3 ms·

The problem here is that we have a condition ("jumping out of aeroplanes") where, without an intervention ("give the patient a parachute") the consequences are

by cstross 14y ago

The problem here is that we have a condition ("jumping out of aeroplanes") where, without an intervention ("give the patient a parachute") the consequences are almost certainly fatal (yes, a handful of people have survived falls from altitude without parachutes: but a fatal outcome is sufficiently certain that defenestration has historically been used as a means of execution). It's a major ethics no-no to expose healthy patients to potentially-fatal environments. It's also a major ethics no-no to withhold known life-saving treatment in the name of continuing a trial. So we can't contrive a proper randomized double-blind placebo-controlled test of the life-saving efficacy of parachutes, where we push people out of planes repeatedly to see how many survive without a parachute vs. with a parachute. We can't test parachutes any more than we can contrive an evidence-based test of the efficacy of being-rescued-from-burning-buildings-by-firefighters, by arranging for a city's fire department to randomly not rescue half the victims of house fires, so that we can subsequently compare their survival rate with the survival rate of those who were rescued. Basically, evidence-based assessment of medical treatments breaks down when it hits the edge condition defined by the patients automatically dying if not treated. At best we can compare different types of parachute, or different types of emergency tratment, and see which has a lower associated mortality rate. But we can't, ethically, compare treatment/no-treatment if there's a high likelihood of no-treatment resulting in death.

knowtheory 14y ago
But the thing is that you can use proxies to study this to an extent. Amongst rock climbers there is a naturally occurring population of free climbers, and it is possible to note the type and severity of injuries between different types of rock climbers (although i'm guessing your n is going to be low). The safety of parachutes themselves is an interesting question because they're not used as a preventative mechanism, I think that's the primary difference between them and climbing ropes/harnesses/pitons. Edit: I just noticed that I didn't address the randomized component. I'd still argue that evidence based medicine can actually include arguments that aren't randomized trials. That said, randomized trials are still one of the strongest sort of argument that can be made. As noted above, seatbelts are another sort of device that I don't think we need randomized trials to test the efficacy of. p.s. Just finished (and enjoyed) the Apocalypse Codex. The Laundry Files is one of my favorite series of books as someone who's always believed that empiricism and existentialism are reconcilable. Please write more :)
- cstross 14y ago
  Please write more :) I'm writing #5 right now. Publication due in mid-2014.
  - knieveltech 14y ago
    Please excuse the hijack, anything in the pipeline for release in 2013?
    - gjm11 14y ago
      http://www.antipope.org/charlie/blog-static/2012/10/still-under-siege.html http://www.antipope.org/charlie/blog-static/2012/10/still-un... mentions "Neptune's Brood", space-opera set 5k years after "Saturn's Children" but it sounds like it may not actually be coming out until next year, along with three volumes of Merchant Princes (the existing books, in omnibus editions with minor changes) and maybe a UK edition of "The rapture of the nerds".
      - cstross 14y ago
        "Neptune's Brood" comes out in July 2013. (It's a high-concept space opera and a meditation on the 2007-08 liquidity crisis. Also, nominally, a sequel to 2008's Hugo-nominated "Saturn's Children".) "The Rhesus Chart" is in the pipeline for July 2014. The other stuff is all, effectively, reprints.
- thwest 14y ago
  You might be interested in this annual compilation http://americanalpineclub.org/p/anam http://americanalpineclub.org/p/anam
makomk 14y ago
> It's also a major ethics no-no to withhold known life-saving treatment in the name of continuing a trial. The problem with this, of course, is that under certain circumstances terminating trials early for ethical reasons causes them to conclude that the treatment works when it doesn't. Actually, pretty much all the apparently well thought-out ethical restrictions can lead to disaster, and there's even a set of studies that manages to accidentally demonstrate all of them - the randomized controlled trials into circumcision as a form of HIV prevention in Africa. In addition to rather unwisely terminating the study early, they were also careful to use sterile surgical instruments, made sure to inform the participants that they'd still need to use condoms and give them a supply of condoms and education on how to use them, and ensured that the newly-circumcised individuals refrained from sex whilst their wounds healed. All perfectly reasonable ethical requirements, and not ones we'd want to do away with. Unfortunately, the actual interventions that have been made based on this study have none of those features. Men are being circumcised with bloody instruments, under the belief that this means they don't have to use condoms anymore, and any funding that's going towards circumcision is funding that's not being used to supply condoms and condom education. The difference between what's actually happening and what can ethically be studied is huge and most likely fatal. I suspect the whole thing's going to end up turning out to be another ill-conceived Western intervention that sows distrust a few years down the line.

by cstross 14y ago

knowtheory 14y ago

But the thing is that you can use proxies to study this to an extent. Amongst rock climbers there is a naturally occurring population of free climbers, and it is possible to note the type and severity of injuries between different types of rock climbers (although i'm guessing your n is going to be low). The safety of parachutes themselves is an interesting question because they're not used as a preventative mechanism, I think that's the primary difference between them and climbing ropes/harnesses/pitons. Edit: I just noticed that I didn't address the randomized component. I'd still argue that evidence based medicine can actually include arguments that aren't randomized trials. That said, randomized trials are still one of the strongest sort of argument that can be made. As noted above, seatbelts are another sort of device that I don't think we need randomized trials to test the efficacy of. p.s. Just finished (and enjoyed) the Apocalypse Codex. The Laundry Files is one of my favorite series of books as someone who's always believed that empiricism and existentialism are reconcilable. Please write more :)

cstross 14y ago
Please write more :) I'm writing #5 right now. Publication due in mid-2014.
- knieveltech 14y ago
  Please excuse the hijack, anything in the pipeline for release in 2013?
  - gjm11 14y ago
    http://www.antipope.org/charlie/blog-static/2012/10/still-under-siege.html http://www.antipope.org/charlie/blog-static/2012/10/still-un... mentions "Neptune's Brood", space-opera set 5k years after "Saturn's Children" but it sounds like it may not actually be coming out until next year, along with three volumes of Merchant Princes (the existing books, in omnibus editions with minor changes) and maybe a UK edition of "The rapture of the nerds".
    - cstross 14y ago
      "Neptune's Brood" comes out in July 2013. (It's a high-concept space opera and a meditation on the 2007-08 liquidity crisis. Also, nominally, a sequel to 2008's Hugo-nominated "Saturn's Children".) "The Rhesus Chart" is in the pipeline for July 2014. The other stuff is all, effectively, reprints.
thwest 14y ago
You might be interested in this annual compilation http://americanalpineclub.org/p/anam http://americanalpineclub.org/p/anam

makomk 14y ago

> It's also a major ethics no-no to withhold known life-saving treatment in the name of continuing a trial. The problem with this, of course, is that under certain circumstances terminating trials early for ethical reasons causes them to conclude that the treatment works when it doesn't. Actually, pretty much all the apparently well thought-out ethical restrictions can lead to disaster, and there's even a set of studies that manages to accidentally demonstrate all of them - the randomized controlled trials into circumcision as a form of HIV prevention in Africa. In addition to rather unwisely terminating the study early, they were also careful to use sterile surgical instruments, made sure to inform the participants that they'd still need to use condoms and give them a supply of condoms and education on how to use them, and ensured that the newly-circumcised individuals refrained from sex whilst their wounds healed. All perfectly reasonable ethical requirements, and not ones we'd want to do away with. Unfortunately, the actual interventions that have been made based on this study have none of those features. Men are being circumcised with bloody instruments, under the belief that this means they don't have to use condoms anymore, and any funding that's going towards circumcision is funding that's not being used to supply condoms and condom education. The difference between what's actually happening and what can ethically be studied is huge and most likely fatal. I suspect the whole thing's going to end up turning out to be another ill-conceived Western intervention that sows distrust a few years down the line.