The ethics (and economics) of paying doctors

If you have friends who are doctors (or keep a close eye on the national news) you will have heard of the recent bust up over a contract for junior doctors. The very short summary is the Department of health wanted to reform existing contracts for doctors, and started negotiations with the BMA. These broke down, but the government threatened to impose the contract anyway, junior doctors, in turn have threatened to strike. 1

I am much more ambivalent about the contract than most of my peers, who are varying shades of outraged. I’m not sure why. Continue reading →


  1. For much, much more detail, consider reading NHS Employers, the BMA, and the DDRB (renumeration board) proposals.

God’s Multiverse?

Mere Creation

Beatrice: We spoke before about the problem of evil. I’d like to talk about a new defence:

First, I’d want to say that, even if there is no justification of the evils we see in the world, that they are nonetheless outweighed by the goods. The world is (pace the anti-natalists or negative utilitarians) net positive, 1 and the objection raised by the problem of evil is not that God did a bad thing in making the world, but rather fell far short of moral perfection.

Adam: And the second consideration?

Beatrice: The second is that it is good to bring positive things into existence. This can be weaker than a Total-view-esque it is as good to bring positive things into existence than it is to improve existing things by the same amount: just something like, “Given the option, it is better (ceritus paribus) to bring something good into existence”. 2

Adam: Okay. Where are you going? Continue reading →


  1. Beatrice: I guess you might want to say that the world including its entire future will be net-positive, and so that entails optimism about how the future is going to go.
  2. Beatrice: I think this is generally plausible, but Theists should be particularly sympathetic. After all, if this were not true, why would God create anything?

God, evil, and appearance

Adam: Consider this:

Neil and Kazumi Puttick, and their son Sam were, by all accounts, an idyllic family. One friend said: ‘If you could bottle up a perfect marriage, theirs would be it’. They were involved in a car accident in 2005. Kazumi’s legs and pelvis were broken. Sam – then 18 months old – had his spine severed at the neck. He would have died were it not for two doctors who happened to be passing by. After being rushed to hospital, Neil and Kazumi were told that Sam’s injuries were catastrophic. Neil was defiant:

I believe in my heart the doctors are wrong and he will win. I believe God is with us and Sam will walk, talk, and breathe again. He was a miracle when came to us, it was a miracle when he survived the crash and it will be a miracle when he recovers. These things do happen and they will happen to Sam.

Sam survived, and although he didn’t recover from paralysis, flourished in all other respects. Neil and Kazumi quit their jobs to devote their time looking after Sam and raising money for his care. The local community pitched in too: one of the things they did was take photographs of themselves from all over the world holding cards saying ‘Hi Sam!’ which Sam enjoyed immensely. Later the local government agreed to pay the costs of Sam’s medical care. Neil and Kazumi continued their work, now directed towards raising awareness of spinal injuries. Sadly, the story doesn’t end there.

Three years after the accident ( just after he’d started at school) Sam contracted pneumococcal meningitis, a highly virulent and aggressive infection. Despite intensive care, it became clear there was no hope of survival. Neil and Kazumi took him back home, and he died shortly afterwards.

Beachy Head is a notorious suicide blackspot, so much so a chaplaincy has been set up expressly to patrol the cliffs and counsel those contemplating whether to jump. Despite this, no one saw two figures wearing rucksacks who leapt to their deaths late at night. The bodies were discovered the following morning. They were Neil and Kazumi Puttick. Sam’s body was in one their rucksacks; the other contained his toys.

The ‘problem of evil’ can mean many different things. It could be a moral problem: ‘What should we do to stop the evil things in the world?’ It could be a motive for existential crisis: ‘How can we bear to live in a world with so much that is evil?’ It could be an obstacle to religious faith: ‘How can I love a God that lets these evil things occur?’ The sort of ‘problem’ I want to talk about is really an argument, that starts from the existence of evil, and ends up concluding that there is no God. Awful stories like the Putticks’ are meant to demonstrate we do not live under the watchful benevolence of God, but rather in one of blind, pitiless indifference to our wellbeing. Continue reading →

Dying in hospital

“Good morning, it’s Gregory the surgical SHO. You bleeped – how can I help?”

To contact a doctor overnight, you generally paged them, and I had a well-rehearsed patter when replying. The delivery was slightly too jaunty for 2AM on a Saturday morning, but there were worse images to project than eccentric enthusiasm.

“Hello, it’s Sabine the sister on ward eight. Can you review Mr. Amir? I think his breathing has gotten worse.”

My heart sank. I was on call, and although Mr. Amir wasn’t under my team when I was working normal shifts, I knew him by reputation. Metastatic colorectal carcinoma, resection was unsuccessful, leaving him with both a poor prognosis and a major operation to try and recover from. I had heard his team talking about him with little hope – the best case scenario would be he would recover from our forlorn attempts to help him and could go home with palliative treatment. The worst case would be that he would die in hospital. I knew he wasn’t doing well: recurrent chest infections, multiple courses of antibiotics – ineffective, poor wound healing, bedbound.

“Of course. Is there a purple form?” Continue reading →

Log-normal lamentations

[Morose. Also very roughly drafted.]

Normally, things are distributed normally. Human talents may turn out to be one of these things. Some people are lucky enough to find themselves on the right side of these distributions – smarter than average, better at school, more conscientious, whatever. To them go many spoils – probably more so now than at any time before, thanks to the information economy.

There’s a common story told about a hotshot student at school whose ego crashes to earth when they go to university and find themselves among a group all as special as they thought they were. The reality might be worse: many of the groups the smart or studious segregate into (physics professors, Harvard undergraduates, doctors) have threshold (or near threshold)-like effects: only those with straight A’s, only those with IQs > X, etc. need apply. This introduces a positive skew to the population: most (and the median) are below the average, brought up by a long tail of the (even more) exceptional. Instead of comforting ourselves at looking at the entire population to which we compare favorably, most of us will look around our peer group and find ourselves in the middle, and having to look a long way up to the best. 1


Yet part of growing up is recognizing there will inevitably be people better than you are – the more able may be able to buy their egos time, but no more. But that needn’t be so bad: in several fields (such as medicine) it can be genuinely hard to judge ‘betterness’, and so harder to find exemplars to illuminate your relative mediocrity. Often there are a variety of dimensions to being ‘better’ at something: although I don’t need to try too hard to find doctors who are better at some aspect of medicine than I (more knowledgeable, kinder, more skilled in communication etc.) it is mercifully rare to find doctors who are better than me in all respects. And often the tails are thin: if you’re around 1 standard deviation above the mean, people many times further from the average than you are will still be extraordinarily rare, even if you had a good stick to compare them to yourself.

Look at our thick-tailed works, ye average, and despair! 2

Continue reading →


  1. As further bad news, there may be progression of ‘tiers’ which are progressively more selective, somewhat akin to stacked band-pass filters: even if you were the best maths student at your school, then the best at university, you may still find yourself plonked around median in a positive-skewed population of maths professors – and if you were an exceptional maths professor, you might find yourself plonked around median in the population of fields medalists. And so on (especially – see infra – if the underlying distribution is something scale-free).
  2. I wonder how much this post is a monument to the grasping vaingloriousness of my character…

Funding cannibalism motivates concern for overheads

Summary: Overhead expenses’ (CEO salary, percentage spent on fundraising) are often deemed a poor measure of charity effectiveness by Effective Altruists, and so they disprefer means of charity evaluation which rely on these. However, ‘funding cannibalism’ suggests that these metrics (and the norms that engender them) have value: if fundraising is broadly a zero-sum game between charities, then there’s a commons problem where all charities could spend less money on fundraising and all do more good, but each is locally incentivized to spend more. Donor norms against increasing spending on zero-sum ‘overheads’ might be a good way of combating this. This valuable collective action of donors may explain the apparent underutilization of fundraising by charities, and perhaps should make us cautious in undermining it.

Continue reading →

Against the internal locus of control

What do you think about these pairs of statements?

  1. People’s misfortunes result from the mistakes they make
  2. Many of the unhappy things in people’s lives are partly due to bad luck
  1. In the long run, people get the respect they deserve in this world.
  2. Unfortunately, an individual’s worth often passes unrecognized no matter how hard he tries.
  1. Becoming a success is a matter of hard work; luck has little or nothing to do with it.
  2. Getting a good job mainly depends on being in the right place at the right time.

They have a similar theme: the first statement suggests that an outcome (misfortune, respect, or a good job) for a person are the result of their own action or volition. The second assigns the outcome to some external factor like bad luck.

People who tend to think their own attitudes or efforts can control what happens to them are said to have an internal locus of control, those who don’t, an external locus of control. (Call them ‘internals’ and ‘externals’ for short).

Internals seem to do better at life, pace obvious confounding: maybe instead of internals doing better by virtue of their internal locus of control, being successful inclines you to attribute success internal factors and so become more internal, and vice versa if you fail. 1 If you don’t think the relationship is wholly confounded, then there is some prudential benefit for becoming more internal.

Yet internal versus external is not just a matter of taste, but a factual claim about the world. Do people, in general, get what their actions deserve, or is it generally thanks to matters outside their control?

Why the external view is right

Here are some reasons in favour of an external view: 2

  1. Global income inequality is marked (e.g. someone in the bottom 10% of the US population by income is still richer than two thirds of the population – more here). The main predictor of your income is country of birth, it is thought to explain around 60% of the variance: not only more important than any other factor, but more important than all other factors put together.
  2. Of course, the ‘remaining’ 40% might not be solely internal factors either. Another external factor we could put in would be parental class. Include that, and the two factors explain 80% of variance in income.
  3. Even conditional on being born in the right country (and to the right class), success may still not be a matter of personal volition. One robust predictor of success (grades in school, job performance, income, and so on) is IQ. The precise determinants of IQ remain controversial, it is known to be highly heritable, and the ‘non-genetic’ factors of IQ proposed (early childhood environment, intra-uterine environment, etc.) are similarly outside one’s locus of control.

On cursory examination the contours of how our lives are turned out are set by factors outside our control, merely by where we are born and who our parents are. Even after this we know various predictors, similarly outside (or mostly outside) of our control, that exert their effects on how our lives turn out: IQ is one, but we could throw in personality traits, mental health, height, attractiveness, etc.

So the answer to ‘What determined how I turned out, compared to everyone else on the planet?’, the answer surely has to by primarily about external factors, and our internal drive or will is relegated a long way down the list. Even if we want to look at narrower questions, like “What has made me turn out the way I am, versus all the other people who were likewise born in rich countries in comfortable circumstances?” It is still unclear whether the locus of control resides within our will: perhaps a combination of our IQ, height, gender, race, risk of mental illness and so on will still do the bulk of the explanatory work. 3

Bringing the true and the prudentially rational together again

If it is the case that folks with an internal locus of control succeed more, yet also the external view being generally closer to the truth of the matter, this is unfortunate. What is true and what is prudentially rational seem to be diverging, such that it might be in your interests not to know about the evidence in support of an external locus of control view, as deluding yourself about an internal locus of control view would lead to your greater success.

Yet it is generally better not to believe falsehoods. Further, the internal view may have some costs. One possibility is fueling a just world fallacy: if one thinks that outcomes are generally internally controlled, then a corollary is when bad things happen to someone or they fail at something, it was primarily their fault rather than them being a victim of circumstance.

So what next? Perhaps the right view is to say that: although most important things are outside our control, not everything is. Insofar as we do the best with what things we can control, we make our lives go better. And the scope of internal factors – albeit conditional on being a rich westerner etc. – may be quite large: it might determine whether you get through medical school, publish a paper, or put in enough work to do justice to your talents. All are worth doing.



Inspired by Amanda MacAskill’s remarks, and in partial response of Peter McIntyre. Neither are responsible for what I’ve written, and the former’s agreement or the latter’s disagreement with this post shouldn’t be assumed.


  1. In fairness, there’s a pretty good story as to why there should be ‘forward action’: in the cases where outcome is a mix of ‘luck’ factors (which are a given to anyone), and ‘volitional ones’ (which are malleable), people inclined to think the internal ones matter a lot will work hard at them, and so will do better when this is mixed in with the external determinants.
  2. This ignores edge cases where we can clearly see the external factors dominate – e.g. getting childhood leukaemia, getting struck by lightning etc. – I guess sensible proponents of an internal locus of control would say that there will be cases like this, but for most people, in most cases, their destiny is in their hands. Hence I focus on population level factors.
  3. Ironically, one may wonder to what extent having an internal versus external view is itself an external factor.

Saving the World, and Healing the Sick

When I applied to medical school, I had to write a personal statement: selling how exceptional my achievements were, what wonderful personal qualities I had, and my noble motivations for wanting to be a doctor. The last of these is the most embarrassing in retrospect:

I want to study medicine because of a desire I have to help others, and so the chance of spending a career doing something worthwhile I cannot resist. Of course, Doctors [sic] don’t have a monopoly on altruism, but I believe the attributes I have lend themselves best to medicine, as opposed to all the work I could do instead.

These “I like science and I want to help people” sentiments are common in budding doctors: when I recite this bit of my personal statement in a talk (generally as a self-flagellating opening gambit) I get a mix of laughs and groans of recognition – most wrote something similar. The impression I get from those who have to read this juvenalia is the “I like science and I want to help people” wannabe doctor is regarded akin to a child zooming around on their bike with stabilizers – an endearing work in progress. As they became seasoned in the blood sweat and tears of clinical practice, the vainglorious naivete will transform into a more grizzled, realistic, humane compassion. Less dying nobly, more living humbly; less JD, and more Perry Cox.

I still have a long way to go. Continue reading →

How far can hard work take us?

There’s a perennial question about how much achievement something depends on talent, and how much on hard work. Perhaps genius (or even garden variety exceptional performance) is written into someone’s genes, or perhaps what separated Einstein from his peers had more to do with his work ethic than his IQ.

Evidence points in both directions. On the one hand, most high performers, whatever their field, emphasize how important hard work – rather than ‘just talent’ – is to their achievements (e.g. Terrence TaoWill Smith, Ira Glass, Thomas Edison). Some, like Malcolm Gladwell, talk about a ‘10000 hour rule‘ as the required hard work before one can truly excel. Perhaps the main proponent of the ‘Arbeit uber alles’ approach is Erikson’s work on deliberate practice. On the other hand, there are lots of instances where innate physical or mental characteristics play an important role: the average height of NBA players is 6’7″, Intelligence (albeit imperfectly measured by IQ) seems to predict lots of things (including various intellectual achievements) – and it appears to remain predictive even into the very high range.

So perhaps it is a mix. But the precise mechanism of the mix could be important; how do innate talents and amount of training relate to one another when it comes to achievement? Could some maths help?

A Growth-mindset model

Here’s one suggestion, implied by Uri Baum:

Performance = Talent + Practice intensity x Time practising 1

On this sort of model, talent counts, but as time passes, practice matters more. Unlike talent – a static given – one can grow a stock of practice over time, and time invested in practice and hard work has a rich return on performance (c.f. Hamming’s remarks). An attractive corollary is that if one can improve one’s practice intensity, be that through more focused training, deliberate practice, better learning styles, etc. this acts as a multiplier – working smarter, as well as working harder may be a stronger determinant of success than talent.

If so, extraordinary talent may be a curse – it could let us coast. Bram suggests there might be a mechanism where if we select for exceptional achievement, we select for people with varying mixes of raw talent and hard work. The group which skew more towards the latter may overtake those skewing to the former former over time: those who skew towards more practice time and intensity will be able to grow faster, whilst those who mainly got to where they were ‘just’ on their talent may find they are hitting a wall unless they can improve how they develop. Continue reading →


  1. Perhaps even better would be to use a time integral here, as likely practice intensity will vary over time. But multiplication is simpler, and simplicity is better than precision for toy models.