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Fish – Now By Prescription


LOVAZA™®© (ask your doctor if LOVAZA™®© is right for you) is an excellent medication. It is extraordinarily safe. It is moderately effective at its legal indication of lowering levels of certain fats in the bloodstream. It has moderately good evidence for having other beneficial effects as well, including treating certain psychiatric, rheumatological and dermatological disorders.

LOVAZA™®© is fish oil.

“Come on,” you say, “surely there’s some difference between Lovaza™®© and the fish oil I buy at my local health food store for a couple of tenners per Giant Jar?”

And you are right. The difference is, LOVAZA™®© costs $300 a month.

“Come on,” you say, “surely there’s some other difference”.

The company behind LOVAZA™®© certainly thinks there is. They boast about how they use a patented process to filter out blah blah purity blah toxins blah certified to be blah blah blah quality blah. On the other hand, every fish oil supplement maker uses about the same phrases. I’m sure it’s not exactly the same patented process and that they check for toxins in a slightly different way, but the evidence that LOVAZA™®©’s methods are superior in some interesting way is, basically, nonexistent.

So, fish oil pills cost $30 at the store, LOVAZA™®© costs $300, which would you rather get?

And the answer is: the LOVAZA™®©, of course. Because you’re paying the $30 for fish oil, and your insurance is paying the $300 for LOVAZA™®©. Maybe you’ve got a copay. Is the copay more or less than $30? Well, there you go.

This isn’t an unusual business model. Off the top of my head I can think of a second drug that works the same way. It is called DEPLIN™®©, and it treats depression. On the one hand, it is a good medicine and I wish it was used more. On the other hand, it is l-methylfolate, which is basically a very shiny chrome-plated version of the folate that your cereal box tells you it has 200% of the recommended daily allowance of. Most studies suggest that for most people without a particular mutation there’s not much difference between the folate in your Cheerios and the l-methylfolate in DEPLIN™®© – but if you have the mutation or are among the significant minority of people who believe there is, you can also walk into a health food store and buy l-methylfolate itself, chemically identical to DEPLIN™®©, at about $10 per Giant Jar. DEPLIN™®© costs $100 per month.

Ask your doctor whether she recommends people go to supplement stores and buy folate or fish oil, and likely she’ll say supplements sometimes make people feel livelier but that they have minimal place in responsible medical practice. Then ask your doctor whether she gives out prescriptions for LOVAZA™®© and DEPLIN™®© and she may very well tell you she writes a dozen of them a day.


When I search the web for people’s LOVAZA™®© and DEPLIN™®© opinions, I see a lot of people talking about greedy pharmaceutical companies. Fair enough. Pharmaceutical companies are pretty greedy, and it’s hard to deny that’s a pretty big factor in how these kinds of drugs (I don’t know a good category name for them, but DEPLIN™®© bills itself as a “medical food”, so we’ll go with that) come to be.

This blog sometimes looks at things from a libertarian perspective. The libertarian perspective says that usually if a for-profit company is making money, it’s probably providing someone with a service somewhere. Is the public getting any service from LOVAZA™®© and DEPLIN™®©?

I say: yes! The companies behind these two drugs are doing God’s work; they are making the world a much better place. Their service is performing the appropriate rituals to allow these substances into the mainstream medical system.

A doctor who prescribes boring regular old supplement fish oil pills is taking a dangerous step into uncharted territory. If anything goes wrong and their conduct comes under review, a clever lawyer could say “I notice your patient had severe hypertriglyceridaemia, a very dangerous condition, and instead of giving her any medicine, you just told her to get fish oil from her local health food store! Fish oil has never been FDA-approved and you have only your personal opinion that it does anything at all.”

And that’s if the patient even gets the fish oil. What does the insurance company say if there’s a patient too poor to pay the $30 for a Giant Jar? This is really common, both in a “a lot of people are legitimately poor and only able to get things Medicaid subsidizes for them” way, and in a way that’s sort of the reverse of how people can always find $50 a day to support their heroin habit. “You want me to pay money for pills to treat a condition which is not at this moment causing my limbs to fall off? Sorry, can’t afford it.” But insurance companies will laugh in your face if you ask them to pay for some random supplement at a health food store which is made out of some slimy animal that swims in the ocean and which doesn’t even have a ® after its name.

And this is even assuming there’s a health food store to get it at. What if you’re in a hospital? Or a nursing home? They don’t have health food stores. They just purchase a bunch of medications, put it all in a big room somewhere, and dispense it to patients who need it. Exactly which medications they purchase is highly highly regulated both by government laws and internal regulations, and it is probably not going to include a Giant Jar of fish oil pills.

I mentioned before that, in a hospital pharmacy stocked with hundreds of different rare and wonderful substances – substances that must be kept frozen at very specific temperatures, substances that can only be given through complicated surgical tubing, substances which must have the dose be absolutely right to within a thousandth of a gram or they will kill you instantly – they don’t have melatonin. The drug that is probably in the bathroom cabinet of half the people reading this post is totally missing. Because it’s not Official.

The point of LOVAZA™®© and DEPLIN™®© is to make fish oil and folate Official. I wish someone would do the same with melatonin so I could start prescribing it in-hospital already.

The high prices of these drugs? Likely at least in part an attempt to recoup costs. In order to make them Official, their parent companies had to perform very specific studies on them. Not just “there are hundreds of studies on fish oil, we’ll just attach them to an email and cc the FDA”. No, that would be too easy. They had to perform exactly the studies the FDA wanted, using fish oil that came from their factory, with their patented process of extraction. That was a couple million to a couple billion dollars. Then they had to hire a bunch of lawyers and lobbyists to make the FDA like them. Then they had to price in the cost of risk from the dozen drugs they try to develop that never get approved and make zero money. Then they had to hire really pretty women to go around to doctors and give them nice pens that say LOVAZA™®© on them, because despite attending medical school for four years and residency for another three, the number one way doctors learn about drugs is through pens with the drugs’ names on them given to them by pretty women. Then lawyers and accountants and executives had to go through a bizarre process in which they all argued among themselves about how much LOVAZA™®© should cost and who should pay for it, which ended up, like all such drug negotiations end up, with parties A, B, and C marking up the sticker price by ten times, parties X, Y, and Z demanding it at one tenth the sticker price, and both sides thinking they pulled a fast one on the other while everybody else facepalms.

My point is, the drug companies are probably making an obscene profit off of it, but less obscene than you might imagine from their ability to stick a fish in a blender and sell you what comes out the other side for $300.

And if you’re still not convinced that this whole thing benefits society, think about this.

Naturopaths and alternative medicine people and “healers” of all sorts have a common form of apologetics for their chosen folk remedy: “Everyone ‘in the know’ has figured out this is a miracle cure, but because it just grows out of the ground Big Pharma can’t make a profit off of it. That’s why they’re suppressing it and poisoning you with toxic medications instead.”

And I used to think that the alternative medicine people were overestimating how evil Big Pharma was. But now I know that’s not right.

Now I know they’re underestimating it.

If it were discovered tomorrow that potatoes cured cancer, then people wouldn’t “suppress” this “natural” remedy. Two years from now there would be an ultrapurified potato extract called POTAXOR™®© that was, on closer examination, physically and chemically identical to mashed potatoes. But these mashed potatoes would be mashed in a giant centrifuge by scientists with five Ph. Ds each. Any time someone got cancer, their doctor would prescribe POTAXOR™®© and charge $6,000 per dose, and the patient would get better, and the thought of just going out and eating a potato would never occur to anybody. Not to the doctor, who doesn’t want to sound like the idiot who tells her cancer patients to eat potatoes. Not to the FDA, who doesn’t know whether potatoes might be contaminated with lead or potato fungus or ketchup or God-knows-what. And certainly not to the patient. They would have to pay 60 cents for a potato at the supermarket, but if they have a good enough insurance the POTAXOR™®© is free!

This system, bizarre as it is, is your guarantee against the pharmaceutical companies suppressing a promising new natural medication. Your insurance company pays $300 on fish oil, and in exchange you go to sleep at night secure that no one has discovered that potatoes cure cancer but decided to cover it up to protect their bottom line. Good deal? Given the current health system, it’s better than you had any right to expect.


I promised yesterday I’d talk about a Jacobin article, so here it is: Bad Science.

Apparently there’s a company called Myriad Genetics which charges a lot of money to test BRCA1 and BRCA2, two genes in which mutations are associated with a very high risk of breast cancer. This is outrageous because genetic testing is very cheap. Worse, they don’t even have the excuse of “the customer is paying extra to reimburse the cost of the research that discovered this”, because the relevant research was done by the government at public expense. From the Jacobin article I don’t understand exactly what their patent/monopoly status is, but it seems to be enough that they can price gouge without repercussion.

I don’t want to comment on the broader points about the scientific community Jacobin is making, but when I read that I thought “Wait! I had an opinion about BRCA testing at one point!”

Yeah. After searching my memory I remembered that the FDA recently banned popular genetic sequencing companies like 23andMe from offering BRCA testing bundled with their other services. The problem was that 23andMe was nonprescription. It was outside the Official Medical System. It was fish oil, not LOVAZA™®©. I was pretty annoyed about that decision.

But after reading this new article I have learned something that puts the whole thing in a new light. Whole genome sequencing companies can sequence all 20,000 or so coding genes for about $1000. Myriad Genetics will sequence two genes for $3000.

[EDIT: Douglas Knight, more expert in this area than I, discusses some of the subtleties here: 1, 2, 3]

I’m not saying that the FDA is in bed with the genetic testing companies. But if the head of the FDA gives birth to a child who looks suspiciously similar to the CEO of Myriad Genetics, I hope her husband gets a paternity test. Assuming those haven’t gotten banned yet.

I am willing to write off LOVAZA™®© as a weird but successful way of adapting to an increasingly crazy medical system. I even find it darkly hilarious. But the high cost of BRCA testing probably turns off a lot of women who would otherwise get the test, and some of them probably develop preventable breast cancer. LOVAZA™®© is a farce. BRCA is a tragedy.

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90 Responses to Fish – Now By Prescription

  1. Ialdabaoth says:

    And this kind of gets to the heart of the kind of libertarianism I like, which is less “yay corporations, boo government” and more “yay corporations and government both doing their own thing, boo perverted incestuous relationships between them”.

    Malthusianism time: any system where corporations and government each do their own thing, will rapidly evolve into a system with an incestuous relationship between corporations and government.

    The Libertarian approach (minimize the size of government) doesn’t work, because then the corporations just grow to fill the gap, and form collusions that mirror the services they want from government (mainly, price-fixing and rent-seeking).

    The Socialist approach (minimize the size of corporations) doesn’t work, because then the government just grows to fill the gap, and forms bureaucracies that mirror the services they want from corporations (rent extraction and behavioral manipulation).

    The Reactionary approach (merge government and corporations into a single thing, and just give them direct power to do whatever the hell they want) doesn’t work, because you don’t just throw your hands up when you can’t make things better and decide to make things WORSE, because “hey, at least it’s HONEST.”

    The Technocratic approach (give control to people who actually know what the hell they’re doing, and let them guide things towards specific ends) doesn’t work, because the only people who can judge their decisions are other experts, and it’s too easy for them to just manipulate their assigned goals into rent-seeking and power-grabbing and what-not.

    We just need a better humanity.

    • suntzuanime says:

      The “at least it’s honest” comes from the idea that there are costs to dishonesty, such as, for example, paying a factor of ten more for our fish oil and genetic testing. The idea is, if nothing works, at least we should not keep paying this cost and tainting our hearts with hypocrisy.

      If nothing works, this seems basically correct to me. Your proposal to get a better humanity has been tried, and the results were sufficiently traumatic that you don’t even list the ideologies that tried them on your list of approaches.

    • anon says:

      Can we limit either governments or corporations by using something else entirely? Social and cultural norms are at least a hypothetical constraint, and certain sorts of decision theory could work too. There might be other options as well.

    • Eli says:

      Put simply, no, we need people who can admit that life is complex and one big idea is not going to solve all their problems.

      (Please note that this excludes omni-ideas genuinely capable of holding all that complexity in themselves, like “Goodness” or “world optimization.”)

      For instance, of the social systems you’ve NOT listed because they don’t consist of One Big Single Thing, the system that has generally given the most people the nicest lives is social democracy. IMNSHO, syndicalism has also worked wonders.

      I think if you examine these ideas, you’ll find that they work for defined reasons. Apparently these are nonobvious enough that I’ll have to get around to posting to my own blog on the subject.

      • Michael Edward Vassar says:

        That would be great to learn about.

      • Samuel Skinner says:

        Syndicalism doesn’t tend to work over a certain size. The biggest syndicate is 60,000 workers and that is only because it is made of multiple smaller ones bundled together.

        Also syndicalism requires a large degree of trust between members to function, has issues with optimal hiring and getting capital to start new businesses.

    • Sarah says:

      If your enemy is basically Coase, then my guess is that you want to develop tools that make it easier to be a new company.

      This includes stuff that lowers cost barriers to entry (the way AWS does in tech) and something like behavioral changes in the public to make cartel laws unenforceable.

      For example: the political climate seems to be trending towards pot legalization because so many people use pot. When there is enormous demand for an illegal product, you can’t actually enforce laws against it very well, and eventually those laws may be repealed. If people knew that they could get Canadian tetrabenazine, in the same way they know they can get pot, there would be actual pressure on the drug companies and government.

      • Nornagest says:

        the political climate seems to be trending towards pot legalization because so many people use pot.

        And it only took, what, seventy-five years?

    • Drake. says:

      i am very thankful that this comment didn’t end with “the X approach does work, because…”

    • Nornagest says:

      Requirements not actionable. Requesting clarification.

      …would be the title of the Cachezilla ticket I’d submit if this came up at work.

  2. Ialdabaoth says:

    The “at least it’s honest” comes from the idea that there are costs to dishonesty, such as, for example, paying a factor of ten more for our fish oil and genetic testing. The idea is, if nothing works, at least we should not keep paying this cost and tainting our hearts with hypocrisy.

    And my assertion is that the costs of dishonesty are less than the costs of depraved, vicious honesty. When you at least have to keep up the shabby *pretense* of not hosing your subjects, you are prevented from the most egregious of abuses.

    I can’t imagine why you’d think that an autocratic sovereign wouldn’t just hike the price up to at *least* 10x what it should be, just because. At least with the pretense, things can’t slip more than two orders of magnitude out of whack without the gig being up.

    • suntzuanime says:

      Man, if I were made autocratic sovereign, jacking up the price of fish oil would not crack the top thousand on my list of things to do.

      • Ialdabaoth says:

        Man, if I were made autocratic sovereign, jacking up the price of fish oil would not crack the top thousand on my list of things to do.

        Of course it wouldn’t. But “appointing people to be in charge of fish-oil production” – or at the very least, “appointing people to be in charge of appointing people to various industries, including fish oil production” probably *would* be.

        At some point someone makes a decision. Will they make that decision in your interest, in the people’s interest, or in THEIR interest? Especially considering, as you just attested, that the price of fish oil isn’t even in the top 1000 list of your concerns?

        • suntzuanime says:

          “The people who make decisions about fish oil make decisions in their own interests” is the system we have now. If they could be honest about it, maybe we at least wouldn’t have to waste effort on pointless studies proving that fish oil does the things it’s already been proven to do. And of course there is the moral argument, that hypocrisy corrupts the soul much more than bare exercise of power does.

        • Ialdabaoth says:

          I’ve seen too much raw power up close and personal to buy that.

    • jaimeastorga2000 says:

      I can’t imagine why you’d think that an autocratic sovereign wouldn’t just hike the price up to at *least* 10x what it should be, just because. At least with the pretense, things can’t slip more than two orders of magnitude out of whack without the gig being up.

      An autocratic sovereign is at least constrained by its own self-interest (cf. Fnargl, Laffer curve), and is less likely to face the kind of coordination problems James A. Donald describes in the comment section of “Premises of the Dark Enlightenment”:

      This is the myth that the US government has unusually low corruption. That is only so if you see lower class corruption, and fail to see cathedral class corruption. To get anything done in the US you need a “consultant”, which is to say person who has a special in with the bureaucrats. You give him some money, and he then gives the bureaucrats some money.

      The problem is not corruption, nor is it tyranny, rather the problem is anarcho tyranny. If you need the approval of one guy to be allowed to create value, you will pay him his cut, then create value. If you need the approval of a hundred people to create value, they will each want ten percent, for a total of a thousand percent, you are just not going to be able to create value.

      Things come to a halt. Then, to get things moving, an “inner ring” is apt to form, a small conspiracy of people who by various means of influence, can get approvals in blocks, forcing each approver of a hundred approvers to accept less than one percent of the added value, providing order in the anarchy of government. However, the inner ring tends to rely on people of the same ethnicity who went to the same school and go to the same church. Inner rings collapse under the impact of affirmative action, which is what is happening now.

      Observe Chicago for counter examples. The corruption produces greater dysfunction without an inner ring, because the state becomes more anarchic (tragedy of the commons) without an inner ring.

      For example, obviously regulation produces revenue for regulators, in the form of payoffs through “consultants”, in the form of direct payouts, for example Angelo and the “friends of Angelo”, and in the form of the revolving door, for example Jon Corzine, the man of many hats. Thus each regulator is incentivized to produce more regulation, resulting in today’s extraordinary avalanche of regulation. An inner ring would say “Hey, hold back, you are killing our golden goose. Your regulations are cutting the squeeze we get from our regulations.” The function of the inner ring is to stint the commons.

      • Desertopa says:

        “An autocratic sovereign is at least constrained by its own self-interest (cf. Fnargl, Laffer curve”

        I don’t buy that the Fnargle scenario accurately describes a course of action that would be in Fnargle’s best interests. Fnargle is basically omnipotent and can respond to human opposition with overwhelming force, and doesn’t care about the well being of humans? He’s better off enslaving everyone. Yes, some infrastructure is necessary to support the slavery. He can enslave people for that too, they’ll work harder. You can extract a *lot* of work from people on the threat of killing their families if they slack off. Fnargle doesn’t have to worry about slave revolts, he’s much too powerful for humans to resist, and he’s not worried about the humanitarian consequences.

        In colonizing powers with sufficiently strong profit motivation, and sufficiently low humanitarian motive, this system has seen a lot of use, even without the advantage of effective omnipotence, because it’s simply so much more profitable than laissez-faire imperialism.

        • Nornagest says:

          Outside of subsistence or low-tech extractive economies, slavery tends to die out, or to evolve to a point where it looks more like a complicated and fairly subtle caste system than the simple and brutal chattel systems we’re most familiar with. I haven’t thought too hard about why this is, but the first thing that comes to mind is informational constraints: you can push your slaves arbitrarily hard as long as you know exactly what they should be doing, but the moment they know more than you do about their jobs is the moment when you stop being able to effectively tell when they’re slacking off (or, worse, participating in what’s charmingly known as “malicious compliance”). Sufficiently grandiose threats might delay the onset of slack, but I don’t think they can stop it entirely.

          Even in those low-tech settings I’m not sure what’s optimal. Serfdom — easily the most common form of unfree labor in Western history — is set up a lot more like Fnargl than like a 1700s sugarcane plantation in Saint-Domingue, economically speaking: it boils down to “keep the serfs from running away and take some percentage of their produce and/or labor time”, where that percentage is set such that most of them can just about avoid utter destitution by their own means.

        • Steve Johnson says:

          Nornagest says:
          June 16, 2014 at 1:46 pm

          “Outside of subsistence or low-tech extractive economies, slavery tends to die out, or to evolve to a point where it looks more like a complicated and fairly subtle caste system than the simple and brutal chattel systems we’re most familiar with. I haven’t thought too hard about why this is…”

          Quite simply it’s because of the abilities and inclinations of the populations of societies that are capable of sustaining and creating economies that are more advanced than subsistence or low-tech extraction. Populations that can do that have members who can arrange their own affairs and provide for their own care.

          Populations composed of people with poor future time orientation cannot make profitable business arrangements because they cannot fulfill contracts that require future performance. In a non-sustenance level economy people like that either starve or are fed and sheltered by others. Since people are self-interested they extract something in exchange for taking on people as wards – either labor in the case of slavery or votes in the case of progressive democracy.

          If the whole society is made up of such people it never develops an economy more advanced than sustenance level.

        • Fnord says:

          Serfdom just IS a caste system. It’s not, as far as I can tell, slavery evolved into a caste system. Indeed, it seems to the opposite: an economic caste system of tenant farmers beholden to land owners formalized into law. It’s not evidence that slavery tends to evolve into a caste systems if it didn’t evolve from slavery in the first place.

  3. Eli says:

    And this kind of gets to the heart of the kind of libertarianism I like

    Has it occurred to you that Marxists also oppose the state’s capture by private profiteer-interests, and that you therefore have no need of libertarianism given your leftism?


    • suntzuanime says:

      Marxists don’t oppose private profiteer-interests’ capture by the state, which is equally important.

      • Eli says:

        Actually, we split down the middle on that one. State-socialists want to nationalize many/most firms. Syndicalists just want to give ownership of firms to workers, institute democratic elections for the management structure, and then leave things running in a worker-owned market system.

        I’m mostly a syndicalist, though I do think any reasonable person can see the case for nationalization in case of things like natural resources or infrastructure.

    • Scott Alexander says:

      I deleted that paragraph since I realized I have no evidence at all that the company influenced the FDA’s decision. Most likely the FDA just believes things about the importance of prescriptions which happen to benefit that company.

      Which libertarianism seems to deal with better than generic-leftism does.

  4. anon says:

    Thanks for boosting my confidence in supplements by a lot. I now will view and research them as something to potentially apply in my own life rather than something to be abstractly curious about. Always nice to gain new opportunities for improvement.

    Interesting to hear you endorse fish oil, as well. I might have been reversing stupidity by doubting that it helped people. I need to give this a second look.

    • Geirr says:

      Eating fish is massively better than taking fish oil FWIW. Romeo Stevens of LW aka nazgulnarsil at HN did a large write up on LW recently on Optimal Nutrition. He also founded a startup to market MealSquares, his contribution to complete nutrition in one product, like Soylent, but a solid food.

      I remember him not being enthusiastic about fish oil because it’s less efficacious than eating oily fish, to the extent that taking enough fish oil pills to get the same effect can have dangerous blood thinning effects.

      • Ghatanathoah says:

        Fish oil pills do have one big advantage over oily fish. They don’t taste terrible.

        Another big advantage is calories, if I eat an oily fish, especially one that is breaded so that it doesn’t taste as bad, I’ll use up a lot of my daily allotment of calories, which is a problem if I’m trying to diet. A pill, by contrast, has far fewer calories. This way one can save one’s calories for something worth eating, like pizza or chocolate.

        Plus you also might overeat because you’ll have to expend willpower to force yourself to eat yucky fish, at which point you might not have enough willpower to stop from eating other foods. Oily fish might have a greater effect, but they can also have greater costs.

        Plus there’s that mercury thing Doug S. mentioned. Especially considering the fish that are the least horrible tasting (i.e. tuna, salmon) are the most full of mercury.

        I think one major reason for my viewpoint is that I believe that eating functions as both nutrition and entertainment, and optimizing one at the expense of the other is a bad idea.

        • Nornagest says:

          If you think oily fish tastes terrible, you’re eating the wrong oily fish or preparing it wrong. Salmon’s reliably tasty if you don’t overcook it; I have no idea why people like to bake it, though, since that’s probably the easiest way to turn it into a tasteless slab of tapioca-like fish matter. Fresh rainbow trout is even better. Forage fish like sardines aren’t so great eaten straight, but work well in jambalaya or miso soup. Sushi is almost always delicious, but it’s also expensive.

          This does work better if you live near a coast, though. Freshness matters more for fish than for most other things.

          (Incidentally, salmon is actually one of the least mercuric food fish, although tuna is indeed high enough in mercury that I try not to eat it much. See the link I posted below.)

          • Flavors aren’t objective, though it might be worth getting salmon from a restaurant with a good reputation to see whether there’s any hope of liking it.

        • Ialdabaoth says:

          Baking salmon with a nice honey glaze is a good option for people who aren’t sure about eating fish. (In the newer thread, I have a recipe that I swear by, that several people who “don’t like fish” have requested from me.)

          Tuna is another fish that, like salmon, is easy to make less-fishy – and if I recall correctly, yellowfin / ahi tends to be lower in mercury due to its place on the food-change. Just get fresh steak cuts rather than eating out of a can (again, check the other thread for a recipe).

        • Nornagest says:

          According to the Wikipedia page, skipjack has about half the mercury of yellowfin or albacore, and bigeye tuna has twice. That’s only a small selection of edible tuna, though. Generally speaking, I’d expect larger species to have more mercury, but all of the above are an order of magnitude or so above what you find in salmon.

        • Ghatanathoah says:


          I will try some of that advice. I have sometimes liked sushi, especially if it has some kind of spicy sauce on it. It’s possible that I will like oily fish if it is fairly flavorless, but has something spicy slathered on it, in the same way I like salads with dressing.

          I’ve tried fish intermittently all my life and not terribly liked it unless it had something added to it, like breading or sauce. Putting it in something with flavor like jambalaya sounds like a good suggestion.

          I am of course aware that many other people probably do not hate fish as much as I do. But I thought that writing from a faux-objective perspective might help underline that it is a big problem for me.

    • Scott Alexander says:

      I agree eating fish is better than fish oil. The FDA only approves Lovaza in case of MASSIVELY elevated triglycerides, which most people don’t have. Cardiovascular benefits are likely exaggerated. Psychiatric benefits are fascinating but currently on shaky ground.

      • Doug S. says:

        Many fish have non-trivial levels of mercury in them, to the point that eating a lot of them can make you very sick. You can mostly blame coal power plants for that.

        • Nornagest says:

          IIRC, that’s mostly a problem for large pelagic predatory fish like tuna, swordfish, and shark. Medium-sized ocean fish like mahi-mahi, and bottom-dwellers like halibut, have less; small schooling fish like sardines, less still; herbivores, and freshwater fish like trout, almost none.

          Wikipedia has the details. The bit that confuses me is that it cites filter-feeding as a contributor, and yet bivalves generally have very little mercury; I don’t know why.

    • speedwell says:

      I knew I’d saved this for something…

      Promising. My brother and his rheumatologist have been using this for several years to help manage his rheumatoid arthritis (it is effective for the inflammation), and he says his diabetic blood sugar numbers and foot neuropathy also improved (there is some evidence diabetes is or is associated with autoimmunity issues). It took several weeks to see the effects. In his case the blood thinning effect may even be medically desirable.

  5. Douglas Knight says:

    genetic testing is very cheap

    That’s not really true. Myriad does not charge $4000 for a subset of 23andme. Probably you could get your exome sequenced for $1k and that would cover Myriad, but that’s not exactly an off-the-shelf product. 23andme (as of v3) only checks for 3 specific BRCA problems that are common (1%) in Ashkenazi. Myriad will check those for $300. 23andme doesn’t check for the BRCA problems that are common (1%) in the Dutch, like Angelina Jolie, but Myriad will test for them for $300.

    But the big thing is that most people with broken BRCA have a mutation unique to their family. 23andme simply can’t test for this with generic SNP tests. The only thing you can do is sequence the whole gene. That’s what Myriad does for $4000. And after they do it, they design a new test for $300 a head to give to all your relatives. So it’s not a 40:1 markup. In fact, if there are 6 or more women in your family, Myriad is cheaper than the alternative.

    (Also, 23andme and Myriad will both discuss minor BRCA variants and say that you have an extra 10% RR of breast cancer. I doubt it’s true, but it’s worthless information. A fully broken BRCA is a big deal: 80% of dying of breast cancer, probably middle aged.)

    • Scott Alexander says:

      Thank you. I did understand the difference between SNP and whole-genome sequencing, but I got the impression somehow that Myriad just tested BRCA SNPs. If they sequence the whole gene, that changes the post quite a bit. I have edited the original article.

      • Douglas Knight says:

        But wait, there’s more!

        There are three products: (1) a million SNPs for $100; (2) the exome, all the genes, for $1,000; and (3) the whole genome, including non-coding regions, for $10,000. At the moment, you post says “whole genome” but also “all 20,000 or so genes, for about $1000.” Those two don’t go together, but this is only a matter of a wrong term, not a substantive error.

    • Julia says:

      Thanks; this was helpful to my understanding of how testing works.

      Note that BRCA testing is not just for women. If you’re a man with BRCA, your prostate cancer risk is elevated, and you need to think about how it may affect your kids. So I would think it would make sense to test everyone, not just the women.

      • Douglas Knight says:

        The important question to ask about medical tests is whether you would act on the information. Most genetic testing says that the odds are slightly different. This is not useful. This doesn’t make the difference between a rare disease that you shouldn’t worry about and a common disease that you should. Even with a common disease, if your risk is slightly higher, that just tells you that you won’t live as long (which is useable information for some), not that you should do anything different for your health.

        As far as I know, the effect of BRCA on prostate cancer is small. It’s not even statistically significant at age 50. And prostate cancer in whites is a slow-moving disease of old age. It’s not clear that deaths are correctly ascribed to it. It’s completely different disease in blacks, with fewer diagnoses, but more death, and much younger, definitely due to the disease. It would be good to know if BRCA interacts with prostate cancer in blacks. Maybe we should assume that it does.

        And a male potential carrier worried about passing it on to his daughters, what decisions will he make with the information? If it will change his decision to have children or select embryos or fetuses, then it’s valuable information, but I don’t think most people would make such a decision.

  6. Some cats get rusty and need to be oiled. says:

    Veterinary fish oil, however, is quite reasonably priced, just with different packaging. (And it’s the easiest medicine ever to give to a cat.)

  7. Douglas Knight says:

    Can you prescribe “l-methylfolate (generic deplin)” and get the malpractice protection from the FDA approval as a free-rider? Or can you only do that if the manufacturer has proved bioequivalence?

    For that matter, why doesn’t the manufacturer jump through the hoops and prove bioequivalence? Because they’ll lose their right to market it as a supplement? (I chose l-methylfolate because you mentioned fish oil patents, but actually l-methylfolate is subject to ongoing patent litigation.)

    • Deiseach says:

      I do wonder if a lot of this is down to the kind of companies which have been producing these supplements all along; not just making this stuff for health food stores, but there’s a whole philosophy behind a lot of them, particularly the German ones.

      Biodynamic principles, anthroposophical principles, the whole crystals-and-vibrations New Age baggage. I wonder if there is a feeling that telling patients “Yeah, nip down to your local health shop and buy a bottle of fish oil capsules” is seen as somehow legitimising or validating these philosophies?

      Quite apart from lobbying by the pharmaceutical companies, do the FDA and comparable organisations elsewhere think that if they give permission for these products, if they say “Yes, the ‘we only hand-feed our fish organic seaweed that is harvested at the correct phase of the moon before we humanely assist them to transition to a higher plane of consciousness’ stuff is every bit as good as the “men in white coats with degrees and SCIENTIFIC METHOD’ product”, that they might as well throw their hat at it and licence homeopathy?

    • Scott Alexander says:

      I am not at all sure. I’m not even sure “malpractice protection” is an official thing, so much as “whatever can be thrown at you in a trial”. I just know I’ve heard doctors voice some worries about it.

      Worst case scenario seems to be that someone points out whatever generic L-methylfolate you prescribe hasn’t been tested for correct levels or for purity. But honestly most doctors aren’t really looking for ways to cut cost by prescribing generics, so the question of what the excuses not to are hasn’t really come up.

  8. Ilya Shpitser says:

    You know Scott, Hanson already occupies the ecological niche of “extremely depressing blog posts.” 🙁

    • Eli says:

      The difference is that Scott posts depressing things when they’re true, whereas Hanson optimizes for making depressing things sound well-evidenced when they’re actually not.

  9. Sarah says:

    When MetaMed did a report on fish oil, we found that drugstore fish oil was very often rancid, which makes it ineffective. So overpriced but fresh fish oil is not as evil as it sounds.

    • Is fish oil in capsules apt to be rancid? Can you identify rancidity by taste and/or smell?

    • Scott Alexander says:

      Do you have any evidence that Lovaza is less likely to go rancid than normal fish oil? As best I can tell the main chemical difference is that it’s an ethyl ester, but a lot of over-the-counter oils are ethyl esters as well, and there’s not much evidence those go rancid any less than the normal fats.

      After a small amount of research, the fish oils I get for Ozy are a liquid preparation that we keep in the fridge, and ze knows to stop taking it if it starts tasting bad.

      This site has good information on purity and a lot of other things.

      See also here: “The company found that several of the products it tested compared favorably to Lovaza, the prescription fish oil marketed by GlaxoSmithKline that can cost hundreds of dollars for a one-month supply.”

      But I can’t find whether they just mean the products had more DHA/EPA, or whether they were actually higher quality in terms of purity, etc

  10. Deiseach says:

    I thought the new current wisdom was that fish oil does nothing after all? Or is this perhaps maybe possibly now that everyone and their granny is cranking out generic “Our fish oil has all the omegas!!!!” own-brand pills, why would people pay for expensive prescription versions, so now it’s not worth the time to send out pretty women (or, as it tends to be over here, blokes in mid-priced suits) with pens to the doctors?

    So when our mothers dosed us with cod liver oil (which tasted absolutely disgusting; this is why the capsule versions are now popular, but you can still get the old-fashioned ‘oil in a bottle’ if you’re a masochist), were they adhering to non-scientific old wives’ tales or acting as forward-thinking medical professionals?

    Maybe I should go back to eating (oily) fish on Fridays not alone as a penitential religious practice, but for the good of my health!

    • tut says:

      Cod liver oil is poor man’s vitamin A and D supplement. It is recommended for children and maybe black people in the winter, if you live somewhere where the winter is too dark.

      Modern fish oil has much less vitamins but is supposed to be good because of something about fatty acids (more of the omega three form and less omega six). It is most likely not as good as eating the fish it is made of, but there is some evidence that it isn’t pure BS.

    • Alrenous says:

      To add to tut, the ratio of A to D in cod liver oil is obscene, like 5000 to 1 IU, which means any appreciable amount of D from cod liver oil will give you vitamin A overdose. The upper allowance for adult males is 3000 IU, which means you get toxicity at less than a tablespoon of oil even if you eat no other A at all that day.

      This is a good reason not to eat liver in general, actually, since most animals store their A in the liver.

      That said A overdose is not just a chronic condition, it come with acute fatigue, so it’s pretty easy to notice that you ate something you shouldn’t have and stop. If you’re in control of your diet, at least.

      Add that to the fact that cod liver oil is usually unrefrigerated and thus probably rancid, and the most likely reason that kids hate it is because it’s bad for them. Notably, with a few restrictions, children instinctively eat a balanced diet. A second study I’ve lost the link to found that children allowed to eat candy ad libitum learned better in a few days and switch to fruit, though of course since I can’t cite, take that with a grain of salt.

      • Anonymous says:

        >This is a good reason not to eat liver in general, actually, since most animals store their A in the liver.

        More so a good reason to not eat liver regularly. Liver occasionally is good. It has an incredible nutritional profile.

        • Alrenous says:

          100g: Vitamin A equiv. 6500 μg (813%)

          Liver is poisonous via vitamin A overdose.

          The Inuit will not eat the liver of polar bears or bearded seals. It has been estimated that eating about 500 grams of polar bear liver may be fatal to a human.[3]

          Hey, if you’re down with poisoning yourself occasionally, then sure, go ahead. I’m not.

        • Randy M says:

          There’s a lot more examples of non-fatal liver eating. I would be happy to hear it is bad, as I don’t really care for it, but I’ve heard it is very good many many times lately.

        • tut says:

          Liver from calves or lambs is good. Liver from old animals who have been exposed to environmental toxins contains a lot of that and might be harmful for that reason. Liver from predators contains more vitamin A than just about any other food so you can only eat a little bit of it.

        • How safe is chicken liver?

        • tut says:

          Don’t eat it every day. Apparently 100 g of chicken liver is considered one serving, and it contains more than half as much vitamin A as is safe to eat per day for a long time. But having just one portion once is not a problem. It is a relatively common food and has lots of several vitamins, proteins, iron etc.

          In terms of environmental toxins, chickens are killed when they are less than a year old so unless they get particularly bad feed it shouldn’t be a problem.

          • My normal approach to chicken liver is to buy a pound, cook it, and consume it over the course of a day or two– this only happens a few times a year, so I don’t seem to be at high risk.

  11. @JohnWBH says:

    I don’t want to trigger a fight about public vs private medicine, but one of the advantages of public systems like the UK’s National Health Service is that they avoid this particular type of perverse incentive, and are incentivised to purchase the substance in the cheapest way possible.

    • Douglas Knight says:

      That’s a theoretical argument, but do you have any examples of it actually working?

      How about the examples in this post? Does NHS do a better job of prescribing fish oil, methylfolate, or melatonin than America?

      Also, the key point here is that the main cost is spreading knowledge of the drugs. NHS ought to have a massive scale advantage. But drug companies have the advantage of a marketing budget

    • peterdjones says:

      Ish. A private healthcare provider that supplies drugs directly, as some do, would be motivated to purchase cheaply (although they also have incentives not to cover that condition,etc)

      Otoh, if the patient is paying direct, pass the inflated cost onto them…

  12. Douglas Knight says:

    From the Jacobin article I don’t understand exactly what their patent/monopoly status is, but it seems to be enough that they can price gouge without repercussion.

    The simple truth is that no one knows what their patent status is. The supreme court made a very unclear decisions and it will only be clarified by further litigation.

    But even if the court had forced it wide open, they would still be price gouging today. You can’t judge monopolies by current market structure because it takes time for these thing to change.

    The only company I’m pretty sure sells exomes ($1100 or $1300 with some interpretation, direct to consumer) also sells BRCA sequencing ($1000), but only by prescription, and not in America. (Actually, maybe this undercuts my previous point, because they have a product ready to go when the patent situation changes. But there’s also marketing momentum.)

  13. Douglas Knight says:

    An example of a DNA product that really is 20x as expensive as 23andme while providing less information is Ashkenazi carrier screenings. They vary in price, from $600 to $10,000, but I think $2,000 is typical.

  14. Charlie says:

    I prefer the tautologist view of pricing to the libertarian one – if a company is making money, it’s probably because they can convince people to give them money.

    The tautologist method perfectly explains (of course) the success of those “natural remedies” that have sodium chlorite in them, which is quite a challenge for frameworks that make assumptions like “humans are sane.”

  15. hexgrin says:

    I happen to work in a department at the University of Utah that has (until recently) received non-trivial funding from Myriad relating to its BRCA patents. I’m inclined to say at least parts of those patents have run out at this point, or at least, my dept. is no longer involved and not on the gravy train anymore. I’m not super in the know though, I’m only a peripheral graduate student (and therefore unimportant).

    I will say, however, that the whole reason the BRCA stuff wound up on a patent (and consequently 23andMe suffered for it) is because of the hardcore start-up culture at the university; it seems a lot (and I mean A LOT) of academic research here gets co-opted by faculty looking to make lots of money. A lot of the research companies in Salt Lake City are also right next door to the university (a place called Research Park), and quite a number of those have money agreements with the University (ARUP comes to mind; ARUP == University of Utah for all purposes). I would imagine a lot of other universities have similar patterns of business (thinking of Stanford, partcularly), but it would be interesting to compare different university cultures and see how often publicly funded research gets eaten by business ventures.

  16. covaithe says:

    Now I want to name my next D&D character POTAXOR™®©.

    • Scott Alexander says:

      There is notable overlap between good drug names and good D&D character names. Lovaza sounds like an wizard. Celexa is probably a beautiful half-elven druidess. Clozaril and Haldol are orcish barbarians. The Nardil is some kind of legendary oracle. Aurorix is a warrior princess. Dolophine is a noble with a shady past. Symbyax is some sort of creepy illithid psion, who was slain by the great hero Taxagon. And Xanax is the dark lich master threatening to destroy them all.

      • Nornagest says:

        My favorite character-naming algorithm is based on mining obscure saints’ names (Abaidas, Cillene, Jarlath…), but I may have to delve into this the next time I need something that sounds excessively high-fantasy.

      • Randy M says:

        Reminds me that I need to include the search for the ergonomicon sometime.

  17. Q says:

    I am trying to get pregnant. Are there any mood substances, which are comparatively safe to try in my situation ?

    I do not have that typical bad depression you describe above, I am just kind of unstable personality and do not trust myself in some situation, for instance I would suck as a manager. And I feel long time miserable on background. I would love not to be me, if any pill could do that.

  18. Zorgon says:

    I’m gonna cut and paste the POTAXO thing for future use next time the Evil Pharma Hiding The Natural Remedies thing comes up. I’ve tried explaining it before but that’s just got so much… punch 😀 Ta muchly.

    • Deiseach says:

      Would it be worth it for an Evil Pharma Company, which decided to have a look at this crazy notion that potatoes are good for you and is really close to launching POTAXOR, to fund a campaign disparaging natural remedies?

      Along the lines of “Not only is this superstitious nonsense and it doesn’t work, it will also kill you to death by poison!!!!” I mean, it seems the newspapers will print any old rubbish dished out as a press release by businesses important scientific research extracts from serious peer-reviewed journals, especially when it comes to “fruit or vegetable X – new miracle food/it will kill you dead!”

      Then, once the public (or the newspaper-reading section of it) has been conditioned not to nip down to the greengrocers for a stone of Kerr’s Pinks, the Evil Pharma Company releases POTAXOR – you can trust us, this is SCIENCE!!!! and makes a fortune from all the doctors who have been given free pens prescribing it to their patients?

      • Anonymous says:

        That didn’t happen in any of the examples in this article. Deplin doesn’t have a PR campaign against methylfolate in the drug store. We can be very sure of that because there is no campaign against it. Maybe the articles about how fish oil goes rancid are promoted by Lovaza brand fish oil. But more likely, they’re promoted by krill oil companies. In any event, I don’t see in them in the newpaper. Instead, the newspaper is very much for fish oil. As you just said, newspapers are just as likely to jump on “new miracle food” as “it will kill you dead.”

      • Besides, it’s a plant! You can’t trust it! You don’t know what’s in it!

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