Some coronavirus news

Some coronavirus news. Good news and bad news.

Bad news first.

As many people know, two prestigious medical journals, the Lancet and the New England Journal of Medicine, both had to retract published papers recently. In fact, it's become a scandal.

The Lancet retracted a hydroxychloroquine study, while the NEJM retracted a cardiovascular disease study. The main issue is data integrity; data may have been compromised. Originally data was provided by a company named Surgisphere, but a co-author of both papers co-founded Surgisphere, i.e., Sapan S. Desai, MD, PhD, and Desai's publications history is rife with research misconduct.

Also on the hydroxychloroquine front, a separate study - likewise published in the NEJM but which did not use the Surgisphere database - found that hydroxychloroquine was not significantly different from placebo:

We enrolled 821 asymptomatic participants. Overall, 87.6% of the participants (719 of 821) reported a high-risk exposure to a confirmed Covid-19 contact. The incidence of new illness compatible with Covid-19 did not differ significantly between participants receiving hydroxychloroquine (49 of 414 [11.8%]) and those receiving placebo (58 of 407 [14.3%]); the absolute difference was −2.4 percentage points (95% confidence interval, −7.0 to 2.2; P=0.35). Side effects were more common with hydroxychloroquine than with placebo (40.1% vs. 16.8%), but no serious adverse reactions were reported.

Now for the good news.

There are still many ongoing studies and trials. Such as one on convalescent plasma which was found to be both safe as well as effective in 19 of 25 (76%) severely ill COVID-19 patients.

In addition, there are several very promising vaccines trials under way. Several in phase 1 trials, a few in phase 2, and a couple moving to phase 3 trials. This includes the much touted vaccine from Moderna which is set to begin phase 3 trials as early as next month in July. The Regulatory Affairs and Professionals Society (RAPS) looks like a good website to track vaccine candidates.

What's the harm?

What's the harm with trying a drug like hydroxychloroquine? For example:

There has been a lot of “what’s the harm” logic for #COVID19 therapeutics going around like @ChrisCarrollMD pointed out.

Let’s talk specifics, here’s the harm that comes from various Rx being evaluated currently. This is why the evidence of benefit is critical 👇🏽👇🏽

— Viren Kaul, MD (@virenkaul) April 7, 2020

Hydroxychloroquine:
🚨Cardiomyopathy and ventricular arrhythmias: ❤️ damage
🚨 Bone marrow suppression: Compromised immunity and bleeding risk
🚨 Hypoglycemia: Low blood glucose

Here’s @US_FDA’s fact sheet: https://t.co/dI40HwZbh4#COVID19

— Viren Kaul, MD (@virenkaul) April 7, 2020

Lopinavir/ritonavir:
🚨QTc prolongation & heart blocks: affects electricity in ❤️
🚨Risk of MI: ie heart attacks esp with previous structural heart diseases
🚨Hepatotoxicity: Liver injury. Critically ill pts can develop liver injury by other mechanisms, so added damage #COVID19

— Viren Kaul, MD (@virenkaul) April 7, 2020

Tocilizumab:
🚨Increased liver enzymes in 20-30%
🚨Liver injury resulting in transplant or death has been reported
🚨Low neutrophil and platelet counts
🚨 Anaphylaxis: Could be life threatening in sick patients
🚨 High TG level’s: makes using propofol (sedative) hard #COVID19

— Viren Kaul, MD (@virenkaul) April 7, 2020

IVIG:
🚨Low BP in 15%
🚨Anaphylactic reactions
🚨Pulmonary edema: fluid in lungs
🚨Aseptic meningitis
🚨Hemolysis: breakdown of 🩸 cells
🚨Kidney failure
🚨Thromboembolism: Increased clotting , which is already an issue with #COVID19

— Viren Kaul, MD (@virenkaul) April 7, 2020

My goal is not to create a scare but provide education on why just using therapies isn’t as simple. The risks need to be weighed against the benefit.

Problem is we don’t have good data to suggest benefit. And we do know the risks.

To deal with this pandemic ...

— Viren Kaul, MD (@virenkaul) April 7, 2020

Drugs against coronavirus

I see a lot of people strongly urging doctors to use the drug hydroxychloroquine/azithromycin as a remedy against the coronavirus or Covid-19. I guess that's in large part because Pres. Trump has been pushing the same drug quite a bit. However:

1. The evidence for the drug in human beings - not in vitro ("test tubes"), nor in vivo in animals (e.g. mice), but in human beings - is still predominantly anecdotal or low quality studies (e.g. here).

Sure, there may seem to be hundreds of coronavirus sufferers who have dramatically improved thanks to this drug combination, but one could say similar things for homeopathy, Chinese medicines, chiropractic manipulation, and so on.

At best, at this point, hydroxychloroquine/azithromycin may indeed be promising, and perhaps it will be proven to be safe and effective in treating Covid-19 in the near future, but there remains much work to be done in order to demonstrate these hypotheses.

2. I realize people are demanding a fix stat. It looks like governments have fast-tracked a lot of the trials. Indeed, it seems to me like we're moving about as fast as we can. However, there are limits to how fast trials can move. We can't time travel.

3. Suppose we have several friends who are badly injured and need to go to the emergency department. So we get them into a car and drive them to the ED as quickly as we can. Suppose we speed, run red lights, and zigzag through traffic to do all we can to get our friends to the ED as soon as possible.

Nevertheless if we're decent people then I presume we wouldn't attempt to run over pedestrians or drive through stores with people shopping or anything like that. As much as we wish to save our friends, all things equal, we wouldn't necessarily want to endanger other people's lives in order to do so.

I realize the analogy is not entirely analogous, but dropping the analogy my point is simply that we may believe this drug will save our friends and family. However, in this case, we wouldn't (or shouldn't) wish to endanger the lives of others in case it doesn't work in other coronavirus patients even if it works in the ones we happen to know.

(Of course, I'm sure we could concoct hypotheticals where it might be morally licit to risk the lives of others in order to save our loved ones.)

4. Finally, as I mentioned in a previous post, there are about 40 other coronavirus therapies doctors and scientists are currently working on spread out across approximately 200 trials. So I don't understand why the focus on this one particular drug when we have about 40 other coronavirus drugs or therapies we are trying. It's not as if this drug hydroxychloroquine/azithromycin is head and shoulders better proven than several of the other drugs or therapies (e.g. here).

Hydroxychloroquine and azithromycin

....be put in use IMMEDIATELY. PEOPLE ARE DYING, MOVE FAST, and GOD BLESS EVERYONE! @US_FDA @SteveFDA @CDCgov @DHSgov

— Donald J. Trump (@realDonaldTrump) March 21, 2020

1. Sure, hydroxychloroquine/azithromycin is promising. However I fear Trump is overselling it. It's far from a panacea at this point in time. Maybe that'll change in the future, but the problem is it's still to be determined. (Edit: A Stanford pathologist's opinion.)

2. In other words, hydroxychloroquine/azithromycin in combination to treat COVID-19 still needs to be proven through clinical trials. That's the standard to ensure safety and efficacy. However, right now, the evidence for hydroxychloroquine/azithromycin is primarily based on case reports. Case reports have sometimes or perhaps often fallen by the wayside in light of further investigation.

3. Same goes for other hopefuls like chloroquine, remdesivir, lopinavir-ritonavir, etc. These likewise need to undergo the gauntlet of clinical trials to demonstrate safety and efficacy. And some of these antivirals are already undergoing clinical trials (e.g. I've mentioned Stanford and remdesivir in the past).

4. By contrast, there already exists a reasonable therapy to tide us over until we can develop antivirals or a vaccine. It's called convalescent plasma therapy (serum antibodies). I think it'd be better to prioritize (in the interim) convalescent plasma therapy. I've described this in the past (e.g. here). Basically what plasma therapy would entail is taking the antibodies of someone who has already recovered from COVID-19 and transferring the antibodies to someone else. This can be done for treatment and/or prophylaxis. Plasma therapy would confer passive immunity to people. This is what infectious disease experts like Ian Lipkin (Columbia University), Peter Hotez (Baylor College), and Amesh Adalja (Johns Hopkins University) have been saying for weeks now.

We could do this for health care workers on the frontlines, the elderly, the immunocompromised. They're at higher risk than the general public of developing COVID-19 and dying. It'd likely be a monthly injection.

Again, plasma therapy is available right now. It's not theory, but reality. There's no large scale clinical trials required. We can start implementing it today.

To be fair, there are some medical issues to be dealt with in certain patients (e.g. allergic reaction), but that's outweighed by its tremendous benefits.

The real challenges are not in the medical technology but logistics (e.g. obtaining enough blood donations from those who have recovered from COVID-19, setting up blood banks, distribution).

Plasma therapy for coronavirus

Here is an interview with an infectious disease and vaccine expert named Peter Hotez (MD, PhD). However I just want to excerpt a segment from the interview. The excerpt starts at approximately 16 minutes.

On potheads and pandemics

Why is Metropolitan Seattle currently the epicenter of the pandemic in USA? I don't know the answer, but I have a question. I believe WA is one of the few and first states to decriminalize weed. When I was still living on the Eastside, there were placards advertising weed map apps with locations and contact info for area physicians who just wrote prescriptions for weed. People must be pretty desperate for their fix! In addition, there was pot shop just down the street ("Seattle's best bud").

I wonder what percentage of Metropolitan Seattleites are now potheads. Do potheads already have compromised respiratory systems that make them more susceptible to contracting the coronavirus and requiring hospitalization if infected. 

To what extent does widespread pot smoking amplify transmission rates as well as amplify fatality rates–because their natural resistance is so lowered? 

I'm not a medical expert, so maybe there's no connection. But I'm curious. 

Holy sexuality

"'Holy Sexuality' – Solas in Conversation with Christopher Yuan"

I never fail to enjoy reading people's testimonies about how they became Christian and how they remain Christian "through many dangers, toils, and snares" over the years. Here's an excerpt:

Meanwhile my parents prayed for a miracle. My mother prayed that God would do “whatever it takes” for me to come to surrender my life to Jesus. She prayed and fasted every Monday for seven years, she fasted once for 39 days, and enlisted over a hundred prayer warriors to pray and fast for me. However I remained totally resistant, to the point that once, when my parents came to visit me I kicked them out! As they left, my Dad gave me his Bible, but I immediately threw it in the trash.

[...]

In prison, I was diagnosed with HIV, and hit a personal low-point. A few days after that I was walking around the cell block and I passed by a rubbish bin, and what I found on top of the trash was a Gideon’s New Testament! I took it to my cell and began reading it...

My gang is Jesus

https://harpers.org/archive/2020/02/my-gang-is-jesus-brazilian-evangelicals/

Puberty blockers

Testosterone is important for normal male brain maturation. Here is a report of an 11 y/o boy on puberty blockers: IQ dropped 11% (80 to 71) after 17 mo.

As the EIC of the BMJ has said, PB are being used in a state of “profound scientific ignorance.”https://t.co/Cb23bBYHye

— William J. Malone, MD (@will_malone) July 17, 2019

Thanks to Steve for sending this my way.

The study mentioned in the tweet is sad, but useful:

1. The so-called "puberty blocker" is Lupron. That's an off-label drug. It's normally used in chemotherapies against prostate cancer in men and breast and ovarian cancers in women. It can cause significant side effects even in adults. Granted, most drugs aren't safe in large enough doses, or in certain populations, but giving Lupron to a little boy seems to be asking for trouble.
2. Of course, the critic might reply "n=1", i.e., you can't generalize from one case to the rest of the population. However, this isn't the only study where PBs have been shown to harm a child's (still developing) brain/IQ. For example, see here, here, here, and here.
3. Likewise, good overviews on puberty blockers in treating gender dysphoria here (Ryan T. Anderson) and here (Paul Hruz, Lawrence Mayer, Paul McHugh).
4. It really should be common sense not to give these kinds of drugs to little kids. A 10 year old boy at the time. Especially to a little kid with an already low IQ. A low IQ of 80 which dropped even further to 71. 80 is classified as "low average" in terms of IQ. 71 is classified as "borderline mental disability". 69 is where the mental disability classification begins. If a mentally deficient little boy thinks he might be a girl, then that might well be explained by the fact that he's a mentally deficient little boy rather than because he has "gender dysphoria". Isn't that common sense? You don't need a medical degree to know that.
5. Sure, this boy gave "consent", but he could easily have been persuaded by an adult to give consent. It's just taking advantage of a mentally deficient little kid. He's a guinea pig for experimental medicine based on a trendy social theory du jour.

   To be frank, it seems almost like a Nazi medical experiment where mentally deficient little kids are tricked into taking this or that drug to see what happens. I suppose a key distinction is the Nazi doesn't care about the kid, but the parents and doctors who advocate for puberty blockers believe it's in the kid's best interest (though there are some shady doctors out there). At best, that might make the latter less culpable if they're ignorant (particularly the parent, but one could argue physicians should know better), but I would think they're still complicit to some degree. Perhaps negligence?

6. This might have already done irreparable damage to the boy's cognitive development. Of course, progressives don't really care for kids with low IQs anyway. That's in evidence by the fact that the majority of abortions are performed on babies who have Down syndrome.

Going to pot

https://www.youtube.com/watch?v=Bzers0vpCfY

http://timhsiao.org/marijuana-fact-sheet/

Fatal overdose

https://anchorednorth.org/the-overdose-that-didnt-kill-me/

Assuming this is true, seems like a case of instantaneous miraculous restoration (from a fatal overdose). 

Reforming drug enforcement

https://thearcmag.com/the-cold-war-on-drugs-61ccb5ecd396#.it0v9rb0y

Cold War on drugs

Do we need to revise our drug enforcement policies? I don't have a firm position, but I have some inclinations on the question. 

i) Some libertarians think we should legalize hard drugs. If drug abuse only harmed the individual user, there'd be a case for legalizing drugs. But humans are social creatures. We live in communities. Certain behaviors are socially destructive as well as self-destructive. If a social behavior is detrimental to the common good, that's a potential reason to legally deter it. 

However, drug enforcement presents a dilemma: On the one hand, the fact that demand is so great demonstrates the danger that it poses for the social fabric. On the other hand, the same enormous, insatiable demand makes it very hard to deter. 

ii) In popular parlance, drug enforcement is called the "war on drugs". One problem with that characterization is that we tend to think of wars as a contest in which one side wins and the other side loses. The war ends. 

But drug enforcement isn't that kind of "war". Given demand, the conflict never ends. 

If we wish to retain the martial metaphor, we might call it the Cold War on drugs. Because both Russia and the US had the bomb, both sides avoided a head-to-head showdown. The American strategy was the containment policy.

It's best to frame drug enforcement in terms of containment. Keeping drug abuse at manageable levels. If enough people want it, you can't prevent it. But you can still deter it. 

iii) Another way to assess drug enforcement is balancing harms. Drug abuse is personally and socially harmful. The more widespread, the more harmful to the common good.

However, drug enforcement has many incidental harms. Although these may be side-effects of drug enforcement, the cumulative effects are considerable. Current drug enforcement is very expansive and very intrusive. The cost of opposing evil should not outweigh the evil opposed. So these need to be calibrated. We need to balance the social harm of drug enforcement against the social harm of drug use, so that drug enforcement doesn't do more harm than good. This isn't a choice between drug enforcement and general legalization, but striking a balance between competing goods. 

iv) Consider some elements of current drug enforcement:

• Gov't involvement at federal, state, and local levels

• Drug raids, no-knock warrants, sting operations, entrapment, seizure and civil forfeiture

• Random checkpoints, stop-and-frisk

• Interdiction, air smuggling

• Undercover operations, viz. recruiting informants, informant payments, protecting informant identity, undercover apartments, undercover patients, fake internet cafes, fake Facebook accounts. 

• Surveillance, viz. domestic drones, laser microphones, Stingrays, RFID chips, spyware, thermal imaging, mail imaging, radio-frequency scans, turning laptop webcams into hidden cameras or cellphones into hidden microphones, use of voice recognition to scan mobile networks.

• Access to bank/phone records

• Targeting possession, drug paraphernalia 

• Corruption of police departments on the take 

v) Some of these are not specific to drug enforcement, but part of a larger pattern. I'd say current drug enforcement policies have become far too expansive and invasive. We need to scale back. 

vi) Some drugs are more addictive and dangerous than others. It makes sense to concentrate on those. 

vii) I think drug enforcement should focus on production (e.g. meth labs) and sales rather than possession. We should consider legalizing possession. Call it supply side drug enforcement.

This would also mean police can't plant evidence to justify arrest and conviction.

Of course, you have possession with intent to distribute, which shades into sales. We could debate that. 

Roof and Suboxone

http://rockingwithhawking.blogspot.com/2015/06/roof-and-suboxone.html

Slavery and abortion

AHA touts the parallel between abortion and slavery. If slavery could be abolished, so can abortion. But even though there are moral similarities, there are crucial differences.

Most folks didn't own slaves. It was basically an upper class thing. So most folks didn't have a direct stake in slavery. Just the ruling class, which was a tiny minority of the overall population. And in America (by the 19C), it was regionally confined.

In principle, it's a lot easier to abolish something that most folks never had or never use. You're not taking anything away from them. That's cost-free. 

To the extent that there was a perceived stake in slavery, that's because an agrarian economic is labor intensive, and slave labor is a source of cheap labor.

Mind you, even from an economic standpoint, that's unnecessary. To begin with, slaves need to be fed and sheltered. So it's not free. Moreover, slaves are motivated to do the least they can get away with. So even apart from moral considerations, there are more efficient alternatives. 

By contrast, there's a huge demand for abortion–national wide, from top-to-bottom. Many people want access to abortion at all social strata. And that includes a significant voting block. 

That makes it far harder to abolish abortion. That doesn't mean we shouldn't try. But the facile parallel between slavery and abortion is politically disanalogous. 

A better comparison would be Prohibition. That failed because popular demand was too great. Same thing with hard drugs. We can't eradicate substance abuse. The best we can do is to minimize it as much as possible. 

The war on drugs

I don't agree with McWhorter's overall position, but in some ways he's a more intelligent critic. Take this statement:

So, what will really make a difference? Really, only a continued pullback on the War on Drugs. Much of what creates the poisonous, vicious-cycle relationship between young black men and the police is that the War on Drugs brings cops into black neighborhoods to patrol for drug possession and sale. Without that policy—which would include that no one could make a living selling drugs—the entire structure supporting the notion of young black men as criminals would fall apart. White men with guns would encounter young black men much less often, and meanwhile society would offer young black men less opportunity to drift into embodying the stereotype in the first place. 

http://www.newrepublic.com/article/119121/ferguson-missouri-and-war-drugs-how-two-are-connected

i) Up to a point, I think that's undoubtedly true. It's the war on drugs that often brings police, including white policemen, into direct contact and conflict with young black men.

In addition, the war on drugs has been the primary impetus for the militarization of the police force. 

I don't have a solution. The war on drugs has many horror stories. Bungled no-knock raids. Police state apparatus. 

ii) But I fear that decriminalizing drugs would just replace one set of intractable social problems with another. Different horror stories.

It's said that prohibition caused organized crime. Probably an oversimplification. But even if that's true, repealing prohibition didn't repeal organized crime. Once established, it was here to stay. Why think legalizing drugs would be any different?

Suppose, instead of fighting the Cali Cartel, Columbia had legalized drugs. Would that put the cartel out of business, or would it simply make it easier for the cartel to do business? Expand business. Have even more citizens and officials on the take? Basically, everyone would be in the drug business. Corrupt everyone by putting everyone on the payroll. Like a company town. 

As long as narcotics are illegal, there's a distinction between gov't officials and narco dealers. But if was decriminalized, then what would hinder gov't officials from having their hand in the till? To my knowledge, libertarians who advocate legalizing drugs also decry the "military-industrial" complex. But wouldn't legalizing drugs create the equivalent public/private sector complex vis-à-vis narcotics?  

In fact, if hard drugs were legalized, then presumably the FDA would step in to regulate them. That would add to the cost of production. And you'd have sales tax. So I imagine there'd still be black market for hard drugs.

iii) One problem with legalizing narcotics is what if it fails? Presumably, legalizing hard drugs would dramatically increase the use and abuse of formerly controlled substances. For one thing, there'd be no danger of arrest and imprisonment. 

But, of course, many of these are highly addictive. And once people are hooked, many are unable to kick the habit.

If legalization failed, you couldn't turn the clock back to the status quo ante. The situation would be much worse. 

That would instantly and greatly escalate the war on drugs. The police would be even more aggressive to rein in a situation which spun way out of control. 

Reefer madness

Joe Carter recently did a post on whether smoking pot is sinful:

http://thegospelcoalition.org/blogs/tgc/2014/01/06/is-recreational-marijuana-use-a-sin/

He used an argument from analogy. I think his basic argument is sound. However, the ensuing comment thread is a swamp of moral confusion. In this post I'll attempt to draw some morally salient distinctions. I expect many parents or pastors would lose the argument against pot smoking because of facile counterexamples. So it's important to beef up the argument.

Of course, some people will resort to any excuse to smoke pot. 

1) Some antinomians bandy the charge of "legalism." But let's define legalism:

i) The notion that we can justify ourselves with God through virtuous activity

ii) Inventing duties or prohibitions that lack divine warrant

2) Some critics accuse Christians of hypocrisy for exempting their own lifestyle choices. But even if that's sometimes true, that doesn't validate your lifestyle choices. 

3) Some activities are sinful. Some activities are intrinsically evil. 

4 ) However, it isn't necessary to always frame the issue in terms of what's strictly moral or immoral. We can also frame some issues in terms of what's prudent or imprudent. What is the objective? What are the likely consequences? What are the risk factors? What's the potential benefit? Is there a greater risk for a lesser gain over against a greater gain for a lesser risk?  

5) Apropos (4), it's often a matter of degree. Something maybe harmless or beneficial in moderation, but harmful if carried to a greater extreme. 

6) As Christians, we have a general duty to be faithful stewards of our time, abilities, and opportunities. Our life is not our own. 

7) Conversely, since human mortality is unavoidable, many people make a calculated decision to potentially shave a few years off their lifespan in exchange for a more enjoyable life. That's a rational decision.

8) There's a difference between cultivating a healthy lifestyle and cultivating a hazardous lifestyle. For instance, there's a middle ground between being a health nut and being a drug addict. 

9) Someone with dependents has greater responsibilities than someone without dependents. 

10) We ought to distinguish between temporary impairment and permanent impairment. Does a particular recreational activity carry a significant risk of permanent impairment?

11) There are different kinds of damage we can do to our bodies. Some damage is worse than others. Damage to vital organs. Brain damage. Memory. Reflexes. 

12) Is a particular activity addictive? Do you control it, or does it control you?

13) There are tradeoffs. Prescription painkillers can be addictive. They can lead to deleterious side-effects. However, that has to be offset by considering the impact of chronic pain. Which is worse? Same thing with psychotropic drugs to treat mental illness. Or cancer therapy. Or medication for Parkinson's Disease. 

14) There's nothing inherently wrong with ingesting mood-altering substances (e.g. alcohol). Whether that's right or wrong, prudent or imprudent, depends on additional considerations.

15) Some mind- or mood-altering substances (e.g. coffee) can enhance rather than impair performance. On the other hand, some performance-enhancing substances (e.g. anabolic steroids) can do long-term damage. 

16) Whether impairment is prudent or imprudent also depends on the setting. Is it safe? Will that endanger you or others?   

Loss of self-control isn't inherent wrong. Take general anesthetic for surgery. But that's a special case. That's not undergoing sedation for its own sake, but as a means to an end. 

17) Contact sports like football aren't risk-free. On the other hand, many boys will indulge in high-risk behavior anyway, so it may be better to redirect their reckless behavior in a controlled setting where the risk is minimized. And team sports can also confer social benefits (e.g. camaraderie). So it's a risk/benefit calculus.

18) As a rule, tobacco products are harmful. To some extent that depends on the degree of intake (frequency, duration). Likewise, tobacco products are addictive.

On the other hand, some (many?) individuals are more productive due to artificial stimulants like caffeine and nicotine. 

19) Obesity can be  harmful. But that's a matter of degree. 

20) The fact that marijuana is "natural" or "organic" doesn't ipso facto make it morally permissible. What is edible for one species may be inedible or poisonous for another species. Mushrooms are natural, but some mushrooms (e.g. the Death Cap) are toxic to humans.

21) Is marijuana a gateway drug to even more harmful drugs? That's not just a slippery slope argument. Something can be harmful it its own right, yet foster an appetite for even more dangerous activities. 

Pot Happy Talk

http://www.nationalreview.com/node/367527/print

Getting high

Two states have legalized marijuana use. On the one hand, there's a libertarian argument for this trend. The "war on drugs" has led to the paramilitarization of the police. The police are increasingly like a foreign occupation force. That's a bad development.

On the other hand, legalizing marijuana will likely make the streets more dangerous. Drinking in moderation doesn't seriously impair your faculties. But from what I've read, it takes very little marijuana intake to seriously impair your faculties. In the nature of the case, if you're under the influence, you're a poor judge of your faculties. 

So it's easy to imagine many more DIU incidents with the legalization of marijuana. More innocent drivers, pedestrians, and bikers killed or maimed by other drivers who had a few puffs on a joint, then got behind the steering wheel. 

I also expect this will hike car insurance and accident insurance for everyone.

Finally, there's the question of "medical marijuana." In principle, I'm not opposed to medical marijuana if, in fact, that provides symptom relief that's unavailable by other means. 

However, I think "medical marijuana" is usually a sentimental trojan horse to legalize marijuana in general. Also, I've never read or heard this discussed by medical experts who specializes in pain management. 

A nation of promiscuous prudes

"Postmodern Prudes" by Victor Davis Hanson.