Covid-19 Deaths In 2020 In the United States

In 2020 there were 385,293 deaths that mentioned Covid-19 on the certificate. Of those, 351,530 listed Covid-19 as the underlying cause of death. (In other words, 33,763 deaths, about 9%, listed Covid-19 as incidental but not necessarily the ultimate cause.) I wanted to take a closer look, because this seemed lopsided to me. Quick overview, the CDC's mortality data list an ultimate cause of death, the single thing that is fingered as the reason the person died. It also lists up to 20 (though typically only three to five) contributing causes of death, things that are relevant but not deemed the ultimate cause. So if someone has a chronic lung condition and dies after contracting covid, most likely the chronic condition will be listed as a contributing cause with "Covid-19" listed as the ultimate cause. 

If you've followed my blog for a while, you've seen my analyses of the CDC's statistics on drug-related mortality. One pattern I've noticed is that if a drug is mentioned, it's overwhelmingly (>90% of the time) listed as the ultimate cause of death. At the same time, you see a lot of chronic illnesses getting listed on these records as contributing causes of death. Is there some bias whereby if drugs are anywhere in the picture they get fingered as the ultimate cause? Or are medical examiners assiduously avoiding any mention of drugs if they don't think they're relevant to the causal story? (While at the same time promiscuously reciting details about the decedents medical history in drug cases?) 

I had a similar thought about the 2020 covid deaths, so I took a closer look. What does a "covid caused" death look like compared to a "covid mention" death (in which presumably covid was incidental)? Early in the pandemic, I suspected that there was some kind of misclassification happening, where covid was blamed even if it was incidental. Such a bias in reporting would inflate the death toll. The excess death statistics quickly ruled that out as a plausible explanation, because those are a measure of total overall mortality and it's implausible that those numbers could be inaccurate. But it could still be true that there is a significant amount of misclassification happening. Excess deaths don't exactly overlap with covid deaths, so there's room for error here. 

After looking into the data, my takeaway is that the deaths really do look like covid deaths. I don't have the actual death certificates, but I do have the large mortality file from 2020 (the Multiple Mortality Cause Files in this link). With this I can see which conditions are listed on a given record. I see a lot of conditions such as: pneumonia, chronic obstructive pulmonary disease, hypertensive heart disease without congestive heart failure, adult respiratory distress syndrome, cardiac arrest, respiratory failure unspecified, etc.  A typical record will list multiple conditions. The average age of decedent is 76. Taken together, this corroborates the story that this disease mostly struck down the sick and the elderly. 

I actually didn't see a huge difference between the records that were marked as covid being the underlying cause versus the ones where some other cause was marked as primary. They are listing the same set of conditions, and the age distributions are similar. If you look at the underlying cause of death for the "covid mentions" records, you see a lot of chronic conditions. Malignant neoplasms (cancer) of the prostate, Parkinson's disease, Alcoholic hepatitis, Other Obesity, Heart failure, Unspecified dementia, etc. You see a lot of these listed as contributing causes of death on the records for which covid was selected as the ultimate cause.  I don't know exactly by what rubric a death is ruled to be "caused" by covid rather than having it listed as a contributing condition. Presumably someone is making that ruling, but these things can be a little arcane. 

I think there's more work to do here, particularly when the 2021 file comes out (which should happen near the end of 2022). There should be a more thorough analysis comparing the official counts of covid deaths to the excess mortality numbers to see if they match up or not. If they don't match fairly closely, it could imply that there is excess mortality (or less than expected mortality) due to some of the lockdown measures. Presumably the disruption of medical services had an effect on some people getting necessary healthcare, and it seems that suicides and "deaths of despair" increased during the past two and a half years. Excess deaths for younger demographics far exceed the official covid counts. It's not plausible that we're under-reporting covid deaths in these demographics by such an extreme factor. The more likely story is that deaths of despair really are taking a bite. Given my review of the CDC data and the close match between the official covid counts and "excess mortality" estimates for 2020, I would guess that there isn't a serious misclassification problem for that year. But there is more to do when the 2021 data becomes available. It's possible that excess deaths due to deaths of despair and disrupted healthcare take a bigger bite later in the pandemic, but these could be concurrent with a reporting bias that over-attributes deaths to covid. Someone could look at covid deaths versus "excess mortality" by month of the year or age or race to see if there are serious mismatches, which could suggest a reporting bias. (See the link above, excess mortality in the younger demographics far exceeds the official covid count, so obviously it's not straightforward to say "excess mortality can all be attributed to covid" as some careless commentators have done.) Overall I'm fairly confident that the official counts aren't wildly off. There have probably been around 1 million covid-related deaths in the US since the start of the pandemic. But it's worth checking. Official narratives have been wrong before. 

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I think we have to start getting really sophisticated about what "excess deaths" means in the current environment. Has anyone projected out what's expected to happen in coming years? Didn't covid kill off a lot of vulnerable people, who would have died anyway within the next few years? Won't this cause overall mortality rates to fall in future years? Are "long covid" or disrupted healthcare or deaths of despair taking enough of a bite that it's overwhelming this expected decline in mortality? I think someone would have to build a reasonably sophisticated statistical model to do this, accounting for mortality at various ages by various conditions, aging the population to project out to future years. "Excess mortality" requires having an expected baseline to measure the actual deaths against. It's probably valid to compare mortality in 2019 to 2020 or 2021 and call the difference "excess mortality", but the further you go into the future the more you have to adjust the baseline and the more assumptions you need to build in. 

Burning Down the House

If you're a libertarian who wants to read something by a progressive that attempts to convert you to progressivism, you should read Burning Down the House by Andrew Koppelman. Alternatively, if you're a progressive who wants to feel an unearned sense of intellectual and moral superiority to libertarians, you should also read Burning Down the House. The book's subtitle is How Libertarian Philosophy Was Corrupted by Delusion and Greed. This is provocative, because it teases the idea of a political philosophy that once made sense in the good ole days, but whose current incarnation is a betrayal of its roots. Modern libertarians are doing it wrong apparently and are foolishly misinterpreting the philosophy's founding documents. While the title and intro hint at this, it never really delivers.

Koppelman frames himself as a pro-market liberal. He's a nearly-extinct species of libertarian who is aware of the flaws of a market economy and the need of government intervention. It was a frustrating book to read, because it all comes off as standard progressivism. The only clue that Koppelman's philosophy is favorable to free markets is his own say-so. He offers few if any examples of favoring pro-market reforms. I heard him concede in a podcast, though not in the book, that the elimination of the Civil Aeronautics Board and deregulation of interstate trucking in the 70s were good. It would have been helpful for him to expound upon this in his book so we know where he positions himself on the spectrum of being "pro-market". His discussion of income inequality is just standard leftism. I was expecting a mature discussion of the reasons for income inequality, or perhaps a neutral, reasonable explanation of why inequality increased in recent decades. No such luck. He offers some statistics that demonstrate income inequality has increased in recent years, but with no argument whatsoever that the increase was unreasonable or that any identifiable group was being undervalued by the market. He spends a lot of time discussing John Rawls and and the Rawlsian "veil of ignorance". (See this piece highlighting some of Rawls's basic logical errors. Despite his popularity, his philosophy seems a bit confused.) Unfortunately, there's little connection between the Rawlsian philosophy and the modern income statistics. (Like, is any increase in inequality always bad? How do I know that the recent increase is too extreme? Or how can I determine what the right level of inequality is so I'll know when society has achieve justice? Koppelman doesn't really tell us.) That is the general theme of the book. He presents a theoretical argument for government regulation, but fails to justify government in actual practice. (He asserts that certain regulations are cost-benefit justified without really making his case, in my opinion. Show you're work if you want to be taken seriously by critics.) It might have been useful for him to contrast himself with standard progressives by giving some examples of markets being positive, examples which progressives would actually disagree with. Or he might have pointed to some period in history when inequality increased but did so for perfectly justified and understandable reasons. (Something like, "Such-and-such era also saw an increase in inequality, but in this case it was because some people chose to work longer hours while others adopted more leisure. Also, this was an age of genuinely beneficial innovations, and it was socially just to reward the innovators..." This would have been a nice contrast to the discussion in his book, which seems to have an implicit premise that any time inequality increases, it's unjustified.) 

The book seethes with an element of  Look at all these libertarian policies doing so much harm in the world! As a libertarian, it's pretty irksome to be catching blame for bad policy outcomes when we don't wield any power. Contra Koppelman, we haven't exactly been getting our way. Our critics grossly overstate our influence on policy. They somehow miss the fact that government has been growing in size and scope (contrary to the policy prescriptions of any prominent libertarian). It reminds me of the drug policy commentators who apparently think we've been living in a libertarian regime for the past several decades, and therefore recent trends in drug overdoses can be blamed on libertarian-influenced permissive drug policy. As someone who knows what the recent drug regime looks like and what the various libertarian policy prescriptions are, I can assure you we haven't recently lived through a libertarian drug policy utopia. This notion that we libertarians are getting our way with policy,and thus society's ills can be blamed on us, is pretty absurd. 

The book's title is a reference to an incident in which a fire department allowed a house to burn down because the owner failed to pay a $75 annual fee. Koppelman's argument bizarrely tries to pin this on the rise of libertarian ideology. In his interview with Koppelman, Reason's Nick Gillespie politely eviscerates this narrative of the event. Gillespie points out that the fire department was not a private service, but instead was a neighboring city's department which contracts with nearby municipalities that don't have their own departments. This is hardly an example of private markets going wild. It sounds more like an extension of the DMV's model of "customer service" applied to government-run emergency services. Gillespie points out that in similar such instances, the private fire department typically puts out the fire and charges the homeowner some reasonable multiple of the original fee. (Some will be tempted to cry foul on this kind of surcharge. But if there weren't any surcharge for non-payment, then everyone would simply decline to pay until their house is on fire, so there would be no funding and thus no fire department.) Private businesses that provide emergency services are very concerned about public perception and bad PR, but a municipal agency pretty much has carte blanche to let someone's house burn down and say, "I don't really give a shit. Not my jurisdiction." I think Koppelman is basically 180 degrees wrong to pin this on libertarianism. This story is an example of the callous indifference of a government bureaucracy, and Gillespie has the right model of how private companies work in similar situations. In Koppelman's defense, he might not be claiming that the fire chief was a devoted Rothbardian/Randian/Reaganite libertarian, applying market fundamentalism to his profession. There was probably no causal connection between libertarian philosophy and the actual event, which would make Koppelman's fixation on it quite strange. He makes the connection more obliquely. Koppelman points to a few prominent libertarian-adjacent commentators (including Glen Beck) who argued in defense of the decision to not fight the fire. This is a little strange, to say the least. The titular event of the book was not caused by libertarian ideology, but because some vaguely libertarian-leaning commentators discussed it after the fact, he can blame us for it? 

I'm a fairly well-read libertarian. I don't think of Glen Beck as being a particularly representative example of this clan. He almost never comes up in the libertarian blogs or books I read or the podcasts I listen to. He may self-describe as libertarian, but comes off as more conservative. Koppelman also lists Kevin Williamson and Jonah Goldberg as having commented on the event, both writing in National Review Online. It almost seems like Koppelman couldn't find any actual libertarians making the argument he wanted to tag us with, so he instead turned to conservative outlets. This is a little strange, as the book makes it seem like the libertarian blogosphere was buzzing with unanimous approval of the decision to let a house burn down. Here is Glen Beck's discussion; it's the transcript of a radio show, not a carefully penned article, so I'd cut him some slack for sloppiness in terms of language or logical structure. Here is Kevin Williamson's (incredibly short) piece. Also see Jonah Goldberg's two-paragraph commentary. Both Beck's radio clip and Williamson's short piece point out a crucial detail, that the South Fulton Fire department (the one that declined to put out a homeowner's fire in another municipality) until recently had declined to put out any fires outside the city limits. The $75 opt-in subscription to their services needs to be contrasted with the alternative of not having a the services of a fire department at all, not at any price. I think Koppelman and other people of his ideological stripe are morally obtuse in failing to comprehend (or declining to entertain) this important truth. He's apparently insisting on a "principle" that once you are capable of providing a service, you then become obligated to provide that service to anyone who needs it. It's worth noting (as Beck, Williamson, and Goldberg all do) that if you don't have some consequences failing to pay up, almost nobody will pay, and the fire department will be unfunded and thus serve no one. 

See this roundup at The Atlantic of pieces that commented on the event at the time. Note that it includes a post by Ron Beasley, a leftist who says he agrees with Williamson. He makes an argument of the flavor: the $75 fee was like a tax to fund a government service, and if you don't pay your taxes you shouldn't get those services. A search on Reason's website turns up one single link, which doesn't express an opinion on the justice of the fire department's inaction. Here's an old post at Volok Conspiracy, to name another libertarian-inflected outlet (Volok Conspiracy has since moved to Reason). The Volok piece appears to be presenting this as an interesting question rather than a justification of the fire department's decision. It even says "one obvious solution is to make the service mandatory: Require homeowners to pay the $75 as a mandatory tax". This is weird. It feels like Koppelman searched for the libertarian take on this question, couldn't find any sources that told his narrative, so he instead reached for any sources making the argument he was looking for. He ended up with a handful of conservatives and apparently zero libertarians, unless you want to reclassify Glen Beck and Jonah Goldberg. 

If you want the authentic libertarian take on this, Gillespie nails it in the Reason interview. The fire department probably should have showed up to put out the fire, especially because some of the neighbors were paying subscribers, and their homes were threatened by the fire. (The fire department took measures to prevent the spread of the fire to those properties, though apparently not by putting it out at the source, which would have been the more humane and direct way of dealing with the problem.) They should have put out the fire and perhaps taken them to collection for some multiple of the $75 fee, or just acknowledged that the homeowner had previously been a dues-paying subscriber who simply forgot to pay one year (as appears to be the case). 

The book has a lot not to like about it. I've only just scratched the surface in this short piece. Basically this post is aiming at the book's title and grand theme. To do a more thorough and targeted critique of the arguments in the book, I would like to re-read and dissect Koppelman's exact language with greater care. I was eager to read it after hearing Nick Gillespie describe it positively in a podcast. I have to say it was a let down. But it's a useful foil in that it's a book-length criticism of libertarianism that basically misses the mark. 

The Right to Medical Self-Defense

A couple of weeks ago I got a panicked email from a friend of mine. His dad was having trouble breathing, and it was really making him miserable. He'd had issues with this before and knew a treatment that worked for him. The steroid prednisone seemed to always work. He was in a lot of pain, and my friend was getting desperate. Their family doctor wouldn't prescribe prednisone because the dad has a heart condition, a contraindication to the prescription he was seeking. 

I won't reveal many more details other than to say that the dad is fine. He managed to get a legal prescription to prednisone, and his breathing cleared up. It apparently didn't affect his heart. 

How should we think about this hypothetical story, which may or may not have happened the way I described it (or at all)? Does a doctor have a "right" to deny you medicine when you're pretty sure it works for you? Should we think of the dad as foolishly overriding the advice of his doctor, whose scientific credentials give him flawless insight? Or should we think of the doctor as robotically following a script, while the dad had proven, time-tested knowledge of which treatment clears up his breathing issues? Suppose it's not totally obvious what the "right" answer is here. Maybe the dad's breathing trouble could actually kill him, but it's also possible that prednisone will fatally exacerbate his heart condition. This is a condition of radical uncertainty. Who ultimately should get to decide whether the dad gets the medicine he wants? 

I will argue for an untrammeled right to medical self-defense. Ultimately, it's your body. You have the right to be mistaken and to make a foolish decision regarding your own health. Other people can try to change your mind, but you have a basic right to overrule them. Assuming you're an adult and are capable of understanding the risks, it's your call.

The dad in the above story had knowledge of how his body specifically responds to prednisone. The family doctor was following a recommendation, which presumably is based on aggregating information about similar cases that have happened in the past. The recommendation comes from some august body reviewing the medical literature, which is composed of various observational studies, clinical trials, and case studies. The dad's medical history is not as large and credible, in the sense of establishing statistical confidence, as the literature review. At the same time, it is more specific to his personal biology. He could well take the position, "Too bad this stuff doesn't work for everyone, but it works for me." And the doctor could reasonably take the position, "In those previous episodes, you just got lucky. You would have recovered anyway without prednisone. And you are playing a risky game with your heart condition." It's actually not clear which one has the wrong answer. Both are making a kind of guess, both are operating under radical uncertainty. Clearly some of the people in the dad's position make the wrong call and end up harming themselves. Since the dad in the story is the one whose health is on the line, I think it's pretty obvious that he should have the final say. Just to be clear, the dad in the story is not some kind of extreme outlier or edge-case. Think of the chronic pain patients whose doctors won't prescribe them opioids. Or think of a desperate, dying patient who wishes to try an experimental drug but can't because of regulatory barriers. Witness all the successful therapies involving MDMA and psychedelics for post traumatic stress disorder, or the same drugs used for the "betterment of well people". (Absurdly, the legal status of MDMA in the United States is Schedule 1 as of this writing, which implies that it has no known medical use. This "schedule" status is entirely a legal fiction, not a scientific assessment of the existing literature.) I think there were plenty of vulnerable people who would have been willing to take the Covid vaccines before they were officially "authorized for emergency use". In a just world, they would have had the option to try. Thousands of lives could have been saved because of this, and vaccine developers could have tried different formulations, perhaps hitting on a more effective vaccine less prone to side effects. What I'm trying to say is that the dad in the story has plenty of company. There are a lot of people who butt up against legal barriers to the treatment they want. In many of those cases, the treatment would indeed benefit them. 

We put too much stock in the notion of modern medicine as a scientific practice. Most doctors follow a "standard of care," which is more a legal concept than a scientific one. The standard of care is a kind of legal safe harbor. It's the protocol you follow to ensure that you don't get sued for malpractice. Of course, the standard is the standard because it has the weight of evidence behind it. If some other regime were more promising, it would (eventually) be the standard. But "standard of care" is a kind of consensus, and consensus only changes slowly and only in light of truly overwhelming evidence. Imagine being a research physician who promulgates such guidelines. You're responsible for an outdated standard of care that was subsequently found to be killing a lot of people (compared to some alternative standard, or compared to "no treatment"). There is naturally going to be resistance to any effort to update the guidelines. Any such update represents a pretty harsh rebuke, insinuating that your poor judgment has harmed thousands or even millions of people. We should conclude that the current practice of medicine is always lagging the best available information. The updating process is likely blocked by a combination of sheer inertia of habit (by typical doctors running a practice) and active resistance by promulgators of the existing standard. On the other hand, guidelines that too readily followed the latest journal publications would be chasing fads that ultimately don't stand the test of time. There is usually a range of plausible treatment protocols, any one of which may have vociferous detractors and enthusiastic advocates. Science doesn't yield unimpeachable answers. It's a process for reaching towards the truth, and the range of plausible answers is quite wide.  

None of this is to say we should just dispense with guidelines and scientific consensus-building, so long as we recognize it as a work in progress. If you are suffering a heart attack, getting the standard of care will probably save your life. But we need to be aware that this is the environment we're swimming in. It does a poor job of trading off one kind of harm versus another. Quite plausibly the doctor in my story was only saying "No" to avoid getting sued. The existing health apparatus is also bad at trading off comfort or pleasure against measurable health outcomes; the patient may prioritize the former while the doctor is biased toward the latter. Even assuming we keep this regime of requiring a doctor's sign-off to get certain kinds of medicine, we should allow the patient to sign some kind of iron-clad waiver saying he won't sue the doctor. (Or perhaps he could get the pharmacist's sign-off if denied by the doctor? Or simply certify that he's taking the medicine against the recommendations of a doctor? Your body, your choice, right?)

We have erected three types of legal barriers to getting medicine. One is the outright prohibition of certain classes of drugs, usually because some people find them fun. Another is the approval process for new drugs as managed by the FDA. The last is the need to acquire a prescription for certain drugs. You could refer to these various barriers as "Not ever," "Not yet," and "Not you." None are legitimate.

I could make an entirely different kind of argument. I could make some kind of consequentialist argument that the world would be a better place by some objective measure if we had an unbounded right to medical self defense. I think that's probably true, by almost any objective measure of the public's general health. But that's not my goal with this post. I merely want to assert that this is a right. I'm planting that stake in the ground. If you are convinced that a certain kind of medicine is the right treatment for you, it is not the business of technocrats to override your decision because they think they know better. I don't think technocrats should be able to veto your decisions about where to live, who to share your life with, or what kinds of books to read. It wouldn't really matter if they had a truly compelling cost-benefit analysis to justify overruling your decisions. There's just something inherently creepy about giving the government this kind of power. Giving technocrats veto power over our health decisions is the same thing in principle.