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A couple of months ago I had breakfast with one of my blog readers and frequent commenters, Mark. At the time he mentioned something interesting, which has been percolating in the back of my mind ever since. He said that medicines get approved by the FDA based on claims that they will accomplish some terminal good. Say, for example, lowering the number of deaths due to heart disease. On top of that they will also probably toss in a general reduction of related adverse health events, like heart attacks. But when they provide data to the FDA in support of these claims it won’t be data on deaths or heart attacks it will be data on how the medicine reduces LDL cholesterol levels.
They do this for several reasons. First, cholesterol is easy to measure, and so that data is consequently easy to provide. Second, the pharmaceutical companies are reasonably certain that atherosclerosis contributes to heart disease, and that high LDL cholesterol contributes to atherosclerosis. Meaning that their claim actually has two parts. They claim that their medicine reduces LDL cholesterol, and that lowering your LDL cholesterol reduces your risk of heart disease. They are able to provide data backing up both claims, but what they don’t provide is data that shows “Our medicine reduces heart disease.” This is all fine, and working as intended, and, in fact, it’s the way I would want it to work. But, and this was the key point mentioned by Mark, after the drug is approved, the company should, at some point prove that it does actually reduce heart disease, not just LDL cholesterol. And the problem is that they generally never get around to that.
From the perspective of a patient, say someone with genetically high cholesterol, say me, for instance. The way this plays out is, you go in for your annual check-up (as I did this week) and get your cholesterol tested (ditto). Upon discovering that it’s high, the doctor prescribes a statin, because he knows that if I take a statin every night before bedtime, that my cholesterol will probably go down. Now, he will also ask whether any relatives have had heart problems, and he’ll look at other risk factors, but mostly he’s reacting to the fact that I have high cholesterol.
This all makes a certain amount of sense, and obviously my wife is very much in favor of me taking the medicine my doctor prescribes. But there’s a lot that the doctor doesn’t know. He’s only making an educated guess at my personal risk of heart disease. And he can’t say that if I decline to take statins that I will definitely have a heart attack. But he’s pretty sure there’s no downside to taking them. Of course, I’m being unfair by talking just about how it works with a single person, but even if we make it more broad, we still don’t fully understood how statins effect atherosclerotic plaques, nor is it clear whether statins do much of anything for someone as young as me, with a low risk of a having a heart attack in the next 10 years. For example this paper:
The current internationally recommended thresholds for statin therapy for primary prevention of cardiovascular disease in routine practice may be too low and may lead to overtreatment of younger people and those at low risk.
The general point I’m trying to get at is that all of us, not just doctors, are quick to substitute something easy, for something that’s more difficult. For doctors it’s substituting reducing cholesterol for reducing deaths from heart disease. It’s easy and cheap to measure cholesterol, it’s expensive and difficult to measure long term mortality from heart disease. Also, remember that the drug has already been approved, meaning even if it wasn’t difficult the pharmaceutical companies have very little incentive to conduct such studies.
Now if these substitutions mostly worked, with only a few minor errors here and there, that would be one thing, but in reality the opposite appears to be true. Health advice is constantly being overturned, or reversed. (As very humorously illustrated by this great Funny or Die Video.) And it’s not improbable to assume that 20 years from now we’ll find out that long term statin use causes some previously unsuspected negative outcome. It’s also possible that the dangers will be more subtle. Perhaps because cholesterol is easy to measure, and change, we’ll ignore paying attention to markers which are harder to measure, but ultimately more meaningful?
As I mentioned this idea has been on my mind since Mark introduced me to it. And just recently I realized that we may be doing the same thing when we assess the wellbeing of society. At the highest level, analogous to deaths from heart disease, we want a society that’s healthy. But of course deciding if a society is healthy is even harder than deciding if an individual is healthy. Right off the bat we run into conflicting standards for what constitutes health. As I’ve mentioned in the past my standard is survival. Just like the doctors don’t want their patients to die, I think it’s reasonable for society to also target deaths, and I extend that to targeting births as well. Other people disagree with this, and claim that we should be aiming for happiness instead. Fair enough, we’ll use that standard for the moment. Let’s assert, for now, that a happy society is a healthy society.
But how do you measure happiness? There are lots of studies which claim that Scandinavian countries are the happiest, but it turns out that it depends on what question you ask. An article in Scientific America claims that there are actually four ways to measure happiness:
Most commonly, you ask people to value their lives on a 0 to 10 scale. This is the method which gives us the aforementioned results of Scandinavian countries on top.
Alternatively you can ask how much positive emotion people experience, in which case suddenly Latin American countries are on top.
On the flip side of that perhaps you’re more interested in preventing negative emotions than you are in encouraging positive emotions, so you look for the country with the least depression. In that case Scandinavian countries do very poorly, but under this measure Australia looks pretty good.
Finally, we can look at the number of people who feel like their life has “an important purpose or meaning” in which case you’ll find countries in Africa at the top of the ranking. And it turns out that religion plays a fairly significant role in the creation of meaning.
Even if we assume that a happy society is a healthy society, it’s still difficult to determine what makes a society happy. In the same fashion that it’s hard to determine exactly how statins effect atherosclerotic plaques, but probably harder. However, and this was my recent insight, in the same way that doctors have decided that targeting cholesterol is the best way to mitigate heart disease, lots of people have decided that targeting material well being is the best way to create a happy society. To put it simply (maybe too simply, but close enough): as long as a nation’s per capita gross domestic product is rising the nation is healthy. Furthermore anything that contributes to that rise is good, and anything which detracts from it is bad.
As you can imagine there are lots of problems with this approach. First, as I just pointed out, there are various standards of happiness. Increasing material well-being through the mechanism of increasing the money possessed by the average individual, seems to mostly target the first one, while being only marginally connected with the other three. And even there we’re still assuming a chain of causation, very similar to the one I described for statins and heart disease, only longer.
1- Increasing per capita GDP means everyone has more money (i.e. the increase is evenly distributed.)
2- People will use this money to acquire possessions and experiences, they value.
3- Materially valuable possessions will turn out to have psychological value as well.
4- All of the foregoing will produce happiness.
5- Asking people to rate their life value on a scale from 0-10 will produce an accurate measurement of the happiness produced in step 4.
And if we decide to broaden things beyond the first metric for happiness we end up making two more connections which are even more questionable.
5- The quantifiable measurement of happiness from step 4, really is the best way to measure happiness. (Better than the other three.)
6- Happiness is the best way to measure the well being of a society.
In the same fashion as heart disease you would hope that people would move past focusing on whether someone has more or less money (i.e. cholesterol tests) and follow this chain all the way to the very end. But in a similar fashion I don’t know that they do, at least not in any systematic fashion. It’s always more straightforward to stick with things that are easy to measure than it is to figure out what really contributes to a society’s well being. It’s easy to assume that if we’re trying to ensure the well being of society that ensuring each individual’s material well being is probably close enough, particularly if you’re a materialist. (And I realize philosophical materialism is different than the common definition of materialism.) But there’s more and more evidence that material well being doesn’t produce happiness to say nothing of overall well being. In particular I think the connection between material well being and psychological well being is especially tenuous.
I have spent a lot of time in this space covering my concerns about psychological well being, and you might think there’s not much left to say, but I came across an article recently that speaks quite directly to the issue of psychological well-being, and to a lesser extent the larger issue of societal well being. It was titled The Happiness Recession, and it opens as follows:
In 2018, happiness among young adults in America fell to a record low….
We wondered whether this trend was rooted in distinct shifts in young adults’ social ties — including what The Atlantic has called “the sex recession,”…
Human beings find meaning, direction, and purpose in and through our social relationships with others. We’re happiest when our ties with others are deep and strong. And the research tells us that the ebb and flow of happiness in America is clearly linked to the quality and character of our social ties…
So we investigated four indicators of sociability among today’s young adults—marriage, friendship, religious attendance, and sex—in an effort to explain the “happiness recession” among today’s young adults.
I’ll get to what they had to say about each of these four areas, but first notice that material well being doesn’t even come up. Possibly because the situation is analogous to a patient who’s cholesterol is fine, so we’re not worried about that risk factor, but it turns out they smoke. Or possibly the situation is analogous to discovering that we’ve been targeting cholesterol all this time and really we should have been targeting four different things, that cholesterol doesn’t matter at all. In any case regardless of whether the recommendations were wrong or just incomplete, it appears that we need to broaden our treatment regimen, and look into different “medicines”.
The first thing they suggest looking at is marriage. It’s interesting that marriage is not an example of a measurement that’s difficult to make, it’s almost certainly easier to tell if someone is married than it is to determine what their financial situation is. Determining the happiness of their marriage is another matter, and I’m sure it’s a factor, but even without accounting for it The Atlantic reports that:
…married young adults are about 75 percent more likely to report that they are very happy, compared with their peers who are not married, according to our analysis of the GSS, a nationally representative survey conducted by NORC at the University of Chicago. As it turns out, the share of young adults who are married has fallen from 59 percent in 1972 to 28 percent in 2018.
As I said, marriage is easy to measure, but perhaps, if there is a problem, it’s less easy to correct. Especially in an age where any suggestion that you’re interfering with someone’s autonomy, particularly in the realm of sex and relationships, is met with violent pushback. As a result it’s one of those things that conservatives talk about all the time, but which gets no attention from the left. (Or perhaps it gets negative attention?)
It can be dangerous to talk too broadly about what a group of people does or doesn’t believe or how they might behave, so in the interest of specificity, at this point I’m going to bring in Steven Pinker’s book Enlightenment Now. Which I “reviewed” previously in this space. As you may or may not recall Pinker set out to create the definitive work showing how great things are currently and how they are likely to only get better, and when I talk about an overemphasis on material progress I largely have him and people like him in mind. In support of my assumption I went back to the book to see what he had said about marriage. It was entirely possible that he mentioned its role in wellbeing and had different data showing that it wasn’t decreasing as much as claimed or that the effect of a lower marriage rate was overstated. As it turns out the word marriage doesn’t even appear in the index. (Note that Louis C.K. and Jainism do, lest you think that perhaps it isn’t comprehensive.)
The Atlantic next moves on to religion. Where they say:
Faith was the second factor. Young adults who attend religious services more than once a month are about 40 percent more likely to report that they are very happy, compared with their peers who are not religious at all, according to our analysis of the GSS. (People with very infrequent religious attendance are even less happy than never-attenders; in terms of happiness, a little religion is worse than none.) What’s happening to religious attendance among young adults today? The share of young adults who attend religious services more than monthly has fallen from 38 percent in 1972 to 27 percent in 2018, even as the share who never attend has risen rapidly.
I confess that this decline is less than I expected, but it’s still declining and the trend shows no signs of reversing itself anytime soon. And once again the decline of religion is something conservatives worry about obsessively, but which Pinker and company actively celebrate. (“Decline of religion” does appear in the index of Enlightenment Now, where it points to more than a dozen laudatory references under the heading of secularization.)
Religion is also something which has next to nothing to do with material well-being, and may in fact be the exact opposite. Once again, in our attempts to improve societal well being are we sure we’re measuring and treating the right thing?
From there The Atlantic moves on to friendship. And here the news is actually good:
The third factor was friendship. The effect of seeing friends frequently is less clear than that of marriage or religion, but young adults who see their friends regularly do seem to be about 10 percent more likely to report being very happy than their less-sociable peers. Friendship among young adults, though, is not on the decline; in fact, since 2006, contact with friends is up. Lack of friendship, then, is not likely to play a role in declining levels of happiness. Indeed, it may be that rising social time spent with friends in recent years could be buffering young adults from the declines in institutions such as marriage or religion, as friends stand in place of other relationships or forms of community.
As I said the news is good, but there are a host of caveats here. First as compared to the 40% increase in the number of people reporting they were happy attributable to religious attendance and the 75% increase from marriage, friendship provides a bump of only 10%. Thus whatever the “buffering” effect of friendship it would appear entirely too small to make-up for the other trends. Also even if it was up to the task, it then becomes a single point of failure. Where previously most people had marriage, religion and friendship in their life, and therefore two things to fall back on if any one of these three failed. Now, by relying solely on friendship, which appears unequal to the task in any event, we risk having nothing to fall back on if friendship should happen to fails. If this failure mode was unlikely, then perhaps we wouldn’t worry, but instead, on top of everything else there’s an epidemic of loneliness, with millions of men reportedly having no close friends.
I should also mention that once again that the word “friend” does not appear in the index for Enlightenment Now.
The final element covered by The Atlantic is the sex recession. Of which much has been said both here and elsewhere, probably because it’s so alarming, and this article was no exception. As part of their coverage they built a counterfactual to see if they could tell how much each element contributed to the reduction in happiness, as far as sex they found:
…changes in sexual frequency can account for about one-third of the decline in happiness since 2012 and almost 100 percent of the decline in happiness since 2014.
This is another illustration of how steep the trend is and how recent in origin, which makes me hope that it’s very temporary because if it continues for very long at all the impact will be nothing short of catastrophic. Also, though at this point it probably goes without saying, there is no reference to sexual frequency in Enlightenment Now.
The point I want to leave you with is that there are a lot of people like Steven Pinker, who think society is healthy, and point to material well being (essentially per capita GDP) as the best measure of that healthiness and also the best thing to target if there’s a problem. But it’s worth asking if that’s all there is to it. To ask how solid the links are between the various steps I listed above. If perhaps there’s some other measurement of happiness, like marriage rate, or religion or even frequency of sex which might be a more accurate measure of societal well being? Or at least need to be considered as part of a more holistic assessment. Now I know I’m simplifying Pinker’s argument to a certain extent, but also remember that in over 500 pages on how great things are going he never mentions marriage or sexual frequency, or for that matter loneliness and he only mentions religion in a negative context, despite the apparently powerful influence all of those have on people’s happiness.
To return to comparing societal health to individual health, which is actually easier to understand? I can only assume the answer has to be individual health. And yet how often have doctor’s ended up giving the wrong advice? Should that not make us more humble when it comes to making declarations about what makes a society healthy? Especially when we’re discussing the long term effects of some new, entirely unprecedented norm? Norms which seem to be proliferating at a truly staggering rate?
I not only have high cholesterol, I have high blood pressure, though they both appear to be mostly genetic. Nevertheless they could mean my early demise. If that happens and you haven’t donated, you’ll feel bad. If you want to avoid that click here.
Happy Easter.
In thinking about this perhaps it may be helpful to pull from the first sermon of the Buddha, also called the Deer Park Sermon.
““The Noble Truth of suffering (Dukkha) is this: Birth is suffering; aging is suffering; sickness is suffering; death is suffering; sorrow and lamentation, pain, grief and despair are suffering; association with the unpleasant is suffering; dissociation from the pleasant is suffering; not to get what one wants is suffering – in brief, the five aggregates of attachment are suffering.”
https://tricycle.org/magazine/the-first-sermon-of-the-buddha/
Perhaps you are making too much of happiness here. Happiness is a lost cause in this sense because one typically desires to be freed from unpleasant things but we also are upset to lose or fear to lose pleasant things. Freeing oneself of starvation, say, brings temporary relief but food itself can become it’s own sort of addiction hence we have people compulsively keeping McDonalds going quarter after quarter. In other words, ‘first world problems’.
In this sense you’re not going to get any accurate reading measuring happiness. The person in the hunter gatherer tribe fretting over a hunt that is going badly is going to have the same stress chemicals in his brain as the teen playing a marathon Fortnight championship who now seems to be faltering. Wherever we happen to be, things are going to stress us out, disappoint, cause us to worry about losing, etc. Even virtual worlds, which could serve us up games where we always win and everyone gets to be #1, can’t solve that issue. Our programming is to be dissatisfied, seeking a tweak to make things better at all times.
Hence I suspect your metric of the healthy society is a bit misplaced. The analogy with the FDA can be summarized by their term ‘surrogate endpoints’ (https://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/ucm606684.htm). But at least with cholesterol you know your target endpoint (avoiding cardiovascular disease, heart attacks, strokes, death). I’m not sure of your healthy society metric. I know of no example of a society that voluntarily ‘devolved’ back to more primitive lifestyles even though there are many individuals who did this (the whites who joined Native American tribes stayed there when they could but the Native Americans who joined whites tried to get back when they could). Perhaps the happiness they experience is contemplating the comparison between the natural lifestyle and the industrialized one…but if that is the source of their happiness then you have to have both civilizations going at all times.
I’m not sure population growth is an indication of a healthy society rather than an expanding one. We are both biased here by American history which has been one of expanding into mostly unsettled land. That is not the norm of human history, not the norm of Europe or Asia where the land was settled long ago. Maybe it is unhealthy for a society to not be able to sit still and simply continue where it’s at.
Thanks for giving me a name for what I was discussing. I can see surrogate endpoints being a useful idea to have around.
As far as the rest I think we basically agree that happiness is not best way to measure a health of society. I think I’ve been pretty clear that I think suffering is necessary. But there are many people who do use happiness and wealth as their primary measurement, which is where we end up with a lot of people pointing to Scandinavian countries as models to emulate. Including people like Pinker. Perhaps they are, but I think there’s more going on than just material wealth. Also, something I didn’t mention in the original, I have my doubts that the Scandinavian models would scale well at US levels of population and diversity.
I’ve always thought the early Native American example is a bit of anachronistic thinking. Anyone who lived in colonial Jamestown, or with the Puritans, or just about any other early colonial/frontier group would have gladly joined the local Indian tribe. We would make the same decision if placed in the same situation based on obvious benefits: you don’t die, they have food to eat, and the colonial society is ill-equipped to the environment.
The problem is we still think of the early Indian populations in the same wrong way the early English/Dutch/French settlers did when they arrived. The Pilgrims thought they were more advanced than the natives. But to the extent we define “advanced” as having a prerequisite that you must be able to “survive in the current environment” most of these European groups were primitive in comparison. People who chose to join the natives were making the choice to go from a less advanced society (one that in many cases collapsed entirely due to starvation) to a more advanced one. That doesn’t mean that if you could choose between living in the hot wet forest you’d choose to pick ticks off yourself in an undeveloped wilderness over living in an air-conditioned house with a lawn you have to mow once a week.
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I agree that the idea of using population growth as any kind of metric is almost certainly a bad idea. Once you target a metric like this, you change the metric in unintended ways. Take, for example, a population calculation between rabbits and foxes. Say you characterize the health of the rabbit population by sheer numbers. You start by noticing that when the number of foxes increases the number of rabbits decreases, so your natural prescription is to limit (or eliminate!) fox populations to help the rabbits out. Soon, however, rabbit populations grow out of control, food becomes scarce, and massive numbers of rabbits die of starvation. The survivors all went through similarly horrible experiences, and you eventually conclude maybe fox control was a bad idea.
What you missed in the initial focus on rabbit population is that increased fox populations would lead to limited decreases in rabbit populations, yes, but then that would be followed by decreased fox populations and allow increased rabbit populations again. It’s a cycle that produces a healthy equilibrium. Disrupting that equilibrium can be as easy as targeting a perceived metric.
“But to the extent we define “advanced” as having a prerequisite that you must be able to “survive in the current environment” most of these European groups were primitive in comparison. People who chose to join the natives were making the choice to go from a less advanced society (one that in many cases collapsed entirely due to starvation) to a more advanced one.”
I don’t think this is quite right. The original Jamestown settlement was 100 people. Not much of a society. I think it would be a valid observation to say English ‘society’ was not well equipped to survive in small numbers compared to Native American groups. Although we don’t really know. If for some reason the Old World was cut off, it’s possible Jamestown would have grown very slowly but over the long run would have done quite well in America. Likewise we don’t know what would happen if you took 100 Native Americans and tried to form a ‘colony’ in some other part of the world. Regardless even in the 1600’s it became clear English society was pretty adapt at survival in the Americas and when you had larger numbers, they did very well at surviving.
I believe many of the accounts of Whites forced into Native American society vs Native Americans forced into white society came from later eras where the survival of white society in America was not an issue.
As a point of clarification, the hard endpoints we care about – like overall survival or number of transient ischemic events – are absolutely required by the FDA for most drugs. It is only for some drugs that receive a special ‘breakthrough’ designation that they are allowed to postpone determination of the hard endpoint until after approval. They can focus instead on surrogate endpoints for the time being. Most drugs must provide data to support their primary endpoint, and the FDA requires the drug to meet their primary endpoint for efficacy of hard endpoints.
The argument in favor of something like a ‘breakthrough’ designation is that sometimes measurement of the hard endpoint is infeasible on timescales that make sense for certain diseases. Because of this nobody makes drugs to target those diseases. Take, for example, non-alcoholic fatty liver disease (NAFLD). In a small percentage of patients, this can progress to steatohepatitis followed by extensive fibrosis of the liver, followed eventually by cirrhosis and/or hepatocellular carcinoma. Let’s say you wanted to target a hard, clinically-meaningful endpoint like cirrhosis or HCC. These take years to develop, so a clinical trial that was well-targeted would require patients to dose for five to ten years at a minimum before you’d be able to measure any effect. Meanwhile, perhaps less than 10% of NAFLD patients go on to develop these conditions so you have to recruit lots of patients to see the effect.
Given the rise in obesity (a strong risk factor for NAFLD) this treatment promises to be a huge unmet medical need in the years to come. But no drug company is going to start a clinical trial that knocks over a decade off their patent time to get results, especially if they don’t know they’ll get positive data (and therefore approval) at the end of it. It’s too high risk for too little reward.
What would they do instead? They would probably seek approval based on some other, non-critical medical condition. Say they determine their drug causes some minimal decrease in triglycerides. In rare circumstances severe hypertriglyceridemia can be a cause for concern, but nobody – including the drug company – is really interested in treating the condition. They do the trial anyway, recruit a bunch of patients and test for the predicted decrease in trigs – and the hard endpoints associated with this transient condition. The studies are quick, and they get get approval from the FDA. The drug company releases data from companion studies looking into the efficacy of their drug on surrogate endpoints against NAFLD. Interesting, but not enough to get approval of course. They send scientists out to explain the results to physicians, assuring them this is a good treatment for NAFLD – based on the available evidence – and physicians begin treating their NAFLD patients with the new drug off label. Why? Because there’s no good treatment (other than weight loss) that works for this condition, so the physician wants to do something and this is the best thing he can find.
So the alternative is that pharma games the system, which some will do anyway, and everybody officially ignores the disease no matter how bad things get. The ‘breakthrough’ designation isn’t perfect, but it doesn’t get you off the hook of providing the follow-up study showing efficacy based on primary endpoints either. That data is still required. And if you don’t provide it, the FDA has the power to pull your drug’s approval.
The catch to that is that they never actually go through with pulling approval. The headlines about the FDA pulling a ‘potentially life-saving drug from the market’ write themselves. An uneducated press agent looks at the research – all of it suggesting surrogate endpoints related to the disease are improving – and a viral social media campaign erodes what confidence people still have in the FDA’s judgement down to nothing. So it’s an empty threat. Indeed, pharma knows this since a few companies have already called their bluff on this, making no effort to provide the requisite follow-up studies with anything like urgency, and they’ve received no punitive action as a result.
The problem isn’t so much that the clinical research industry is bad at focusing on hard endpoints. The problem is that the incentives inherent in the system encourage multiple parties involved to ignore difficult-to-measure hard endpoints. You said this last part above, but I wanted to correct some of the finer details.
It is interesting how long the awareness of the cholesterol-heart attack link has been around, and how little is really settled. I remember reading an article by Thomas Moore in the Atlantic, back in 1989 that made the point that although the correlation between cholesterol and heart disease was clear, it is much less clear that lowering cholesterol by artificial means will result in a lowering of heart disease. I made this point with my doctor when he prescribed a statin for me. He assured me that the use of statins had been validated to reduce deaths due to heart disease. I tried the statin for a week and it made me feel like crap, so I quit taking them. When I told the doctor, he didn’t disagree. Although he felt lowering cholesterol was a worthy goal, he didn’t feel it had enough value to justify the side effects of statin use.
There’s much better evidence that raising HDL is protective against cardiac risk, but that’s not as easily medicated as letting LDL. In that sense much of pharmaceutical development ends up like the old story about looking for your keys under the lamppost because that’s where the light it.
I’ve heard changing your diet to include sources of monounsaturated fats helps with this. Meats are great sources of healthy fats, often moreso than expensive topical oils.
It does seem like cardiac related deaths have fallen dramatically since 1980. Since then we have seen a big increase in drug use to lower cholesterol and lower BP. If the surrogate endpoint was invalid then that effort is wasted but nonetheless we are managing to pull off fewer deaths. The answer almost certainly is not a mass change in people embracing better diets and exercise as obesity has increased over that time.
A counter argument might be that we are just very good at saving people when they have a heart attack. Possible that is contributing something I suppose.
“When I told the doctor, he didn’t disagree. Although he felt lowering cholesterol was a worthy goal, he didn’t feel it had enough value to justify the side effects of statin use.”
Here’s the rub I think with this. It’s a bit like vaccines. You are probably not going to get the disease you are being vaccinated against anyway. So in that sense the vaccine is likely to not do anything for you. To the doctor, though, if he has 1000 patients vaccinated he will see, say, 200 fewer cases. To the doctor that’s a lot of saving but to 800 patients they got nothing out of the deal. Strictly speaking…and that’s a very strictly speaking.
Hence your doctor initially pushing you on the drug then seeming to be ok letting you get off it when you made a fuss. Using the above example, the doctor would push the vaccine on 1000 patients but if 1 patient felt it was giving him some bad side effect, the doctor could shrug and say ‘don’t bother with it then’ as there would be an 80% chance he wouldn’t get sick anyway.
Of course vaccines are a bit more immediate affairs. The statins work over years to reduce risks so the doctor would have time with you to see if other things like lifestyle or newer drugs might be a better fit for you.
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a6.htm
https://www.stateofobesity.org/obesity-rates-trends-overview/