There is an implied collectivism in your statements. The idea that "we choose to reward people who are successful" implies there is a collective with the legitimate authority to make such determinations. I reject this idea. Instead I propose that legitimate authority only exists to create a liberal ecosystem, not to meddle in the outcomes that ecosystem produces. A person's fortune (or misfortune) to be born with particular traits, into a particular childhood environment, is entirely their own. I see no source of legitimacy to redistribute that fortune to other people without explicit consent.
This view makes no sense given any cursory view of history. What about European countries going to the Americas, taking people's land (with out consent) and gold (without consent) to enrich themselves? Or what about the relative success of any tribes in the Americas prior to Europeans showing up by defeating other tribes?
At what arbitrary point would you like to start counting as to where we should start respecting this "consent"? Do you want to undo any previous actions or should we just take whatever arbitrary power structures we've landed on and start? C'mon, this is ridiculous.
We live in a society which, by definition, requires multiple people participating. Your right to consent (or not) sometimes doesn't exist because society takes priority. There is no high philosophy here, it's just the reality of how things work. Get over it.
First of all, I'm not talking about international conflict, where the law of the jungle still effectively applies to this day. I'm talking about domestic liberalism, where ideas like the fundamental equality and the consent of the governed are held to be self-evident. If you disagree with these ideas then I suspect you will be intractable.
> At what arbitrary point would you like to start counting
There is no need to keep count. We are all born into this world with no possessions, and we all negotiate with those already here for everything we come to own. It is true that people and circumstances vary widely, but that doesn't provide legitimacy for one person's claim over another (equal) person's legitimate good fortune.
> We live in a society which, by definition, requires multiple people participating
It is exactly the nature of this participation which I am litigating. I hold that it should be maximally voluntary and consensual. The only justified violation of fundamental liberty is in defense of liberty itself. Drafting people into the army (effectively enslaving them) is justified in direct defense of the nation (not to attack eg. Vietnam). Redistributing legitimate (earned through consensual exchange) wealth by force simply doesn't pass this test.
> There is no high philosophy here, it's just the reality of how things work. Get over it.
Funnily enough this is the exact sort of reasoning has been used to rationalize the most horrific atrocities ever perpetrated.
> First of all, I'm not talking about international conflict, where the law of the jungle still effectively applies to this day.
Then why should we take this seriously? Some huge disparities in outcomes in this world are the consequence of "international conflict". What do you want to do about Native Americans in the USA, for example?
> We are all born into this world with no possessions, and we all negotiate with those already here for everything we come to own.
This is not meaningfully true. If you are born into a rich family, you almost certainly are going to live a life with more access than those who are not. If you are born into a country with socialized medicine you are going to have access to opportunities that someone who isn't does not. We are not born equal in any way that is meaningful.
> It is exactly the nature of this participation which I am litigating. I hold that it should be maximally voluntary and consensual.
It isn't and can't be. Any right of consent you are given in society is society choosing to give you that right. It doesn't exist above society. That's just the breaks.
> Funnily enough this is the exact sort of reasoning has been used to rationalize the most horrific atrocities ever perpetrated.
People find any reason to justify their actions. You'll find a lot of terrible things have justifications that overlap with non-terrible things. It doesn't really say much.
Yes, it does. Or at least that's the line of reasoning you seem to be disagreeing with.
> We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.
The entire line of enlightenment liberal thought that gave rise to our society fundamentally disagrees with your position. The right to liberty is not bestowed by the good graces of society, but is fundamental and unalienable.
> That's just the breaks.
This isn't a justification, it's a rationalization, and not a particularly good one. I am arguing that liberty, ie. the right to interact with other people on a consensual basis, ought to be the primary determining factor as to whether any particular action is legitimate. You have not replied with an argument on why this ought not to be.
> It isn't and can't be.
Yes, it can. Or at least, it can be more consensual. I hold that charity is a more ethical means of wealth redistribution than taxation, exactly because of charity's voluntary nature. I also hold that before the New Deal, the status quo was much more liberal. Government was a small entity mostly charged with administering the vital institutions that maintained the liberal order. There were of course still overreaches and failures, as with any human system. Do you really think that tearing down much of the New Deal can't be? I think it can, whether it will remains to be seen.
> You'll find a lot of terrible things have justifications that overlap with non-terrible things.
Then the justifications are wrong. The ends do not justify the means. Legitimate action should be possible to justify from first-principles in a manner that precludes illegitimate action. Otherwise how could we possibly come to an agreement on a distinction between the two? I would also note that the ideas I'm articulating do exactly that: provide a concrete, universalizable framework to distinguish the legitimate from the illegitimate.
> The entire line of enlightenment liberal thought that gave rise to our society fundamentally disagrees with your position. The right to liberty is not bestowed by the good graces of society, but is fundamental and unalienable
You're quoting a document that is defining what rights it will give to the people. Whatever language you want to add around it can't get past the point that the document is giving rights to people and we as a society are agreeing to follow that document.
And please, this document is written in a time where many of its signers were holding slaves. Clearly not every man was considered equal.
The document does not give any rights to anyone. It is a piece of paper. What it does is describe an idea. The idea is that there are certain unalienable rights. You may disagree with that idea, but you cannot deny its existence.
> many of its signers were holding slaves
I can separate the idea from the people that held it. Can't you? I think this idea of liberty was a very good idea, and I support the expansion of those who qualify to be as free as described. What I'm arguing against is the erosion of the definition. We are not nearly as free now as free people were when the document was written. We are subject to much more authority.
It seems as though in your view, anything "society" does is legitimate, is that so?
My claim, this entire time, is that the reality is that you, as an individual, have no rights to consent or volunteer beyond what society bestows upon you. Your usage of documents from the founding of the United States of America, if anything, entirely support my argument. The Declaration of Independence might talk about equality but the reality is that blacks and women were not equal. It took society choosing to give them rights for them to receive them. That's not an idea, that's the reality. Whether or not you like it or not or think it's a good idea doesn't get in the way of that is what reality is.
> We are not nearly as free now as free people were when the document was written. We are subject to much more authority.
Tell this to a slave in 1776.
> It seems as though in your view, anything "society" does is legitimate, is that so?
No, "legitimate" is a judgement, I'm saying that what society does is what society does and there is no philosophy or higher abstraction defining it. It's just reality. I think if society is functioning in a way we disagree with, our only option is to try to convince enough people to change it. We can use language that tries to define philosophies around consent and individual rights in order to be persuasive but if society doesn't agree then you don't get those things, even if you really think that's how it should work.
It’s still an insurance system though, whether it’s publicly owned or privately. There are still bureaucrats who decide what is covered and what is not, and they make that decision for the entire population. Things like cutting edge cancer treatments (often developed in the US) are many years late arriving to public healthcare systems. And many expensive treatments are simply not covered, or covered as second or third line (eg. immune therapy), when patients in the US with appropriately good insurance receive them as first line with far better outcomes.
> No one negotiates rates with the hospital
No one negotiates period. Coverage decisions are made unilaterally by government officials, and services that those officials deem too expensive are simply not offered. The same issue exists with medical equipment. The wait time for an MRI is absurd in eg. Canada because government only funded so many machines. In the states there are simply more machines, because supply was more elastic, and more freely
able to meet demand.
Sure. Don't get me wrong, I'm sure American healthcare system can be amazing in certain cases, and like you said, in specific instances the "market demand" is able to solve issues that socialized systems struggle with. But the same is true in the opposite direction - plenty of stories of people being denied lifesaving care because insurance companies decide it's not worth it. People who have their cancer treatment stopped because their employer changed the insurer and the new insurer has to do a full re-evaluation before they approve the treatment to continue, so in the meantime you get no cancer drugs for months while they do their process. And so on and so on. We could both do this I'm sure.
>>when patients in the US with appropriately good insurance receive them as first line with far better outcomes.
The problem I have with that is basically you're saying the quality of the treatment depends on what insurance you have. In socialized healthcare everyone gets the same treatment.
And in fact this is reflected in the average quality of care received on average, with outcomes in US being much worse than elsewhere. US has mortality from "preventable causes" twice as bad as Australia, Japan or France(paragraph 5). So in US few people get amazing care better than anywhere else. And most people get worse care than anywhere else.
>>Things like cutting edge cancer treatments (often developed in the US) are many years late arriving to public healthcare systems.
Obviously it's hard to make a general statement on this because every country has varied policies around this. But to share an anecdote - my own dad was enrolled into an experimental programme at a leading oncology hospital in Poland because he had a very rare and ultra aggressive cancer which had no known treatment other than a brand new(then) Glivec, which wasn't even approved for that cancer yet, but he had the whole course of his treatment fully funded under our socialized healthcare. In those very very rare cases where regular treatment is not available there are avenues to explore experimental treatments, and they then serve to direct general treatment plans for the rest of the population. Again, this is a specific example from one country.
You would concede that, as a consequence of imposing involuntary obligations on their citizens, socialized systems are less free? And you would also concede that reasonable people can disagree about the priorities of their values, and that valuing personal autonomy over collective well-being is a reasonable position?
> people being denied lifesaving care because insurance companies decide it's not worth it
You get what you sign up for. Like in any business transaction, doing your due diligence and understanding the details of both parties obligation is table stakes. We also have courts precisely for cases when such disputes become intractable.
> so in the meantime you get no cancer drugs for months while they do their process.
No one is stopping you from paying for the drugs yourself. Insurance will reimburse you once they validate your claim. Bureaucracy takes time.
> the average quality of care received on average
And the quality of care on the upper end is markedly worse in many ways. Wealthy people from all over the world travel to the US for their medical procedures for a reason. You're effectively arguing that net-contributors to society (people who pay a lot of taxes) should accept an increase in their tax burden for the privilege of a degradation in their personal access to and quality of care, in order to bring up the average. I hope you appreciate just how directly this opposes the interests of this class.
> From each according to his ability, to each according to his needs
You can't have a system like this in a free country. I want the freedom to associate (in an insurance pool) alongside other people with a similar risk profile to myself (eg. no drinking/drugs/smoking, daily exercise, good sleep, healthy body composition) to the exclusion of others. I want my insurance company to carefully scrutinize its applicants and claimants, on my behalf, to ensure that my interests are being well-represented. Insurance does not mean absolution from personal responsibility.
The government still negotiates. Refusing to buy a product/service at X rate is a negotiation, and there is a back and forth with providers/manufacturers.
Same for state employed healthcare professionals, which have salary set by the state.
Refusing to pay for medical care is hardly murder. It’s a standard monetary dispute, and we have a due process for these. If you think that so many claims are being unreasonably denied, why not start a company offering bridge loans, and funding legal challenges?
Maybe the courts are too inefficient to handle these disputes, but that’s an argument for reforming the courts, not for shooting executives.
> In some countries if you don't give care to someone who is in danger of dying you are yourself responsible for murder.
So everyone in said countries is guilty of murder because they're not donating 100% of their time and energy to helping cure cancer?
That's not at all how this works. You can't just legislate infinite resources into existence. And infinite resources is exactly what it would take to give everyone a 100% perfect standard of care.
Deciding what's covered and what isn't is literally the whole job of an insurance company. Otherwise we could just put money into a pot and let anyone take out any amount they feel like, whenever they feel like it, for whatever purpose they deem necessary at their sole discretion. (And if that sounds like a good idea to you, I'd urge you to think things through a bit more carefully before you waste your money by trying it.)
> In some countries if you don't give care to someone who is in danger of dying you are yourself responsible for murder.
Certainly not murder, involuntary manslaughter maybe. In any case, what is the basis for this obligation? You would concede that, as a consequence of imposing involuntary obligations on their citizens, these countries are less free? And you would also concede that reasonable people can disagree about the priorities of their values, and that valuing personal autonomy over collective well-being is a reasonable position?
> Murder by inaction and calling it anything else is playing in their hands.
What about doctors and nurses who refuse to work for free? Should we also shoot them? What about pharmaceutical companies that refuse to invest billions into drug development, or hospitals that refuse to purchase expensive facilities and equipment, without without a reasonable expectation of a return on their investment? Are they murderers too?
This worldview of holding people accountable for failing to intervene is simply not tenable. People are responsible for their direct actions. If you injure someone, you are responsible for your actions and the outcome they produced. If you simply come across an injured (or sick) person, you are in no way more obligated to them than you are to such a person on the other side of the world.
You also seem to be operating from the presumption that insurance companies do not add any value to the system, and that careful scrutiny of claims is motivated only by greed. I beg to differ. I want to be insured alongside other people with a similar risk profile to myself (eg. no drinking/drugs/smoking, daily exercise, good sleep, healthy body composition) to the exclusion of others. I want my insurance company to carefully scrutinize its applicants and claimants, on my behalf, to ensure that my interests are being well-represented. Insurance does not mean absolution from personal responsibility.
Not american. But how people will get to the ER in the first place? Not sure if true, but I heard people will run away from ambulances in the US because the costs are so high.
It’s not a standard monetary dispute - one party is under duress and holding a potential time bomb that the other party needs to defuse, but is arguing over.
The mess is deeper, but starting an insurance company is not easy either, one could blame the regulations. And then one cannot blame regulations either, it's the regulators/govt who are ultimately voted/allowed by the people. It's a case where every one passes the buck, and so no one single entity is responsible for the mess.
You're ignoring a litany of intentional efforts by powerful people to keep the system as broken as possible so that they can take advantage of it. Things didn't just get this bad on their own; this is the result of decades of strategizing, billions of dollars in lobbying, and intentional efforts to profit off of the sickness and death of others. It's not like there's a lack of responsibility to go around.
What you say is true, but collectively people are ultimately to blame for their non-vigilance when their rights are slowly eroded.
Look at even small groups of common people, the most power hungry get to the top, common people vote for the most charismatic/popular, not the most competent. Blaming the powerful evil people is self defeating and absolves personal responsibility.
Common people are also a divided lot. Petty issues, bickering and entertainment keep them engaged. As the saying goes: divide and rule.
"When all are guilty, no one is; confessions of collective guilt are the best possible safeguard against the discovery of culprits, and the very magnitude of the crime the best excuse for doing nothing."
> Refusing to pay for medical care is hardly murder. It’s a standard monetary dispute, and we have a due process for these.
> Maybe the courts are too inefficient to handle these disputes, but that’s an argument for reforming the courts, not for shooting executives.
You do realize that these companies lobby to make sure that it stays inefficient, right?
In the cases where they don't use the court system, they use arbitration, which is usually tilted in the favor of insurance companies.
If you want a fair shake at getting the benefits you paid for, you have to go through the courts. Given the nature of the subject of the lawsuit, there's a real chance that you'll be dead or bankrupt before you get your day in court. That's not a system that works. And when there are systems that don't work, there are on occasion people who will go outside the system to make their own. There is no scenario in which vigilantism is completely eliminated when you have people making massive sums of money off of refusing to do business in good faith.
More people need to read the cautionary tale of Ken Rex McElroy and the town of Skidmore, MO.
> If you want a fair shake at getting the benefits you paid for, you have to go through the courts.
Maybe I’m in the minority, but my health insurance makes it very clear what the benefits I paid for are. There’s guidance after guidance and tool after tool to help minimize any surprise costs.
Good for you, but there's an entire branch of the law profession dedicated to cases where that's not true and insurance companies have to be held to the letter of the contracts that they came up with.
> Maybe I’m in the minority, but my health insurance makes it very clear what the benefits I paid for are. There’s guidance after guidance and tool after tool to help minimize any surprise costs.
...and how has it gone when you tried to use them? Just as a personal anecdote: I once tried to get UHC to partially reimburse me for an out-of-network mental health expense. My policy explicitly covered such reimbursement (at a lower rate, of course). I tried for months to get the claim reimbursed. My employer at the time retained the services of a "healthcare concierge", and one of the main things they did was fight insurance companies on your behalf. That concierge service tried for six months to get a single claim reimbursed.
We all gave up.
It was such a small dollar amount; UHC likely spent more time and effort denying the claim than it would have cost to reimburse. It boggles my mind, to this day.
Just because your health insurance "makes it very clear what the benefits I paid for are" has no relation to whether or not they will actually pay those benefits out to you. If you haven't really experience this yet in America, I can only conclude that you are either rather healthy (and haven't used the benefits much), very lucky, or possibly both.
> Refusing to pay for medical care is hardly murder.
This is crazy. Maybe it's not "murder" in the traditional sense but you are making a choice on whether someone gets life-saving care, or lives in immense pain for the rest of their lives until they commit suicide. Again, this kind of normalized violence is justified when it's a business making choices to increase profits. We are so disconnected from our humanity that rounding errors in an Excel sheet mean actual lives are being ended, but that's okay.
> you are making a choice on whether someone gets life-saving care, or lives in immense pain
Is the care life-saving or pain-preventing?
There is an additional option: the person pays for it. Or someone else pays for it. Since the 1980s U.S. emergency rooms have been required to provide life-saving care regardless of whether someone can pay.
> normalized violence
It is not violence to fail to reimburse someone.
If someone cannot pay his bills, then he declares bankruptcy, the debts are wiped out, his creditors take a haircut and he moves on with his life. In many/most states he will get to retain his home and perhaps his vehicle. It’s not the end of the world?
Is it ideal? No, of course not. It’s better than dying, and of course it’s not murder.
Those can be the same thing for some people. Chronic pain patients have a dramatically worse mortality rate.
> If someone cannot pay his bills, then he declares bankruptcy, the debts are wiped out, his creditors take a haircut and he moves on with his life.
I’ve done this. Due to medical expenses, in fact. It costs money up front, and was difficult to navigate as a well educated person with family support.
The idea that this is an easy option for a single person with no supports and a disabling condition is insane.
Many doctors won’t see you after, either. Bankruptcy doesn’t mean people you burned have to keep doing business with you.
Most Americans get their health insurance through their employers. You are technically free to not sign up for this and purchase your own health insurance, but when you consider that you then give up the employer subsidy to your monthly premium, and that said subsidy often amounts to thousands of dollars each year, it does not make financial sense to participate in the market.
Most health insurance (and the lowest cost insurance) in the US is tied to a person's employer, a system that shifts the balance of power substantially to large corporate employers over workers and small companies.
Furthermore, absent major life events (job change, marriage, new child, etc) there is only one time of year when health insurance changes can be made, a time of year called Open Enrollment.
Finally, if you are self employed and you don't live in a state with a well functioning Obamacare market, your health insurance options are often quite limited.
Well, in the US, most people get insurance through their employer, who pays part of the cost. Switching would mean having to pay all the cost yourself, which would be economically painful.
And why doesn't the employer switch? Because health care plans typically have doctors that they like more than other doctors ("in network" vs "out of network"), so most people gravitate toward the preferred doctors. ("Like" means "cover better", so the patient pays less.) If your company changes health care insurers, then many people would have economic pressure to switch away from their current doctors, which is a hassle.
TL;DR: There's a lot of friction in various forms here. That's why. Yes, people can switch, but it's expensive and painful, so most don't, even though the option is technically there.
We don’t, or at least not everyone agrees we do. Some of us think that we only have an institution that administers peace and order, and believe that pursuing the good is a private, voluntary concern.
In MrBeast's case, his revenue is directly correlated with customer engagement via YouTube's algorithm. I'm sure that were it legal, gladiatorial combat would be very popular and profitable on YouTube. I suppose one could make an argument that it would therefore "beneficial".
In the other aforementioned cases, in absence of an algorithm, revenue-generating activity wasn't as well correlated with meeting customer expectations. The point is that companies will always optimize for their own revenue, regardless of how well or poorly their activity meets customer expectations.
There are no traits that distinguish us from other animals. We're just a little bit smarter than apes, elephants, and dolphins, which has pushed us past a tipping point into civilization.
Our societies are still ecosystems, and cannot escape from the rules thereof. Competition, hierarchy, and economic inequality are emergent properties of ecosystems. There's nothing inhumane or immoral about an ecosystem.
A bit as in: on the spectrum of civilization-capable organisms, between bacteria and human beings, we're only a bit ahead of dolphins, which is where the tipping point happens to be. Aside from dolphins et al, this space was also occupied by our hominid ancestors.
It took us ~50,000 years to get to computers. We're not biologically different from humans then. Civilization itself is a new mechanism of transmitting information that dolphins do not possess (because they've not passed the tipping point) which allows transmission and accumulation across generations exponentially faster than DNA and culture (which dolphins do possess). We're also anatomically rather more suited to building things than dolphins.
Punished by the same people who punishes all the other infractions.
The same way doctors are punished if they are abusing their patients, or drug dealers who are selling drugs, or rioters that burn cars, or ...
No one is going to build a brand new parallel tribunal to just process the infractions on this law, and it will never fly as it is a clear violation of power separation.
If now you are saying that the current judicial system is controlled by the politicians in power, then this law is harmless: they can already arrest their opponent by just saying "they killed an old lady, let's have a trial to see if they are a murderer"
So you're suggesting that politicians lying be tried (with prosecutorial discretion) by a jury of their peers in order to determine whether a lie was told? How would this law be written? Would politicians be imprisoned for giving a deceptive compliment? eg. "No, that dress doesn't make you look fat at all"
You realize that lies are already illegal in plenty of other situations. For example, lawyers and doctors cannot lie or deliberately deceive. Or you can be prosecuted if you lie when under oath. You know that no lawyer or doctor are arrested for saying "no, that dress doesn't make you look fat at all", right?
It is just extending the laws that already apply to parliament or judicial system to a broader set of situation easily identifiable. Pretending that it is equivalent to be able to raid a political opponent because they said "that dress doesn't make you look fat" is just ridiculous.
We already deal with these situations, and there are easy and proven solutions to avoid misuse.
This is just an engineer's disease argument, using "extension" to do all the intellectual work of justifying the position. It's a pseudo explanation and works like how all misinformation works, using specious logic. Ironic given the topic of this thread.
> Loaning money at 200% interest to vulnerable people is usury and should be illegal
Stop with the patronizing. Any transaction between consenting parties (backed by bankruptcy protection) should be allowed. We're all grown ups, let people make their own decisions.
Setting upper limits on interest rates simply makes it so that high-risk borrowers are unable to access credit. This harms those borrowers more than anyone else, by limiting their opportunities.
Regarding the Sacklers, they never prescribed any drugs to anyone. Doctors did. Why aren't we holding them responsible? It is doctors who have a duty of care to their patients, not pharmaceutical companies.
> Stop with the patronizing. Any transaction between consenting parties (backed by bankruptcy protection) should be allowed.
Any? Can I sell my kidney?
You are arguing an extreme minority opinion, consumer protection laws exist because it is not possible for an average consumer to understand all safety implications of vehicle design, house construction or a medical procedure.
> it is not possible for an average consumer to understand all safety implications of vehicle design
and that is why there is and must be independent regulation. The consumer doesn't need to understand vehicle design, they just need to understand safety _ratings_ that must be assessed via third parties (typically, a gov't institution).
So why did the FDA fail to assess the drug properly?
I don't see why not. Me saying you can't would imply that I have a stronger claim to your own kidney than you do. This is a pretty hard claim to substantiate. The majority can be, and often is, wrong.
> So I should be able to sell myself into slavery.
No, because that would imply that a person can own another person. Free, morally equal, people cannot own each other. It would also imply that present-you can obligate future-you in a way that fundamentally compromises future-you's freedom.
Present-you can however terminate his own existence, since present-you has the strongest claim on it.
Interactions must be consensual with the possibility to opt-out backed by bankruptcy protection. If you agree to donate your organs in return for compensation (presumably to your estate), but change your mind on the operating table, you should be perfectly entitled to do so. You may incur a bankruptcy protected obligation if you signed an agreement to that effect
Consent should be the fundamental principle guiding all interactions. It also conveniently precludes slavery.
> Interactions must be consensual with the possibility to opt-out backed by bankruptcy protection
So student loans, as they are not discharge able in bankruptcy, are a form of debt bondage / slavery?
Also in UK you have to pay to declare yourself bankrupt, which is also questionable.
Also you can’t back-out of an organ sale, you are under Anastasia and then you are dead. The idea that it’s better than still being alive seems morally myopic to me.
Student loans are not dischargeable by bankruptcy because an education is not an asset that can be seized and sold during the process. There should be (and are) pretty strict limits on how your wages can be garnished to repay this debt. However I do agree that student loans are a form of debt bondage, and are questionably ethical for that reason. I would much prefer student loans not be given special protection. That would at least help us stop subsidizing educations that do not lead to productive careers.
I would not be opposed to licensed professions (eg. doctors, lawyers) adopting policies that would revoke licenses for members defaulting on their student loans via bankruptcy. I don't imagine any intervention would be required for such policies to arise if the special status of student loans were to be reconsidered.
> Also you can’t back-out of an organ sale
Yes of course you can only back out up until the point you are rendered unconscious. You have to reconsider before then. The idea that "life" and "death" are somehow morally important states is what has been "hammered into us from a young age". Morality is a relationship between (free and equal) moral agents. The important concept is therefore agency and its expression via consent.
You have just spent four paragraphs outlining how it must be important to be able to backout of any agreement, how freedom is important, and now you propose semi-facist system!
> licensed professions (eg. doctors, lawyers) adopting policies that would revoke licenses for members defaulting on their student loans via bankruptcy.
Let's consider the meaning of this, and why it smells of fascism:
* An unrelated third party is recruited to use it's power to enforce government policy (if it's taxpayer money) or protect someone else's private investment. This is no longer an agreement between two parties, the loan is now backed by threat of force. The lender no longer has to ask themselves "well if we raise interest rate too much, people will default and we will suffer"
* The revoked license cannot be sold, like a house would be, it is of no use to the bank, the only effect is punitive and moral police
* If i am the doctor's employer, you have just inflicted loses upon me, to protect your investment that I have nothing to do with.
* If I am a customer or patient, and paid for a service, you have also inflicted loses upon me, it's now a crime for me to receive treatment from this doctor, despite the fact that they are qualified.
* It is affected by government policy and macroeconomics that even professional fund managers cannot predict, let alone an 18-year old student. You get high inflation due to war in Ukraine, and suddenly half of your doctors have their license revoked! Great result!
> an education is not an asset that can be seized and sold during the process
As any unsecured loan, you can take out a loan and spend it all on hookers and drugs.
I think this entire attitude is driven by the fact that in the English speaking west there is great contempt for the younger generation and they are okay to exploit. They are subject of derision and almost seen as sub-human. Why don't we treat pensioners this way, make them do some mandatory community service in the nursery to get their state pension! There would be riots in the streets!
There's no force here, and hence no fascism. Having your license revoked, while harmful to your career, is not violence. Professional licensing boards and private lenders are also free agents, and can come to any sort of agreements they please. I would oppose any government intervention, as I already mentioned.
I don't however agree with any laws that bar anyone from practicing their profession without a license. If all you can afford is to get your tooth extracted with a rusty tool by a street dentist (as is common for lower classes in places like India), there should be no law preventing that from happening. It represents a consensual exchange. Making it illegal harms exactly the people who cannot afford anything else.
> You can take out a loan and spend it all on hookers and drugs
Lenders don't typically offer unsecured loans, for exactly this reason.
> the younger generation
This has nothing to do with the younger generation. It stems from from a definition of liberty that rejects implicit obligation, and emphasizes consent. We are all born into this world with nothing, and all must negotiate with the people already here for everything.
> Why don't we treat pensioners this way
I would be all for entirely abolishing taxpayer-funded old age security, which represents a quarter of the federal budget in the US. There is no consent, nor any ability to opt-out of this mandatory insurance scheme. Preparing for your old age is an individual responsibility, not a collective one.
Taboos are bullshit. Either something is a clearly articulated, written, rule with an enforcement mechanism, or it's fair game.
Prescribing doctors are responsible for the opioid epidemic. Doctors failed in their duty of care to patients. Doctors massively overprescribed, failed to track their patient's medication usage, and failed to spot addictive behaviour. Why aren't we holding them responsible? Simply because that's hard to do?
Purdue aggressively marketed OxyContin as having a very small rate of addiction to doctors who weren't pain specialists and thus had little experience with controlled medications, while providing a dosing regime that was almost designed to cause addiction. (It's sole advantage was as a timed-release medication; if pain returned before time for the next dose, doctors were instructed (strongly) to raise the dosage rather than increase the number of doses per day.)
> . (It's sole advantage was as a timed-release medication; if pain returned before time for the next dose, doctors were instructed (strongly) to raise the dosage rather than increase the number of doses per day.)
The same thing happens with ADHD medications, the timed release dosages are supposed to last 12+ hours, but in reality they vary from 8 to 16.
Thankfully most doctors will willingly prescribe a small after lunch short acting dose.
There is a large delta between the average response curve and an individual's response curve!
> The same thing happens with ADHD medications, the timed release dosages are supposed to last 12+ hours, but in reality they vary from 8 to 16.
Modern ADHD meds are really not comparable to powerful opioids. They are both dopaminergic, but they are night and day in terms of addictiveness. Even weak opioids vs strong opioids is night and day.
> There is a large delta between the average response curve and an individual's response curve!
True! But the word "average" is actually not, itself, precise. It has at least three typical meanings: mean, median, mode. These all have quite large deltas to each other when talking about dose-response curves, and since they are curves, you would also have to pick a norm first.
There are a lot of sources of variability, but variation does not actually make it very difficult to detect improper opioid prescribing behavior. Just like the variation in people's weights would not tell you much about the strength of asphalt roads. These things are not measured in the same scale.
The majority of the pharmaceutical problem came from a very small number of people who churned out prescriptions like a literal mill. Like 5 minute appointments all day every day - not random doctors overprescribing their patients by accident. What is true is that the random doctors overprescribing provided a certain amount of cover for the corrupt doctors, for a while.
> Modern ADHD meds are really not comparable to powerful opioids. They are both dopaminergic, but they are night and day in terms of addictiveness. Even weak opioids vs strong opioids is night and day.
True, my point more was that false advertising about "duration of extended release action" is a problem across multiple types of prescription drugs.
> True! But the word "average" is actually not, itself, precise. It has at least three typical meanings: mean, median, mode. These all have quite large deltas to each other when talking about dose-response curves, and since they are curves, you would also have to pick a norm first.
The marketing material doesn't care. "All day", "24 hour", "12 hour" are the phrases that get used.
Meanwhile reality is that every person who takes a drug is different and doctors need to be aware of this and just ask the patient how well things are working out.
> The majority of the pharmaceutical problem came from a very small number of people who churned out prescriptions like a literal mill. Like 5 minute appointments all day every day - not random doctors overprescribing their patients by accident. What is true is that the random doctors overprescribing provided a certain amount of cover for the corrupt doctors, for a while.
Yeah it got out of hand, but I'd imagine that this wasn't happening from day 1.
Also when we talk about preventative measures, people going to a pill mill doctors to get a refill are already addicted, but what can have a long term impact is putting in the effort to prevent people from becoming addicted in the first place, which means understanding how so many people who did not want to get addicted to opioids ended up that way.
> Also when we talk about preventative measures, people going to a pill mill doctors to get a refill are already addicted, but what can have a long term impact is putting in the effort to prevent people from becoming addicted in the first place, which means understanding how so many people who did not want to get addicted to opioids ended up that way.
This has changed over time. At first it was the pharmaceutical route, largely due to the shift in medical norms to prescribe opioids for chronic, not just acute, pain. Prescribing them for chronic pain is a near guaranteed recipe for addiction. However, I think things have changed in the past decade or so, with people largely moving straight to fentanyl and/or other illicit opioids. I don't think the pipeline is largely pharmaceutical in nature anymore.
Blindly listening to a company trying to sell you something has never been a good idea. Doctors doing just that despite the clear, obvious, conflict of interest is their failure, not Purdue's.
Thinking that an individual or organization with a vested interest will not bullshit you at every turn is absurdly naive. This is why third-party testing, accreditation, certification, and audits are a thing.
> doctors who weren't pain specialists
Then they should have insisted on third party, board approved, usage guidelines; especially when it became obvious that OxyContin is highly addictive. It doesn't take that long. Doctors have not however been held responsible for their abject failure towards their patients, and continue to prescribe a month's worth of Oxy for minor issues. This will continue until doctors start losing their licenses.
Everyone in every industry that I know about relies on true information from their suppliers, from software to produce. They're the ones who know about the products, after all. In fact, pharmaceuticals are the one industry most likely to treat suppliers at adversaries, with FDA regulations continually attacked as too stringent.
Purdue was actively lying about their drugs.
"Purdue trained its sales representatives to carry the message that the risk of addiction was “less than one percent.”50(p99) The company cited studies by Porter and Jick,51 who found iatrogenic addiction in only 4 of 11 882 patients using opioids and by Perry and Heidrich,52 who found no addiction among 10 000 burn patients treated with opioids. Both of these studies, although shedding some light on the risk of addiction for acute pain, do not help establish the risk of iatrogenic addiction when opioids are used daily for a prolonged time in treating chronic pain. There are a number of studies, however, that demonstrate that in the treatment of chronic non–cancer-related pain with opioids, there is a high incidence of prescription drug abuse. Prescription drug abuse in a substantial minority of chronic-pain patients has been demonstrated in studies by Fishbain et al. (3%–18% of patients),53 Hoffman et al. (23%),54 Kouyanou et al. (12%),55 Chabal et al. (34%),56 Katz et al. (43%),57 Reid et al. (24%–31%),58 and Michna et al. (45%).59 A recent literature review showed that the prevalence of addiction in patients with long-term opioid treatment for chronic non–cancer-related pain varied from 0% to 50%, depending on the criteria used and the subpopulation studied.60"
"Purdue has known about the problem for decades. Even before OxyContin went on the market, clinical trials showed many patients weren’t getting 12 hours of relief. Since the drug’s debut in 1996, the company has been confronted with additional evidence, including complaints from doctors, reports from its own sales reps and independent research.
"When many doctors began prescribing OxyContin at shorter intervals in the late 1990s, Purdue executives mobilized hundreds of sales reps to “refocus” physicians on 12-hour dosing. Anything shorter “needs to be nipped in the bud. NOW!!” one manager wrote to her staff."
From what I've seen (women sent home days after a c-section with Ibuprofen as the only pain medication; all of the doctors near me displaying signs saying they will not treat chronic pain), pain medication may well be under-prescribed at this point.
> Prescribing doctors are responsible for the opioid epidemic. Doctors failed in their duty of care to patients. Doctors failed to track their patient's medication usage, and failed to spot addictive behaviour. Why aren't we holding them responsible? Simply because that's hard to do?
This is a nice idea, but most Oxycontin is not prescribed by someone's doctor (it is prescribed by a doctor, but it is power-law distributed, most of it is sold by dealers). There are a small number of doctors in the country at any given time that prescribe almost all of the supply. This is not something you can readily fix with responsibility at the doctor level. It may seem like you can, because you could just prosecute "those doctors", but the problem is that the incentives are too concentrated.
That isn't to absolve these individuals of responsibility. They are responsible, and we should prosecute them legally. The problem is that we already do and always have. We should keep doing it, but I don't expect it to fix anything.
EDIT: To be clear I'm not necessarily for or against this settlement. There was a time that we might have stopped the opioid crisis at the corporate or pharmaceutical level, but that time has long since past. We could criminalize all opioids tomorrow and it would make almost no difference. Most opioid addicts use fentanyl now, and most fentanyl is produced/sold illegally. Heroin, for instance, has been Schedule I forever - the only thing that reduced its popularity was a cheaper substitute in fentanyl.
If we are going to bother prosecuting or civilly charging Purdue or its principals, it would have to be for purely punitive reasons. Corporate behavior unfortunately does not matter anymore.
The on-ramp from minor pain or surgery; to a massive, blindly-renewed, over-prescription of Oxy; to an opioid addiction that spirals into street drugs is still mediated by doctors. Until these doctors start losing their licenses for their clear and obvious breaches in their duty of care, this on-ramp will remain open.
> a small number of doctors in the country at any given time that prescribe almost all of the supply
The fact that medical boards allow these doctors to retain their licenses is the core of the issue.
> we already do and always have
I am only aware of a handful of the most obvious, blatant, and egregious pill mill operators being prosecuted. Regular doctors who simply cannot be fucked to care for their patients, and prescribe them pills so they leave their office, have yet to be held accountable.
> The on-ramp from minor pain or surgery to a massive, blindly-renewed, over-prescription of Oxy to an opioid addiction that spirals into street drugs
This is mostly not a thing. I have known hundreds of current and former opioid addicts. I don't think I know a single one that was "on-ramped" from Vicodin or Percocet in any truly meaningful sense. It is the case that people almost always use these first. But it is relatively rare to become an opioid addict as the result of a one-off, acute vicodin prescription, per se.
> is still mediated by doctors. Until these doctors start losing their licenses for their clear and obvious breaches in their duty of care, this on-ramp will remain open.
I hope that is true! It doesn't seem like that to me, but I admit to not having carefully studied the data. Casually, there are 1.6 million opioid addictions currently in the US [1]. There were ~50,000 overdose deaths in 2019. That is, 1/1600 opioid addicts died in 2019 alone. To a first approximation, 0 people overdose annually from vicodin/percocet and other short term acute pain treatments.
It would be fairly surprising to me if (much) more than 1/1000 strong opioid users (per year) dies from an overdose. If the numbers were substantially higher than this, the epidemic would burn itself out in the population rather quickly. We can infer from this that most active opioid addicts are users of strong opioids, which are basically never prescribed for acute use. Hence, the overwhelming majority of current addicts are users of strong, non-acute opioids.
This doesn't mean there can't be some gateway effect (I do in fact think there is), but it does mean that "the problem" is mostly the presence of the strong opioids, not the Vicodin prescription for your wisdom teeth.
I'd be open to contrary data on the matter, though.
> The fact that medical boards allow these doctors to retain their licenses is the core of the issue
It is an issue, and we should absolutely try to improve it. It's just unlikely to materially dent the larger issue.
> I am only aware of a handful of the most obvious, blatant, and egregious pill mill operators being prosecuted. Regular doctors who simply cannot be fucked to care for their patients, and prescribe them pills so they leave their office, have yet to be held accountable.
I can personally attest to this being false. It was really quite annoying - I had to find new doctors on a number of occasions as a result, and that was ~15 years ago. Things have gotten much, much tighter on the pharmaceutical side since then. Every doctor who wrote me something was in prison
or dead (from suicide, in prison) within 2-3 years of the last time I saw them, and I didn't even turn them in.
It is true that at any given time the Oxycontin prescriptions are power-law distributed, with most of the scripts being written by a small number of doctors. But this is a little bit like looking at the profits in the high frequency trading industry, or the cartels in Mexico (not to morally equate these things). Yes, there are a small number of them and they seem to make a lot of excess profits, but that does not mean you can knock them off and change anything. Nature abhors a vacuum, as they say.
Taboos are part of how a society functions. Taboos can prevent the 'tragedy of the commons' in a way that rules and laws cannot. Think about it - people break the law all the time. They rarely break taboos.
Taboos are not simply undesirable things, they are rules which carry severe penalties if you break them. The difference is that rather than going through the effort of getting society on the same page and agreeing what is okay and what isn't, you instead leave ambiguity that harms the well meaning and benefits the malicious. If something is bad enough that it should be banned by an unwritten rule, it's bad enough to be banned by a written rule. If you aren't willing to ban something by law, then it ought to be permissible.
I am not a lawyer. I am from a legal family (three generations) and I understand jurisprudence
> you instead leave ambiguity that harms the well meaning and benefits the malicious.
Two points
1. Law advantages those with access, and often benefits the malicious and harms the good. Case in point: Drug law. Another is IP law
2. Law is not objective. The words that form it are in black and white, but there are courts and judges because the application of the law is subjective. The boundary cases are numerous and important
More generally....
> If something is bad enough that it should be banned by an unwritten rule, it's bad enough to be banned by a written rule.
Sotp, just stop! This is the idea that we must punish and scantion people into being good.
I think of things that are good (like treating drug addicts as ill, not criminal or imoral). I think not of "bans". They accomplish little.
Permissible, impermissible, these are blunt concepts that are not very useful. We can be, and should be, aspirational and collegial not judgemental and competitive
> Sotp, just stop! This is the idea that we must punish and scantion people into being good.
You're not understanding what this conversation is about. Taboos punish and sanction people into being good. We are in full agreement that this is undesirable. There are some things that should be banned, and if they should be banned, they should be banned explicitly. There are many other things that should not be banned, and if it should not be banned it should not be a taboo, which is a form of ban.
You give a perfect example for my argument - treating drug addiction as an illness that should be treated instead of a moral failure to be punished. Where drug use is a taboo, you can't treat it; eliminating the taboo and accepting that these are people in need of help is, in my and many other people's opinion, the correct course of action. Most would agree that making drug use legal but ostracizing drug users would be an absurd strategy.
Taboos are fundamentally about what is permissible and impermissible, there is no other framework in which to talk about them.
I would argue that fiduciary responsibility mandates that corporate leaders do everything right up to the legal boundary in pursuit of their shareholders interests. In fact profitably violating regulations would also be the right thing to do in this case. Certainly most shareholders seem to appoint executives that do exactly that.
Sociopaths and other dark triad types have been the driving force in unifying and leading people since prehistory. It takes exactly that kind of person to unite tribes of strangers in order to go conquer, subjugate, and murder your neighbours.
"Evil" is immaterial. Markets and society are ecosystems, and the optimal patterns of behaviour in ecosystems are as ruthless as they are predictable.
