Wednesday, December 28, 2022

Drug Poisoning Update for 2021 Data

I haven't done one of these in almost three years, but I wanted to do an update. Here is my most recent one with data through 2018, also with links to prior years' analyses. I think not much has changed about the overall narrative, so I'll direct readers to the previous years' posts for those details.

The CDC's large mortality file gets posted here, in case anyone wants to download and do their own data mining. 

There were 107,027 drug-related deaths in 2021. This includes 98,722 accidents, 4,239 suicides, 3,852 incidents of "undetermined intent", and 214 murders. (Not included in the 107,027 figure is 7,017 "other" deaths, where drugs were mentioned on the death certificate but weren't listed as the immediate cause of death. Some of these really are caused by drug use, so presumably they should count for anyone who's concerned about drug-related public health issues.) In the past I've made a big deal about the difference between the total and accidental deaths. Sensationalist journalists reach for the largest number they can find, so they cite the total. This will often be in the context of an "opioid epidemic" story. But it doesn't make much sense to blame suicides on the opioid epidemic. A suicide is a death that would most likely have happened anyway, just by another means. At any rate, as the years go on the "accident" category is becoming such an overwhelming majority that it feels a little pedantic to make this distinction. Still, bonus points for honesty to any journalists who cite the 98k figure rather than the 107k figure. Here's a chart of the proportion of deaths by the various categories over time, where you can see "accidental" swallowing up a greater and greater share of the total:

I do suspect a lot of these "accidental" overdose deaths have a question mark over them. A lot of these people are taking such tremendous risks (like shooting up alone with a powder of unknown origin and potency) that it's worth asking whether it should count as an attempted suicide. But the best I can do is analyze the data we have and caveat with my personal suspicions. 

Above is a chart showing the deaths by major substance categories. The pink line that dominates in the most recent years is "synthetic narcotics", which mostly refers to fentanyl being sold as a street drug. Fentanyl has largely replaced heroin as the major opioid of abuse. This view can be slightly misleading in the following sense: most drug poisonings are multi-drug interactions. So if one category of drugs is skyrocketing, it can drive up the apparent deadliness of other drugs (even if the risk or abuse rates of, say, cocaine or benzodiazepines are basically unchanged). This is actually my value-added. Because this CDC file is at the individual record level, I can count, say, cocaine deaths excluding fentanyl and heroin. I think what looks like a general trend of increasing drug deadliness is in reality almost entirely a fentanyl story. 

Below I have created a similar time series, but this time I'm splitting each substance into two lines. The first line is unconditional count, and it should match the chart above. The second (necessarily lower) line excludes deaths involving heroin or fentanyl. The normal green line is cocaine deaths, while the pukish-green line is cocaine deaths excluding those that also involved heroin or fentanyl. The first looks like it's taking off, the second looks like it's relatively flat. This is clearly a case of fentanyl driving up cocaine-related deaths. Presumably in most of these deaths, the cocaine was either not a factor or not sufficient to kill without the added effect of a potent opioid. 


For clarity (the above chart is too busy to read clearly), here are prescription opioids inclusive and exclusive of heroin/fentanyl. The dishonest way to report on this is to look at the raw number and say "prescription opioid deaths are still rising." A more honest assessment is that prescription opioid deaths are falling, but the extremely high mortality of illicit fentanyl users is spuriously driving up the number of death certificates that mention prescription opioids. There are fentanyl users who happen to have prescription pills on them when they fatally overdose, and there are people who abstain from fentanyl but who fatally overdose on prescription pills. The non-overlap in these categories explains the huge gap between the two lines.


Here's benzodiazepines. Almost all benzodiazepine-related deaths involve some other substance, typically an opioid but sometimes alcohol or some other prescription medication. This is once again a story of fentanyl driving up the total.


Here are "psychostimulants with abuse potential", which mostly means methamphetamine. I think I have heard some commentators suggest that meth is on the rise again, which possibly exonerates opioids. The rising rates of meth use, this narrative goes, are simply a continuation of a longstanding trend of increasing overdose rates, which extends back to the 1970s (possibly earlier). Meth just happens to be in vogue again. This appears not to be the case. Undoubtedly the red line is increasing dramatically, but in the most recent year the blue line is almost three times as high as the red line. Pure meth-related mortality is several times higher than it was twenty years ago, but at the same time the vast majority of meth-related drug poisonings also involved fentanyl or heroin. 


By the way, heroin deaths seem to have reached a peak in 2017, at 14,870. By 2021 they were down to 9,064. So overwhelmingly the most fatal street drug is fentanyl, which appears to have almost totally taken over the heroin market. 

If you want more information about which drugs in combination are killing people, here is a cross table. (To read the lower table, take the second column of the first row. Read this as "22.48% of heroin deaths also involved cocaine.") 



The elephant in the room here is that I've added the Covid years to the analysis. My previous update went through 2018, where drug-related deaths appeared to be leveling off. Well, 2019 looks like a clone of 2017, if not slightly worse. 2020 and 2021 both saw large increases over the prior year. I don't know if the "deaths of despair" narrative makes sense here, or if we're just seeing a continuation of that longstanding trend reaching back to the 1970s. Shouldn't despair have been worse in 2020, when lockdowns were harsher, society was more closed, and drug users would have been more likely to shoot up alone (thus not having anyone who could call for help if they overdosed)? Or was there some kind of accumulation of despair from 2020 to 2021? That is, even though 2021 was milder in terms of social isolation, that isolation was still wearing people down and driving them to risky drug use. 

I have limited patience for the notion that drug-related mortality can exponentially increase for multiple decades. Obviously this can't go on forever. I haven't done a population dynamics calculations to check this, but at some point you'd start running out of drug users. A little Googling suggests there are around a million heroin users in the United States. (Maybe double or triple that if you think most heroin users are homeless and out of reach of household surveys of drug use). If these are the people being killed by fentanyl, then with the numbers we're seeing it would only take a few years for them to all die off. Even with new addicts refreshing their ranks, the mortality is high enough that some depletion should be happening. And these very high mortality rates should be scaring off a lot of potential new users. (Presumably that's happening, but some countervailing force is attracting them?) We should probably take seriously the notion that a large number of deaths are misclassified. Does anyone have a story for why methamphetamine-related deaths, excluding those involving heroin/fentanyl, have increased 30-fold since 1999? Were we perhaps undercounting back then and/or are we overcounting now? I don't want to selectively dismiss or down-weight government data, but at the same time this kind of dramatic increase makes me really suspicious. My attempt to find some pattern in all-cause mortality or a redistribution from one cause-of-death category to another was pretty inconclusive, but that's not to say a deeper dive wouldn't turn up something interesting. 

How to Means Test Social Security and Medicare

Social Security and Medicare make little sense as anti-poverty programs. They pay out based on age, not need. A retiree who earned a respectable income over their lifetime shouldn't need Social Security to provide for their retirement. They had the means to save back enough to cover their retirement years. Such a person could easily have a million or so dollars saved up.

The obvious way to means test is...to observe your means. Look at the retiree's assets, then apply some kind of threshold at which point benefits are subtracted. (More likely a sliding scale, such that holding an extra dollar doesn't magically cause thousands of dollars worth of annual payments to disappear.) This may seem superficially fair, because such means testing would avoid the bad optics of making government welfare payments to millionaires and billionaires. But there's an obvious moral hazard problem. If saving less results in a higher Social Security income, people will be encouraged to save too little for retirement. Some people save back nothing for retirement, leaning on the lazy assumption that Social Security will be adequate to cover living expenses. (It's not for most retirees.) Means testing based on current assets would exacerbate this problem. Some fools would deliberately aim for zero assets to literally maximize Social Security. That's an extreme case, but even normal, rational people would be nudged in the direction of inadequate savings.

The smart way to means test is to count total lifetime income, not current assets at the time of retirement. Two people who have had identical incomes over their lifetime have had roughly equal opportunities to save. If one saves frugally and the other saves back nothing, we shouldn't feel compelled to help out the latter. Both people had the same lifetime means, but they made different choices for what to do with their earnings. There still may be some frugal individuals with modest incomes who retire millionaires. They may get Social Security payments because their lifetime income was low, even though they don't technically need it. And there will be people with high lifetime earnings but inadequate savings who get nothing. Hopefully, the government makes a credible commitment to not bail out these people. The best scenario is that they get the message early in their working lives that nobody is coming to save them, and that they should set aside what they'll need for their own retirement. 

This scheme mostly avoids the moral hazard problem. There might be some people who deliberately earn less over their lifetimes to game the system, but a smartly designed payment scheme would avoid any such gaming. There should be no "cliffs", whereby earning one extra dollar causes thousands of dollars of Social Security payments to disappear. And there should be no point on the sliding scale where earning a dollar in income loses you more than a dollar in Social Security payments. Social Security payments should be such a gentle slope with respect to lifetime income that there is no temptation to earn less in the marketplace. This should be easy enough to do if we think of it as a program to avoid indigence in old age, rather than a program to fund the retirements of middle-income earners. A minimalist income floor can be provided without distorting the incentives to earn and save over a lifetime. 

Medicare is a little more complicated, because it's not just an entitlement program. It vastly distorts the market for medicine by being one of the largest single payers. We would need to have pro-market reforms, whereby people get comfortable paying out of pocket for most of their medical expenses rather than having third parties pay for almost everything. Patient price shopping and transparent pricing would bring costs down and eliminate a lot of wasteful spending. But given that, the same arguments would apply. 

I think there are a couple of major barriers to this kind of reform, one ideological and one selfish (both are cynical). The selfish one is that current and near-future retirees don't want to see anything happen to a government program that they're planning to draw an income from. I think the kind of means testing I describe here wouldn't impoverish many retirees, because people with modest or high incomes typically save for retirement (beyond what they expect to collect from Social Security). Still, it would be a little unfair to change the deal on people who are in or near retirement. So a more palatable (you could even say fairer) plan would be to start the means testing on people who will be retiring more than, say ten years in the future. Means testing could be on a gradient that scales up over time, so people retiring in ten years could get essentially the same benefits as current retirees while people retiring 25 or 30 years in the future could get the full effect of means-testing. This solution is so obvious that the "It's unfair to current retirees" argument carries no water at all. We should be asking, "What's the optimal state of this welfare program? What does the transition look like if we have decades or a century to ease into it?" The specter of current retirees being left in the cold, having their incomes revoked without warning, is nothing but a scare tactic. 

The ideological opposition comes from the left's knee-jerk love of entitlement programs. They prefer to have a broad base of recipients for these programs so it becomes difficult to reform them, even if that means throwing government money at people who don't need it. They want everyone to have "buy-in" so the whole population becomes part of the program's constituency. When politicians start talking about fiscal responsibility and reigning in the unsustainable spending of Social Security and Medicare, they want boomer-cons and senior Trump voters to fight back saying, "Get your government hands off my Social Security." This dynamic serves up some delicious hypocrisy, but it also makes government transfer programs politically untouchable. It's a dishonest way to sell something to the public. If transfer programs that specifically target the needy are politically unpalatable, if the American public wouldn't vote for them or would underfund them because of a lack of buy-in, then we shouldn't have them in their current incarnation. But it looks like we're stuck with them for the long term. 

Sunday, November 27, 2022

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. 

Wednesday, November 23, 2022

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. 

Thursday, November 3, 2022

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. 

Friday, September 16, 2022

The Criminalization of Gays in the United States

I recently read two books that detail the history of mistreatment of homosexuals in the United States. Secret City: The Hidden History of Gay Washington by James Kirchick is focused on the implications of being a homosexual for one's career in government. Vice Patrol by Anna Lvovsky is more focused on the tactics used by municipal police departments to entrap gay men. Both are worth reading if you want to know more about the official government oppression of gays in the 20th century. This was a topic I knew existed, but I'd never seen a proper book-length treatment of it before. The closest to it was a chapter Norm Stamper gave to it in his book Breaking Rank. Stamper is a former police officer (former chief of police of Seattle in fact), and he's old enough to have been part of a vice squad. He recounts a few grossly homophobic jokes by the director of the squad, which gives a flavor of the scene he was working in. Secret City and Vice Patrol give me a fuller view of this world. 

Gays were essentially barred from serving in government. The ostensible reason for the prohibition being that gays, having a dirty secret to hide, would be easy to blackmail. If a homosexual were in a role that involved handling sensitive information and a foreign agent figured this out, that person would be a security risk. It's superficially plausible, but Kirchick points out that this is a self-fulfilling prophecy. A gay person's career is in constant peril because of the official policy of "no gays in government." Codifying this policy (which was already in play in the cultural layer of society before it was ever officially codified) makes it easier to blackmail them. Kirchick tells the story of a gay government employee who gets outed. He makes no effort to deny or cover up who he is, he simply tries to argue, "There's nothing to blackmail me over. My status as a gay man is known to everyone." This didn't work, he was fired anyway. There was something else at play beyond the official rationale for the prohibition, probably that people in that time just thought "Those people are gross" and didn't feel any remorse for openly discriminating against them. Kirchick finds there was little to no evidence that blackmailed homosexuals were responsible for any security leaks. 

It's regrettable that this is how Washington worked in the 20th century. But what really revolted me is the level of "due diligence" that the government went through to root out gays in their midst. Government employees often faced rigorous background checks by serious FBI agents. It might not have bothered me quite as much if there was some kind of "don't ask, don't tell" policy, where everyone was notionally against homosexuality but they didn't bother too hard to uncover it. But they invested serious resources into these background checks. Bachelors were automatically suspect and got extra scrutiny. Interviews with friends and acquaintances often turned up minor clues. A background-checker who was a decent human being, who recognized he was conducting a witch hunt, would have simply declined to overturn every stone he found. The FBI agents who conducted these inquisitions must have seriously believed they were fighting a righteous war against the wicked, because they went to great lengths to track down every 2nd and 3rd-hand clue about someone's past. Secret City describes several instances of these investigations discovering a homosexual past, sometimes turning up an incident that was decades old. Those days are basically behind us, and I'm generally one to accept progress for what it is and let the past be the past. But the FBI's hunt for homosexuals reaches a high bar of depravity. I think there should be some kind of reckoning. At least a public naming and shaming of some higher-ups who were complicit in these investigations. It doesn't rise to the level of "Nazi prison guard". But it's still in the realm of, "This is sufficiently wicked that you should have recognized it at the time. You ruined people's lives over nothing." It would be interesting to hear someone try to justify their complicity in this kind of inquisition. I feel like some kind of message has to be sent that "just following orders" is not sufficient cover for wrongdoing. You have a responsibility to resign if you're ordered to do something unconscionable, at the very least to refuse the orders. I'm not saying we should go doxing these by-now senior citizens, who (assuming any are left) are probably living out their remaining years in some kind of quiet dignity. But some kind of cross-generational line in the sand has to be drawn against this kind of domestic persecution. (Maybe we wait until we're pretty sure they're all gone and unseal the relevant files? Similar to the unveiling of the Stasi files after the fall of East Germany, which revealed the wrongdoings of Stasi agents and their informants. Or maybe we get a few of them, who truly had regrets and a change of heart, to step forward and renounce what they did? I feel like there needs to be some kind of clearing of the air. The State Department has issued an apology for the so-called Lavender Scare, which is a start at least.) 

Secret City is mostly about the career implications of being outed as a gay person, specifically in the federal government. Vice Patrol gets into the weeds of anti-gay law enforcement at the municipal level. Again, I was shocked by the amount of manpower and resources that went into persecuting homosexuals. Vice patrols used different tools than the FBI background checkers and had a different motive. The FBI wasn't concerned with criminal prosecution or capturing someone in the act. They merely wanted to establish someone's status as a homosexual. Anti-gay vice cops, on the other hand, were primarily motivated to get convictions. This usually did entail catching someone in the act, which implied the need for subterfuge and hidden surveillance. Homosexual behavior (of the kind the vice squad is concerned with) is consensual, so the police needed to trick gays into revealing themselves. (Victims of crimes generally come forward willingly, so less subterfuge is necessary to identify and apprehend the criminals.) Some vice cops would dress as gay men and hang around in gay bars or public restrooms that were known to be frequented by gay men. If someone made too direct a proposition, they would be arrested and charged. Responding to this environment, gay men had indirect, often non-verbal cues to coordinate with others. The book recounts an exchange in which a vice cop tries to get a (presumably) gay man to make an explicit proposition, and the (very wise) gay man repeatedly declines to oblige him. They both grow frustrated with the exchange and part company. 

This legal ecosystem of cat-and-mouse games created a lot of borderline prosecutions, in which it wasn't totally clear to an objective third party whether a proposition had been made. A gay man caught in this trap could often successfully argue in court that no proposition had been made and it was all a misunderstanding. The police had to resort to arguing that they had special expertise in recognizing gays and gay behavior. Some gay stereotypes may be easily described in objective terms, things like "tight pants" or "speaks with a lisp". Other traits might defy description. Some series of subtle cues might have set off the vice cop's "gaydar," though explaining this to a judge may be impossible. (Quick, look at some images of a man's face and a woman's face, explain in terms of objective measurements how you know one from the other. "Well the nose is kind of...and the ears are slightly..." It's hard to describe in words, yet somehow you can tell the difference with near certainty in most cases. It seems plausible that some people have this kind of tacit classification mechanism when it comes to identifying gay people.) This actually created a kind of legal tension, a contradiction of legal arguments. The police would often insist that they had expertise in identifying homosexuals. At the same time, they often targeted gay bars, whose owners would plead ignorance, arguing that they have no way of knowing what a gay person looks like. How are they supposed to know the sexual proclivities of their clientele? The police could turn around and insist that it's obvious when someone is gay, but that would undermine their claim to have a special skill in this area. 

The book also gets into the topic of liquor licensing boards. The boards would target gay bars, attempting to remove their liquor license. But obviously in a world where homosexuality is against the law, no bars were advertising their status as a gay bar. Owners would simply deny that they could distinguish gay customers from straight customers, so they had no way of strictly maintaining a straight clientele. Licensing boards couldn't just issue a summary judgment and revoke a license on a suspicion. Owners of (allegedly) gay bars had legal recourse. There was some kind of due process that generally worked in their favor. 

What revolted me most about this book was the surveillance of public restrooms. Once again, these were consensual acts between adults, so the authorities must resort to morally questionable behaviors to catch and prosecute them. That meant entrapping someone in a sting operation or staking out and spying on the bathroom's users. Some vice cops would sit in an adjacent stall and give some kind of cue (like tapping their foot). If a person in the adjacent stall fell for it, they'd be arrested and prosecuted. The police would also install video cameras and listening devices, or observe through binoculars from some perch (through a hole in the wall or a tiny window that was hard to notice). It's hard for me to fathom the rationale for this. If people (gay or straight!) were wantonly having sex in public restrooms (without availing themselves the cover of a bathroom stall), it would be easy enough to catch them without entrapping or surveilling anyone. An occasional random check-in would catch a couple in the act, and they could be arrested for public indecency. It would not take much of this to discourage the practice, and thrill-seekers would be more discrete about their dalliances. 

No, the effort that vice cops put into prosecuting gays suggests they thought they were on the side of the angels, fighting a crusade against sinfulness. Surveilling these mostly innocent restroom users truly crosses a line. And this isn't just the moral clarity of a distant generation talking, not a case of "moral hindsight is 20/20". Some judges who presided over these prosecutions offered the same misgivings. A bathroom stall, some judges argued, was a strictly private space. There was never a state interest in snooping on the occupants, and doing so inherently runs afoul of 4th amendment protections. Judges also felt that some of the arrestees had been entrapped. They may have had no inclination toward homosexual conduct if the police hadn't enticed them with suggestive conduct. That's hardly an enlightened attitude toward the gay community by today's standards, but it's clear that the judiciary provided pushback against the excesses of vice enforcement.  

Once again, I think there should be some kind of reckoning for the police officers and officials who were complicit in this culture of actively persecuting homosexuals. It was long enough ago that most of these people would be retired or gone, so there wouldn't be much in the way of career consequences. But some kind of naming and shaming is in order for anyone who played a part in this regime. This isn't a case of, "Moral standards shifted unpredictably over a couple of generations, so it wouldn't be fair to judge them by the new standards." It's not an instance of "They have audio of me saying a word that later became a no-no, so now I'm cancelled." It's not merely, "I failed to stand up for what's right in a wicked world". I think the actions of vice cops were morally revolting in a way that was obvious at the time. And they zealously pursued their targets, selecting the persecution of a despised minority as a career. (In an interview that I can't locate now, I heard Anna Lvovsky describe her experience interviewing an instructor of a vice squad. This was the man who taught young cops how to successfully persecute gays. She honorably played the part of the impartial scribe, and we have an excellent book because of it. I don't think I could have remained so calm in her situation. Bless her.) Norm Stamper has set a phenomenal example here. He dedicated a chapter of Breaking Rank to his time as a vice cop. He apologizes for being late to the party on gay rights issues, though he was decades ahead of his colleagues. We could start with a few more voluntary about-faces and apologies by former vice patrolmen, maybe involuntary naming-and-shaming for truly egregious examples of anti-gay policing. 

I haven't done justice to either book, and obviously I'm adding my own reactions of moral outrage. Secret City is over 800 pages, Vice Patrol just shy of 300 pages of actual text. This post barely scrapes the surface. I'm merely trying to paint the basic historical landscape and contrast it to present enlightened views of gay rights. I think it's worth offering a few observations from a libertarian perspective. 

It's worth noting that extra-legal persecution of homosexuals would probably have been happening even absent the vice squads and federal rules banning them from government posts. Politics is downstream of culture. That is to say, government is for the most part constrained by what the general population finds acceptable. Official policy is often the codification of something that's already happening in private society. This is something that libertarians need to struggle with. The "gays are easy targets for blackmail" rationale may be bogus for the reasons given above, but it's still the case that publicly outing someone could have destroyed their life. This was probably true up until the very latest part of the 20th century. Persecution of minorities can happen without the government lifting a finger. This kind of thing can run on the cultural layer of society if a social consensus forms that "homosexuality is icky." There is a school of thought that insists on libertarianism as being a strictly political philosophy, which shouldn't be offering commentary (not speaking as libertarians anyway) on these kinds of cultural issues. Assuming there is a free labor market, homophobic employers could fire gay people. Landlords could discriminate against gay tenants in a free market for housing, etc. And this could be the norm rather than an isolated act of bigotry. Worse, it could be the case that homophobic tenants and employees are the ones insisting on being in a gay-free environment, so even enlightened gay-positive employers or landlords may feel pressured to discriminate by the less enlightened mobs they serve. It's a little bit weird to see society coordinate to discriminate against a minority group and insist that libertarianism has nothing to say about it. It's not exactly "government", but it's still a kind of coordinated power being directed against a relatively powerless minority group. I think most libertarians don't subscribe to this strict separation of political and cultural prescriptions, but the ones who do should squirm a little at this thought. Anti-discrimination laws, as a general tool, don't solve the problem in this kind of society, because such laws would reflect the general public's understanding of who should and shouldn't be a protected class. I'm still a radical advocate for freedom of association, up to and including the right of bigoted shopkeepers or employers to exclude whoever they don't like for any reason. I think in today's society such bigots wouldn't survive the first flex of their "right to discriminate." They'd be boycotted and shamed out of existence. But 50 years ago? I'm not so sure. Discriminating against despised minorities may have helped rather than harmed their bottom line. We should keep in mind that in less enlightened parts of the world, there are still bloody race riots. Resented minorities are often beaten, raped, or murdered. Violent pogroms are carried out by mobs. Sometimes governments are complicit in such racial violence, but often these are impromptu lynch mobs composed of "normal" people. These are incredibly powerful social forces, projecting power and initiating violence. It makes little sense for libertarians to build this wall of separation between strictly political philosophy and social philosophy that condemns extra-judicial violence, as if the latter were not part of our mission. Race riots happen in some cases because of anocracy, a lack of sufficient government, or a failure by existing governments to enforce the law (though it could do so if it were inclined to). Sometimes governments protect unpopular minorities from a society that would initiate violence against them; this thought should make libertarians of the anarchist persuasion (and I am one by the way) squirm a little. Sometimes a big, central government secures the rights of minorities against smaller state and local governments; this thought should make secessionists and extreme federalists uncomfortable. There is plenty to squirm about here. (To statists I would say, sometimes the government simply reinforces and codifies the bigotry of the surrounding society, see the contents of this post for numerous examples. So "government prohibits bigotry" isn't such a straightforward answer to the problem, either.)

It's also worth reflecting on the difference between the gay lifestyle today and the one that was practiced in the 20th century, when it was considered illicit. Neither of the above mentioned books discusses gay relationships as long-term bonding between a loving couple (or if they did, it was so brief I missed it, sorry). Surely there were some long-term gay couples, though they must have gone to great lengths to disguise their relationship. Two men cohabiting for a long period of time would have raised eyebrows, eventually attracting the attention of family members, landlords, employers, and possibly the authorities. No, most of the homosexual encounters described in both books were "hook ups." These were one-time dalliances between two people who would most likely never meet again. (John Kennedy was propositioned by a man who, to his great credit, he remained a life-long friend with. Presumably such propositions sometimes paid off, which would result in two acquaintances knowing one another to be gay. I'm sure this led to some repeat encounters, if not actual cohabitation or long-term relationships.) What am I driving at? In this kind of environment, homosexuality really does seem illicit. People are engaging in subterfuge, trying to evade the law, possibly lying to cover their tracks. And what they're covering up is not a loving, long-term relationship, but (to onlookers in the mid-20th century) a form of sexual depravity. In the present day, a gay identity really does mean long-term relationships. It means introducing your friends and family to your partner. It's perfectly wholesome. In the early to mid 20th century, it meant late night hookups in public parks or bathrooms. There is a generalization here, which is that criminalizing something makes it seem sleazy, even if it isn't inherently so. The obvious analogy is drug prohibition. Under a prohibition regime, drug dealers really are sleazy people. They use violence to silence witnesses or settle disputes. They hire drug mules to swallow condoms filled with dangerous powders and cross borders with them, which sometimes results in the condom failing and causing a fatal overdose. They sometimes use minors as delivery boys. The chemical processes they use to manufacture some drugs are toxic enough to make the property they're done in uninhabitable. When a drug cop busts a drug dealer, they're likely apprehending someone who has murdered a rival or cooked up a batch of bad dope that killed one of his customers. They end up thinking they're fighting a holy war because the people they arrest really do engage in destructive behavior. These cops mostly lack the imagination to see what the counterfactual is: the world in which drug commerce is legal. Markets that are above board aren't generally associated with these sleazy behaviors. The guy who sells me beer at the liquor store (or the grocery store) has no inclination to second-guess my motives, to pat me down in search of a wire, to shoot me if he finds one. Likewise, a vice cop in the mid-20th century who apprehends a homosexual is catching someone in the middle of an act that society deems morally revolting.* He doesn't see the counterfactual world that has only come to light in the past 30 or 40 years, where openly gay couples have long-term, loving relationships. To explain is not to forgive. Obviously I'm not trying to justify the criminalization of homosexuality or of drugs. But we owe it to ourselves to get into the heads of people who prosecute these government orchestrated wars on vice. They think legalizing the vice means "Without the deterrent of the legal prohibition, there would be lot more of the ugly stuff we see on our jobs." They often lack the imagination or the inclination to see the counterfactual. They can't see that they're creating their own dragons to slay.

I was looking for a book in the libertarian canon that handled these topics, but I now don't think one is needed. Secret City and Vice Patrol lay out the historical details matter-of-factly with little editorializing or moralizing. To a modern reader, none is needed. The moral commentary writes itself in the reader's head. In this light, libertarian commentary on the history is kind of redundant. (Should someone write the same book from the libertarian perspective, offering the same history and factual details but pausing occasionally to say, "This is bad, because it violates the non aggression principle"?) At best, I think some libertarian editorializing is possible with regard to how to the moral arc is bending. Government prohibitions on drugs, prostitution, and gambling are analogous to the prohibition of homosexuality.** Driving an activity underground forces practitioners to engage in "sleazy" behaviors to cover their tracks. This causes onlookers (typical members of the broader society) to associate unseemly behaviors with the prohibited activity, even when there's nothing inherently wrong with it. There's something almost wholesome about drinking a few beers at a family barbecue. When you encounter the median beer drinker "in the act", there's nothing inherently sleazy about it. In most cases there wouldn't even be noticeable intoxication. But when the activity is illegal, the responsible practice of it stays hidden. It only becomes uncovered when something dangerous happens. Like someone crashing into a tree after snorting too much coke or discovering someone is an opioid addict when they fatally overdose.  There is certainly a "libertarian take" on this history that puts it into the context of other violations of our liberties. But I wouldn't want to supplant these two fine volumes with a libertarian version. I would simply add these books, exactly as they are, to any libertarian bookshelf (or any bookshelf for that matter) and leave it at "The libertarian editorializing writes itself." 

________________________________________________

I apologize for slipping into using the language of earlier times for parts of this post. It's not cool to refer to gays as "homosexuals" (even though it seems like a scientific, Latinized word for the people who engage in the behavior, it sounds wrong). I hope it's obvious when I'm giving voice to a person living two to four generations ago versus when I'm using my own language. 

*Imagine a vice patrol kicking down the door of an elderly gay couple, shouting "Freeze, police!" and barking orders. The couple would appear as harmless, decent folk who'd been needlessly terrified. I could imagine at least some of these cops having second thoughts about their mission after a few of these. This is a different mindset than someone who regularly catches homosexuals in the middle of the act in a public place. The undercover vice cop who routinely has a man proposition him by running a hand up his leg probably feels a sense of moral disgust. A more domestic gay lifestyle just isn't part of his world, so he never sees it.

**With an important difference. I think "gay" as an identity is possible if it's legalized in a way that it's not when homosexuality was criminalized. I don't know if "drug user" or "gambler" can or should become parts of your identity in the same way.  

Wednesday, September 14, 2022

Financing the Purchase of a Box Containing One Million Dollars

Suppose you have an opportunity to purchase a box containing a million dollars. It's not actually cash, but a series of IOUs that are only redeemable by you. Because the box is only valuable to you, the current owner has no other buyers. He's willing to sell for, say, $50k. 

A very confused onlooker observes this situation and says, "But, you don't have $50k. You can't afford to purchase this box!" I hope we can all agree that this is silly. Obviously you can finance the purchase of the box out based on your expected future windfall. You don't have $50k yet, but if you can credibly prove that you'll make good on your investment, you can borrow some money at a reasonable rate and pay back the loan out of your profits. (Most obviously, you can say, "Let me have the box and I'll immediately open it and give you $50k", and you and the current owner can then part ways.")

Change the example a little bit. Now it's not one big IOU for a million dollars. It's a series of IOUs that reach maturity at different times, stretching indefinitely into the future. The net present value, discounting future cash flows, is one million dollars. But really that's summing up your increased income over a lifetime. It would still be incredibly silly to say that you "can't afford" to purchase the box. It's worth just as much. The different maturities change the timing of your loan payback, but it's still overwhelmingly a good deal. 

Change the example a little more. Now it's not a series of IOUs, but rather a collection of extremely rare seeds that only you know how to cultivate. The resulting crop will be extremely valuable. The expected payoff is still a million dollars over the course of a lifetime, but making good on that requires some planting and nurturing. It's not something that will be your full-time job, but once you learn the craft it'll be a light hobby that pays off handsomely. Or maybe the box is full of a kind of cryptocurrency that requires solving some math or logic problems by hand. (Only solutions worked out by you will unlock the crypto, it somehow knows.) Given consistent effort, these math problems will definitely pay off. You will never get stuck on any one problem indefinitely. You can skip some of them if you truly get flummoxed, but there are enough such problems to solve that the expected net present value is still $1 million. All you have to do is put in the time. It's probably still worth purchasing this box. In this latest scenario, it would still be incredibly silly for someone to come along and say you "can't afford" to buy the box. It would be equally silly to take a look at your finances at some time before your loan was paid off and say you need financial help. It's still the case that you can finance the purchase of the box out of your expected future earnings, and still make an absurdly high rate of return on your purchase. 

This arrangement is starting to look more and more like a college education. The later examples change the timing and certainty of the payoff and the element of labor required to make the investment worthwhile. College isn't equivalent to a box full of ready cash, but it is a really good deal if you make good on it. It pays for itself several times over. You can finance a college education out of the expected increase in your future earnings. You can make those expected future earnings more certain by choosing a remunerative major (STEM or pre-professional) and working hard while in school (versus slacking off and getting bad grades, which I saw a lot of in my college days). 

Looking up some quick figures, a college degree pays off to the tune of around $1 million over a lifetime. (Obviously this is an average that glosses over several relevant variables, like choice of major.) The average cost of tuition is about $10k per year for in-state, $20k per year for out-of-state. (Once again, glossing over some relevant variables. A prospective student has a lot of choices s/he can make to lower or raise this figure.) The figures I used in the "magic box" example are roughly in the same ballpark. A student making the right decisions can make this a really good deal. They don't need help. It's true that some students overpay to go to fancy private schools or get worthless degrees. Some pay exorbitant tuition for elite private schools. They are essentially deciding to buy an overpriced status good, possibly seeing it as their key to elite positions in government. They don't really deserve our sympathy and they certainly don't need help. Some drift aimlessly in college and eventually decide they don't want to finish. That's unfortunate. I wish I could counsel some of these people before they made an impertinent life choice or talk them into sticking it out for a couple more years. But I don't think they deserve our help. This is someone who is declining to pick up a million dollar bill on the sidewalk. 

The recent chatter about the proposal to cancel student debt has been maddening. It's obvious that this is a middle-class and upper-class entitlement. The benefit of this debt forgiveness accrues to those people who are reaping that $1 million boost in lifetime earnings (on average). The cost, assuming the government eventually pays for it, is being spread to everyone. This means people who don't go to college are, on net, paying for the people who do. 

Tuesday, September 6, 2022

The Quantified Self

I've recently subscribed to the Oura ring and 23andMe. The goal is to learn a little bit more about myself. I would describe the results as mostly, "Confirming stuff I already knew and getting almost no actionable information." 

The Oura ring tracks a few vital signs, such as heart rate, respiratory rate, pulse ox, and body temperature. It also tracks movement, so it can tell if you're moving around or not. My interest was in tracking my sleep quality. The Oura ring guesses what phase of sleep you're in based on the various bio markers it can measure. You actually need the proper equipment (as in electrodes connected to the head) and brain-wave detection to measure which phase of sleep you're in, but the Oura ring makes a best guess based on movement, heart rate, etc. Its estimates leave room for improvement. See this paper comparing the ring to a proper polysomnography: 

From EBE analysis, ŌURA ring had a 96% sensitivity to detect sleep,and agreement of 65%, 51%, and 61%, in detecting “light sleep” (N1+N2), “deep sleep” (N3),and REM sleep, respectively.

That's not great. See also this video by a professional sleep researcher, who compared the measurements from his ring to what he got from professional-grade equipment. He got an overall accuracy just shy of 60% on phase-of-sleep detection. My own measurements usually show that I get around one hour of deep sleep. But sometimes it (alarmingly) tells me I only got about 20 minutes worth. I tend to average 1.5-2 hours of REM sleep, the remainder being light sleep. But I don't really believe it. My subjective well-being after a night's sleep is pretty uncorrelated with my Oura ring's sleep score. I wish it gave a lot more caveats and warnings to the user that "this is just an estimate", perhaps giving some kind of confidence interval. It was easy enough to find online reviews of the Oura ring, but I would worry about some users becoming needlessly anxious about their sleep quality based on the ring's inaccuracy. (See also this review by a doctor, who was not impressed.) 

The one thing that I did find useful is that it shows how your heart rate decreases over the course of the night. I have a resting heart rate in the 60s, which is normal. I previously had no way of knowing what my heart rate was while I slept. I now see that it tends to fall over the night and dips down into the 50s or even the high 40s. It also may be useful to know if your sleeping heart rate stabilizes early or late during your sleep. If it stabilizes late, that could mean you're over-training and need to take a break from physical activity. 

I'll give the Oura ring credit for highlighting a recurring pattern in my sleep. I routinely wake up feeling like garbage on Wednesday morning (specifically Wednesdays). My best guess is that it's due to eating a late meal Tuesday nights. I go to jiujitsu Tuesday evenings and get home at around 8:30, usually eating around 9 or later. If you eat a large meal too close to bed time, it can affect your sleep and lead to a late stabilization of your heart rate. I hadn't put this together, but I may experiment with smaller meals Tuesday evenings.

The other handy thing is tracking my average oxygen saturation. I sometimes snore, and I wanted to know if this was just annoying or if it could be full-blown sleep apnea. It runs in my family, so I have a reason to be worried.  I'm in better shape than some of my snoring family members, so maybe it's not a problem. (I don't snore as often or as loudly as my parents or brother, so something that I'm doing is probably working.) My Oura ring almost never detects a problem here. It's reading consistently at 98%. On an occasional night of cruddy sleep, I get a reading of 97% (never lower than that) and a message saying that it detected interruptions in breathing. Flawed as the Oura ring is, I think it's useful to flag potential issues. If it flags too many nights as having had breathing interruptions, I'll do a proper sleep study. (Likewise, if it fails to detect these, but my wife tells me my snoring is getting worse or I'm suffering excessive daytime sleepiness, I'll throw out my Oura ring and get a proper sleep study done.)

The Oura ring also tracks movement, so it can tell you if you move around a lot at night. This is interesting, but not really actionable. I get varying stats on different measures of my sleep score (time in deep sleep, REM sleep, etc.), but I consistently get poor marks for "restlessness." I do have to wake up an reposition myself a few times during the night, but the Oura ring is tracking a lot of tiny movements that don't rise to this level. I don't know what I'm supposed to do with this information. If I went to bed earlier and gave myself longer time to sleep, presumably I'd still be a restless sleeper. 

The information I got from 23andMe was likewise interesting but unsurprising. And none of it was actionable (though in theory it could have been). You get various reports telling you that you are more or less likely than average to experience IBS, sleep apnea, restless leg syndrome, and a host of other conditions. My issue with most of these is that you know from your subjective experience whether you're suffering from them or not. The information that your genes predispose you to it isn't useful. (Perhaps their test counter-indicates the condition, though you have it anyway. A false negative test on a question you already know the answer to.) I think many of these are polygenic tests. That is, they aren't testing for one or two specific genes that vastly change your probability of having the condition. They're based on an analysis of hundreds or thousands of genes, detecting correlations to various conditions. But there are also tests for certain "variants", genes that do have a well-understood connection to various diseases. (Examples are Cystic Fibrosis, Tay-Sachs Disease, and a bunch of conditions I've never heard of.) I was negative for all variants, so it didn't affect me. But I could see how someone would find this information actionable. You'd at least want to follow up with a doctor or work out some kind of monitoring plan. If you and your partner both tested positive for a given variant, it could spark a conversation with a genetics counselor about the potential affect on children. 

23andMe also provides some limited information about ancestry. My ancestry composition was pretty boring and predictable for an American of European ancestry. It pegs me as northwestern European, mostly English/Irish and German. My surname is German, my mother's maiden name is Irish, and both sides have a lot of Irish and German surnames going back generations. I also have a Swedish great great grandmother, though my 23andMe test pegs me as ~2% Finnish and 0% for the other Nordic states. I don't know if the genetic test is inaccurate or if perhaps my Swedish ancestors were recent transplant from Finland before they came to the United States. The breakdown of the British/Irish ancestry was leaning toward the English side, whereas I'd always thought of my ancestry as being more Irish. Maybe my Irish ancestors were also recent transplants from elsewhere in the UK? There was nothing I'd call "exotic". It apparently detected a small trace of Ashkenazi Jewish ancestry, which was intriguing to me. It reads as 0.1%, which comes out to one relative about ten generations ago. (I desperately wish to know more about this person, assuming s/he is real!) But it's hard to know what this means. Should I round it off to zero because it's within some margin of error? But then, why is the test yielding zero percent exactly for Italian, Spanish, East Asian, South Asian, etc., rather than a smattering of 0.1%s all over the place? 

23andMe can also connect you to other people who use the service, though you have to opt in to make yourself "discoverable." It pointed me to a number of distant cousins, only one of whose name I recognized. And it incorrectly marked him as a second cousin, whereas he's really a first cousin, once removed. It's still impressive, given that it's inferring these relationships based on a small market penetration. If, say, 10-20% of the US market used 23andMe, the family trees would be fuller and the connections would be made with more accuracy and greater confidence. 

A neighbor of mine was adopted as a baby. He recently discovered some of his birth siblings because his daughter was a 23andMe subscriber. Apparently they didn't know about him, the birth mother having died without revealing any details, so it's hard to imagine they would have met each other any other way. I think it's wonderful that a consumer service can make such discoveries for us. I don't know exactly what I was hoping for. Like, some forgotten branch of the family tree that nobody knows about. A "Grampa's little secret". (My paternal grandfather did have an out-of-wedlock son, but it's not a family secret.) 

I have heard people say they don't want to do a genetic test because it might conceivably affect their insurance rates. Perhaps the 23andMe data becomes discoverable by insurance underwriters, and they use the information to price or deny disability, life, or health insurance. I actually think this is nuts. You should want as much information as you can get that's relevant to your long-term planning. If there's information in your genes that suggests you're only going to live to, say your mid 50s, it's worth knowing that for planning your future. You probably won't want to have a kid in your 40s, for example. (Though you still may! Maybe you're a raging natalist, bless you, and you care about your hypothetical child's future whether you're around to enjoy it or not.) You might want to save more of your earnings to take care of your spouse and children, or (alternatively) you may decide to spend down your existing savings knowing that you won't be needing it. You may decide to drop some of those nagging health habits that will only pay off in your 70s and 80s. A lot of these decisions could actually go either way. What's weird to me is making this pact with your future insurers: "I won't peek if you don't." For most kinds of insurance, it's irrelevant anyway. Typically you get health insurance through your employer. They basically have to issue you the policy, they can't deny or change rates based on health status. So unless you're buying health insurance on the open market (hardly a "market"), you're fine. For life insurance, typically you'd have a term policy with a rate that was locked in when you bought it (hopefully when you were young). Say you buy a 30-year term life policy when you're 30. It's ten years later, you're curious about what you'll find in a genetic test, so you do 23andMe. Well, your term life policy is locked in. They can't cancel based on new information. It'll cover you until you're 60. At that point, maybe you want another policy and there's some adverse information in your genetic test. (Why, though? A life insurance policy is meant to cover the lost earnings of a breadwinner. By age 60, you've had time to accumulate savings and are usually an empty-nester, so this is less of an issue.) Okay, but if you get the genetic test at age 40 you still have 20 years to plan for that. That's 20 years worth of savings and compounding interest. If I'm genetically predisposed to dying early, I think I'd rather have that information and be able to plan with it, rather than preserving this option of buying cheaper life insurance at age 60. (And wouldn't the life insurer's underwriting discover whatever conditions you have by then? Wouldn't such a condition have started to manifest and leave a trace in your medical history?)

Tuesday, August 30, 2022

Two Books on the Trump Administration from the Inside

 I recently read two books about the internal workings of the Trump administration from people I respect. Casey Mulligan's You're Hired and Scott Atlas's A Plague Upon Our House are both very good. They offer a different lens through which to view an administration that's usually portrayed as oafish and arbitrary. I'm no fan of Mr. Trump. He generally had a terrible policy agenda and the way he conducted himself in office (particularly on the way out!) was atrocious. At the same time, the media's derangement at him (a literal syndrome) often led to an inaccurate picture of his administration. Seriously, it's like some of his detractors think his staff were a bunch of morons wandering aimlessly around the White House saying "Duh. Duh." to each other. Not that they were all great minds, but they were mostly professional, honorable people who wanted to serve their country. I'm sure they had intelligent conversations about policy including discussions of various considerations (if not full blown cost-benefit analyses). It's likely most of them were not particularly big fans of Mr. Trump but saw an opportunity to steer the beast. 

I've known about Scott Atlas for years. I was introduced to him by an Econtalk episode, which led me to read his earlier book In Excellent Health. I thought the media treatment of him was shitty, and people I know recited talking-points about him to me. These were mostly know-nothing, NPC-style recitations on topics they had no background information on. I sometimes had the energy to push back and say I knew something about him. Atlas is clearly a knowledgeable person on public health issues in addition to being an honorable person. 

Atlas was the "anti-Fauci". Anthony Fauci and Deborah Birx were two of the other advisers to Trump's pandemic policy. Atlas paints them as being reflexively pro-lockdown, favoring anything that might plausibly reduce Covid numbers and ignoring any costs of such policies. Atlas was an important counter-weight to the establishment faction. It was a virtual guarantee that the establishment/alarmist position would be represented among Trump's advisors. Someone had to be in the White House to offer the non-catastrophizing take on Covid policy. We were lucky to have had someone like Atlas, who had the president's trust and respect. Fauci and Birx are depicted as not really having their bags packed, so to speak. They had at best passing familiarity with literature on, for example, the effectiveness of masking. (When Atlas asked Birx for the evidence that convinced her of the effectiveness of masking, Atlas explains that he'd read the same paper and found it unconvincing. It was not exactly an RCT.) They were more concerned about consistent, simple messaging than they were about how those messages mapped on to the underlying reality. That's a dangerous play for a prominent figure in public health. The risk is that you cling tenaciously to a dangerous falsehood even as discrediting information comes in, or that your lack of nuance turns off citizens who are paying close attention. Atlas was a wink at those more observant citizens, as if to say to them, "Yes, we know that slogan-length public health messaging is oversimplified and often wrong. The president knows that they are picking which actions they want you to take, then back-fitting the messaging to get you to do it."

In You're Hired, Mulligan paints an interesting picture of the internal workings of the White House. Trump's tweets are often depicted as impulsive, as if he pounded out stray thoughts with his thumbs before rolling over and going to bed. Mulligan describes a more deliberate approach. Trump himself was not the author of most of those tweets. They were crafted by a team, often with some internal A/B testing or informal focus grouping. These tweets were often used to take the public's temperature, rather than to cram a half-baked policy down their throats. The intent was often to gauge the public's reaction. In describing this, I'm not opining on the morality of his approach to the public. There is something creepy about a president behaving this way. But Mulligan's narrative does contrast with the dominant media narrative of the Trump White House. 

A couple of things bothered me about Mulligan's book. He had an entire chapter on the "opioid epidemic". He basically recited the standard narrative, that a bunch of irresponsible doctors, encouraged by greedy pharmaceutical companies, overprescribed opioids. And this supposedly created a new class of addicts. There are serious problems with this narrative. He even blamed "lax drug policy" for the increase in overdose deaths, specifically calling out Eric Holder for his memo encouraging some laxness in applying harsh statutory sentencing. He suggests (I can't recall if implicitly or explicitly) that we could have kept fentanyl from hitting the drug market through stricter enforcement. The opposite is true; there never would have been demand for recreational fentanyl in a legal market. (This is really absurd. The sheer potency of fentanyl makes it impossible to interdict.) People need to seriously stop pretending like we've been trying libertarian drug policy for the last 20 years. Nothing could be further from the truth. The Holder memo might have had some tiny marginal effect on drug trafficking, but blaming it for an already-existing trend in rising overdose deaths is pretty dubious. I have to give Mulligan a strike or two for getting this one wrong, because I think it's one of the greatest injustices of American domestic policy. This is a massive moral blind-spot for him. Interestingly, he repeatedly plugs some kind of software algorithm called "theory guru". Supposedly this algorithm can automatically check if your economic assumptions are consistent with each other. He should have turned this loose on his musings about drug policy. If you place any credence at all on economics as a way of thinking, you will come to the conclusion that drug prohibition is an utter contradiction. Mulligan is using a very simple analysis, "If you raise the cost of doing something, you get less of it." Okay, but you "raise the cost" by gratuitously hurting people. Most people who think about this clearly will say that demand for drug use is inelastic, so a 1% increase in the "price" (monetary and non-monetary, including harms from the legal system etc.) will yield less  than a corresponding 1% drop in drug use. This is a losing game. The harm to remaining users is necessarily greater than the "savings" to those who are successfully deterred. I like Mulligan, but it feels like he seriously fell down on this one. 

The other thing I didn't care for was Mulligan's qualified defense of populism. He has some righteous anger at technocrats. I understand the sentiment. Technocrats can get things badly wrong, and people get hurt because of it. But the alternative is to basically yield to popular demands, which can be even worse. Seriously, he had me reaching for Bryan Caplan's The Myth of the Rational Voter to serve as an antidote.  Maybe his point was merely that DC technocrat-types are out of touch and don't care about the same issues as the median American (whatever that means). But it's a confusing message for a mostly free-market style economist like Mulligan. He has some harsh words for Peter Navarro, who is basically the public face of Trump's idiotic protectionism. I feel like he needed to grapple a little more with the fact that Trump's protectionism has broad popular appeal. Voters are mistaken about the effects of such economic policies, and it's his job as an economist to push back and correct their errors. If voters have a tendency to be authoritarian and to impose bad laws on their neighbors, I say technocrats can serve as a useful counterweight. I don't want to be ruled by either a populist mob or an academic technocracy, but I can see a useful role of each as a check on the other.  

I don't intent to write a comprehensive review of either book. I did want to share a slightly more coherent view of the Trump administration. If nothing else, these books offered some mild assurances that there's an adult in the room, even if the president is an idiot. There's usually someone around to say, "That's a terrible idea," or "Um, the president can't do that, sir."