think the difference in medicine is specifically that the people using the service are generally in no position to understand the issues involved. Most people don’t have even a high school understanding of human biology. They don’t understand enough to know if something is dangerous or not. What most people end up doing is treating medicine like they would have treated witchcraft 800 years ago— the guy in funny clothes told me I have to eat/drink this or let him do this thing to me. They don’t have any expertise or experience to say “hey wait, is this really a good idea?”

With things like swimming pools or other sports or activities, a person is in a bit better shape in making a good decision because they know what they’re looking at. If my kid wants to go swimming, I know whether he has that skill, I know whether he’s going to a pool or a river or lake, I can therefore have a reasonable assessment of the risks. If he wants to play football, I’ve seen enough football to know it’s a rough sport with a fair number of injuries. Alcohol is again something people know enough about to make reasonable decisions about. They know it can be addictive they know it impairs judgement and coordination and they have probably seen a drunk uncle or two.

As far as the agency I’d use — most states already have medical boards with all kinds of record keeping, requirements to keep up with the field through continuing education hours, requirements for the facilities, requirements for outcomes. Every state already has this, you have to have a state medical license to practice medicine (and a similar thing for pharmacies) in any given state. I don’t see a problem with adding a check that you’re not giving out opioids or adderall at 2σ above the normal base rate and having someone check up if you are. If every child coming to your psychiatrist practice is being diagnosed with gender dysphoria, then there’s very likely a problem, just like if you’re giving every single person coming to your clinic adderall or OxyContin.

The risk vs benefit of swimming pools vs opiates is far different. Swimming pools don't give you cities where part of the place is taken by drug zombies. It is relativism to act as if they are comparable. And so it goes for many things. There is a line to be taken, and refusing to support a line ends up with predictable large problems. Because you can in fact have a society of different levels of corruption and harmful behavior.

You aren't really encountering in this thread safetyism purity spiral supporters. There isn't a sufficient negative to swimming pools, even if a small percentage of people using them and having fun swimming (and improving cardiovascular health possibly in doing so), end up drowning.

An important point to mention, is also as the ancient Greeks, Romans, Christians, and others understood, and through continuity through the ages wise people understood, is the problem of people being enslaved to their passions. The drug addict not only harms his health, but is fundamentally not a free man. This is also bad for the group as a whole since from a collective point of view, such behaviors degenerate society.

It isn't an accident that "Do what thou wilt shall be the whole of the Law" is so identified with the modern Satanist movement. Even from a secular perspective, it tells you something that this is the philosophy of a movement that adopts the symbol and name of evil and sin, in accordance to the dominant religion of western civilization. The attempt of inversion of morality, leads predictably to an immoral code that harms civilization.

Swimming pools don't give you cities where part of the place is taken by drug zombies.

That's true, but if I recall correctly, when I was looking at different causes of death in the United States, swimming pools turned out to kill a similar number of people (mostly young kids) to accidental gun deaths in the United States annually. Obviously, you'd have to compare the base rate of pool ownership (as well as time spent around the pool) to the rate of drowning to get good numbers on the actual risk of owning a swimming pool, but I wouldn't blame a less risk-tolerant person if they didn't own a swimming pool because they were concerned about the risk of their own kids drowning.

I think the problem with bringing up "safeteyism" is that there is obviously a point in any situation where anyone except the most committed libertarian would eventually agree a law of some kind is necessary for society's well-being. Many regulations are written in blood, and I understand the impulse of a person who is more likely to ask "are the trade offs of enforcing this regulation worth it?" rather than "does this regulation reduce individual liberty?" or whatever. Sometimes it takes an unregulated amusement park ride decapitating the son of a state senator for a law to be written.

That’s because accidental gun deaths are a trivially small problem because the sorts of people who own guns are more likely to be responsible with them than average.

but I wouldn't blame a less risk-tolerant person if they didn't own a swimming pool because they were concerned about the risk of their own kids drowning

This person does not want to have to maintain and/or pay for a swimming pool, and is telling his wife it’s too dangerous as a trump card.

That's true, but if I recall correctly, when I was looking at different causes of death in the United States, swimming pools turned out to kill a similar number of people (mostly young kids) to accidental gun deaths in the United States annually.

That says more about accidental gun deaths than it says about swimming pools.

You can limit the harms of people’s shit decisions and put barriers in place to deter them making the worst ones.

That said, I agree with the spirit of what you’re saying. I tend towards being maximally permissive about self-funded medical procedures by adults. From plastic surgery to suicide, as long as the state isn’t contributing a penny, you’re a compos mentis adult, and no-one else will be directly harmed, then I see no good reason for imposing any significant limits. Minors are obviously a very difficult case, and deserve greater protections.

You can limit the harms of people’s shit decisions and put barriers in place to deter them making the worst ones.

You can put rules in place. But that only works so long as people either (a) voluntarily follow the rules - which, if they really disagree with the rule and really want to do the thing it forbids, they won't - or (b) can be forced into doing so. And the powerful, wealthy, or well-connected will always be able to disproportionately slip the net.

You don't have to make a rule to cover literally 100% of people such that they can never evade it. 99.8% is good enough. A better rule for 99.8% of people is better than a crappier rule for 100%.

IMHO, Tennessee is backed into a corner. If all it were, was that some parents horribly medically abuse their children with elective surgeries, it's horrifying. However, for all the reasons you listed, the urge to "JUST DO SOMETHING!!" will likely be ineffectual and counter productive.

But that is not the situation Tennessee is facing. The issue Tennessee, and parents everywhere, is facing is an already massive and growing institutional pipeline that convinces children they are trans, and then violates parental rights to mutilate them. This is no longer a question of "Can you protect people from their own folly?" and becomes a question of "Can you protect people from single minded institutions that want to chop the genitals off as many children as they possibly can?"

The answer to the second question, I would hope, is yes.

Tennessee has to do something about lefty NGOs, in other words, and that’s generally a tough nut for red states to crack.

You can just let people do what they want with their own bodies, including drugs or surgery, even if it is stupid or gross. What is wrong with people taking adderall for better grades if they see it as a good tradeoff vs side effects?

Did you ever read Meditation on Moloch? The argument, briefly stated, is that in a state of high competition people will end up being forced to compromise on anything that doesn’t provide competitive advantage in order to keep up.

In China, for example, that meant children sacrificing almost all leisure time to study at cram schools. The hierarchy of ability ultimately shook out the same way (because everyone was cramming) but everyone had to bear an extra load of useless misery. AFAIK when Xi banned cram schools everybody breathed a sigh of relief and nothing else changed.

I think the same applies to adderall. One of the limiting factors on how much we can throw away for competitive advantage is our physical capacity for concentrated work.

The vast majority of people literally cannot focus on boring tasks for 12 hours a day and so can’t be compelled to. The rise of adderall has the potential to change that. I for one would rather ban it than live in a world that’s exactly like this one but where white collar jobs expect 12 hours of focus a day.

Notably, this has to be done collectively or else people will ‘cheat’ by sabotaging the commons for good grades.

Purely going off of the China example, it seems to me that one can see the problem as people being incentivized to study more than is needed to establish a hierarchy, which is a waste of time and effort best cut short by limiting the time spent studying, or as the entire structure of the thing being perverse because it requires studying unnecessary material that could be ignored at no cost if the exams didn't establish hierarchy based on the ability to study useless information.

I ramble, but I do think there are multiple angles of attack one could take there, and banning cram schools is just the easiest one, rather than necessarily the best.

I see where you’re going. I think it’s a case of metrics making bad targets. The material the students were cramming probably had some value beyond forming a hierarchy. But competitive pressure forced them to expand vast effort squeezing out a very small amount of extra knowledge which is valuable but not valuable enough to be worth the effort under normal circumstances.

This is close to your first suggestion but maybe not quite the same.

This is because of regulations, not despite them...You've proven the opposite.

The field can be level if nobody has adderall or everybody has adderall. I am arguing that the former state is generally preferable.

But the latter is arguably preferable if there is more productivity. Sure, the cram schools example works well be ause there doesn't actually appear to be much value in the additional knowledge. But a bunch of, say, programmers on Adderall means we all get to enjoy more and better software.

Productivity in what area? Zero sum enshittification in service of engagement and clicks? No thanks.

But a bunch of, say, programmers on Adderall means we all get to enjoy more and better software.

More I'd agree with. Better... I would tend to doubt.

What is wrong with people taking adderall for better grades if they see it as a good tradeoff vs side effects?

The part where the rest of us are paying for it, as well as the part where many aspects of education are competitive.

Amphetamine salts are simple and cheap to manufacture, less than a penny per dose in an unregulated market. Yes education is competitive, what is fair about being born smart or more in control rather than taking drugs? Ritalin me that.

The sorts of people who take illegal drugs are mostly not the sort who use adderal for its performance enhancement.

I can't disagree with this statement more.

Methheads are known for deep concern with their test scores.

Those aren't the only people taking drugs - cocaine is rather famously a rich person's drug extremely popular with people in finance who absolutely abuse whatever drugs they can get for performance enhancement.

Why do you disagree with it, or on what grounds?

It seems clear to me that most people who use illegal drugs are not using them for performance enhancement, but rather using them for pleasure. If that's true, wouldn't the above statement necessarily be true as well?

I'd assume that most people who use illegal drugs don't care about violating rules if they can get away with it. This would mean they're more likely to violate rules against using performance enhancers as well as rules against recreational drugs. It's not because the pleasure drugs and the performance enhancers are similar, it's because the same kind of people use both.

That has not been my experience.

Just an FYI, AhhhTheFrench’s comment is filtered and not visible.

Wake me up when we're dealing with an unregulated market or a fairness-based reality.

We are discussing currently non-existent future states of humanity, and what it would take to get there. An unregulated fairness-based reality would be preferable, at least for me, to a gilead style oligarchy where everything is permissible for the .001% and everything is prohibited for everyone else.

I don't think 'we cannot realistically prevent the 0.001% doing things they want to do' and 'oligarchy where everything is permissible for the .001%' are equivalent, morally speaking. To take a provocative example, we cannot prevent sufficiently powerful and motivated individuals from having parties at Mr. Epstein's island, but that doesn't mean we should legalise paedophilia.

I'm more inclined to agree with you at the 1% and especially at the 10% mark, where I think hypocrisy and two-tier policing are more corrosive (because more frequent and visible) and more preventable.

I've been to epstein's island. Post conviction, on a lark with our tour guide/captain. But as you say, far below his level of depravity and privilege the double standard becomes an issue.

These drugs are long term bad for you. The true cost of long term use is not a penny per dose.

Yes I already addressed this.

Nobody in any position of power is arguing for that, so it's not really relevant to the political debate.

As to Adderall in law schools, it's a zero sum, competitive, ordinal grading system. Allowing one person to cheat harms someone who doesn't directly, and pressures others into cheating as well. Though I suppose the argument could be made that biglaw is full of drug addicts anyway so who cares if it's a level playing field it's the playing field you'll be on.

I'm well aware of law school grading practices, I just don't consider adderall cheating. Is getting enough sleep and eating right cheating? Is being rich enough to not have to work or stress about money cheating? Is being naturally smart and driven cheating? The list goes on forever of different factors that may or may not be beyond your control being "cheating". I never relied on it because I think it can't possibly be good for you long term, but it is a hell of a party drug. The only thing I think of as cheating, is literal cheating. All gatekeeping of surgery or drugs does is make sure poor people can't use the good ones.

Getting enough sleep and eating right doesn't harm you. Neither does being rich. Using Adderall does, and if you don't prohibit it you get a race to the bottom where everyone takes it, everyone is as bad off as they would otherwise be (because the competitive advantages all cancel out), except they're worse because they also have the negative effects of Adderall.

Does it harm you more than being rich doesn't?

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