Vinay Prasad on Pharmaceuticals, the FDA, and the Death of Duty
Jan 30 2023

doctor-duty-300x300.jpg Oncologist and epidemiologist Vinay Prasad argues that too many very expensive drugs get approved by the FDA that have very limited impact on the lives of patients. Prasad explains the incentives that distort the current system. The general problem, he explains to EconTalk host Russ Roberts, is the death of duty--too many players in the health care landscape and elsewhere stay quiet or do the wrong thing in order to serve themselves.

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Explore audio transcript, further reading that will help you delve deeper into this week’s episode, and vigorous conversations in the form of our comments section below.


Jonathan Andrews
Jan 30 2023 at 1:52pm

Very interesting and a little painful.

Duty is really important. I’m a school teacher and have a duty to the child I work with to do my best. I can’t say that I manage that every day but there has to be a sense of shame when one fails to do one’s duty.

I fear you were right, that shame is not as important today as it was. In earlier generations, perhaps, we shamed people unreasonably but now we have over corrected.

I thought the same as Russ; I don’t feel I can criticise those policeman who failed to go into that building and save some children but their failings were shameful. We just hope for remorse and repentance from them.

Mind, I’m happy to criticise those teachers in the UK about to take strike action and harm children who have already been harmed.

Ed Derian
Jan 30 2023 at 4:14pm

A nice talk about Duty and Courage.  As an Economics Podcast the discussion would be better if you explored changes in incentives at the FDA which would produce better out comes.   My understanding is that currently the FDA is incentives to regulate Pharmaceuticals to be safe and effective.  I think they are doing this well as far as government goes.  Is Medicare required to provide all drugs approved by the FDA? This seems crazy.

The problem with the current system is no one is measuring the value of the approved drug.  Congress should fund Medicare to perform this function.

Mike Sappington
Jan 31 2023 at 10:05pm

I’m a huge fan of the podcast and this episode is an example of why I find it so valuable.  Thank you for continuing to invest the time and energy.

Dr. Prasad said something near the end of the conversation that was factually incorrect.  I’m sure it was entirely unintentional and, unfortunately, understandable.  I came here to see if it had been commented on or corrected.  Since it hasn’t, I’d like to make an attempt to correct the record.

In referring to the police shooting of Jacob Blake, Dr. Prasad said that he was “unarmed” and commented about the tragedy of other similar situations.  It has clearly been established with video evidence as well as testimony from those on the scene that Mr. Blake was armed with a knife that he refused to relinquish.

From a 10/8/21 NBC report:  “State prosecutors decided not to file charges against Sheskey in January after video showed that Blake had been armed with a knife. He was wanted on a felony warrant.”  Federal prosecutors came to the same conclusion.  I’ll provide a link to the story if your comment system permits it.

I realize this was not core to the subject of the podcast, but I think it’s important.  Just as “Hands up, don’t shoot” has become something that “everybody knows” as a part of the Michael Brown encounter and has resulted in chants and t-shirts for almost 10 years – in spite of the fact that it never happened – these narratives become “facts” as they are told and retold.  It hurts our ability to have the kinds of fruitful conversations that I know are important to you.

I look forward to your next episode and future conversations with Dr. Prasad.

Officer who shot Jacob Blake won’t face federal civil rights charges (

Todd D Mora
Feb 1 2023 at 10:45am

Dr. Prasad’s comments on duty were some of the most poignant observations I’ve heard in a long time. We have lost the concept of duty, honor, and courage. The idea that there are things more important than self is lost because we have fallen down the narcissistic rabbit hole that is today’s social media-driven culture.

We are all selfish hedonists and so many people don’t see that this selfishness is destroying our future generations. The school shooting example is spot on. The school shut down conversation highlighted the fact that public schools no longer serve students, they serve adults. The idea that a child’s education is paramount should be the first thought for every adult involved with public education, yet that’s not what we hear.

Kudos to Russ and Vinay for having the courage to speak truth to power! Keep it up and remember, not all heroes wear capes.

Jamie G
Feb 10 2023 at 8:48pm

Well said Todd

I listen to each and every episode and have been doing so for more than 10 years.  This episode is a prime example why it’s my top podcast.

I don’t recall if I ever posted here but if so it was many many years ago.  I fully agree with your comments on duty.  I found from minute 44 onward, it was so good that I replayed it for my wife.  She generally doesn’t nerd out on such things but she was nodding and agreeing with many of the points raised.

I don’t post often, so maybe I shouldn’t of done it via a ‘reply’ to you but was moved enough to comment on the site.

Love the directness of Doc Prasad! This is has been added to my short list for the 2023 survey!

Fred Giertz
Feb 5 2023 at 3:58pm

I believe your analysis of the Uvalde shooting was somewhat superficial. The response was clearly a colossal failure, but it was not basically a lack of courage. First, there was a lack of command and control of the overall operation. In addition, the responders were not trained for this type of event. Training for combat is very complicated and demanding. They were not navy seals.

Combat requires both technical skills as well indoctrination to instill appropriate risk taking. I suspect that the responders had little ongoing training about weapon use and strategy. In addition, entering a room full of children with guns blazing would be a daunting challenge.

As an example, American troops in North Africa in WWII did not perform well early on even though they had months of training. It required learning-by-doing to become proficient in combat. On the other extreme, a recent book suggests that aggressive government raid on the Branch Dividians in Waco resulted in many unnecessary fatalities.

I believe the response to the Uvalde situation would have better had just one or two armed responders been present where there was no dilution of responsibility or alternatively, a well trained and efficiently led SWAT team (which was not available).

Luke J
Feb 7 2023 at 11:29am

Remember Marcia Angell on Big Pharma? What I’m hearing from Vinay Prasad echoes a lot of Marcia Angell’s FDA criticisms (Prasad cuts pharma a bit more slack). A year after Russ Roberts interviewed Angell, IQ2 hosted a debate on the suitability of FDA caution. Neither side was persuasive (in my opinion) but it is an interesting source of criticism that the FDA is neglecting its duty

Feb 10 2023 at 1:46pm

Russ says,

That’s what’s out of fashion: The willingness to judge other people to impose a cost of shame, intolerance, judgmental, a judgmental attitude is totally out of our culture in many settings

But is that really true? My read of the current culture is an extreme opposite: judgement is omnipresent and indiscriminate. You will be judged, harshly and publicly, regardless of who you are or what you do in any setting. Duty was always at least marginally reciprocal. It’s hard to value one’s duty to an employer that would kill you and sell your organs tomorrow if they thought it’d have positive ROI. It’s hard to value one’s duty to religions that have been making it palpably clear that you are not welcome. It’s hard to value duty to society when society consists entirely of targeted ads. It’s impossible to feel loved because there will always be at least one more troll going out of his way to hate you. It’s impossible to even determine a cogent standard by which to be lovely.

Duty is no longer a rationally defensible position. The rationally defensible position now is “Don’t Get Noticed.” And, since it takes something as blatantly egregious as aducanumab to draw our attention, the FDA’s behavior makes total sense.

Mason R
Feb 24 2023 at 2:13pm

I don’t understand the complaint about testing new drugs against old treatments being “inadequate control” (8:20 section). The implication seems to be that legal approval for a treatment should be contingent on that treatment being more powerful than previous treatments. There are many reasons a less-powerful treatment (B) can assist one that already exists (A): use B to treat low-severity cases to reduce opportunity cost for A, substitute for A when there is a shortage, B could be more accessible/cheap than A, B could have fewer side effects than A, B could avoid allergies to A.

Comparison with other trials is useful, but doesn’t seem like a reasonable bar for determining whether a treatment should exist at all.

Mar 18 2023 at 12:20pm

One can disagree Dr Prasad’s basic thesis — that too many cancer drugs are getting approved. Gleevec is a terrific example. When it was first approved, we simply knew that it gave high response rates that seemed to last. After years and year of study, and many large clinical trials, we now know that patients who take the drug have a life expectancy similar to those who never had the disease. Its a remarkable medicine. But if we had waited to generate all that evidence before ever approving the drug, 1000s of people would have died before the drug was made available. So we use ‘surrogates’ that indicate it is likely that a new drug will provide a big benefit when studied in larger trials. That seems a reasonable compromise.

Russ also dislikes the fact that Medicare cant negotiate drug prices. Well the IRA changed that, except one would hardly now call it ‘negotiation’. Perfect competition requires no buyer large enough to set prices — and we now have a very large buyer who will indeed set prices. Vito Corleone couldn’t have had a better gig. The only ‘negotiation’ room the seller has is to not make their product available.


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Watch this podcast episode on YouTube:

This week's guest:

This week's focus:

  • "The Tragedy of Oncology," by Vinay Prasad. Substack, Vinay Prasad's Observations and Thoughts, Dec. 21, 2022.
  • "Duty," by Vinay Prasad. Substack, Vinay Prasad's Observations and Thoughts, May 28, 2022.

Additional ideas and people mentioned in this podcast episode:

A few more readings and background resources:

A few more EconTalk podcast episodes:

More related EconTalk podcast episodes, by Category:

* As an Amazon Associate, Econlib earns from qualifying purchases.

TimePodcast Episode Highlights

Intro. [Recording date: January 10, 2023.]

Russ Roberts: Today is January 10th, 2023 and my guest is oncologist and Professor of Epidemiology Vinay Prasad. This is Vinay's third appearance on EconTalk. He was last here in July of 2022 talking about the pandemic. Vinay, welcome back to EconTalk.

Vinay Prasad: Russ, such a pleasure to be back.

Russ Roberts: I want to remind listeners to go to where you'll find a link devoted our annual survey of your favorite episodes of last year.


Russ Roberts: Our topic for today is the state of cancer research and pharmaceuticals based on an article from Vinay's Substack page that we will link to, but I suspect we'll get into other topics as well.

I'm going to start with a quote. You write, quote:

I am a capitalist. I believe that profit is a powerful and fruitful incentive. Without it, often, people become lazy and complacent. As such, I believe it should exist in cancer medicine. But, it must be used wisely. Money should be given for real advancements and breakthroughs, hard work and going the extra mile, but be kept away from products that don't benefit people. This is essentially the theme of my book Malignant, which has specific recommendations for how to incentivize what works.
The tragedy in oncology is that we have dismantled the system that is meant to tell these two apart (real innovation from pseudo-innovation). [Parentheses in original--Econlib Ed.]

Endquote. Explain.

Vinay Prasad: Yeah. I think many of your listeners may feel similarly, but I am a capitalist. I do believe that one of the greatest engines for human prosperity and development is that we incentivize people to the fruits of their labor so that a person who is working in the hospital might get paid a little bit extra if they stay late and do the extra procedure. And, I think you want to find the right balance. You don't want to pay them so much extra that they're looking for business that doesn't exist, but you certainly want to use incentives to get the behavior you so desire.

And, the same is true in drug development. I think we have a system where we incentivize, heavily, pharmaceutical products to be developed; and I like that, too. And I'm happy to incentivize drugs that are really transformational. Drugs that turn once-fatal diseases to diseases with near-normal life expectancy should have a large return on investment.

But what I worry about is the system has been so manipulated and so hijacked, and is very technical so that the average person watching may not be able to grasp all the evidence, that you cannot tell apart a drug that's a blockbuster because it has really strong marketing and a drug that's a blockbuster because it's really changing lives. And to me, the fact we're reimbursing both of those drugs similarly: that's a problem.

Russ Roberts: I know it's kind of an unanswerable question, but of the number of drugs that are subsidized through Medicare, Medicaid, and most private insurance companies, what proportion of those do you think are actually blockbusters? Or, what proportion of money that's spent actually is transformational rather than extends possibly life a few months as opposed to something close to normal life expectancy?

Vinay Prasad: So, I would say it's a minority that are really transformational in terms of people's wellbeing. But, in terms of blockbuster--which is typically defined as $1 billion per annum--many are blockbusters.

But here are the facts. I mean, one is: if you look consecutively at drug approvals--you just take them as they come off the assembly line--you find that the median improvement in survival of a new cancer drug coming on the market is 2.1 months. So, that's the median. So, the 50th percentile, I think, is about 2.1 months.

At the upper end, maybe the top 10 percentile, the top 5 percentile, now you're talking about some really transformational drugs.

And, the single best drug I can think of in the last 30 years took a disease that if you were diagnosed in your 50s, you'd have a life expectancy of three years. Now, just because of one medication you have a life expectancy that's pretty much normal life expectancy. So, that's the best drug. That's Gleevec--or Imatinib--and that's to me what we should be aspiring for.

Now, it's okay that not every drug has to be a Gleevec, but 2.1 months I think is the median and I think we can do better than that.

Russ Roberts: What does Gleevec fight?

Vinay Prasad: Gleevec is for chronic myeloid leukemia, chronic myelogenous leukemia, CML, which is a type of blood cancer. It also has some other roles. It's used in a rare type of stomach cancer and some other blood conditions.


Russ Roberts: But, 2.1 months is--I mean, it's not zero and it's certainly not zero for the person in the right-hand tail, although we don't know exactly how much of the right-hand tail, the longer life expectancy might be due to that person's unique genetic makeup, situation, all kinds of other factors. The problem for me is that we give those drugs primacy over drugs that work really remarkably well or quite well. Instead, this works a little bit better and so suddenly it gets the monopoly treatment that was created to incentivize the large and long approval process that is the reality of pharmaceuticals.

So, I think if you go back to the earliest episodes of EconTalk, when I wasn't anything more of a capitalist. I was naive about how the process gets used by the industry. And, it's very depressing that that small improvement often entitles a drug to effectively monopolize the market. And, the drug that worked just almost nearly as well is now not subsidized at all and is therefore off the table, giving the latest drug essentially monopoly power.

Vinay Prasad: Yeah, absolutely. And, governments are often by law, particularly the United States, Medicares by law required to cover the drugs. A lot of private insurance companies, they're going to cover the drug. They may have certain sort of pathways in place to try to minimize that. Even Medicaid is often required to cover cancer drugs because it's thought to be an essential condition.

But, Russ, one of the things we didn't mention was: we're having this discussion as if we know the number for every drug. But we have to acknowledge it's only about a third of the drugs that I can actually tell you with some confidence that it's 2.1 months. There's a lot of missing data. And why--listeners may wonder: Why is there missing data?

Many drugs are developed in the following fashion. I have 60 people with a cancer. They have what we call exhausted earlier drugs. They've had their cancer grow despite having all the drugs we have available. And now, we give those 60 people the new drug. And let's say 20 of them live 11 months and have their tumor shrink; and let's say 40 of them, the tumor doesn't shrink and they live eight months. That's the basis for approval. You don't really have a control group. You don't know what would have happened had you just tried something from that you've had in the pharmacy for a few months; and there's uncertainty. So, I really don't know if they live longer.

Recently we've had a few of these drugs. They finally had what we call the confirmatory randomized study, and many of them have failed. One drug, Melflufen, was--actually had a survival death signal. It looked a little bit worse than what we'd been doing before.

Another drug did no better than. And, people were trying to spin this study, saying, 'Well it's as good as,' but it wasn't technically a equivalence or non-inferiority randomized trial--which is the kind of statistical proof we need to say 'as good as.' It was a failed superiority study.

So, I guess the other thing I want to talk point out to your listeners is that there's a lot of uncertainty here and that uncertainty benefits the makers of the product. They want the uncertainty because, if you're willing to tolerate uncertainty, I can get some drugs through that I otherwise might not be able to.


Russ Roberts: So, what--we're going to look at a couple actors you identify in your essay that you blame for this problem.

Let's start with the FDA [Food and Drug Administration]. Historically--I've said this many times on the program--economists were upset with the FDA because they were so cautious and they were worried about side effects. They were worried about, mostly side effects, and therefore delayed approval or did not give approval. And people died in the meanwhile. And, most economists until very recently, that was their main critique of the FDA. But, you have a different critique.

Vinay Prasad: I do have a different critique. But I also--and I'm kind of curious what you think about it--we could have a few thought-experiments. One is we could imagine a total free market in the healthcare space--just as there's a free market in the cellphone space where any manufacturer can bring a product to the market. And, you'll have more trust in, perhaps, the Roche--the Apple--than you would some brand you've never heard of. And, you might have a system like that.

But, I think historically, at least in American 20th century, there have been a few seminal events that pulled us away from that model. And, the first event was of course in the time of Upton Sinclair where it was the original Food and Drug Safety Act. And, that was done largely because we were worried about contamination and even very dangerous products being sold.

And so, in 1906 we had regulations saying there should be at least some minimum safety standard for drugs. We can't have mercury and syrups given to children, or excessive amounts of morphine. Or, our food can't be openly defecated on by rats. I mean, we need some basic food/drug safety standards.

Then, fast forward: It wasn't until the 1960s that we had the next big leap in FDA regulation, which was the Kefauver-Harris Amendments. And, that came in the wake of the thalidomide scandal, where really it was sort of one person at the right place at the right time in the USFDA [United States Food and Drug Administration] who prevented us from approving the morning sickness drug, thalidomide, which ended up resulting in being a great teratogen and causing the thalidomide problem in the United Kingdom where they didn't have that regulatory arm.

And, then in the 1960s we said, 'Look, we'll have safety as we've had and maybe we'll have some basic efficacy standard.'

And, that's largely been the American sort of path to our current system where we don't have a free market. We have a regulator. The regulator's job is to, ostensibly, protect average American people from making choices out of desperation that are not really in their best interest.

And, I think I view that as the philosophical basis for the FDA: I'm sick, I have cancer, I'm not an expert in science. I'm tempted to be charmed by any salesman who could offer me something. And, the government steps in and says, 'We are going to have some basic standards to make sure they're not selling you snake oil.'

But, what I worry about is, in the last 30 years, is that they're not doing their job. Because, if you are allowing studies without control alarms[?], if you're allowing studies to be run testing a new drug against a drug we haven't given in the United States in 15 years or what I call an inadequate control arm--we've documented this problem--if you allow the drug to measure an endpoint that's not really living longer, living better, but some marker of tumor shrinkage that may or may not perfectly correlate with that. If you allow these kinds of gains in the study, you end up creating a bar for companies that makes it difficult for small entrants to jump on the market, makes it easy to sustain lofty prices, but actually doesn't really guarantee that the product works.

And that to me is kind of the current system. It's a system that I think benefits large corporations. It penalizes the small entrepreneur. And, it's meant to keep us healthier and safer, make us have better choices, but I'm not sure it actually fulfills that goal. And, I do think that the FDA is the crux of the issue because they're choosing to insert themselves in this process, but they're not doing it in a smart way.


Russ Roberts: Well, I'd say it's the FDA combined with the way we've decided to subsidize healthcare, and particularly drugs--

Vinay Prasad: Yes--

Russ Roberts: So, I think if you were spending your own money and you had an opportunity to extend your life by a few months--most people would want to know how much money they'd have to spend to get those extra months.

And if it was a small amount, they might be willing to do it. If it was an enormous amount, they'd be less willing--don't know how many, etc.

But, I wonder sometimes whether my obsession with trade-offs, as an economist, clouds my vision here.

Many people like the idea, I think, of saying, 'Well 2.1 months, it's positive. So, no matter what the cost of that is, it's worth it.' What's your answer to that? I mean, as an economist I don't agree with that. But as a doctor, how do you answer that?

Vinay Prasad: I mean, I can even bring it back to the patient in my office. I can imagine a patient get with a certain type of solid cancer--maybe it's colon cancer, maybe it's lung cancer. They're going to get a couple of old-fashioned chemotherapy drugs that are known to extend survival.

Then let's say a new drug comes on the market--that drug, let's just call it Avastin or Bevacizumab. It's a drug that might add a little bit of survival, something in the 1.5 to 2.5 months sort of survival advantage. But, it's going to come at a great cost, $40,000. And, I think about that person in my office--

Russ Roberts: A year? A dose?

Vinay Prasad: It's probably for the course of treatment, let's just say $40,000, but per year, I think now something in the $70- to $80,000 ballpark for a year of Avastin. That was when I last checked. But, listeners can tell me if I'm wrong. I wouldn't be surprised if it's higher.

The person in my office--what if I went to them and I made the following thing? I said the following, 'Look, you're on these two drugs. They're going to shrink the cancer. They make you feel better. I could add the third drug. It might extend survival a little bit. Does have side effects, more high blood pressure. There's a risk of perforation of the bowel, slightly higher.

Or, I could take that money, just give it to you. And even half--I'll give you half the money, cash and you can hire somebody to come to your house and help you do the dishes or somebody to drive you to the appointments or somebody to help you keep track of when to take the medicines or somebody just to help you out because you have cancer and it's not so easy to live alone when you have cancer.'

I'm pretty confident, in my practice, the majority of people will take that every day of the week. And I will personally take it every day of the week myself, too.

And so, I think you're onto something when you talk about what we've chosen to subsidize. We're subsidizing one thing and not the other. We're subsidizing a specific drug that's manufactured at a very low price that's sold at a very high price. Presumably the value is R&D and that money is transferred to shareholders.

And, we're not subsidizing the nurse that comes to your house and helps you get out of bed, helps you stay clean, helps you get dressed. We're not subsidizing the person helps you clean your dishes or do laundry.

That's subsidizing a labor force. That's subsidizing lots of people with a lot of maybe lower middle class jobs. That's what we're not choosing to subsidize.

So, we're taking all this societal money in the name of cancer patients. We're choosing to do one thing with it, not the other thing. And, I think it's contrary to what people would actually want and I think it's--cynically, it's done to enrich the shareholders who have lobbied for the system that benefits them.

Russ Roberts: You don't think the person who comes by to help a person get out of bed, they're not powerful politically in the halls of Congress? I guess not. Kind of rhetorical question, sorry, not really fair.

The other thing, of course, you could do with it is you're going to leave it to your kids. You could say--by the way, the good news is you're certainly going to live an extra month or two. It's only $40,000, it's not $80- or $120,000--to make a really ugly joke. But, it's a serious question. If I give you, and if I say, and we're--'You're going to get two treatments of this; it's $80,000.' I could give you half of it and you could choose to spend it on care around the house or you could give it to your grandchildren or your children. Because, right now you're taking that money out of their pocket through taxes--not your literal children, but through the generation that's working and funding these programs--you're taking out of their pocket to get an extra month or two. I think most people would say, 'I'd be ashamed to do that.'

They don't think about it that way. They say, 'Well, the drug is free because Medicare covers it.' They don't think about the fact that someone has to pay for it. And, when you remind people of that. they get tired of it. It's like, 'Oh, there's no free lunch.'

But, it's really important to remind people, because there is no free lunch. And so, what you're doing when you take those drugs is you're taxing your children and grandchildren--or other people's children and grandchildren--to live a few more months. And, I think a lot of old people would say, 'Hey, that's not so nice.'

Vinay Prasad: I completely agree with you. Culturally, I think it would be unthinkable for people that--my parents are from India, in our culture--to use your money for very marginal gains when you could give it to your children. It would almost be--as we're going to talk about--your duty to give it to your children, and it would be considered selfish to use it on yourself.

That's my personal view of it, too. You know? That's how I view life, as well. And I think you're onto something: that the reason this is treated differently is that that's not the trade-off. You don't see that trade-off. You can't leave it to your kids. It's either use it or lose it. You've already been giving up your paycheck for your whole career to the system--the healthcare premiums you've been paying--so why not take advantage of it? And, there's nothing else you can do with that money. It's either use it or lose it.

And so, we've taken out that trade-off. We've buried it from the person. And, if we made it explicit, I think a lot of things would be different.

One more thing along these lines, Russ. This is something we're working on. We have a paper under review, but I think you'll find it interesting. Quality of life is now increasingly measured in cancer drug trials. But, in these drug trials, the company will give the drug for free in the trial. But, in the real world there are many drugs you get for free, but there's often a little bit of a co-pay. That copay is not the full value of the drug, but it might be enough to caust some discomfort. Maybe a few hundred--now the new Biden Administration has lowered it to $1000 or $2000 per year. But for a while, it was about $7,000, $8,000, $9,000 a year, which can cause some difficulty in the lives of many people.

And, I always thought it was interesting that the quality of life you're measuring is quality of life when you get it for free. But, the quality of life in the real world is quality of life when you got to pay $9,000 a year for that. And that might not be the same thing, because when you have to start paying your own money into it, your quality of life is, as many studies show, it's going to go down. You're going to have a real reduction in quality of life.

And so, the trial is not really measuring quality of life, the construct in the real world. It's measuring quality of life in this mythical world where people give you this product for free. And, I think that's inaccurate. That's the theme of our paper.


Russ Roberts: And the other thing I think we need to think about--and it doesn't really mesh very well with the sausage factory of politics but in theory it's a lovely idea--that the elderly are treated with respect and dignity. And, we should say, 'Two months of an old person's life might mean they get to go to the wedding of a grandchild.' And, that's not unimportant. The problem I have is that I don't think that's the motivation for this kind of drug intervention.

And, as we point out--both of us agree--there are many, many better ways to honor the elderly rather than saying, 'We're going to devote an enormous portion of our government budget to making sure that you get access to the very latest drug.' By the way, in the abstract that's a great idea. The problem is it changes the incentives for drug companies; and that's often hard to remember.

Vinay Prasad: I mean I think about that, what you're talking about. I mean, I think it's very important point, respect and honoring the elderly. And, I think about all the ways in which the modern cancer system dishonors them. It dishonors them by giving them appointments at the crack of dawn that are inflexible. It dishonors them by making them come to these huge cancer mecca[mega?] hospitals and try to find parking in a cramped parking garage. And then they have to come and sit in the plastic chair and wait for the appointment and maybe the doctor's not running on time. Then they have to go back to their house and keep track of this heavy infusion schedule, come in, get delays and spend six hours a day waiting in the chair. And, then they go home and there's nobody to help them with their dishes or to help them get dressed or to help them around their house.

That's a type of dishonor. I mean, you're honoring them because you're giving them the lucrative pharmaceutical product, but you're dishonoring them because their life is a lot more difficult than it would be had you actually invested that money and just making the whole experience, I think, better. Maybe the doctor could come visit you or a nurse practitioner could visit you some days. Maybe we can come to your house and hang the infusion--which is what very wealthy people in this country get done. Maybe we can make the whole process of coming to the hospital a little bit more convenient for you.

But we don't seem to be thinking about any of those things. We're thinking about the latest one-month drug.


Russ Roberts: Are we being too harsh here? Is it really the case that these are one-month drugs, two-month drugs? And as you say, we don't know in advance? You could argue we should have a better idea in advance of what we're subsidizing, but are we being a little too cynical here? Or are you being a little too cynical, Vinay?

Vinay Prasad: I mean, yes, because I think we're focusing on the 50th percentile and not the 90th percentile.

Let's talk about the 90th percentile. I mean, let's just talk about the good side of this whole system.

This system does develop good drugs. There are people who come in--not everybody but a few people--who would have been dead had it not been for last year's drug that's keeping them alive. And, there are people who have really good outcomes with individual drugs who are on that tail of the distribution who do really well.

And, there is an excitement to innovation. I mean, even if the innovation is mixing pseudo-innovation and real innovation, it's exciting to be in a field that has something new. And when a field has nothing new for decades, I think it's hard to recruit the best talent.

So, by seeing all this innovation and all this excitement, all these job prospects, we are recruiting better people.

And so, I do think there is an upside to this system. I don't dispute that and I'm grateful for these new drugs.

I think the question boils down to: what's the balance of efficiency and waste? There is a waste, these mediocre drugs or these drugs that may not add anything; and there are transformational drugs. Are we in the sweet spot, or could we move to a sweeter spot? And, I think that's really what we should be talking about.

Russ Roberts: So, if we were in a real free market where people spent their own money, as I suggested, many people would not be willing to spend an enormous amount of money to extend their life by a small number of years. They'd rather spend it on something else to make the remaining months more pleasant. They might leave it to their children, their grandchildren.

But that's how the trade-off would work. You'd make your own call. Richer people might be more willing to take a chance on a drug that was less certain, and so on.

But, we don't have that system. We're not close to it, remotely close to it. So, how should we possibly think about what we should allow in terms of innovation that we do subsidize? We've had Robin Feldman on the program talking about how generics are penalized--the various shenanigans that are played by the industry. But, just putting that to the side, how would we--who could make that trade-off?

And, we've made it in one direction. And it's unidirectional: Anything that extends life in a clinical trial, we'll subsidize it and we'll punish its predecessors and privilege the newcomer. What's the alternative?

Vinay Prasad: I mean, I guess I'd say a couple of thoughts. One is that I think there are many economists who believe, sincerely, that if you didn't have a system that reimbursed so well for those marginal drugs, then you would have less transformational drugs created per annum--

Russ Roberts: Maybe--

Vinay Prasad: Maybe.

There are other people who, on the other side of the spectrum, which I kind of put myself in--and again, I also probably will admit I'm on shaky ground here. Like, neither of us have rock-solid evidence of our beliefs. But, I believe that if you raise the bar for drug approval--you approve fewer drugs, made companies aspire for greater benefits--they would prune their R&D [Research and Development] pipeline like a bonsai tree. I mean, they will aggressively prune that pipeline. They'll be much wiser about what they pursue. They're not dumb people. They're smart people. They know that some of these things are likely to be marginal and some of these things are likely to be transformational. They'll change that.

I think you'll roughly get the same amount of transformational drugs per year because I don't think the constraint is just tossing more capital in the fire. I think the constraint is a biological constraint. The constraint of, like: do we even know what the targets are? Do we even know sort of the ways in which we could interdict upon biology?

But, that's also a belief. I think--there are many, many papers on this topic, retrospective looking at innovation in biomedical and science. But they're all really limited. I mean, they're limited by, they're all constrained by the world we live in and they're all constrained by small sample size--200 drugs over 10 years--sort of sample sizes. And so, neither one of us knows for sure which one of our worldview is right.

I would say I think what makes this market unique is society has made a choice. And, that choice is: We are going to provide healthcare. We're going to tax everybody to provide a societal good.

Some people will call that we believe in a right to healthcare. Others will call that we believe that this is something a shared value. We do it the same way we do roads and we do schools. Healthcare is one of those things.

And, all I would say--the weak position--I'll argue a stronger position, but the weak position I think is: You can't tax everybody and pay for things that in aggregate don't work. And so, if there's a drug like melflufen--this is a real drug. They took a drug from the 1960s and they added a little molecule to the side. I think many of us knew off the bat it's not going to be that innovative. It's a modification of an older drug. They brought it to the market because they gave it in an uncontrolled study to people with myeloma. And, we know the parent drug shrinks myeloma; and this shrank myeloma in some fraction of people.

Then finally they do a randomized control trial against the weakest acceptable control arm they could think of. Not what I would do in my clinic, but what I might have done seven years ago or what might be done in, you know, Hungary or Romania where they're running this study. They're picking, literally, the weakest arm that the FDA will allow them to get away with in a randomized study.

Then, they have no survival benefit. In fact, the hazard ratio trends towards harm. In other words, if anything it might be harmful. And, the company was asked to withdraw the product from the U.S. market. They put up, you know, hurdle after hurdle. They find some subgroup that they think it works better with. The FDA mocks them at their own public hearing and says, 'Look, people in May, they had a survival advantage but people enrolled in June didn't.'

So, just to show that you keep slicing and dicing a randomized trial, you're going to find these spurious things. This is the system we're living in.

And, what I would suggest is: Multiple myeloma, how would I have solved this problem? There are 10 or 15 different active drugs in myeloma. There are many combinations you can give; and you can combine drugs that previously worked and give them again and they can work again. And, I would say that--and people live, median survival is like seven to 10 years. It's not a space where you should approve drugs based on uncontrolled studies. We can wait for the answer. We don't have to shell out hundreds of millions of dollars on uncertain drugs. We can just have a bar that says, 'Look, if your new drug improves survival over a real standard of care we're giving in America, we'll approve it. And, if not, no.' Not the current system of: If your new drug shrinks the tumor, which is a much lower bar.

And, then I'd say that what you're talking about is raising the bar even further. Why accept any statistical improvement in survival? Maybe it should be three months or four months or five months or six months. Something that patients think is meaningful.

And, I actually am close to that position. I would support that.

But, where we're starting from is so far beneath that, that you can get a drug approved if it shrinks the cancer in the bloodstream of somebody and you don't even know if they live longer. And, in this case, they didn't live longer: they would've lived longer had we never had the drug. Arguably. I mean I think that's the reality of where we are.

And so, to me that speaks to a very broken system--that we're using taxpayer money to pay for something that might have even hurt people over not even having it on the market. That's where we are.


Russ Roberts: And of course, the challenge is: Who makes that decision? Should it be four months, six months, a year? There's very little accountability in those kind of decisions that are made. They're not made at the ballot box. They're not made by people appointed by people who went through the ballot box. They're just so-called experts.

And, every country does it differently. I'm living in Israel. I'm sure I don't--will not--have access to many cancer drugs here because it's paid for by the government or subsidized by the government dramatically. And, they make arbitrary decisions. And, the results of that system, by the way, is that there's not much profit here in Israel--or in France or in England or in Romania. And, the United States' taxpayer is funding all the innovation. Some of it good, some it not.

And, I pay very little money for my blood pressure medicine here. And, sometimes I feel good about that, but most of the time I feel guilty--because, well, I paid my share when I was an American citizen for a long time, I guess.

But, again, it's the non-free lunch that's not easily observed. An enormous portion of the profitability in the drug market comes from the unconstrained pricing that Medicare pays for, that comes out of the pocket of American taxpayers, that benefits people all over the world because they get a different price. And, that drug wouldn't exist without that enormous opportunity in America to make a lot of money. So, that is also part of the story.

Vinay Prasad: Yeah, that's the part of the story that I think makes--you said, are we being too cynical? That's the part of the story to keep in mind.

But, one of the things we haven't mentioned is the tone of my article. The tone of my article is it's melancholy. I mean it's a sad article. It's written from a place of pain. And, I mentioned in the article--I was on vacation and I had a lot of distance from the day-to-day. And, what was I sad about? It wasn't the pharmaceutical industry. And I think that's the thing that I want to make clear to your listeners. The best lectures I've ever given are to the pharmaceutical industry. Tthey're the best audience, they're the most engaged. I would say the vast majority of people who work at the pharmaceutical industry, not only are they brilliant, but also their hearts are in the right place. They really want to make better drugs for people.

That's never where I put the criticism, because to me that's like criticizing the tiger for being the tiger. Their job is--fiduciary job is--a duty to their shareholders. They are taking advantage of the system as it is. What can I say about the tiger? It is a tiger. It's the nature of the animal.

The place I'm really sad about are the other parts of the--that we talked, that I talk about in the essay. One is the FDA. Why am I sad there? We just had Congress investigate the FDA over Biogen's aducanumab which is their Alzheimer's drug. And, the Congressional report which was published in Wall Street Journal about a week and a half ago, shows a pattern of coordination--and I want to choose my word carefully--a close relationship between FDA and Biogen as they brought a very disputed product to market, despite a negative advisory committee vote. Their own advisor said, 'Don't do it.' They still brought it to market in a very cozy relationship, with many improprieties. And, the report is a scathing report of the FDA's conduct during that drug process.

And, I always point out to people, this is the drug we investigate. We don't investigate every drug.

So, for most of the drugs, you don't know what the conduct was between the two groups.

And so, the reason I fault the FDA so much is I think, like, so many regulatory agencies, they are being captured. They are increasingly seeing their duty. What is their duty? Their duty is to the American people. But they see their duty as a duty to their client; and their client as a company: 'How can I help this company whose heart's in the right place to get their product to market as quickly and painlessly as possible?'

But, that's not their duty. Their duty is to the American people.

And, sometimes that means telling the company the hard news that, 'I'm sorry, you're not going to come to this market.'

And, what are all the sort of the systemic factors there?

I think that the one systemic factor is that a tiny and vocal minority can always defeat a large disinterested majority. It's hard to think about the American people and what they need. It's easy to think about the Biogen people. They're in your office, they're in the waiting room. Yeah, they're knocking on the door. That's one.

Two, I think the job opportunities. You go to work at the FDA and, you know, that's a job that's unfortunately underpaid and maybe undervalued. But, you'll know in five years of FDA experience on your CV (curriculum vitae), you are going to go work for Biogen! You're going to go work for Genentech.

And in fact, we published a paper in the British Medical Journal where we show the majority of people who leave FDA as medical reviewers go to work for and consult for pharma. It shouldn't be surprising. That's their skillset.

But it is a revolving door.

Scott Gottlieb is Commissioner and now he's on the Board of Directors of Pfizer. Okay. That to me is a structural problem. It tells me that, you know, look, if I knew that I'm going to have a huge chance of working at the University of Pittsburgh, I'm going to take it easy on University of Pittsburgh when I read about whatever they're doing in their local marketplace. So, that's why I--


Russ Roberts: And you also pick on--or are melancholy, I'll say--about academics and people in academics. What's the issue there?

Vinay Prasad: I guess-- I think that's absolutely true. Including the younger generation which we can come to last. That's what made my heart break the most. I was always optimistic, the younger ones would fix these problems. But, I think that they're just falling along the same lines.

But, why academics? You know, I do worry that the modern American university, because it's been so starved of state funding and so starved of sort of societal funding, has forgotten that the goal of university in my mind is scholarship, debate, and preserving knowledge; and puts new ideas and having a freedom to pursue these ideas in a contentious but fair and I think respectful environment. I think they've forgotten that whole mission. And, universities now, their sole mission is finding ways to keep their revenues up in times of shifting state funding.

So, for instance, you can walk around campuses, my own university--the name of the lecture hall is Genentech Hall. That's the lecture hall.

Many universities are entering into partnerships with pharmaceutical companies where we're selling our IP [Internet Protocol] and we're building, you know, facilities on our campus that are joint ventures where we're going to manufacture some products like CAR-T [Chimeric Antigen Receptor T cells] therapy together. We're going to work hand in hand. If you are an academic oncologist, I'm an exception because I'm in epidemiology and that's sort of a different hat I wear.

But, the average academic oncologist, what is their job? You see patients a little bit a week and then you run clinical trials for pharmaceutical companies. You are enrolling patients on their trial, some of which you might have had a little bit of a say in, but many of which you're just following the recipe that the baker sent you and you're just following through.

We have a huge exodus of academic oncologists to pharma. People always wonder why, why, why? I say: they were working for pharma when they worked for you, too.

You are already working for pharmaceutical. You are just now explicitly working for pharma and you're getting stock options and maybe a little bit better pay. Better hours. So, that's why you're moving.

We've forgotten, I think, scholarship and teaching.

If you write a paper critical of a pharmaceutical product, it's very tough for you. I know many people who say, 'I can't say I agree with you--listen to your podcast on whatever drug. I agree with you, but I got to go to the company on Monday and have a meeting about a trial I want to run. I cannot say anything. I can't even like it on Twitter because I can't even like it. I want to like it, but I can't like it.'

That to me is what I find tragic: that, the universities increasingly see collaboration with pharma as a very lucrative opportunity, and they're pursuing it so doggedly that this idea that we'll serve as check or balance or be critical of them, I think that's falling by the wayside. And, you can count on one hand the number of academic oncologists who are critical of this system. Which, to me, is shocking because I would think everyone would be critical of this system.


Russ Roberts: But, you do want to run trials? You want to be part of the system in some dimension, at least what you hope is a system that will produce truth. It's currently run through, funded by, subsidized by pharmaceutical companies. How has this affected you personally, though? I mean, is your salary lower? You're still in--no, it's a serious question. I'm watching you on YouTube but, on Zoom. But has it hurt your salary? Does it increase your chances of being fired? What's the nature of the pressure that you're invoking here?

Vinay Prasad: So, for me personally, I think the answer is: Because I'm not in the Department of Medical Oncology and I'm the Department of Eepidemiology--which I find a better place to put my criticisms. And, in part also I think they are statistical and epidemiologic criticisms, but also it's a shielded place because I'm not directly in the fire of oncology. Is my salary less? The answer is yes.

I mean, I think we have public payment. You can look up anyone's salary in the Department. Probably I would make a $100,000 more if I was in the Oncology Department because they're paid higher. I mean, that's just the nature of the market.

And, they would probably make several hundred thousand dollars more if they went to private practice, or a $100,000 more if they went to the pharmaceutical industry directly.

So, that's true. Obviously, as we'll come to in the second essay, money is not really what I believe is the motivating force of life--it's duty. And so, we'll talk about that.

So, that doesn't bother me as much.

I think, you know, there are certainly times where somebody says, 'We wanted you to be the keynote speaker at a conference. We wanted you to be a grand round speaker, but you took a really hard stance on--insert drug X--and, you know, there's a lot of discontent on the committee.'

And people are, like, 'You can't have him here. You were too hard on that trial.' So, that's definitely happened to me.

Not that I'm complaining: I'm not looking for more speaking. I travel enough. I want to cut that down. But, okay. But, that is a repercussion.

And, one thing I don't do, is I don't personally spend my time running the trials myself. In the past, I've enrolled many patients on trials. I've even drafted some--like, we do in our training. But I don't make that a portion of my career--in part because we all have limited time. We have to choose what we want to do. I want to work on books and I want to work on some writing and I want to do some other stuff.

But, for people who wanted to have a foot in both camps--they want to work with the companies and also be critical of the companies--it's the hardest path to trod. I know many people who were doing this kind of critical work and then there came a moment in their career often very early where they decided they have to lose one or the other and they've chosen, 'I'm just going to stop all the policy work I'm doing. I'm going to focus on just running the trials.' And, I know some junior people who are struggling to find the balance, and I suspect it's a difficult balance.

So, the pressure, I think, is peer pressure. The pressure is your boss will talk to you. I know many people who say--you know, the company called the cancer center director and said, 'Why do you have a faculty member talking ill about our products?' I think that's a pressure. And, then the pressure to find your salary. Even though we work at a university, I'm a small business owner. I'm looking for my salary--I'm like a Mary Kay salesman trying to find people to give me some money to do some research. So, I think that's a pressure.

Russ Roberts: I disagree with what you think is the driving force behind this. I don't think it's a lack of funding at the government level. If anything--

Vinay Prasad: Sure--

Russ Roberts: the funding of government, of the university system over the last 50 years in America, has made academic life dramatically more lucrative than it was in say 1950, 1960, 1970. Somewhere around 1970 or 1980, you could really make a lot of money as an academic. It's not a sacrifice. True, it's a little sacrifice relative to industry, sometimes--as you alluded to. But fundamentally--it's hard to admit it, but you've laid it out very beautifully--it used to be that universities cared about truth. And that got too expensive, and pharmaceutical industry is one place where that's the case.

But, there are a lot of places. I used to joke that the number of economists who think they could be Chair of the Fed someday is enormously large. About half the macroeconomists in America think they're in the top 10%. So, they think they've got a shot someday at Chair of the Fed. So, they never say anything critical of the Fed. And, it's the same sort of corruption--it's not literal corruption: it's just a subtle corrosion of values that money can do if you're not careful. And, the system has evolved--the academic system, the grant system in general from the government, whether it's in medicine or elsewhere--to reward people who play by the rules rather than seek the truth.

And, people have a lot of romance about academic life. Those of us who are the kitchen don't have the same level of romance.

Vinay Prasad: I think you're so right, Russ. I think you're hitting on a big thing, which is that they are thinking about the next career step and the next career step and they want to keep quiet as a result.

But, I always tell people that when I look back on my field--and I don't know how you feel about economics; I'm very curious--when I look back on oncology and I read--you know, I like to read papers from the 1940s and the 1950s and the 1960s and the 1970s, and I have my own heroes. And not a single one of my heroes is a person who kept quiet because they wanted to be Dean someday. All of my heroes were the people who pushed on issues that were hard. And, some of the greatest heroes in oncology, I think, were incredibly controversial in their times.

There was this guy, Bernie Fisher--he was the reason why women get a lumpectomy rather than half their chest wall removed. The old way, they removed the breast, and the pec [pectoral] major, pec minor. And, how did he do that? He ran a randomized trials that randomized people to the big barbaric surgery or a lesser surgery. That showed the barbaric surgery was no better than another study to even a lesser surgery. And, in the course of a couple of randomized studies, he moved us from barbaric Halsted paradigm to lumpectomy.

And, the history books say, when he gave lectures people would shout out, 'Murderer! You're murdering women.' And, they'd curse him out, and they'd insult him. I mean, he was vilified by a lot of his fellow colleagues. He withstood it and he pushed on an issue. It might have hurt him professionally, a little bit. I mean maybe he could have accomplished--he would've been promoted higher. But he's a hero of mine.

And, not to even put what we're doing is not the same thing. What--I don't claim that thinking about policy is the same thing; but I think anybody who does courageous science, it's going to ruffle some feathers.

And, if you're not ruffling any feathers, you've got to ask yourself: What are you doing as a scientist? Are you really pushing on it?

And, life is short, I think we'll both agree. I feel like I started faculty a minute ago and it's been eight years; and time is going faster than I would've liked it to go. And, you want to do something in your 25 years in academics or 30 years. You don't get forever. You want to do something of meaning. And, I think that means you have to forget about yourself a little bit and just push as hard as you can sometimes.


Russ Roberts: Well, let's turn to the question you mentioned a couple times already, which is the question of duty. You wrote a really--it's a screed, but it deserves to be a screed. I think that duty is out of fashion. It isn't what motivates most people. You write,

Our ancestors used to know what that word means, but, in the modern world it has [fallen] out of favor. Instead, [it has] been replaced with weakness and cowardice, narcissism and careerism.

And, I think duty is definitely out of favor. Yuval Levin, in a very nice book, A Time to Build, talks about how most people use their platform--whatever they have, whether it's an academic platform or a government platform--for self-aggrandizement: for building up themselves for what he calls performative--opportunities to perform, to be seen, to attract attention, to get followers--rather than to do the right thing. And, why did that happen? Before I ask--that's a tougher question.

But let's talk about why you wrote an essay about that in the medical field. You've just given a couple examples from the cancer field, but most of this essay was related to the pandemic.

Vinay Prasad: Yeah. So, I've got to give one piece of background to you that you may not know. The essay is very harshly worded. And why was I feeling emotionally that way? The essay was written, I think, one or two days or three days after the Uvalde massacre--those kids in the classroom. And, in my mind that broke me--I'll tell you, to be honest with you, Russ. It broke me because we've become so desensitized to school shootings, and I don't think we should be. I think it's something we should be sensitized to. And, they always break me. I mean, I think that it's unthinkable. and I understand how so many people feel about how horrible that is. So, that always breaks me. This broke me extra, because they stood in the hallway for one hour while those kids were shot over and over and over again, and the shots were spread out in time. And there was hundreds of them armed right outside that door, and they didn't break down that door and go in. And, there's been countless--

Russ Roberts: You're talking about the secure--the police or the--

Vinay Prasad: The cops.

Russ Roberts: Yeah.

Vinay Prasad: Yeah, the cops. They failed in their duty. There's a duty of being a cop. And, that duty is: Even if you're scared, even if your colleague was shot, these kids are in the classroom, you've got to break down that door.

And, honestly, it doesn't matter to me what your bosses are telling you on the radio. You're the ones there. You have a duty. And, they didn't go in.

And, I can't think of what that would be like. Because, there's so many times in healthcare somebody tells me, 'You can't do something, Dr. Prasad. That's against the rule. The patient, we can't do that. There's no play to pay[?].' And, I always find a way to break the rule. I don't know, people should ask: I always break the rule. Because, if it's right for my patient, that's my duty. And, I'm sorry: You may cut the check at the end of the day, but I don't really work for you. I work for that patient. And so, I will break the rule. I'll bend the rule.

I've become an expert in doing this. And this is my small space, but that's what I've chosen to do with my life. They've chosen to be a cop. And, I think you got to run in that room--a 100 times out of a 100 you've got to run in that room right away, and you've got to kick down that door. And, if you hear the gunshots, you've got to go in.

And so, that was my emotional state writing that essay. I was broken by that. I try not to comment too much about things outside of my wheelhouse of biomedicine, but that was my emotional state.

And to me, it's different. But, it is an abdication of duty, which is that so many academics don't participate in the big topics of the day.

I think that was, that's kind of what I'm talking about in the sense of duty of our line of work.

You know, you're a great person who has had conversations with people on so many topical issues, policy issues--you're an exception. I think that mentality you kind of alluded to in the last part of your comments about the careerist academic judging very carefully what topics should I even talk about? That's a mindset that's pervasive in the academy. People are trying to get that next position.

To me, one of the examples I give in the essay is: I know many people. They've spent their career devoted to educational outcomes in underrepresented minority populations. They care about black, Hispanic inner city kids and their educational outcomes. And, during COVID-19 [COronaVIrus Disease, starting in 2019; also called SARS-CoV-2] on the issue of prolonged school closure, particularly in liberal cities, they did not say a word publicly.

And, to me, I can't imagine what that's like. You live for that issue. That's your moment to shine and go in and say what you know and participate. And, you might not be right, but you get in there. That's your debate to be had.

I got in that debate. That's not my debate to be had. I'm an oncologist. But even I got in the debate because I knew it was so important, and I felt strongly about the issue. And, that to me is a similar 'standing outside the door,'-moment in someone's career.

Russ Roberts: Yeah, I think about it a lot. I think about--a lot of the reason that that school shooting is so salient as an example is because most of the time the stakes are small. You might not get a promotion, you might not get put on the committee you want to get put on. You might not be able to run that clinical trial. This is life and death. This isn't small stakes. And this is the test. And those people failed the test. Tragically.

And, you could argue that a successful society honors people who run toward danger, not away from it. We all understand why you want to run away from danger. It's in certain sense, you can't judge anybody for not risking their life to save another person. But, you can judge them when that's what they signed up for and you don't have to sign up for it. That's the deal.

And, it's hard to run toward danger. I'm not sure I've ever had to face that choice myself, so I don't want to--it's hard for me to judge those people. But when you sign up for it, that's the deal.

And, in many ways, it's what makes up a life well-lived, is duty, honor, fulfilling your obligations. And all of those things--honor, duty, fulfilling your obligations--they're all a little bit out of fashion. You said, falling out of favor. They've also fall out of fashion. We don't make movies so much about them anymore. We don't instill them in our children through hagiography and myth of heroes. We're much more eager to tear our heroes down, at least in the United States. And, something deep is lost there.

Vinay Prasad: Yeah, that's really well put.

And, I think you're saying what I wished I could articulate as nicely as that, which is: you know, we're taking Lincoln off the high school name because he wasn't good enough. He didn't do enough good things. We're not respecting our heroes. We're not teaching people a sense of duty. Everything is about how you feel and how it makes you feel, not: What is your obligation in life?

And, that school shooting broke me. I think I cried in my car when I was listening to the news coverage of that. And, why did it break me? It broke me because as you say, it was the most important thing. It's life or death. It's children behind that door. And, yes, you signed up for it. And, when you sign up for a job like that, that's the risk that comes. And, you got to go in. That's the moment you were trained for.

I think about it a little bit in healthcare. I allude to it a little bit. It's not the same. But, when the pandemic hit, you found me. I was in the middle of switching jobs, but by the peak pandemic, early summer 2020, I'm back in clinic every day. I mean, I'm back in clinic every week seeing patients. They gave you a thin surgical mask. Why was I there? It's my duty. I'm much more likely to get COVID than had I just said, 'Don't schedule any patients.' Or 'I'll just do Zoom visits.' But, people's cancer is not stopping growing, and so we have to go do our job.

And, I don't want to pretend I'm the only one. Most healthcare people did go back in there.

And, I think some of us who went and worked in person have a very different perspective than some of the reporters who covered COVID from the luxuries of their--behind Zoom and from their apartments.

I think that's one perspective that is different. And I think that is lost, because there are many rotations where they said--I was told that, 'Oh, the residents can't come because it's too high-risk to go have a resident[residency?], see the COVID patient.' And, that to me is an unthinkable thing to say. Because when you're a doctor, that's what you signed up for.

I remember as a resident, I had to sew in lines and put needles into patients who were, like, HIV [human immunodeficiency virus]-positive, uncontrolled, HIV. It's a risk you can cut yourself. But it's a risk you take. Because that's what it means to have the job.

And, many of us have nicked ourselves or stuck ourselves; and we've had to deal with that.

I do think that's lost. And I'm not sure where that decline comes from.

But, I do think we are still singularly focused on our happiness, our immediate gratification, and our selves. We forget that duty often means it comes at some cost to you. It's often towards others. It's not about yourself. And, I think it is something more important.

And, what life is really about is fulfilling your duty. I don't pretend to know everyone's duty, but I think you have to figure out your duty and you have to doggedly pursue it, even if it hurts.


Russ Roberts: Try to give some insight into how we've come to this point in much of the Western World. I think I just unintentionally learned something about myself, right? You told a story about cowardice. Because that's really what it's about: Here are a group of people whose obligation was to take a risk and they failed. They stayed in the hallway and hoped it would go away and that they would not have to pay a price for it.

So, in commenting on that, do you notice what I said? I didn't think about it. I said, 'It's hard for me to judge them.' And, I think we live in this strange time where we're incredibly critical and one very small mistake can ruin a person's life through the public response to it.

At the same time, we're very uncomfortable shaming people for their lack of duty. We're much more likely to say, as I said, parenthetically--it may not be that I would judge any; it's hard for me to judge someone in that situation, because I worry that in that situation I might have done the same thing. And were it my cousin, I like to think I would still invite them to my house to break bread even if I feel they had failed.

But, as a culture and a society, that's not a very healthy attitude. And, I think a lot about Adam Smith.

Adam Smith says basically the reason we do things for other people is because we want to be judged favorably and respected. And, we want other people whose respect we crave to respect us. And, we want to be praiseworthy.

And, not just praise, but praiseworthy.

And, that's out of fashion. That's what's out of fashion: The willingness to judge other people to impose a cost of shame, intolerance, judgmental, a judgmental attitude is totally out of our culture in many settings. Not all, because in other settings it runs rampant. It's a certain weird aspect of modern life for me, when I think about it.

But, you know, we tolerate lots of bad behavior. We see things around us that are shameful and we stay silent. We don't judge them publicly. We don't criticize them publicly.

So, I salute you for that essay.

In passing you defend past EconTalk guest Emily Oster, who spoke out very bravely and publicly against school closure and took an immense amount of vilification for it. But, most of the time people just put their head down and they let other people--just rather not say anything. They leave it alone.

And, that's our culture to a large extent, at least in a face-to-face way. Not on social media: obviously, it's very, very different. But, in face-to-face culture: I see you do something shameful, a lot of times I'll just keep quiet. I like to think, not I personally, but I think a lot of times I do. And, we do. We just say, 'Well, I don't know what that person's going through.' And, nice thing about that in a certain way. But, kids died, and it's not nice.

Vinay Prasad: Yeah, I mean, you're onto something that I think--it's difficult to sometimes articulate how you feel about somebody failing their duty. And, maybe I'll give you an example of one where recently that occurred that I haven't articulated that I think we're on the wrong track.

I think medicine is a field where one of the things you've got to teach trainees: So, it doesn't matter how you feel that day. The person coming in your office, they are often having a worse day. I mean, they're dealing with a very important medical problem in their life, and it might be the life-limiting medical problem. You might have had something happen in the morning. You might have something happening this evening. Often it'll pale in comparison to what they have going on. That's one.

And, two: You have a duty. The duty is to be there; and you've got to do your best job; and you've got to forget everything.

And, sometimes this duty changes all the time. I move from a room where I have to tell someone there's nothing we can do and we might have to go on hospice, to move to a room you tell someone you cured them. I mean, they're very likely to be cured.

And so, you have to constantly be changing and wearing these different hats.

And, I do worry our medical training is drifting away from this. And, we're sort of rewarding different values that I'm not sure I agree with.

I'll just give you one example. We had, maybe about a year and a half ago at the height of the George Floyd protest--there was a shooting in Kenosha, Wisconsin. I think Jacob Blake was the gentleman who was shot--he was unarmed--by the police. And, of course, I categorically disagree with shooting unarmed men. The police should never shoot an unarmed black man. I think that's wrong. That's an easy thing to persuade me of--that the police can be exuberant in their force and they ought not be. And, they need better training. Or I don't know how to solve it--it's not my expertise. I won't even pretend to try to solve it. But, I do think it's a problem.

I got a memo or something that said the school is going to be closed for a week--our medical school. And I was kind of confused: What was the basis of the school closure? And, the answer was that the faculty or the administrators felt like some of the students might be so upset about the events of Jacob Blake, that they need a break from medical school.

And, I strongly disagree. I still disagree: that that's not what we should be teaching our students. Because if I'm the trauma surgeon and some guy's wheeled in and he's exhanguinating, and somebody tells me the cop shot him, he's unarmed, it's going to be a bad thing if I stop doing my job all of a sudden. I need to be ready to do my job. No matter what they tell me about this person or what happened to them.

And, that's medicine. You might not be feeling perfect. You might be feeling upset. But you've got to do your job cause somebody's life is on the line. And, I think rewarding--or not rewarding, but just giving people a week off, it's absolutely unacceptable in my mind.

And, if we're doing this for the shooting, there could be a shooting a week for the rest of the year. I mean, this is not an infrequent occurrence. And so, would we give the whole year off? When will they learn how to be doctors?

I know there's another trend where I know people are saying that we've got to give so many mental health days to residents. I totally agree; it's a stressful time. We have to think about ways to make medical training more humane and less stressful.

But, I'm not sure the right idea is to let people have a bank of days where they can just declare, 'I don't feel like being a doctor today.' Because there are many days where I'm having a tough day. But I have a duty. And, we have to teach people: You've got to follow your duty.

And so, these kinds of cultural changes in the--this didn't exist when I was a student. I'm not that old. And, I'm not sure the best way to--who to go talk to, who is actually capitulating to this culture. I mean, who is making these decisions? I'm still trying to figure that out.

But, that's a decision that so many faculty tell me they disagree with these decisions in our school, but nobody is in any position to say anything and they feel uncomfortable saying something because they don't want to be labeled as the person who opposed giving the students the week off or that sort of thing. And, I think that's part of this problem that's linked to this duty problem.


Russ Roberts: Yeah, I think about you sitting in your car crying, and we all have days where things go wrong at home. Things go wrong with our own bodies, things--mental issues, stress. We don't feel 100%. Most of the time we don't feel 100%. And, a culture that says if you don't feel 100% you can sit it out, is going to generate a certain set of results, as opposed to a culture that says you have an obligation to overcome whatever is on your mind.

Now, we understand that to go through life at certain times under great emotional stress and, quote, "pretending that everything is fine" is not a road to health. But, I think some of it is definitely the privileging of our day-to-day wellbeing, which I've argued is a little bit overrated. There are many, many things more important than our day-to-day wellbeing: our dignity, our pride, our principles, fill in the blank. And, in your case, our conversation: your duty. And, we're much more likely to coddle people for better or worse. And--how old are you, Vinay?

Vinay Prasad: Forty.

Russ Roberts: Forty. I'm 68. So, when I say it's, like, 'Ah, that old codger--he's cranky and he longs really the good old days,' you're too young to be put in that category, although you may have an old soul. I suspect you do.

Vinay Prasad: I think so.

But, I think the way you articulated that is exactly how I feel, which is that I think a value is that even when you're not feeling a 100%, you need to go there and give 100%. And, I think that that is something for, especially in medicine, it is so important because there's not going to be someone to cover for you. That's what I want to tell these students someday. I have patients I've seen for years and there's a conversation that needs to be had on Tuesday, for instance. And, if I'm not there for that conversation, you can't--there's nobody, you can pull in. There's nobody who knows this person. There's nobody who has had this relationship with--there's nobody they want to hear it from--other than you. There's nobody to cover for you.

So, it doesn't matter. I always tell you, you're going to find me there. It doesn't matter how I'm feeling. It doesn't matter what happened to me. I'm going to be there.

And, somebody recently said--I think this culture expands in so many directions--but I told somebody I'm going to meet them for dinner at some place and time. And, they said, 'Just so you know, if you're going to cancel, you've got to give me 24-hour notice to cancel the reservation.' And, I tell them, frankly, I was like, 'I will not cancel. I do not cancel. And, I will be there at that date and time, because I've made a commitment to you and I'm going to show up. Nothing is going to get in the way of that. And so, do not worry about that.'

But, the fact that they have to ask that, it speaks to the culture where they just think I can cancel on a whim. I want to tell them I'm not that type of person.

And, I think it's important that medical doctors don't become that kind person. It's the one job that you got to show up. And, I know you can be having a rough day, but we have to train people to find ways to compartmentalize. You have to do it. You have to compartmentalize even from the 9:30 visit to the 10 o'clock visit--find a way to put your emotions aside. Because it's not about you. It's not about you. You're not the patient. It's about somebody else. And, that's what you signed up for.

Russ Roberts: Well, a part of that is so interesting to me is: you said on Tuesday you've got an appointment with the patient and you're the only person who can have it. And, that is a great gift. That is not just a pleasant sidelight to your job. That is what makes your job as a doctor so extraordinarily profound--is that you are given the opportunity to do something that no one else can do well, and it comes with obligations precisely because of that.

It's not, 'Oh, here's the pluses and here's the minuses,' or 'Here's the things you have to do, and some of them conflict at times.' Because you are the only person, because you have the chance to have that very meaningful and profoundly, often satisfying, gratifying, poignant, painful, deep, intense interaction with another human being, you've got to show up. That's the deal.

And, most of us don't get that job. Most of us have a job with different responsibilities. We can take a day off, and our job is less intense. It's less dramatic; and often less meaningful. You've got the meaningful job. Congratulations; but it does come with obligations.

Vinay Prasad: Yeah, I couldn't agree more, Russ. That's really well put.

And, I think that's why I love medicine and I think that's why I chose to do what I want to do. People always ask, 'Why oncology? It's so tough.' It's also so rewarding and people need you. And, sometimes you feel like--particularly maybe I feel this way because my decision-making on some issues is different than a lot of my colleagues--I feel like were it not for me, things would've unfolded in a different way just because I have my views about evidence and drug price.

But, I want to say one thing: in medicine there are a range of fields and there's a lot of fields that have become more prominent recently where you are more of an exchangeable part. They're known for having a fixed start time and a fixed stop time and you can sign out your shift to the next person.

And, students are flocking to them. I mean, I think they have a lot of allure. They pay well, and you know you're going to be out at 3:30.

And, I always tell people: You know, there's two types of medicine: there's hours to work and things to do. And the hours to work means: you look at the clock and you know at 3:00 you're out of there. And, there's things to do, where I have so many things to do in a day and I don't know when I'm going to be out of there. And, that sometimes means that I'm not going to be home till 10:30 or 11 or later. But, you have to figure out the kind of person you are and which type of field you want to go into. And, I could never be in the first field. To me, that's not what I signed up for, that's not what I think medicine really is at its core. So, it has to be the second.

Russ Roberts: Our guest today has been Vinay Prasad. Vinay, thanks for being part of EconTalk.

Vinay Prasad: Thanks, Russ.