Antifragile Quote 41 – Iatrogenics

In a complex domain, only time—a long time—is evidence.

The “do you have evidence” fallacy, mistaking evidence of no harm for no evidence of harm, is similar to the one of misinterpreting NED (no evidence of disease) for evidence of no disease. This is the same error as mistaking absence of evidence for evidence of absence, the one that tends to affect smart and educated people, as if education made people more confirmatory in their responses and more liable to fall into simple logical errors.

Now consider the adventure of a human-invented fat, trans fat. Somehow, humans discovered how to make fat products and, as it was the great era of scientism, they were convinced they could make it better than nature. Not just equal; better. Chemists assumed that they could produce a fat replacement that was superior to lard or butter from so many standpoints. First, it was more convenient: synthetic products such as margarine stay soft in the refrigerator, so you can immediately spread them on a piece of bread without the usual wait while listening to the radio. Second, it was economical, as the synthetic fats were derived from vegetables. Finally, what is worst, trans fat was assumed to be healthier. Its use propagated very widely and after a few hundred million years of consumption of animal fat, people suddenly started getting scared of it (particularly something called “saturated” fat), mainly from shoddy statistical interpretations. Today trans fat is widely banned as it turned out that it kills people, as it is behind heart disease and cardiovascular problems.

For another murderous example of such sucker (and fragilizing) rationalism, consider the story of Thalidomide. It was a drug meant to reduce the nausea episodes of pregnant women. It led to birth defects. Another drug, Diethylstilbestrol, silently harmed the fetus and led to delayed gynecological cancer among daughters.

These two mistakes are quite telling because, in both cases, the benefits appeared to be obvious and immediate, though small, and the harm remained delayed for years, at least three-quarters of a generation.

Now we can see the pattern: iatrogenics, being a cost-benefit situation, usually results from the treacherous condition in which the benefits are small, and visible—and the costs very large, delayed, and hidden. And of course, the potential costs are much worse than the cumulative gains.

Second principle of iatrogenics: it is not linear.

pharmaceutical companies are under financial pressures to find diseases and satisfy the security analysts. They have been scraping the bottom of the barrel, looking for disease among healthier and healthier people, lobbying for reclassifications of conditions, and fine-tuning sales tricks to get doctors to overprescribe. Now, if your blood pressure is in the upper part of the range that used to be called “normal,” you are no longer “normotensive” but “pre-hypertensive,” even if there are no symptoms in view. There is nothing wrong with the classification if it leads to healthier lifestyle and robust via negativa measures—but what is behind such classification, often, is a drive for more medication.

If the patient is close to death, all speculative treatments should be encouraged—no holds barred. Conversely, if the patient is near healthy, then Mother Nature should be the doctor.

What made medicine mislead people for so long is that its successes were prominently displayed, and its mistakes literally buried—just like so many other interesting stories in the cemetery of history.

Metric-lowering drugs are particularly vicious because of a legal complexity. The doctor has the incentive to prescribe it because should the patient have a heart attack, he would be sued for negligence; but the error in the opposite direction is not penalized at all, as side effects do not appear at all as being caused by the medicine.

The same problem of naive interpretation mixed with intervention bias applies to cancer detection: there is a marked bias in favor of treatment, even when it brings more harm, because the legal system favors intervention.

Every time you take an antibiotic, you help, to some degree, the mutation of germs into antibiotic-resistant strains. Add to that the toying with your immune system. You transfer the antifragility from your body to the germ. The solution, of course, is to do it only when the benefits are large. Hygiene, or excessive hygiene, has the same effect, particularly when people clean their hands with chemicals after every social exposure.

if the person is very ill, there are no iatrogenics to worry about. So it is the marginal case that brings dangers.

Let us close on this business of b***t “evidence.” If you want to talk about the “statistically significant,” nothing on the planet can be as close to “statistically significant” as nature. This is in deference to her track record and the sheer statistical significance of her massively large experience—the way she has managed to survive Black Swan events. So overriding her requires some very convincing justification on our part, rather than the reverse, as is commonly done, and it is very hard to beat her on statistical grounds—as I wrote in Chapter 7 in the discussion on procrastination,

in the past, many faced the question “Do you have evidence that trans fat is harmful?” and needed to produce proofs—which they were obviously unable to do because it took decades before the harm became apparent.

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