• Cory Doctorow: The enshittification multiverse, in which Doctorow proposes a general theory of enshittification to match his initial, special theory. I enthusiastically concur.
• Anonymous on the Marginal Revolution comments section: On health care price transparency. The only non-Xified content you can find on Marginal Revolution these days is in the comments, so I am glad that Cowen highlighted this minute dissection of the madness called American medical billing. Needless to say, I concur.
• Reese Richardson: A do-or-die moment for the scientific enterprise. ⊕ [Note: ᔥAndrew Gelman, who sure loves his mile-long headlines. ] This is the author’s summary of a more detailed paper in the academic journal PNAS which points to a looming catastrophe of LLM-boosted scientific paper mills holding hands with pliant journal editors to decimate the signal-to-noise ratio of the literature. Of course I concur!
• Cory Doctorow, again: Ada Palmer’s “Inventing the Renaissance”. His review after actually reading the whole book, and yep.

Last week I wrote about the scammy way in which a large hospital system, Johns Hopkins, tried to bully us into paying them money we didn’t owe. The responses to it on Mastodon after a boost from Corey Doctorow were unlike anything I have received before, at least in the English language. [Note: There was a period of about a year or two, early 2020 to late 2021, when a thing I tweeted in Serbian ended up in a tabloid. Around the same time a Serbian TV station lifted an annotated covid graph I had been updating, without attribution of course. Crazy times, may they never return. ] Who knew that American “health” “care” “system” could arouse such strong feelings.

An unexpected turn in the conversation was towards veterinary medicine and how it too is undergoing general enshittification under pressure from private equity and no regulatory barriers. Which got me thinking: could veterinary medicine serve as a proxy for what would happen to human medicine if it were to become deregulated? What would a wholly free-market medicine, a libertarian’s wet dream, look like? Now clearly I have neither the time nor the will to sink hours into this kind of research, but do you know who does?

Yes, I asked Gemini to formulate a research plan, then passed on the plan with the Deep Research toggle on to create a report titled “A Comparative Analysis of Veterinary and Human Medicine: Evaluating Deregulation Proxies in the United States Healthcare System”. The goal was to test whether veterinary medicine could serve as a proxy for deregulated human healthcare and personally I don’t think it achieved that objective — this could be just my anti-AI bias — but it did provide a few juicy quotes, such as:

Theoretical free-market economics suggests that corporate consolidation should benefit the consumer by driving down costs through supply-chain efficiencies, centralized administrative services, and immense economies of scale. The empirical data from the veterinary sector directly contradicts this theory. Instead of utilizing their massive scale to lower consumer costs, corporate consolidators have leveraged their localized monopolies to exercise extreme, unchecked pricing power.

And two paragraphs down:

Furthermore, corporate management fundamentally alters the clinical culture at the ground level. Veterinarians operating within these corporate structures report worsening working conditions, including intense pressure from non-medical corporate managers to “do more and see more patients,” meet specific monthly revenue quotas, and upsell clients on expensive and potentially unnecessary diagnostics to satisfy debt obligations. (21) To protect their market share and ensure high practitioner retention despite these conditions, these corporations frequently deploy aggressive non-compete and non-solicitation agreements, legally preventing veterinarians from opening independent practices nearby and artificially suppressing labor mobility. (21) This data definitively indicates that in a deregulated medical market, institutional capital prioritizes relentless profit extraction and margin expansion over consumer cost-savings or provider well-being.

Reference 21, to save you a click, is a letter from Elizabeth Warren to CEO and President of Mars Inc — which in addition to hocking teeth-numbing treats is also apparently a veterinary behemoth — outlining her concerns about the industry consolidation with ever more references. An actual report would have to dig down into them and find primary sources for Gemini’s claims, but even this is publishable.

And here is the conclusion:

Ultimately, the hypothesis that veterinary medicine serves as a highly accurate proxy for human medical deregulation is remarkably robust. The comprehensive data confirms that stripping away third-party mandates, emergency care obligations, and unlimited tort liabilities yields a highly efficient, point-of-care transaction model that eliminates administrative bloat, enforces total price transparency, and accelerates clinical innovation. Yet, it simultaneously exposes the harsh, unyielding realities of a pure free-market health economy. The veterinary paradigm proves definitively that while deregulation optimizes the speed of scientific advancement and the profitability of specialty providers, it structurally abandons the foundational concept of healthcare as a universal human right, replacing it entirely with a ruthless, capital-gated commodity market.

Woah there, Gemini. With such strong language I do feel obligated to declare that the original prompt was as neutral as possible. I wonder what ChatGPT, Claude or Grok would have to say on the topic, and if Grok in particular would have a different view.

Apart from looking like he has just been on the losing end of a fistfight, and having occasional bouts of nausea, Ben Sasse seems to be doing as well as someone recently diagnosed with metastatic pancreatic cancer possibly could. Both the nausea and his face peeling off are because of daraxonrasib, a new drug which targets KRAS G12 mutations which are common in many cancers but are found in most pancreatic ductal adenocarcinoma (PDAC). As a reminder, PDAC is the one that Steve Jobs did not have, the one that has the dubious distinction of being both the most common and the most lethal cancer of the pancreas.

Well, daraxonrasib seems to be doing its job and doing it well, based on a company press release. Remember, most press releases should not count as evidence for anything. This particular one, however, is worth reading because it is (1) for a randomized controlled trial with (2) a “hard” endpoint of overall survival ⊕ [Note: OK, putting my pedant hat on, the pre-specified co-primary endpoints are progression-free survival (PFS) and overall survival (OS) in the RAS G12-mutant population. What is reported in the press release is only OS in the “intent-to-treat” which is to say both G12-mutant and wild type populations, which was a secondary endpoint. A bullet point at the beginning says that all primary and key secondary endpoints were met, so why not report both? Probably because one looked better than the other, but would it not be a tad suspicious that a less targeted population did better than the more targeted one? But this is just speculation, let’s see review the actual data once they come out. ] which will (3) be presented at the ASCO annual meeting, I imagine as a plenary talk, in early June of this year. The thing to look for there will be informative censoring, in particular early censoring of frail participants — the ones more likely to die early of their disease — who were randomized to receive daraxonrasib but then withdrew due to the “manageable” toxicity of a melting face. The fact that there are no participant numbers reported at all in the release makes me suspicious, though information on the number of patients enrolled is readily available: 501. That’s a lot of patients!

The company is certainly feeling optimistic: they have already received a National Priority Voucher from the US FDA and will now submit a New Drug Application. Kudos and congrats for designing and testing a working drug without using AI, because to read both professional and lay media the past two years it is a miracle there were any drugs being discovered until Large Language Models came along.

Yes, I had to invoke AI, because it is becoming exceedingly common for people to give algorithms credit where it is not due. This is what Tyler Cowen wrote yesterday about pancreatic cancer research:

AI and the pancreatic vaccine. More testing is needed, but there is a reasonable chance that we have a good treatment for pancreatic cancer, and AI was instrumental in that. It is mRNA as well, so a double burn on the haters.

The link is to a post on X by one Rotimi Adeoye, a “contributing opinion writer @nytimes” (one guest essay as of today which is one more than I have so congratulations, I guess?) who in true X fashion superimposed a screenshot from an uncredited journal abstract over someone posting a link to an NBC news article about the updated results of a phase 1 trial of an mRNA vaccine for pancreatic cancer. ⊕ [Note: For those not keeping track, you are right now reading a blog post about a blog post about a retweet of a tweet about a news article based on a press release. You’re welcome. ] These were presented yesterday at the annual meeting of the American Association for Cancer Research but were hinted at in a press release (?) from Memorial Sloan Kettering, where the vaccine — generic name autogene cevumeran which rolls right off the tongue doesn’t it? — was being tested.

Remember how a few paragraphs above I had implied that you should ignore most press releases? Well, news on academic websites should rank even lower as no one there has to answer to the SEC. The primary study was great for what it was, a first-in-human trial with laboratory endpoints meant to test whether the participants’ immune system responded at all to the vaccine. And it seems that it did, as shown in not one but two papers in Nature published two years apart. The number of original participants, all of whom had early-stage, freshly resected and otherwise untreated PDAC upon enrollment, was 19. Three of these did not make it to the vaccine as they had progression, died, or had toxicity from adjuvant chemotherapy before being dosed. Chemotherapy? Yes, in addition to the vaccine everyone also received “adjuvant” (meaning: there to “clean up” any residual cancer after surgery) chemotherapy (FOLFIRINOX, not for the faint of heart) and immunotherapy (atezolizumab which is in comparison to the chemo a walk in the park but even that has its side effects). There was no control.

Of the 16 participants, 8 were “responders” to the vaccine as measured by some highly sophisticated laboratory tests — not that the patients would care what their blood work showed — and in 7 of those the cancer hasn’t come back for 3 years as noted in the follow-up Nature paper or for 4-6 years as noted in yesterday’s update. This compares to 2 of 8 who were “non-responders” to the vaccine.

If you don’t have your calculator handy let me do the math for you: 9 of 16 patients, or 56.25%, with newly resected PDAC who received chemotherapy, immunotherapy and the vaccine were still alive more than 3 years after treatment. You may not know this, and I didn’t until I looked it up just now as it has been a while since I have treated patients with newly diagnosed early-stage pancreatic cancer, but the median OS after (modified) FOLFIRINOX alone in a recent large, randomized Phase 3 trial was 53.5 months, with 43.2% of patients still alive 5 or more years. Did the addition of atezolizumab and the vaccine change anything? I can’t tell and neither can anyone else until there is a randomized controlled trial, which isn’t to cast shade on the investigators — kudos to them as well for a successful first-in-human study — but let’s curb our enthusiasm.

So we have some updated results from a tiny trial that didn’t really move the needle one way or another, and yet Cowen et al. feel the need to push AI into the narrative. To be clear, there is absolutely no mention of LLMs, machine learning, algorithms or artificial intelligence of any kind anywhere in the autogene cevumeran literature. Granted, it is a “personalized” vaccine, meaning that every potential participant had their tumor sequenced and up to 20 vaccine targets identified among the newly mutated proteins. I am sure there was a lot of computation involved. But not every sophisticated computer analysis is AI, let alone an LLM, so I truly don’t see how they could legitimately be brought into the conversation.

And in case you were wondering, no, the screenshotted abstract did not in fact back up Adeoye’s claim. Best as I can tell this was the paper in question, a speculative review article in an obscure journal written by a Shanghai-affiliated group of authors who had nothing to do with BioNTech whose purpose was to be a never-looked-at reference for a false claim, that “AI played a critical role in advancing the vaccine”. Anything for the clicks, am I right?

Adeoye’s behavior was regrettable but Cowen’s is detestable, especially when paired with his look-at-the-sheeple attitude towards humans. ⊕ [Note: The linked to article from Cowen is particularly wrongheaded if you realize who the Luddites really were and that the label should in fact be a positive one. ] Cory Doctorow had warned about AI companies over-promising their capabilities for a short-term gain. But they don’t really need to: there are plenty of useful fools willing to promise on their behalf, giving it credit even where there is none.

For reasons that will soon become apparent, I would like to share with you a joke I heard back at medical school. I will remind you that this was in Belgrade, Serbia in the early 2000s, but the joke would apply to any Serbian institution of higher education, or indeed any place anywhere in the world that uses oral exams [Note: I have heard these called viva voce in the US, which is a bafflingly cheerful-sounding name for a rather traumatic ordeal. ] to determine the final grade. Please also bear in mind that I am not the best at telling jokes.

Anyway, here it is. A not very well prepared student comes in for his Anatomy 1 exam with a rather erratic professor (the joke had the actual name, which I am sure changed from time to time and from school to school). While sitting in front of the office waiting for his turn, a teaching assistant (again, named) approaches him. “Look”, the TA says, “I know he can be tough but for 100 euros things would go a lot easier for both of you. I’m going into his office now so if you have enough with you I can pass it on.” It so happened that the student did have a fresh 100 euro bill with him, which he gave to the TA, who then knocked on the door, spent a few minutes in the office, then came out with a smile and a nod. With newly boosted confidence, the student did better than he could have hoped for and got a 7 (on a 5 to 10 scale). Beaming with pride for his academic savvy and mental fortitude, he winks at the TA hanging around in the hallway. The TA winks back.

So when the time came for Anatomy 2 ⊕ [Note: Technically, there was no “Amatomy 1” and “Anatomy 2” but rather a mid-oral exam you had to do after the first two semesters where you got drilled about everything but the central nervous system, followed by the final oral exam in which everything was in play. Fun times. ] , our student was even more confident and less prepared, and by now you should know where this is going. Same professor, same hallway, same TA coming in with an offer for the privilege to pay a 100 euro lubrication fee. Alas, the professor was in a foul mood that day and flunks the student within 10 minutes. Crestfallen, the student slouches out of the office and sees the TA. “So sorry about that”, says the TA while handing him back the 100 euros, “but you were so bad that there was no chance he could let you pass.”

The joke, if you can call it that, is that the professor was psychotic but not corrupt, and that the TA was playing a game of chance. If it works it works, if not, well, there is always the money-back guarantee. It is as close as you can get to a victimless scam.

A phone call my wife received this morning reminded me of the scheme. It was from someone presenting as staff from the Johns Hopkins billing department. Apparently, there was a balance past due, back from November of last year. This was only a courtesy call, you see, but would you like to pay now or set up a payment plan, to avoid it being sent for collection?

Between the six of us we get about two dozen Explanations of Benefit each quarter. I may not be diligent about looking at every line item, but if there is one thing our insurance company helpfully provides even without logging in to the portal and opening the PDF it is the amount owed. Now, if my wife and I were inundated with work the way we usually were something could have slipped through the cracks, but I was on paternity leave with more time than usual to deal with the overhead of living in the United States so I was pretty sure there was nothing we could have received from insurance that we would have missed.

Except for a pile of snail mail on our dining room table, which I collect about once per week. And there, in an envelope addressed to my wife, was an account statement from Hopkins dated last week — due early next month — that said that we did indeed owe just shy over half a grand for hospital services rendered last November.

This was the first we had ever heard about owing for these particular services, rendered in an in-network facility, performed by in-network physicians. And was that not a curious sequence of events, an early morning phone call urgently asking you for money you didn’t even know you owed until, at best, just the week before? I didn’t want that particular loose thread hanging over me on Tax Day of all days so there I was, HRA card in hand, ready to settle the balance online, until my wife who is as wise in the ways of health insurance and billing as she is in the ways of shopping asked me to cross-check the Hopkins statement with the insurance EOB before I did anything rash.

What a good thing I did, as they did not match. If you are lucky enough not to have to deal with American health care, this is how billing works: hospitals have a list price for their services which they pull out of thin air. Insurance companies have their own opinion about what those services are worth, and a hospital being “in-network” means that they have agreed on the insurance company’s price while “forgiving” the rest. On the hospital bill this will be the “insurance adjustment”. Well, the adjustment our insurance said they negotiated and what was shown in the Hopkins statement differed by exactly the amount Hopkins was now asking from us, which as an in-network hospital they were not allowed to do.

So now it was me on the phone calling the Hopkins billing department, asking about the charge, the person on the other end of the line checking — on a 15-minute muzak hold — what was going on, not finding out, promising a call back in 5 to 7 business days and not to worry about the collection because we will get to the bottom of this mysterious error (if it is an error at all, let’s wait and see) that the hospital made, happens very rarely, practically never, always in the hospital’s favor. I look forward to receiving a voicemail, 5 to 7 business days from today, telling me that the magnanimous Hopkins billing department staff has forgiven all our transgressions and that our balance was zero.

Back when there was such a thing as guidance on conflicts of interest for federal employees, it was drilled into and onto us that even semblance of impropriety, what social network warriors would tag as not a good look, was to be avoided at all costs. It does not matter if you did or did not mean to pick this contractor because your spouse works there — they may be the best company in the world for the job for all we care — you should not be involved in the decision. I agree with this now-antiquated viewpoint and propose extending it to scammy behavior or large corporations. It doesn’t matter whether you used a fake charge on a late bill to threaten collection while offering a quick solution with the express intent to defraud or if an unfortunate series of events led to only the appearance of a scam: it is not a good look. One that, unlike our fictional teaching assistant’s, can and does have real victims.

Per Tanner Greer, China is all-in on leading the new industrial revolution, which will of course first be a revolution in science and technology. My only insight into the tech part is that Chinese companies now make the most innovative earphones and the most electric cars, and from reading Apple in China I have a vague sense that they were contract manufacturers in those fields first, then perfected the craft and outdid their former employers.

Most relevant to the world is what they [Note: But who are “they”? CCP leadership which sets the tone, startups and conglomerates which do the actual legwork, or the provincial bosses who act as intermediaries? I won’t even pretend to know. ] have done and will do with renewable energy, batteries, quantum computing and the like. The most relevant to me is what they are doing with biomedical research, particularly in cell & gene therapy. And as the field progresses from discovery to manufacturing — both research-grade and commercial — to clinical trials and actual practice so does the extent of their involvement.

On the discovery side, Chinese authors have already overtaken their American counterparts in the number of papers in top scientific journals. A crude metric for sure — and let’s not get into the whole peer review debate — but it is a measure of general lab activity. Determining whether China overtaking the US is a direct or indirect result of American sinophobia or evidence that the sinophobia was justified I will leave as an exercise for the reader.

In manufacturing, China is in the “let us do your work for you” stage. Not a week goes by that I don’t get an email from a China-based CDMO [Note: Contract Development and Manufacturing Organization, which just to make things confusing is often shortened even further to Contract Manufacturing Organization, or CMO, which means so many different things within the same field (Chief Medical/Manufacturing/Marketing Officer, anyone?) that it has become ridiculous. ] and WuXi Biologics — headquarters in Shanghai — is among the top 5 companies of that type in the world. These companies specialize in being taught how to do things and then doing them at scale, picking up a few things about process development and optimization on the way. Why the US would not want CDMOs from China was so obvious that the bill forbidding federally funded entities from contracting with them sped through Congress, though not after being revised to not explicitly mention WuXi by name.

“They” are not taking the same approach with clinical trials: a wise decision on their part, since the only thing they could have possibly learned from American trialists was inefficiency and bloat. No, the big push is for investigator-initiated trials which can speed up approvals — they only require local oversight, not a national FDA-equivalent to give their blessing — and get cell & gene treatments to patients within weeks, provided of course that they are manufactured in China.

An eternity ago I wrote about two different types of trials, ones meant to introduce new treatments and others meant to establish guidelines and prune less effective therapies. I argued that the regulatory burden for the two should be different, since the latter — Set 2 as I called them — are clearly less risky and carry less uncertainty. We have of course already experienced the world of unregulated trials of new therapies, and it was not pretty. With its IIT push, China is speeding them up further. The risks are clear, but who benefits?

Top of mind are the patients who will get effective treatments sooner. The invisible graveyard will shrink! But of course most treatments won’t work and most patients who take part in IITs and their family members will have spent much time, some even money, to get false hope. A much larger proportion of the beneficiaries will be companies that hit a false positive, and in single-center IITs of small sample size there will be many of those. They will of course be willfully ignorant of the fact that their high response rate in a 10-patient single-arm open-label trial was spurious, but will instead get just enough conviction to pass on the asset to the greater fool. And so will the roulette wheel keep spinning, fueled by financialization that somehow ends up being the root cause of most of the world’s current ills.

I fully expect the American biotech establishment to learn the wrong lesson from Chinese IITs and instead of feeling relief that someone else is taking on the foolish risk be pressured into copying them. Here is to the steadfast box-checkers and blank faces whom I trust to put on the brakes.

A lovely early afternoon tea and French pastries spoiled because of chatter from a nearby table — in Serbian! — about “quantum medicine”. I don’t care if University of Chicago conned someone into funding research on it, the whole field is Scientology-level bullshit.

• Raghuveer Parthasarathy: Space mirrors, solar panels, fools, and their money.

A few months ago I noted that the one of the main reasons biotech was not like tech was its almost unlimited freedom do bullshit. Well, people are able to raise money by BS in other areas as well, as this article shows, but an order of magnitude less because most investors are able to do back of the envelope calculations.

• Bryan Vartabedian: The Measure of Everything.

A take on Goodhart’s Law as applied to medicine, this time through the lens of instrumentalisation. If any of these articles tickle you and you haven’t yet read Zen and the Art of Motorcyle Maintenance, please do so now. Ted Gioia recently wrote about the book and its legacy. As an occasional note-taker I am in the minority club of Lila fans as well, though both of Pirsig’s books are due for a re-read.

• James Olds: The Chronology Problem.

The point is in the subtitle: “how our bias towards recency in scientific discovery hurts our understanding”. It rings true, and even reminded me of the 26 years it took for CRISPR/Cas systems to travel the path from an oddity to a gene editing platform, until I realized that those 26 years were not spent idling as this review in Cell describes in detail. So, the (lack of) developments in theoretical biology would be a much better example.

• Phil Price: Ted Williams and Me.

Ted Williams was, apparently, a base-ball player about whom John Updike had this to say: “For me, Williams is the classic ballplayer of the game on a hot August weekday, before a small crowd, when the only thing at stake is the tissue-thin difference between a thing done well and a thing done ill.” This applies to any profession you can imagine, and indeed things outside of one’s professional life. People who have the inner drive to do things well even in the absence of stakes could unkindly be called “perfectionists”, but let’s remember that they are the ones who keep the wheels of civilization in motion, in opposition to the hordes of blankfaces, lazy asses and morons.

Proactive vs Reactive DDAVP: The Clamp Finally Faces an RCT from Joel Topf is a perfectly good hyponatremia article if you are into that sort of thing, but what got me interested was the preamble:

Note: This was one of my first posts on Roon.com If you are an American physician who likes to chat about medicine, you should sing up.

Roon.com is “a community for physicians to connect, share knowledge, and shape the future of medicine.” A walled garden for physicians? Made and funded mostly by ex-Pinterest people? Sign me up!

The titular “it” is enshitification, particularly of the “let’s digitize everything” type.

Next year will be a full decade since my initial board certification in oncology, and with that comes another set of multiple choice questions for quarterly completion. We can debate whether ABIM’s MOC scheme is fair — I think not — but still being the law of the land, it led me to think about board prep for the first time since 2018, when I completed my hematology boards.

Being an over-preparer (as people who finish medical school tend to be), I started looking into the size and cost of ASCO-SEP [Note: “ASCO” is the American Society of Clinical Oncology. “SEP” stands for “Self-Evaluation Program”. “ASCO-SEP” was something oncology fellowship programs gave to their trainees free of charge some time during their second or third year of fellowship to get them ready for the board exam. This was less from the goodness of their hearts and more because fellowships were graded — and to the best of my knowledge still are — on the percent of their graduates who pass the boards on the first attempt. A rate lower than around 80% would raise all sorts of flags and could lead to audits, suspensions and even closures. So, mid and low-tier programs would overselect on good test takers during fellowship match season, with interesting consequences (the discussion of which is better left for some other time). ] and was dismayed to learn that it is no longer a physicial book published every 3 or so years which one could use as a reference, doorstop or paper weight long after passing the boards, but rather a 12-month digital subscription with no option for a print copy. You would think that ditching print would lead to all sorts of dematerialization efficiencies — no typesetting, no printing, storage, etc — that could potentially lower the price and make it more affordable for everyone. Alas, if there were any efficiencies to begin with, they didn’t trickle down to the end-user: the cost of subscription for members if $550. And did I mention it was only for a year? Enshittification in action.

ASCO’s quirky sibling is ASH, the American Society of Hematology, which publishes ASH-SAP. [Note: “SAP” is for “Self-Assessment Program”, and the fact that they chose different acronyms for the same thing tells you much about the world of medicine. ] It is a smaller organization with fewer members yet it managed to put out a print copy for $60 over the digital-only offering — a more than fair price for a textbook. This is not the first time ASH has been on the right side of history.

So if anyone knows anyone in the ASCO leadership, please nudge them over to the ASH approach. Maybe you can mention ASH-SAP explicitly and let mimetic forces do their magic. And if you can influence decisions at ASH, whatever you do don’t highlight that ASCO-SEP is digital-only and please don’t talk about efficiencies, lockup and similar matters lest hematologists get any wrong ideas.

• Aaron Cheng: On the emotional weight of a life in medicine. Thoughts of a newly-mintend hematologist which act as a good counterbalance to the popular fictional accounts. Feel free to peruse the few pre-2017 posts from the Infinite Regress archive for my own thoughts from that period.
• Fred Vogelstein: Enveda’s drugs from plants will turn pharma upside down. This is what Ruxandra Teslo warned us about a few months back.
• Joseph Howlett for Quanta Magazine: The Man Who Stole Infinity. On Georg Cantor, plagiarist. It does cause one to become more cynical, as we keep discovering that high-profile scientists built their reputiations on the backs of people with more scrupules and less need for attention. Taleb’s minority rule applied to sociopaths.
• Adam Mastroianni: The one science reform we can all agree on, but we’re too cowardly to do. It is to abolish for-profit scientific publishers, and I am all for it. But, people being people, I do not have high hopes that this prisoners’ dilemma will have a positive outcome.