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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:
The decision from which they appealed concluded that:
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?
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.
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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.
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More I'd agree with. Better... I would tend to doubt.
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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.
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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.
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That has not been my experience.
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Just an FYI, AhhhTheFrench’s comment is filtered and not visible.
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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.
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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.
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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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