The Amazing Randi

I went to a talk by James Randi yesterday. He used to perform magic as the Amazing Randi, although at 78 and recovering from a double bypass, he said he now merely aspires to be the Mildly Astonishing Randi. He is of course best known as a debunker of paranormal claims (though he said that he prefers to consider himself to be an investigator, not a debunker). His foundation offers a one million dollar prize to anybody who can show “under proper observing conditions, evidence of any paranormal, supernatural, or occult power or event.” They have received hundreds of applications, but the prize has as yet gone unclaimed.

Randi discussed homeopathy for a while. It is quite astonishing to consider that homeopathy has failed every scientific test, and indeed homeopathic medicines are essentially indistinguishable from water, yet homeopathic medicines are sold in every drugstore in the country. Since you can’t fool all of the people all of the time, this would seem to point to some systematic problem somewhere.

I see the following possibilities, some of which will occur together, and none of which are original:

• Homeopathic medicine may work, despite the scientific evidence.
• Most people recover from illness, so any widely accepted medicine which does no harm will continue to be accepted.
• Most people are not aware of the tests showing that homeopathic medicine has no effect, and operate on the assumption that if they sell it in the drugstore, it must do something.
• Most people don’t consider that the extraordinary advances in medicine are due solely to the scientific method, and thus continue to give unwarranted weight to older systems of medicine (not that homeopathy in particular is all that old).
• Modern medical practice heals the body but not the soul: the emphasis is on fixing problems rather than actually making people feel better.

To focus on the last point, traditional medical practice is clearly not as effective as modern medicine, as can be seen by the extraordinary increase in average lifespan during the 20th century. But traditional medical practice had the significant advantage that somebody visibly cared. Modern medicine, as we know, involves being shunted to a series of specialists, few of whom know you at all, and all of whom are paid to perform a procedure rather than to achieve a result. This is not to say that doctors do not in general care about their patients; it is to say that the system as a whole operates to minimize that care.

How can we make it better? Obviously this is a huge topic which many people think about, and one which in the U.S. is tightly constrained by ideology. If you think about insurance systems, it is obvious that they only work to guard against unpredictable events. Insurance is a sound system for protecting people from the most adverse effects of house fires and car accidents. It would also be a sound system for protecting people from the financial effects of catastrophic medical events due to accident. This is because the insurance company can pool premiums across a large number of people, and can use reasonably statistical studies to estimate the required payouts and thus the required fees. The key feature is that the payouts are randomly distributed–the clients can not predict whether they will need a payout–and that the insurance company can use historical data to predict the approximate required payouts over time.

But you can not use an insurance system to protect yourself from predictable events, such as old age or chronic illness. The whole idea makes no sense. People will naturally select the insurance plan which will work best for them: the payouts will not be randomly distributed. Over time the fees for people who need a lot of medical care will increase, and the fees for those who do not will not. Effectively people will pay the insurance company the same amount of money they would otherwise pay for medical care, plus a percentage which is the profit of the insurance company. The insurance company thus becomes a tax on medical services, rather than a useful mechanism for spreading risk.

It’s not quite that bad, of course, because large companies put all of their employees into a single pool, and small businesses pool together as well. But these pools are smaller and much less randomly distributed than the pools for which insurance systems work. The effect is that, apart from catastrophic medical care, the U.S. has chosen a system for paying for medical care which is broken by design.

Note that one of the underlying assumptions is that medical care is expensive. Despite that, as soon as you get to a problem which is beyond the ample skills of your primary doctor, there is nobody in the system whose job it is to make you feel better. As a society, I think we would be better served if such people existed. It would in essence be a new specialty: general medical counseling. Unfortunately, this kind of specialty can not be covered under an insurance system, since as we’ve seen insurance fees approximate insurance costs. It could only be covered under a system in which society covered the costs, effectively putting everybody into the same insurance pool. Note that the actual service could be provided by private organizations, and the fees could be performance based. The flaw in the medical system is not free market competition of medical providers, it is the insurance system by which they are paid.

I would like to imagine that having somebody to care about you, and who could give you sound advice about over the counter medicine, would tend to diminish the use of homeopathic medicines and other unsupported drugs. But that is probably far-fetched. I left out a reason above: people like to think that they know something which the experts don’t know. Since health is so important to us all, medical quackery will probably always exist.