medicine

pnrj core principles, market failure, public policy , , , , , , , , , , , , , , , , ,

There should be a glut of nurses.

Jan 15 JDN 2459960

It will not be news to most of you that there is a worldwide shortage of healthcare staff, especially nurses and emergency medical technicians (EMTs). I would like you to stop and think about the utterly terrible policy failure this represents. Maybe if enough people do, we can figure out a way to fix it.

It goes without saying—yet bears repeating—that people die when you don’t have enough nurses and EMTs. Indeed, surely a large proportion of the 2.6 million (!) deaths each year from medical errors are attributable to this. It is likely that at least one million lives per year could be saved by fixing this problem worldwide. In the US alone, over 250,000 deaths per year are caused by medical errors; so we’re looking at something like 100,000 lives we could safe each year by removing staffing shortages.

Precisely because these jobs have such high stakes, the mere fact that we would ever see the word “shortage” beside “nurse” or “EMT” was already clear evidence of dramatic policy failure.

This is not like other jobs. A shortage of accountants or baristas or even teachers, while a bad thing, is something that market forces can be expected to correct in time, and it wouldn’t be unreasonable to simply let them do so—meaning, let wages rise on their own until the market is restored to equilibrium. A “shortage” of stockbrokers or corporate lawyers would in fact be a boon to our civilization. But a shortage of nurses or EMTs or firefighters (yes, there are those too!) is a disaster.

Partly this is due to the COVID pandemic, which has been longer and more severe than any but the most pessimistic analysts predicted. But there shortages of nurses before COVID. There should not have been. There should have been a massive glut.

Even if there hadn’t been a shortage of healthcare staff before the pandemic, the fact that there wasn’t a glut was already a problem.

This is what a properly-functioning healthcare policy would look like: Most nurses are bored most of the time. They are widely regarded as overpaid. People go into nursing because it’s a comfortable, easy career with very high pay and usually not very much work. Hospitals spend most of their time with half their beds empty and half of their ambulances parked while the drivers and EMTs sit around drinking coffee and watching football games.

Why? Because healthcare, especially emergency care, involves risk, and the stakes couldn’t be higher. If the number of severely sick people doubles—as in, say, a pandemic—a hospital that usually runs at 98% capacity won’t be able to deal with them. But a hospital that usually runs at 50% capacity will.

COVID exposed to the world what a careful analysis would already have shown: There was not nearly enough redundancy in our healthcare system. We had been optimizing for a narrow-minded, short-sighted notion of “efficiency” over what we really needed, which was resiliency and robustness.

I’d like to compare this to two other types of jobs.

The first is stockbrokers.Set aside for a moment the fact that most of what they do is worthless is not actively detrimental to human society. Suppose that their most adamant boosters are correct and what they do is actually really important and beneficial.

Their experience is almost like what I just said nurses ought to be. They are widely regarded (correctly) as very overpaid. There is never any shortage of them; there are people lining up to be hired. People go into the work not because they care about it or even because they are particularly good at it, but because they know it’s an easy way to make a lot of money.

The one thing that seems to be different from my image may not be as different as it seems. Stockbrokers work long hours, but nobody can really explain why. Frankly most of what they do can be—and has been—successfully automated. Since there simply isn’t that much work for them to do, my guess is that most of the time they spend “working” 60-80 hour weeks is actually not actually working, but sitting around pretending to work. Since most financial forecasters are outperformed by a simple diversified portfolio, the most profitable action for most stock analysts to take most of the time would be nothing.

It may also be that stockbrokers work hard at sales—trying to convince people to buy and sell for bad reasons in order to earn sales commissions. This would at least explain why they work so many hours, though it would make it even harder to believe that what they do benefits society. So if we imagine our “ideal” stockbroker who makes the world a better place, I think they mostly just use a simple algorithm and maybe adjust it every month or two. They make better returns than their peers, but spend 38 hours a week goofing off.

There is a massive glut of stockbrokers. This is what it looks like when a civilization is really optimized to be good at something.

The second is soldiers. Say what you will about them, no one can dispute that their job has stakes of life and death. A lot of people seem to think that the world would be better off without them, but that’s at best only true if everyone got rid of them; if you don’t have soldiers but other countries do, you’re going to be in big trouble. (“We’ll beat our swords into liverwurst / Down by the East Riverside; / But no one wants to be the first!”) So unless and until we can solve that mother of all coordination problems, we need to have soldiers around.

What is life like for a soldier? Well, they don’t seem overpaid; if anything, underpaid. (Maybe some of the officers are overpaid, but clearly not most of the enlisted personnel. Part of the problem there is that “pay grade” is nearly synonymous with “rank”—it’s a primate hierarchy, not a rational wage structure. Then again, so are most industries; the military just makes it more explicit.) But there do seem to be enough of them. Military officials may lament of “shortages” of soldiers, but they never actually seem to want for troops to deploy when they really need them. And if a major war really did start that required all available manpower, the draft could be reinstated and then suddenly they’d have it—the authority to coerce compliance is precisely how you can avoid having a shortage while keeping your workers underpaid. (Russia’s soldier shortage is genuine—something about being utterly outclassed by your enemy’s technological superiority in an obviously pointless imperialistic war seems to hurt your recruiting numbers.)

What is life like for a typical soldier? The answer may surprise you. The overwhelming answer in surveys and interviews (which also fits with the experiences I’ve heard about from friends and family in the military) is that life as a soldier is boring. “All you do is wake up in the morning and push rubbish around camp.” “Bosnia was scary for about 3 months. After that it was boring. That is pretty much day to day life in the military. You are bored.”

This isn’t new, nor even an artifact of not being in any major wars: Union soldiers in the US Civil War had the same complaint. Even in World War I, a typical soldier spent only half the time on the front, and when on the front only saw combat 1/5 of the time. War is boring.

In other words, there is a massive glut of soldiers. Most of them don’t even know what to do with themselves most of the time.

This makes perfect sense. Why? Because an army needs to be resilient. And to be resilient, you must be redundant. If you only had exactly enough soldiers to deploy in a typical engagement, you’d never have enough for a really severe engagement. If on average you had enough, that means you’d spend half the time with too few. And the costs of having too few soldiers are utterly catastrophic.

This is probably an evolutionary outcome, in fact; civilizations may have tried to have “leaner” militaries that didn’t have so much redundancy, and those civilizations were conquered by other civilizations that were more profligate. (This is not to say that we couldn’t afford to cut military spending at all; it’s one thing to have the largest military in the world—I support that, actually—but quite another to have more than the next 10 combined.)

What’s the policy solution here? It’s actually pretty simple.

Pay nurses and EMTs more. A lot more. Whatever it takes to get to the point where we not only have enough, but have so many people lining up to join we don’t even know what to do with them all. If private healthcare firms won’t do it, force them to—or, all the more reason to nationalize healthcare. The stakes are far too high to leave things as they are.

Would this be expensive? Sure.

Removing the shortage of EMTs wouldn’t even be that expensive. There are only about 260,000 EMTs in the US, and they get paid the apallingly low median salary of $36,000. That means we’re currently spending only about $9 billion per year on EMTs. We could double their salaries and double their numbers for only an extra $27 billion—about 0.1% of US GDP.

Nurses would cost more. There are about 5 million nurses in the US, with an average salary of about $78,000, so we’re currently spending about $390 billion a year on nurses. We probably can’t afford to double both salary and staffing. But maybe we could increase both by 20%, costing about an extra $170 billion per year.

Altogether that would cost about $200 billion per year. To save one hundred thousand lives.

That’s $2 million per life saved, or about $40,000 per QALY. The usual estimate for the value of a statistical life is about $10 million, and the usual threshold for a cost-effective medical intervention is $50,000-$100,000 per QALY; so we’re well under both. This isn’t as efficient as buying malaria nets in Africa, but it’s more efficient than plenty of other things we’re spending on. And this isn’t even counting additional benefits of better care that go beyond lives saved.

In fact if we nationalized US healthcare we could get more than these amounts in savings from not wasting our money on profits for insurance and drug companies—simply making the US healthcare system as cost-effective as Canada’s would save $6,000 per American per year, or a whopping $1.9 trillion. At that point we could double the number of nurses and their salaries and still be spending less.

No, it’s not because nurses and doctors are paid much less in Canada than the US. That’s true in some countries, but not Canada. The median salary for nurses in Canada is about $95,500 CAD, which is $71,000 US at current exchange rates. Doctors in Canada can make anywhere from $80,000 to $400,000 CAD, which is $60,000 to $300,000 US. Nor are healthcare outcomes in Canada worse than the US; if anything, they’re better, as Canadians live an average of four years longer than Americans. No, the radical difference in cost—a factor of 2 to 1—between Canada and the US comes from privatization. Privatization is supposed to make things more efficient and lower costs, but it has absolutely not done that in US healthcare.

And if our choice is between spending more money and letting hundreds of thousands or millions of people die every year, that’s no choice at all.

How can we fix medical residency?

pnrj ethics, public policy, science and academia , , , , , ,

Nov 21 JDN 459540

Most medical residents work 60 or more hours per week, and nearly 20% work 80 or more hours. 66% of medical residents report sleeping 6 hours or less each night, and 20% report sleeping 5 hours or less.

It’s not as if sleep deprivation is a minor thing: Worldwide, across all jobs, nearly 750,000 deaths annually are attributable to long working hours, most of these due to sleep deprivation.


By some estimates, medical errors account for as many as 250,000 deaths per year in the US alone. Even the most conservative estimates say that at least 25,000 deaths per year in the US are attributable to medical errors. It seems quite likely that long working hours increase the rate of dangerous errors (though it has been difficult to determine precisely how much).

Indeed, the more we study stress and sleep deprivation, the more we learn how incredibly damaging they are to health and well-being. Yet we seem to have set up a system almost intentionally designed to maximize the stress and sleep deprivation of our medical professionals. Some of them simply burn out and leave the profession (about 18% of surgical residents quit); surely an even larger number of people never enter medicine in the first place because they know they would burn out.

Even once a doctor makes it through residency and has learned to cope with absurd hours, this most likely distorts their whole attitude toward stress and sleep deprivation. They are likely to not consider them “real problems”, because they were able to “tough it out”—and they are likely to assume that their patients can do the same. One of the primary functions of a doctor is to reduce pain and suffering, and by putting doctors through unnecessary pain and suffering as part of their training, we are teaching them that pain and suffering aren’t really so bad and you should just grin and bear it.

We are also systematically selecting against doctors who have disabilities that would make it difficult to work these double-time hours—which means that the doctors who are most likely to sympathize with disabled patients are being systematically excluded from the profession.

There have been some attempts to regulate the working hours of residents, but they have generally not been effective. I think this is for three reasons:

1. They weren’t actually trying hard enough. A cap of 80 hours per week is still 40 hours too high, and looks to me like you are trying to get better PR without fixing the actual problem.

2. Their enforcement mechanisms left too much opportunity to cheat the system, and in fact most medical residents simply became pressured to continue over-working and under-report their hours.

3. They don’t seem to have considered how to effect the transition in a way that won’t reduce the total number of resident-hours, and so residents got less training and hospitals were less served.

The solution to problem 1 is obvious: The cap needs to be lower. Much lower.

The solution to problem 2 is trickier: What sort of enforcement mechanism would prevent hospitals from gaming the system?

I believe the answer is very steep overtime pay requirements, coupled with regular and intensive auditing. Every hour a medical resident goes over their cap, they should have to be paid triple time. Audits should be performed frequently, randomly and without notice. And if a hospital is caught falsifying their records, they should be required to pay all missing hours to all medical residents at quintuple time. And Medicare and Medicaid should not be allowed to reimburse these additional payments—they must come directly out of the hospital’s budget.

Under the current system, the “punishment” is usually a threat of losing accreditation, which is too extreme and too harmful to the residents. Precisely because this is such a drastic measure, it almost never happens. The punishment needs to be small enough that we will actually enforce it; and it needs to hurt the hospital, not the residents—overtime pay would do precisely that.

That brings me to problem 3: How can we ensure that we don’t reduce the total number of resident-hours?

This is important for two reasons: Each resident needs a certain number of hours of training to become a skilled doctor, and residents provide a significant proportion of hospital services. Of the roughly 1 million doctors in the US, about 140,000 are medical residents.

The answer is threefold:

1. Increase the number of residency slots (we have a global doctor shortage anyway).

2. Extend the duration of residency so that each resident gets the same number of total work hours.

3. Gradually phase in so that neither increase needs to be too fast.

Currently a typical residency is about 4 years. 4 years of 80-hour weeks is equivalent to 8 years of 40-hour weeks. The goal is for each resident to get 320 hour-years of training.

With 140,000 current residents averaging 4 years, a typical cohort is about 35,000. So the goal is to each year have at least (35,000 residents per cohort)(4 cohorts)(80 hours per week) = 11 million resident-hours per week.

In cohort 1, we reduce the cap to 70 hours, and increase the number of accepted residents to 40,000. Residents in cohort 1 will continue their residency for 4 years, 7 months. This gives each one 321 hour-years of training.

In cohort 2, we reduce the cap to 60 hours, and increase the number of accepted residents to 46,000.

Residents in cohort 2 will continue their residency for 5 years, 4 months. This gives each one 320 hour-years of training.

In cohort 3, we reduce the cap to 55 hours, and increase the number of accepted residents to 50,000.

Residents in cohort 3 will continue their residency for 6 years. This gives each one 330 hour-years of training.

In cohort 4, we reduce the cap to 50 hours, and increase the number of accepted residents to 56,000. Residents in cohort 4 will continue their residency for 6 years, 6 months. This gives each one 325 hour-years of training.

In cohort 5, we reduce the cap to 45 hours, and increase the number of accepted residents to 60,000. Residents in cohort 5 will continue their residency for 7 years, 2 months. This gives each one 322 hour-years of training.

In cohort 6, we reduce the cap to 40 hours, and increase the number of accepted residents to 65,000. Residents in cohort 6 will continue their residency for 8 years. This gives each one 320 hour-years of training.

In cohort 7, we keep the cap to 40 hours, and increase the number of accepted residents to 70,000. This is now the new standard, with 8-year residencies with 40 hour weeks.

I’ve made a graph here of what this does to the available number of resident-hours each year. There is a brief 5% dip in year 4, but by the time we reach year 14 we’ve actually doubled the total number of available resident-hours at any given time—without increasing the total amount of work each resident does, simply keeping them longer and working them less intensively each year. Given that quality of work is reduced by working longer hours, it’s likely that even this brief reduction in hours would not result in any reduced quality of care for patients.

[residency_hours.png]

I have thus managed to increase the number of available resident-hours, ensure that each resident gets the same amount of training as before, and still radically reduce the work hours from 80 per week to 40 per week. The additional recruitment each year is never more than 6,000 new residents or 15% of the current number of residents.

It takes several years to effect this transition. This is unavoidable if we are trying to avoid massive increases in recruitment, though if we were prepared to simply double the number of admitted residents each year we could immediately transition to 40-hour work weeks in a single cohort and the available resident-hours would then strictly increase every year.

This plan is likely not the optimal one; I don’t know enough about the details of how costly it would be to admit more residents, and it’s possible that some residents might actually prefer a briefer, more intense residency rather than a longer, less stressful one. (Though it’s worth noting that most people greatly underestimate the harms of stress and sleep deprivation, and doctors don’t seem to be any better in this regard.)

But this plan does prove one thing: There are solutions to this problem. It can be done. If our medical system isn’t solving this problem, it is not because solutions do not exist—it is because they are choosing not to take them.

Because ought implies can, can may imply ought

pnrj core principles, ethics, futurism, inequality , , , , , , , ,

Mar21JDN 2459295

Is Internet access a fundamental human right?

At first glance, such a notion might seem preposterous: Internet access has only existed for less than 50 years, how could it be a fundamental human right like life and liberty, or food and water?

Let’s try another question then: Is healthcare a fundamental human right?

Surely if there is a vaccine for a terrible disease, and we could easily give it to you but refuse to do so, and you thereby contract the disease and suffer horribly, we have done something morally wrong. We have either violated your rights or violated our own obligations—perhaps both.

Yet that vaccine had to be invented, just as the Internet did; go back far enough into history and there were no vaccines, no antibiotics, even no anethestetics or antiseptics.

One strong, commonly shared intuition is that denying people such basic services is a violation of their fundamental rights. Another strong, commonly shared intuition is that fundamental rights should be universal, not contingent upon technological or economic development. Is there a way to reconcile these two conflicting intuitions? Or is one simply wrong?

One of the deepest principles in deontic logic is “ought implies can“: One cannot be morally obligated to do what one is incapable of doing.

Yet technology, by its nature, makes us capable of doing more. By technological advancement, our space of “can” has greatly expanded over time. And this means that our space of “ought” has similarly expanded.

For if the only thing holding us back from an obligation to do something (like save someone from a disease, or connect them instantaneously with all of human knowledge) was that we were incapable and ought implies can, well, then now that we can, we ought.

Advancements in technology do not merely give us the opportunity to help more people: They also give us the obligation to do so. As our capabilities expand, our duties also expand—perhaps not at the same rate, but they do expand all the same.

It may be that on some deeper level we could articulate the fundamental rights so that they would not change over time: Not a right to Internet access, but a right to equal access to knowledge; not a right to vaccination, but a right to a fair minimum standard of medicine. But the fact remains: How this right becomes expressed in action and policy will and must change over time. What was considered an adequate standard of healthcare in the Middle Ages would rightfully be considered barbaric and cruel today. And I am hopeful that what we now consider an adequate standard of healthcare will one day seem nearly as barbaric. (“Dialysis? What is this, the Dark Ages?”)

We live in a very special time in human history.

Our technological and economic growth for the past few generations has been breathtakingly fast, and we are the first generation in history to seriously be in a position to end world hunger. We have in fact been rapidly reducing global poverty, but we could do far more. And because we can, we should.

After decades of dashed hope, we are now truly on the verge of space colonization: Robots on Mars are now almost routine, fully-reusable spacecraft have now flown successful missions, and a low-Earth-orbit hotel is scheduled to be constructed by the end of the decade. Yet if current trends continue, the benefits of space colonization are likely to be highly concentrated among a handful of centibillionaires—like Elon Musk, who gained a staggering $160 billion in wealth over the past year. We can do much better to share the rewards of space with the rest of the population—and therefore we must.

Artificial intelligence is also finally coming into its own, with GPT-3 now passing the weakest form of the Turing Test (though not the strongest form—you can still trip it up and see that it’s not really human if you are clever and careful). Many jobs have already been replaced by automation, but as AI improves, many more will be—not as soon as starry-eyed techno-optimists imagined, but sooner than most people realize. Thus far the benefits of automation have likewise been highly concentrated among the rich—we can fix that, and therefore we should.

Is there a fundamental human right to share in the benefits of space colonization and artificial intelligence? Two centuries ago the question wouldn’t have even made sense. Today, it may seem preposterous. Two centuries from now, it may seem preposterous to deny.

I’m sure almost everyone would agree that we are obliged to give our children food and water. Yet if we were in a desert, starving and dying of thirst, we would be unable to do so—and we cannot be obliged to do what we cannot do. Yet as soon as we find an oasis and we can give them water, we must.

Humanity has been starving in the desert for two hundred millennia. Now, at last, we have reached the oasis. It is our duty to share its waters fairly.

A Socratic open letter to transphobes everywhere

pnrj core principles, ethics, personal, public policy, Uncategorized , , , , , , , , , , , ,

Feb 23 JDN 2458903

This post is a bit different than usual. This is an open letter to those who doubt that trans people actually exist, or insist on using the wrong pronouns; above all it is an open letter to those who want to discriminate against trans people, denying trans people civil rights or the dignity to use public bathrooms in peace. Most of my readers are probably not such people, but I think you’ll still benefit from reading it—perhaps you can use some of its arguments when you inevitably encounter someone who is.

Content warning: Because of how sex and gender are tied up together in transphobes’ minds, I’m going to need to talk a little bit about sexual anatomy and genital surgery. If such topics make you uncomfortable, feel free to skip this post.

Dear Transphobe:

First of all, I’m going to assume you are a man. Statistically you probably are, in which case that works. If by chance you’re not, well, now you know what it feels like for people to assume your gender and never correct themselves. You’re almost certainly politically right-wing, so that’s an even safer assumption on my part.

You probably think that gender and sex are interchangeable things, that the idea of a woman born with a penis or a man born without one is utter nonsense. I’m here to hopefully make you question this notion.

Let’s start by thinking about your own identity. You are a man. I presume that you have a penis. I am not going to make the standard insult many on the left would and say that it’s probably a small penis. In fact I have no particular reason to believe that, and in any case the real problem is that we as a society have so thoroughly equated penis size with masculinity with value as a human being. Right-wing attitudes of the sort that lead to discriminating against LGBT people are strongly correlated with aggressive behaviors to assert one’s masculinity. Even if I had good reason—which I assuredly do not—to do so, attacking your masculinity would be inherently counterproductive, causing you to double down on the same aggressive, masculinity-signaling behaviors. If it so happens that you are insecure in your masculinity, I certainly don’t want to make that worse, as masculine insecurity was one of the strongest predictors of voting for Donald Trump. You are a man, and I make no challenges to your masculinity whatsoever. I’m even prepared to concede that you are more manly than I am, whatever you may take that to mean.

Let us consider a thought experiment. Suppose that you were to lose your penis in some tragic accident. Don’t try to imagine the details; I’m sure the mere fact of it is terrifying enough. Suppose a terrible day were to arrive where you wake up in a hospital and find you no longer have a penis.

I have a question for you now: Should such a terrible day arrive, would you cease to be a man?

I contend that you would remain a man. I think that you, upon reflection, would also contend the same. There are a few thousand men in the world who have undergone penectomy, typically as a treatment for genital cancer. You wouldn’t even know unless you saw them naked or they told you. As far as anyone else can tell, they look and act as men, just as they did before their surgery. They are still men, just as they were before.

In fact, it’s quite likely that you would experience a phantom limb effect—where here the limb that is in your self-image but no longer attached to your body is your penis. You would sometimes feel “as if” your penis was still there, because your brain continues to have the neural connections that generate such sensations.

An even larger number of men have undergone castration for various reasons, and while they do often find that their thoughts and behavior change due to the changes in hormone balances, they still consider themselves men, and are generally considered men by others as well. We do not even consider them transgender men; we simply consider them men.

But does this not mean, then, that there is something more to being a man than simply having male anatomy?

Perhaps it has to do with other body parts, or some totality of the male body? Let’s consider another thought experiment then. Suppose that by some bizarre event you were transported into a female body. The mechanism isn’t important: Perhaps it was a mad scientist, or aliens, or magic. But just suppose that somehow or other, while you slept, your brain in its current state was transported into an entirely female body, complete with breasts, vulva, wide hips, narrow shoulders—the whole package. When you awaken, your body is female.

Such a transition would no doubt be distressing and disorienting. People would probably begin to see you as a woman when they looked at you. You would be denied access to men’s spaces you had previously used, and suddenly granted access to women’s spaces you had never before been allowed into. And who knows what sort of effect the hormonal changes would have on your mind?

Particularly if you are sexually attracted to women, you might imagine that you would enjoy this transformation: Now you get to play with female body parts whenever you want! But think about this matter carefully, now: While there might be some upsides, would you really want this change to happen? You have to now wear women’s clothing, use women’s restrooms, cope with a menstrual cycle. Everyone will see you as a woman and treat you as a woman. (How do you treat women, by the way? Is this something you’ve thought carefully about?)

And if you still think that being a woman isn’t so bad, maybe it isn’t—if your mind and body are in agreement. But remember that you’ve still got the mind of a man; you still feel that mental attachment to body parts that are no longer present, and these new body parts you have don’t feel like they are properly your own.

But throughout this harrowing experience, would you still be a man?

Once again I contend that you would. You would now feel a deep conflict between your mind and your body—dare I call it gender dysphoria?—and you would probably long to change your body back to what it was, or at least back to a body that is male.

You would once again experience phantom limb effects—but now all over, everywhere your new body deviated from your original form. In your brain there is a kind of map of where your body parts are supposed to be: Your shoulders are supposed to end here, your legs are supposed to end there, and down here there is supposed to be a penis, not vulva. This map is deeply ingrained into your mind, its billions of strands almost literally woven into the fabric of your brain.

We are presumably born with such a map: By some mindbogglingly complex mix of genetic and environmental factors our brains organize themselves into specific patterns, telling us what kind of body we’re supposed to have. Some of this structuring may go on before birth, some while we are growing up. But surely by the time we are adults the process is complete.

This mental map does allow for some flexibility: When we were young and growing, it allowed us to adjust to our ever-increasing height. Now that we are older, it allows us to adjust to gaining or losing weight. But this flexibility is quite limited: it might take years, or perhaps we could never adjust at all, to finding that we had suddenly grown a tail—or suddenly changed from male to female.

Now imagine that this transformation didn’t happen by some sudden event when you were an adult, but by some quirk of ontogeny while you were still in the womb. Suppose that you were born this way: in a body that is female, but with a mind that is male.

In such a state, surely something is wrong, in the same way that being born with sickle-cell anemia or spina bifida is wrong. There are more ambiguous cases: Is polydactyly a disorder? Sometimes? But surely there are some ways to be born that are worth correcting, and “female body, male mind” seems like one of them.

And yet, this is often precisely how trans people describe their experience. Not always—humans are nothing if not diverse, and trans people are no exception—but quite frequently, they will say that they feel like “a man in a woman’s body” or the reverse. By all accounts, they seem to have precisely this hypothetical condition: The gender of their mind does not match the sex of their body. And since this mismatch causes great suffering, we ought to correct it.

But then the question becomes: Correct it how?

Broadly speaking, it seems we’ve only two options: Change the body, or change the mind. If you were in this predicament, which would you want?

In the case of being transferred into a new body as an adult, I’m quite sure you’d prefer to change your body, and keep your mind as it is. You don’t belong in this new body, and you want your old one back.

Yet perhaps you think that if you were born with this mismatch, things might be different: Perhaps in such a case you think it would make more sense to change the mind to match the body. But I ask you this: Which is more fundamental to who you are? If you are still an infant, we can’t ask your opinion; but what do you suppose you’d say if we could?

Or suppose that you notice the mismatch later, as a child, or even as a teenager. Before that, something felt off somehow, but you couldn’t quite put your finger on it. But now you realize where the problem lies: You were born in a body of the wrong sex. Now that you’ve had years to build up your identity, would you still say that the mind is the right thing to change? Once you can speak, now we can ask you—and we do ask such children, and their answers are nigh-unanimous: They want to change their bodies, not their minds. David Reimer was raised as a girl for years, and yet he always still knew he was a boy and tried to act like one.

In fact, we don’t even know how to change the gender of a mind. Despite literally millennia of civilization trying at great expense to enforce particular gender norms on everyone’s minds, we still get a large proportion of the population deviating substantially from them—if you include mild enough deviations, probably a strict majority. If I seem a soft “soy boy” to you (and, I admit, I am both bisexual and vegetarian—though I already knew I was the former before I became the latter), ask yourself this: Why would I continue to deviate from your so ferociously-enforced gender norms, if it were easy to conform?

Whereas, we do have some idea how to change a body. We have hormonal and surgical treatments that allow people to change their bodies substantially—trans women can grow breasts, trans men can grow beards. Often this is enough to make people feel much more comfortable in their own bodies, and also present themselves in a way that leads others to recognize them as their desired gender.

Sex reassignment surgery is not as reliable, especially for trans men: While building artificial vulva works relatively well, building a good artificial penis still largely eludes us. Yet technological process in this area continues, and we’ve improved our ability to change the sex of bodies substantially in just the last few decades—while, let me repeat, we have not meaningfully improved our ability to change the gender of minds in the last millennium.

If we could reliably change the gender of minds, perhaps that would be an option worth considering. But ought implies can: We cannot be ethically expected to do that which we are simply incapable.

At present, this means that our only real options are two: We can accept the gender of the mind, change the sex of the body, and treat this person as the gender they identify themselves as; or we can demand that they repress and conceal their mental gender in favor of conforming to the standards we have imposed upon them based on their body. The option you may most prefer—accept the body, change the mind—simply is not feasible with any current or foreseeable technology.

We have tried repressing transgender identity for centuries: It has brought endless suffering, depression, suicide.

But now that we are trying to affirm transgender identity the outlook seems much better: Simply having one adult in their life who accepts their gender identity reduces the risk of a transgender child attempting suicide by 40%. Meta-analysis of research on the subject shows that gender transition, while surely no panacea, does overall improve outcomes for transgender people—including reducing risk of depression and suicide. (That site is actually refreshingly nuanced; it does not simply accept either the left-wing or right-wing ideology on the subject, instead delving deeply into the often quite ambiguous evidence.)

Above all, ask yourself: If you ever found yourself in the wrong sort of body, what would you want us to do?

The replication crisis, and the future of science

pnrj core principles, ethics, public policy, science and academia, statistics , , , , , , , , , , , , , , , , , ,

Aug 27, JDN 2457628 [Sat]

After settling in a little bit in Irvine, I’m now ready to resume blogging, but for now it will be on a reduced schedule. I’ll release a new post every Saturday, at least for the time being.

Today’s post was chosen by Patreon vote, though only one person voted (this whole Patreon voting thing has not been as successful as I’d hoped). It’s about something we scientists really don’t like to talk about, but definitely need to: We are in the middle of a major crisis of scientific replication.

Whenever large studies are conducted attempting to replicate published scientific results, their ability to do so is almost always dismal.

Psychology is the one everyone likes to pick on, because their record is particularly bad. Only 39% of studies were really replicated with the published effect size, though a further 36% were at least qualitatively but not quantitatively similar. Yet economics has its own replication problem, and even medical research is not immune to replication failure.

It’s important not to overstate the crisis; the majority of scientific studies do at least qualitatively replicate. We are doing better than flipping a coin, which is better than one can say of financial forecasters.
There are three kinds of replication, and only one of them should be expected to give near-100% results. That kind is reanalysis—when you take the same data and use the same methods, you absolutely should get the exact same results. I favor making reanalysis a routine requirement of publication; if we can’t get your results by applying your statistical methods to your data, then your paper needs revision before we can entrust it to publication. A number of papers have failed on reanalysis, which is absurd and embarrassing; the worst offender was probably Rogart-Reinhoff, which was used in public policy decisions around the world despite having spreadsheet errors.

The second kind is direct replication—when you do the exact same experiment again and see if you get the same result within error bounds. This kind of replication should work something like 90% of the time, but in fact works more like 60% of the time.

The third kind is conceptual replication—when you do a similar experiment designed to test the same phenomenon from a different perspective. This kind of replication should work something like 60% of the time, but actually only works about 20% of the time.

Economists are well equipped to understand and solve this crisis, because it’s not actually about science. It’s about incentives. I facepalm every time I see another article by an aggrieved statistician about the “misunderstanding” of p-values; no, scientist aren’t misunderstanding anything. They know damn well how p-values are supposed to work. So why do they keep using them wrong? Because their jobs depend on doing so.

The first key point to understand here is “publish or perish”; academics in an increasingly competitive system are required to publish their research in order to get tenure, and frequently required to get tenure in order to keep their jobs at all. (Or they could become adjuncts, who are paid one-fifth as much.)

The second is the fundamentally defective way our research journals are run (as I have discussed in a previous post). As private for-profit corporations whose primary interest is in raising more revenue, our research journals aren’t trying to publish what will genuinely advance scientific knowledge. They are trying to publish what will draw attention to themselves. It’s a similar flaw to what has arisen in our news media; they aren’t trying to convey the truth, they are trying to get ratings to draw advertisers. This is how you get hours of meaningless fluff about a missing airliner and then a single chyron scroll about a war in Congo or a flood in Indonesia. Research journals haven’t fallen quite so far because they have reputations to uphold in order to attract scientists to read them and publish in them; but still, their fundamental goal is and has always been to raise attention in order to raise revenue.

The best way to do that is to publish things that are interesting. But if a scientific finding is interesting, that means it is surprising. It has to be unexpected or unusual in some way. And above all, it has to be positive; you have to have actually found an effect. Except in very rare circumstances, the null result is never considered interesting. This adds up to making journals publish what is improbable.

In particular, it creates a perfect storm for the abuse of p-values. A p-value, roughly speaking, is the probability you would get the observed result if there were no effect at all—for instance, the probability that you’d observe this wage gap between men and women in your sample if in the real world men and women were paid the exact same wages. The standard heuristic is a p-value of 0.05; indeed, it has become so enshrined that it is almost an explicit condition of publication now. Your result must be less than 5% likely to happen if there is no real difference. But if you will only publish results that show a p-value of 0.05, then the papers that get published and read will only be the ones that found such p-values—which renders the p-values meaningless.

It was never particularly meaningful anyway; as we Bayesians have been trying to explain since time immemorial, it matters how likely your hypothesis was in the first place. For something like wage gaps where we’re reasonably sure, but maybe could be wrong, the p-value is not too unreasonable. But if the theory is almost certainly true (“does gravity fall off as the inverse square of distance?”), even a high p-value like 0.35 is still supportive, while if the theory is almost certainly false (“are human beings capable of precognition?”—actual study), even a tiny p-value like 0.001 is still basically irrelevant. We really should be using much more sophisticated inference techniques, but those are harder to do, and don’t provide the nice simple threshold of “Is it below 0.05?”

But okay, p-values can be useful in many cases—if they are used correctly and you see all the results. If you have effect X with p-values 0.03, 0.07, 0.01, 0.06, and 0.09, effect X is probably a real thing. If you have effect Y with p-values 0.04, 0.02, 0.29, 0.35, and 0.74, effect Y is probably not a real thing. But I’ve just set it up so that these would be published exactly the same. They each have two published papers with “statistically significant” results. The other papers never get published and therefore never get seen, so we throw away vital information. This is called the file drawer problem.

Researchers often have a lot of flexibility in designing their experiments. If their only goal were to find truth, they would use this flexibility to test a variety of scenarios and publish all the results, so they can be compared holistically. But that isn’t their only goal; they also care about keeping their jobs so they can pay rent and feed their families. And under our current system, the only way to ensure that you can do that is by publishing things, which basically means only including the parts that showed up as statistically significant—otherwise, journals aren’t interested. And so we get huge numbers of papers published that tell us basically nothing, because we set up such strong incentives for researchers to give misleading results.

The saddest part is that this could be easily fixed.

First, reduce the incentives to publish by finding other ways to evaluate the skill of academics—like teaching for goodness’ sake. Working papers are another good approach. Journals already get far more submissions than they know what to do with, and most of these papers will never be read by more than a handful of people. We don’t need more published findings, we need better published findings—so stop incentivizing mere publication and start finding ways to incentivize research quality.

Second, eliminate private for-profit research journals. Science should be done by government agencies and nonprofits, not for-profit corporations. (And yes, I would apply this to pharmaceutical companies as well, which should really be pharmaceutical manufacturers who make cheap drugs based off of academic research and carry small profit margins.) Why? Again, it’s all about incentives. Corporations have no reason to want to find truth and every reason to want to tilt it in their favor.

Third, increase the number of tenured faculty positions. Instead of building so many new grand edifices to please your plutocratic donors, use your (skyrocketing) tuition money to hire more professors so that you can teach more students better. You can find even more funds if you cut the salaries of your administrators and football coaches. Come on, universities; you are the one industry in the world where labor demand and labor supply are the same people a few years later. You have no excuse for not having the smoothest market clearing in the world. You should never have gluts or shortages.

Fourth, require pre-registration of research studies (as some branches of medicine already do). If the study is sound, an optimal rational agent shouldn’t care in the slightest whether it had a positive or negative result, and if our ape brains won’t let us think that way, we need to establish institutions to force it to happen. They shouldn’t even see the effect size and p-value before they make the decision to publish it; all they should care about is that the experiment makes sense and the proper procedure was conducted.
If we did all that, the replication crisis could be almost completely resolved, as the incentives would be realigned to more closely match the genuine search for truth.

Alas, I don’t see universities or governments or research journals having the political will to actually make such changes, which is very sad indeed.

Medicaid expansion and the human cost of political polarization

pnrj current events, public policy , , , , , , , , , , , , , ,

JDN 2457422

As of this writing, there are still 22 of our 50 US states that have refused to expand Medicaid under the Affordable Care Act. Several other states (including Michigan) expanded Medicaid, but on an intentionally slowed timetable. The way the law was written, these people are not eligible for subsidized private insurance (because it was assumed they’d be on Medicaid!), so there are almost 3 million people without health insurance because of the refused expansions.

Why? Would expanding Medicaid on the original timetable be too arduous to accomplish? If so, explain why 13 states managed to do it on time.

Would expanding Medicaid be expensive, and put a strain on state budgets? No, the federal government will pay 90% of the cost until 2020. Some states claim that even the 10% is unbearable, but when you figure in the reduced strain on emergency rooms and public health, expanding Medicaid would most likely save state money, especially with the 90% federal funding.

To really understand why so many states are digging in their heels, I’ve made you a little table. It includes three pieces of information about each state: The first column is whether it accepted Medicaid immediately (“Yes”), accepted it with delays or conditions, or hasn’t officially accepted it yet but is negotiating to do so (“Maybe”), or refused it completely (“No”). The second column is the political party of the state governor. The third column is the majority political party of the state legislatures (“D” for Democrat, “R” for Republican, “I” for Independent, or “M” for mixed if one house has one majority and the other house has the other).

State Medicaid? Governor Legislature
Alabama No R R
Alaska Maybe I R
Arizona Yes R R
Arkansas Maybe R R
California Yes D D
Colorado Yes D M
Connecticut Yes D D
Delaware Yes D D
Florida No R R
Georgia No R R
Hawaii Yes D D
Idaho No R R
Illinois Yes R D
Indiana Maybe R R
Iowa Maybe R M
Kansas No R R
Kentucky Yes R M
Lousiana Maybe D R
Maine No R M
Maryland Yes R D
Massachusetts Yes R D
Michigan Maybe R R
Minnesota No D M
Mississippi No R R
Missouri No D M
Montana Maybe D M
Nebraska No R R
Nevada Yes R R
New Hampshire Maybe D R
New Jersey Yes R D
New Mexico Yes R M
New York Yes D D
North Carolina No R R
North Dakota Yes R R
Ohio Yes R R
Oklahoma No R R
Oregon Yes D D
Pennsylvania Maybe D R
Rhode Island Yes D D
South Carolina No R R
South Dakota Maybe R R
Tennessee No R R
Texas No R R
Utah No R R
Vermont Yes D D
Virginia Maybe D R
Washington Yes D D
West Virginia Yes D R
Wisconsin No R R
Wyoming Maybe R R

I have taken the liberty of some color-coding.

The states highlighted in red are states that refused the Medicaid expansion which have Republican governors and Republican majorities in both legislatures; that’s Alabama, Florida, Georgia, Idaho, Kansas, Mississippi, Nebraska, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Utah, and Wisconsin.

The states highlighted in purple are states that refused the Medicaid expansion which have mixed party representation between Democrats and Republicans; that’s Maine, Minnesota, and Missouri.

And I would have highlighted in blue the states that refused the Medicaid expansion which have Democrat governors and Democrat majorities in both legislatures—but there aren’t any.

There were Republican-led states which said “Yes” (Arizona, Nevada, North Dakota, and Ohio). There were Republican-led states which said “Maybe” (Arkansas, Indiana, Michigan, South Dakota, and Wyoming).

Mixed states were across the board, some saying “Yes” (Colorado, Illinois, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, and West Virginia), some saying “Maybe” (Alaska, Iowa, Lousiana, Montana, New Hampshire, Pennsylvania, and Virginia), and a few saying “No” (Maine, Minnesota, and Missouri).

But every single Democrat-led state said “Yes”. California, Connecticut, Delaware, Hawaii, New York, Oregon, Rhode Island, Vermont, and Washington. There aren’t even any Democrat-led states that said “Maybe”.

Perhaps it is simplest to summarize this in another table. Each row is a party configuration (“Democrat, Republican”, or “mixed”); the column is a Medicaid decision (“Yes”, “Maybe”, or “No”); in each cell is the count of how many states that fit that description:

Yes Maybe No
Democrat 9 0 0
Republican 4 5 14
Mixed 8 7 3

Shall I do a chi-square test? Sure, why not? A chi-square test of independence produces a p-value of 0.00001. This is not a coincidence. Being a Republican-led state is strongly correlated with rejecting the Medicaid expansion.

Indeed, because the elected officials were there first, I can say that there is Granger causality from being a Republican-led state to rejecting the Medicaid expansion. Based on the fact that mixed states were much less likely to reject Medicaid than Republican states, I could even estimate a dose-response curve on how having more Republicans makes you more likely to reject Medicaid.

Republicans did this, is basically what I’m getting at here.

Obamacare itself was legitimately controversial (though the Republicans never quite seemed to grasp that they needed a counterproposal for their argument to make sense), but once it was passed, accepting the Medicaid expansion should have been a no-brainer. The federal government is giving you money in order to give healthcare to poor people. It will not be expensive for your state budget; in fact it will probably save you money in the long run. It will help thousands or millions of your constituents. Its impact on the federal budget is negligible.

But no, 14 Republican-led states couldn’t let themselves get caught implementing a Democrat’s policy, especially if it would actually work. If it failed catastrophically, they could say “See? We told you so.” But if it succeeded, they’d have to admit that their opponents sometimes have good ideas. (You know, just like the Democrats did, when they copied most of Mitt Romney’s healthcare system.)

As a result of their stubbornness, almost 3 million Americans don’t have healthcare. Some of those people will die as a result—economists estimate about 7,000 people, to be precise. Hundreds of thousands more will suffer. All needlessly.

When 3,000 people are killed in a terrorist attack, Republicans clamor to kill millions in response with carpet bombing and nuclear weapons.

But when 7,000 people will die without healthcare, Republicans say we can’t afford it.

What’s wrong with academic publishing?

pnrj public policy, science and academia , , , , , , , , , , , , , , , , , , , , , , , , , , ,

JDN 2457257 EDT 14:23.

I just finished expanding my master’s thesis into a research paper that is, I hope, suitable for publication in an economics journal. As part of this process I’ve been looking into the process of submitting articles for publication in academic journals… and I’ve found has been disgusting and horrifying. It is astonishingly bad, and my biggest question is why researchers put up with it.

Thus, the subject of this post is what’s wrong with the system—and what we might do instead.

Before I get into it, let me say that I don’t actually disagree with “publish or perish” in principle—as SMBC points out, it’s a lot like “do your job or get fired”. Researchers should publish in peer-reviewed journals; that’s a big part of what doing research means. The problem is how most peer-reviewed journals are currently operated.

First of all, in case you didn’t know, most scientific journals are owned by for-profit corporations. The largest corporation Elsevier, owns The Lancet and all of ScienceDirect, and has net income of over 1 billion Euros a year. Then there’s Springer and Wiley-Blackwell; between the three of them, these publishers account for over 40% of all scientific publications. These for-profit publishers retain the full copyright to most of the papers they publish, and tightly control access with paywalls; the cost to get through these paywalls is generally thousands of dollars a year for individuals and millions of dollars a year for universities. Their monopoly power is so great it “makes Rupert Murdoch look like a socialist.”

For-profit journals do often offer an “open-access” option in which you basically buy back your own copyright, but the price is high—the most common I’ve seen are $1800 or $3000 per paper—and very few researchers do this, for obvious financial reasons. In fact I think for a full-time tenured faculty researcher it’s probably worth it, given the alternatives. (Then again, full-time tenured faculty are becoming an endangered species lately; what might be worth it in the long run can still be very difficult for a cash-strapped adjunct to afford.) Open-access means people can actually read your paper and potentially cite your paper. Closed-access means it may languish in obscurity.

And of course it isn’t just about the benefits for the individual researcher. The scientific community as a whole depends upon the free flow of information; the reason we publish in the first place is that we want people to read papers, discuss them, replicate them, challenge them. Publication isn’t the finish line; it’s at best a checkpoint. Actually one thing that does seem to be wrong with “publish or perish” is that there is so much pressure for publication that we publish too many pointless papers and nobody has time to read the genuinely important ones.

These prices might be justifiable if the for-profit corporations actually did anything. But in fact they are basically just aggregators. They don’t do the peer-review, they farm it out to other academic researchers. They don’t even pay those other researchers; they just expect them to do it. (And they do! Like I said, why do they put up with this?) They don’t pay the authors who have their work published (on the contrary, they often charge submission fees—about $100 seems to be typical—simply to look at them). It’s been called “the world’s worst restaurant”, where you pay to get in, bring your own ingredients and recipes, cook your own food, serve other people’s food while they serve yours, and then have to pay again if you actually want to be allowed to eat.

They pay for the printing of paper copies of the journal, which basically no one reads; and they pay for the electronic servers that host the digital copies that everyone actually reads. They also provide some basic copyediting services (copyediting APA style is a job people advertise on Craigslist—so you can guess how much they must be paying).

And even supposing that they actually provided some valuable and expensive service, the fact would remain that we are making for-profit corporations the gatekeepers of the scientific community. Entities that exist only to make money for their owners are given direct control over the future of human knowledge. If you look at Cracked’s “reasons why we can’t trust science anymore”, all of them have to do with the for-profit publishing system. p-hacking might still happen in a better system, but publishers that really had the best interests of science in mind would be more motivated to fight it than publishers that are simply trying to raise revenue by getting people to buy access to their papers.

Then there’s the fact that most journals do not allow authors to submit to multiple journals at once, yet take 30 to 90 days to respond and only publish a fraction of what is submitted—it’s almost impossible to find good figures on acceptance rates (which is itself a major problem!), but the highest figures I’ve seen are 30% acceptance, a more typical figure seems to be 10%, and some top journals go as low as 3%. In the worst-case scenario you are locked into a journal for 90 days with only a 3% chance of it actually publishing your work. At that rate publishing an article could take years.

Is open-access the solution? Yes… well, part of it, anyway.

There are a large number of open-access journals, some of which do not charge submission fees, but very few of them are prestigious, and many are outright predatory. Predatory journals charge exorbitant fees, often after accepting papers for publication; many do little or no real peer review. There are almost seven hundred known predatory open-access journals; over one hundred have even been caught publishing hoax papers. These predatory journals are corrupting the process of science.

There are a few reputable open-access journals, such as BMC Biology and PLOSOne. Though not actually a journal, ArXiv serves a similar role. These will be part of the solution, most definitely. Yet even legitimate open-access journals often charge each author over $1000 to publish an article. There is a small but significant positive correlation between publication fees and journal impact factor.

We need to found more open-access journals which are funded by either governments or universities, so that neither author nor reader ever pays a cent. Science is a public good and should be funded as such. Even if copyright makes sense for other forms of content (I’m not so sure about that), it most certainly does not make sense for scientific knowledge, which by its very nature is only doing its job if it is shared with the world.

These journals should be specifically structured to be method-sensitive but results-blind. (It’s a very good thing that medical trials are usually registered before they are completed, so that publication is assured even if the results are negative—the same should be done with other sciences. Unfortunately, even in medicine there is significant publication bias.) If you could sum up the scientific method in one phrase, it might just be that: Method-sensitive but results-blind. If you think you know what you’re going to find beforehand, you may not be doing science. If you are certain what you’re going to find beforehand, you’re definitely not doing science.

The process should still be highly selective, but it should be possible—indeed, expected—to submit to multiple journals at once. If journals want to start paying their authors to entice them to publish in that journal rather than take another offer, that’s fine with me. Researchers are the ones who produce the content; if anyone is getting paid for it, it should be us.

This is not some wild and fanciful idea; it’s already the way that book publishing works. Very few literary agents or book publishers would ever have the audacity to say you can’t submit your work elsewhere; those that try are rapidly outcompeted as authors stop submitting to them. It’s fundamentally unreasonable to expect anyone to hang all their hopes on a particular buyer months in advance—and that is what you are, publishers, you are buyers. You are not sellers, you did not create this content.

But new journals face a fundamental problem: Good researchers will naturally want to publish in journals that are prestigious—that is, journals that are already prestigious. When all of the prestige is in journals that are closed-access and owned by for-profit companies, the best research goes there, and the prestige becomes self-reinforcing. Journals are prestigious because they are prestigious; welcome to tautology club.

Somehow we need to get good researchers to start boycotting for-profit journals and start investing in high-quality open-access journals. If Elsevier and Springer can’t get good researchers to submit to them, they’ll change their ways or wither and die. Research should be funded and published by governments and nonprofit institutions, not by for-profit corporations.

This may in fact highlight a much deeper problem in academia, the very concept of “prestige”. I have no doubt that Harvard is a good university, better university than most; but is it actually the best as it is in most people’s minds? Might Stanford or UC Berkeley be better, or University College London, or even the University of Michigan? How would we tell? Are the students better? Even if they are, might that just be because all the better students went to the schools that had better reputations? Controlling for the quality of the student, more prestigious universities are almost uncorrelated with better outcomes. Those who get accepted to Ivies but attend other schools do just as well in life as those who actually attend Ivies. (Good news for me, getting into Columbia but going to Michigan.) Yet once a university acquires such a high reputation, it can be very difficult for it to lose that reputation, and even more difficult for others to catch up.

Prestige is inherently zero-sum; for me to get more prestige you must lose some. For one university or research journal to rise in rankings, another must fall. Aside from simply feeding on other prestige, the prestige of a university is largely based upon the students it rejects—its “selectivity” score. What does it say about our society that we value educational institutions based upon the number of people they exclude?

Zero-sum ranking is always easier to do than nonzero-sum absolute scoring. Actually that’s a mathematical theorem, and one of the few good arguments against range voting (still not nearly good enough, in my opinion); if you have a list of scores you can always turn them into ranks (potentially with ties); but from a list of ranks there is no way to turn them back into scores.

Yet ultimately it is absolute scores that must drive humanity’s progress. If life were simply a matter of ranking, then progress would be by definition impossible. No matter what we do, there will always be top-ranked and bottom-ranked people.

There is simply no way mathematically for more than 1% of human beings to be in the top 1% of the income distribution. (If you’re curious where exactly that lies today, I highly recommend this interactive chart by the New York Times.) But we could raise the standard of living for the majority of people to a level that only the top 1% once had—and in fact, within the First World we have already done this. We could in fact raise the standard of living for everyone in the First World to a level that only the top 1%—or less—had as recently as the 16th century, by the simple change of implementing a basic income.

There is no way for more than 0.14% of people to have an IQ above 145, because IQ is defined to have a mean of 100 and a standard deviation of 15, regardless of how intelligent people are. People could get dramatically smarter over time—and in fact have—and yet it would still be the case that by definition, only 0.14% can be above 145.

Similarly, there is no way for much more than 1% of people to go to the top 1% of colleges. There is no way for more than 1% of people to be in the highest 1% of their class. But we could increase the number of college degrees (which we have); we could dramatically increase literacy rates (which we have).

We need to find a way to think of science in the same way. I wouldn’t suggest simply using number of papers published or even number of drugs invented; both of those are skyrocketing, but I can’t say that most of the increase is actually meaningful. I don’t have a good idea of what an absolute scale for scientific quality would look like, even at an aggregate level; and it is likely to be much harder still to make one that applies on an individual level.

But I think that ultimately this is the only way, the only escape from the darkness of cutthroat competition. We must stop thinking in terms of zero-sum rankings and start thinking in terms of nonzero-sum absolute scales.