Last night, I went to see Lessig pitch his latest book, Republic, Lost. His latest spiel is fantastic, fine-tuned, gripping, thrilling, inspiring. I’ve been an avid fan of Lessigian story-telling for 13 years now. The way he sets up his argument, the way he goes far beyond the obvious, far beyond the quick fix, and the way he absolutely destroys any shred of doubt that may remain about his thesis. I saw him giving one of his first “Code” lectures at Harvard in 1998. In 2002, I waited in line at the Supreme Court and got to see the last five minutes of his argument. I saw him in the TV studio debating Jack Valenti. I was at the Creative Commons launch in 2003. I saw his first Corruption lecture at Stanford in 2008. It just doesn’t get old.
The central thing I deeply admire about Lessig is that he takes on gigantic battles with care and determination. He’s not deluded about his chances, but he fights anyways. He looks for, and finds, incredibly aggressive wins. Copyright reform against the Disneys of the world didn’t work, but Creative Commons is genuinely affecting how we share. The corruption of the political process is an impossible challenge, yet Lessig sees a path, and I believe his is the the most likely path to success. I don’t yet know how Lessig will find the equivalent of the Creative-Commons-win in this much larger battle. But I know he’s thinking about it, and I believe that, in time, he will move the needle, significantly.
That kind of “crazy” optimism is deeply inspiring, because it is, indeed, the only way to change the world. Time is too precious not to focus on the big, gigantic, mind-blowing battles. Lessig reminds me of that every time I attend one of his talks.
So, a quibble. Lessig brought up one argument I’ve seen him make before: because vaccine policy is influenced by experts who may have received compensation from the pharmaceutical industry, people may lose trust in vaccine policy. Now let’s be clear: Lessig is not saying that vaccines are unsafe. He’s saying that, because some vaccine experts do not appear to be fully unbiased, it is understandable that people lose trust in vaccine policy.
I disagree, and I think it weakens Lessig’s argument to make this connection. I’d like to see Paul Offit and his peers deciding our vaccine policy (in a public forum of course), even though he’s getting rich from his amazing Rotavirus vaccine. Checks and balances in areas that require deep expertise cannot be achieved by banning from advisory boards all experts with a potential conflict of interest. In fact, that’s a recipe for disaster by way of mediocrity. We have other checks and balances for this. We can require peer-reviewed publications. We can fund counter-studies. We can let the truth rise to the top via competition. This country’s national vaccine policy is something to be proud of.
There is, however, a subtle but serious corruption in the medical world that should make it into Lessig’s slideshow: pharmaceutical reps routinely treat physicians to dinners, trips, etc. They leave free drug samples, they leave pens and paper pads with drug logos prominently featured, they suggest that new drugs are better than old tried-and-true drugs, and sometimes they very subtly suggest off-label uses. Drug companies receive prescription records for individual physicians: they know where they’re having an impact and can calculate very clear Return On Investment. The result: Vioxx. Physicians aren’t evil, but they are human. The grey areas in medicine are large and common, providing fertile ground for skilled influencing.
That needs to stop: where vaccine policy is a mostly public forum with competing ideas, there isn’t any oversight or counter-balance to drug-rep influence. We can change this. Doctors could be required to provide to all patients, alongside the insane HIPAA disclosure form, a funding disclosure form of all compensation received from drug reps. That disclosure form alone might make doctors think twice before prescribing a drug, and drug reps before paying for dinner. And institutions should follow the path blazed by Mass General, banning their physicians from accepting gifts and banning pharmaceutical reps from physician offices.
2 responses to “an ode to lessig’s optimism, taking on gigantic challenges… and a quibble”
I know some very caring and thoughtful physicians who use drug rep samples to make sure that the poor and under-insured can bridge a tough month where their choices might be to buy food or to buy their prescription drugs. I think there’s a path here where through disclosure and “best practices” like samples for the under-insured, we could funnel drug company marketing budgets into public service. Banning all drug reps from physicians offices might solve some problems, but it leaves some other holes that aren’t easily otherwise filled. Better to use their money for good than to remove it from the equation, I think.
While in general I agree with you, there are much bigger distortions. Companies tend to publish only those trials that show positive results (because this benefits their product), and academic journals tend to select only papers that show positive results (because negative results aren’t so interesting). Ben Goldacre of Bad Science fame suggests that all results of all medical trials should be at least made public and preferably published.
See, e.g. http://www.badscience.net/2010/07/pharmaco-epidemiology-would-be-fascinating-enough-even-if-society-didnt-manage-it-really-really-badly/