Book Review: The Last Well Person: How to Stay Well Despite the Health-care System by Nortin M. Hadler
There appears to be a large discrepancy between how effective most people think modern medical practices are and the evidence that experts have presented suggesting that it does very little to extend life. This book gives the impression of describing a pattern of ineffective or harmful practices that might be offsetting the benefits of the practices that are known to work. But there are enough flaws in his argument that I can’t decide how much of his conclusions I should accept.
He starts by saying he’s a Popperian, but often acts like he’s following some other, more dogmatic, philosophy. I’m particularly annoyed at his certain feelings of inevitability that we will die by about age 85:
I am aware of no data to support the premise that we can alter the date of death. … When high-functioning octogenarians decline, it is because their time is approaching.
He starts by making a plausible claim that many people get cardiovascular surgery when there’s no evidence that it will benefit them (and is likely to create some risks).
But starting in the next chapter it becomes easy to find flaws in his arguments. He raises some plausible doubts about the evidence for statins, but then tries to imply that if the imperfect evidence that’s available shows that less than 2% of people who are prescribed statins will benefit, then we should doubt that those people ought to take statins.
He presents evidence that prostate cancer treatments save fewer lives than is commonly thought. It appears that sometimes the treatment merely changes the cause of death to something else. Yet he concludes that the treatment is useless, when the data he presents indicate nontrivial benefits. He hints that the evidence doesn’t meet the usual standard of statistical significance, but feels comfortable concluding (without even saying how close it is to being statistically significant) that the lack of proof is strong evidence of ineffectiveness.
He has a somewhat interesting proposal that the final phase of drug testing be done by the FDA rather than by drug companies. If the FDA were run by angels, that would solve a number of problems with the existing regulatory incentives, but with an FDA run by humans it would replace them with new problems. For instance, the choice of which drugs to test is something that only a few special interest voters (i.e. mainly those working for large drug companies) would understand, so their interests would be likely to influence those choices to the benefit of those companies.