Do You Really Want to Know Your Future? A New Freakonomics Radio Podcast

(Photo: Micah Baldwin)

Our latest podcast is called “Do You Really Want to Know Your Future?” (You can download/subscribe at iTunes, get the RSS feed, or listen via the media player above. You can also read the transcript; it includes credits for the music you’ll hear in the episode.) 

If you could take a test that would foretell your future – at least your medical future – would you? And if you did, how would that affect the way you live your life?

The economist Emily Oster wondered how people at risk for the neurological disease Huntington’s answer those questions. Huntington’s is genetic: the children of a person with the disease have a 50 percent chance of carrying the mutation themselves. Symptoms usually surface in one’s 30s or 40s, worsen over time, and end in death. Oster wanted to know how people with the gene respond to the prospect of a shortened lifespan.

OSTER: The question we started with was how does knowing that your lifespan is limited impact your choices about investments in the future? Basically ask the question, if you knew you were going to die at 60 rather than at 90 would you change the amount of education that you got? And that has actually quite broad implications for understanding things like as countries get richer and people get higher life expectancy, will that impact their education and then impact economic growth?

Oster worked with neurologists Ray Dorsey and Ira Shoulson to survey people at risk for the disease. They found that people who know they carry the gene do in fact make different choices about education, retirement, and marriage (paper available here). But a second paper found that although a $300 blood test can tell people whether they will get the disease, only 5 percent of those at risk choose to do so.

To explain why that number would be so low, Stephen Dubner talks with Nancy Wexler, a professor of neuropsychology at Columbia and president of the Hereditary Disease Foundation. Wexler’s mother died of Huntington’s in 1978, and Wexler led the team that located the gene for the disease in 1993. The discovery enabled genetic testing, but she understands why so few people want to know their future.

WEXLER: You know, I think this is something that is horrific information, very, very powerful information. If you’re somebody who has a 50 percent risk … there is nothing, nothing whatsoever that you can do that makes any difference whatsoever. There’s no treatment you can take. There’s nothing to forestall it. And if we actually had something that made a difference in treatment, I think that would make a huge difference.

You’ll also hear from three women at risk for the disease about why they haven’t taken the test.

Audio Transcript

[MUSIC: Rob Bridgett, “ava”]


Nancy WEXLER: I think for my mother and for our family, the whole family was very important. You know, she was very kind to us, and she was very loving, and very warm. I think a lot of my warmth I get from her.


Stephen J. DUBNER: That’s Nancy Wexler. She’s a professor of neuropsychology at Columbia University.  One morning in the late 1960s, something strange happened to her mother, Leonore Wexler. She was 53 at the time.


WEXLER: Mom was on jury duty crossing a great big street in Los Angeles, at 8 o’clock in the morning, very well dressed, very well-kempt, and the policeman just screamed at her and said you know, “Aren’t you ashamed of yourself being drunk so early in the morning?” And she realized that her unsteady gait was one of the very first signs. She called my dad in a panic and said I think this horrible thing is happening. And she was diagnosed that afternoon with Huntington’s.


DUBNER: Huntington’s disease is a horrible thing, a fatal neurological disorder.


WEXLER: Huntington’s affects every aspect of mind, thinking and body. It causes all kinds of uncontrollable movements throughout your body. Your face wiggles, your arms move. And then also people very often have very severe depression, hallucinations, delusions, paranoia, obsessive-compulsive disorders. And also cognitive problems, so difficulty thinking, remembering, executive functions, you know so every aspect really of mind and body and thought.


DUBNER: One more thing about Huntington’s: it is purely hereditary. Which means that if one of your parents has it, you have a 50 percent chance of inheriting the gene, which means you’ll almost certainly get the disease itself. Nancy Wexler’s mother had already seen all three of her brothers die from Huntington’s, as well as her father.


WEXLER: You know, she knew the fate that was before her. In fact, at one point my mother said I’m not living this way, and she tried to commit suicide. I think the only thing that really saved our entire family is that my father, being totally brilliant and optimistic, said, “Well, you know, let’s just find a cure.” So in 1967, our family started the Hereditary Disease Foundation. Curing Huntington’s has turned out to be vastly more difficult than we thought. But I’ve been working on it ever since 1967.


[MUSIC: Crushed Stars, “Outside the Stars Are Falling” (from Self Navigation)]


DUBNER: Nancy Wexler had just graduated from college. She became a psychologist, and took over the hereditary disease foundation that her father had started. She funded research, organized symposia. In 1972, Wexler learned from a colleague about some villages in Venezuela where Huntington’s ran rampant. In the U.S., the disease affects about 1 in 10,000 people. But in these Venezuelan villages, where families had intermarried for years, the rate was far, far higher. In nearly every household, at least one person had Huntington’s. So Wexler began traveling to Venezuela. She collected blood samples and she started to build huge family trees. She needed to learn where, exactly, Huntington’s came from.


WEXLER: You know, we were looking for the gene because we knew if you could cure the gene, that’s the cure for Huntington’s.


DUBNER: The breakthrough took a long, long time. But finally it happened. In 1993, a research team led by Wexler found the Huntington’s gene—IT15. It was on the short end of chromosome 4.


WEXLER: In the middle of this totally tiny, teeny tiny, stilt village in the middle of Lake Maracaibo. It was these families on the stilt village who literally, it was their DNA that gave us the gene, their DNA.


DUBNER: The idea was that finding the gene for Huntington’s disease would lead to a cure for Huntington’s disease. But it hasn’t —although Wexler and many others are still working on it. What finding the gene did enable was a test, a $300 blood test that allows you to learn whether you will get Huntington’s. Wexler’s mother had died years earlier, in 1978, at the age of 63. The test had not been available in her lifetime.


DUBNER: If there had been a test available then, a test like the one that you helped develop later, do you think your mom would have taken it at a young age?


WEXLER: No.


DUBNER: Why?


WEXLER: Why should she have?


[THEME]


ANNOUNCER: From WNYC and APM, American Public Media: This is Freakonomics Radio, the podcast that explores the hidden side of everything.


[MUSIC: Greenhorse, “Aquasong”]


DUBNER: If you could take a test that could foretell your future, at least your medical future, would you? Would it be valuable for you to know if something bad was going to happen? Or would it be more valuable to not know?


Emily OSTER: This is actually quite a broad question of general interest to economists.


DUBNER: Emily Oster is an economist, at the University of Chicago’s Booth School of Business. She’s been doing research on Huntington’s disease. Why?


OSTER: The question we started with was how does knowing that your lifespan is limited impact your choices about investments in the future? Basically ask the question, if you knew you were going to die at 60 rather than at 90 would you change the amount of education that you got? And that has actually quite broad implications for understanding things like as countries get richer and people get higher life expectancy, will that impact their education and then impact economic growth?

 

DUBNER: People with Huntington’s usually start to get sick in their 30s or 40s, but there’s a lot of variance, even a toddler can start to show the symptoms. It worsens over time and eventually will kill you. So if you’re in your 20s, let’s say, and you’ve got one parent who has Huntington’s disease, you have likely already started to see its effects on your mother or father, and you know that you have a 50 percent chance of getting sick yourself. Emily Oster was intrigued by how people responded to this dilemma. She teamed up with two neurologists, Ira Shoulson and Ray Dorsey, to find and interview people at risk for Huntington’s, some of whom had already tested positive and some of whom had a parent with Huntington’s but hadn’t been tested themselves. Besides asking these people about the disease itself, Oster also wanted to know things like: are you going to college? are you getting job training? are you getting married, or planning to have a family?


OSTER: So we see differences on a few dimensions between people who know that they carry the Huntington’s mutation and know that they don’t. So one is that we see more early retirement among individuals who know that they carry the mutation. We see more divorce. We see individuals reporting changes in their recreation activities. They’re more likely to borrow money.


DUBNER: What about if you go back to people who are younger and acquiring human capital, more college, more job training, things like that?


OSTER: Yeah, so when we look at that what we see is that individuals who find out that they carry the mutation actually get much less education than individuals who find out that they do not. So we see much lower rates of college completion among individuals who know that they will develop Huntington’s. We also see much lower rates of engagement in job training, both of which are sort of typical markers for human capital investment.


DUBNER: What about marriage and having children?


OSTER: So, we see on average, quite similar rates of overall fertility in these different groups. That’s something that’s not actually in either of these papers because it’s a little hard to think about what direction you’d expect that to go. But from other analysis of this data it looks like fertility is relatively unaffected by the disease.


DUBNER: Really? So that’s surprising to me, is it to you?


OSTER: Yeah, I found that surprising, although I think it’s difficult to think about how you would react to this disease. I think it’s sort of quite difficult for me to think about.


DUBNER: Now, let me ask you this, I also see that Huntington’s is accompanied by a variety of disorders including cognitive disorders, for instance, difficulty planning, organizing and prioritizing tasks, according to the Mayo Clinic, as well as difficulty learning new information. But also depression and things like that. So persuade me that you know for a fact that what you’re seeing among these people who are diagnosed isn’t in fact a result of the condition itself as opposed to a conscious decision to not invest in themselves.


OSTER: When we look at education in particular one of the tests that we do involves taking people who have no symptoms who are tested early in life before they’ve completed their education decisions, but at that time are completely asymptomatic, so there is no sense in which there is a difference in whether they’re sick. And so there when we compare the educational choices of people who test and find out they carry the mutation to those who test and find out they don’t, we can be at least somewhat confident that it is not about symptoms of the disease. Now, that’s different than the question of depression, which I think is also quite important. And largely what we can say about depression is actually in the data we see evidence on whether people are depressed and we see people are initially, the first year after they get a bad test result they are somewhat more depressed, but then they basically return to baseline for quite a long time. Most people are kind of about the same amount of happy most of the time.


[MUSIC: Blackbird Blackbird, “Avalanche” (from Summer Heart)]

DUBNER: Coming up on Freakonomics Radio: you would think that if you stood a 50-50 chance of getting a fatal disease, you’d want to know, wouldn’t you? Or would you?


WEXLER: You know, I think this is something that is horrific information, very, very powerful information.

[UNDERWRITING]


ANNOUNCER: From WNYC and APM, American Public Media: This is Freakonomics Radio. Here’s your host, Stephen Dubner.


[MUSIC: Color Radio, “Vespers” (from Architects)]


DUBNER: The economist Emily Oster was trying to figure out what kind of life decisions are made by people who are at risk for Huntington’s disease. Now, some of these people had had the blood test and knew they would eventually develop symptoms and die from the disease. Others had a 50-50 chance of having the genetic mutation but hadn’t been tested.


OSTER: So for the people who had not been tested and know they have a parent, the choice that we were most interested in was the choice to undergo testing. So, one theory you might have and this would be a theory that would be informed by standard economics is that people should value information and they should want to get the test because even if it is a bad result, bad in a sense that they have the mutation, it will still help them make better decisions in their life. But in practice what you see, and this isn’t just in our data, this is many people have shown this, is that in fact there’s very little testing, very few people seem interested in finding out whether they carry the mutation or not. And that’s actually similar to some other settings like BRCA testing for breast cancer markers where we haven’t seen as much testing as people might have thought.


DUBNER: When you say very few you mean how few, Emily?


OSTER: So in our population, something like 5 percent of people who are at risk get the test. So these are people, of people with a 50 percent chance of developing Huntington’s, only about 5 percent of them choose to find out whether that will happen.


DUBNER: That number was to you, I assume, shockingly low, yes?


OSTER: Yeah that number seemed very low. I certainly would not have expected it to be 100 percent. But I think 5 percent seemed really very small. And so I think sometimes, you know, as economists we think information is good. I think we do need to ask the question, is information in fact good, would it makes these guys better off to know this and so should we be really, really encouraging people to do this, or in fact does it seem like it would really be making them worse off, in which case we definitely don’t want to do that.


DUBNER: And I guess also you need to ask, think about is it better off for whom? Is it better off for them or is it better off for the rest, you know, their family, friends, society, too.


OSTER: Exactly.


DUBNER: So do you have an answer to that question at all?


OSTER: Yeah, so I think in some sense, in some sense we do. So what we do in our paper about testing is we try to think about, exactly as you asked, the question of why people don’t want to undertake this test. And we go through some stories I think economists would like, like is it because the test is expensive or people don’t know about the test, or…And those don’t seem to be stories that really hold up. The test isn’t very expensive; everyone seems to know that it is something that’s available. And then we try to think about, think about a model, like an economic model of why people might not get this, this test. And I think what we come down to is the view that in fact largely the reason that people don’t want to get this test is because while they are untested they seem to be able to basically be able to basically pretend everything is fine and that that may be very valuable.


DUBNER: What does that say to you just about the way that human beings, as kind of decision makers, think about the future, how they budget for the future in terms of you know time, and human capital, and money, and all that?


OSTER: I think what it tells us is that people care both about what they think will happen in the future and what actually happens. So you know, I enjoy going on a cruise, but I also value the time leading up to the cruise where I get to think about how great the cruise is going to be. I think often our normal, or standard economic models would basically say we only value the second thing, the only thing that’s beneficial of a cruise is the literal experience of being on the cruise. I think that what this says is in fact something that’s probably more comfortable for most non-economists, which is that there’s some value of, kind of, what you think is going to happen that that has like real benefits, or real costs for you.


DUBNER: Well let me ask you this then, and we should make clear, your parents are both economists aren’t they?


OSTER: That’s true, and my husband.


DUBNER: And your husband. And you have a child who’s what, a year or so old?


OSTER: Two.


DUBNER: Two, that child will almost certainly then be an economist.


OSTER: Right, it’s almost inevitable.


DUBNER: Well here’s what I wanted to ask you. I mean, we do know that economists think about the world differently and we appreciate that, especially on this program. I mean, we love that. On the other hand, there is this assumption among economists and within economics that people do value information and that they eschew or try to get rid of uncertainty, because economists see that uncertainty brings about bad things. But I’m just curious if the rather strong evidence that so many people embrace uncertainty in their own private lives may have changed or nuanced a little bit the way that you as an economist think about the downsides of uncertainty and maybe there is something to be said for it.


OSTER: No, absolutely I think that I have come to think that in fact for a much larger share of the population than I would have expected it seems like this preference for living with uncertainty is quite strong. And I would have said some people have that preference. It seems surprising to learn that basically, at least in this population, it’s like the vast majority of people appear to be much more interested in living with uncertainty, which isn’t something that I think would be true for me, and I would not have thought would be true for some many people.


DUBNER: And it doesn’t weaken your preference for certainty at all.


OSTER: No, I don’t think so.


[MUSIC: David M. Young, “Iridentalism”]


DUBNER: One of the papers that Emily Oster co-authored was called “Optimal Expectations and Limited Medical Testing: Evidence from Huntington’s Disease.” Another was “Limited Life Expectancy, Human Capital and Health Investments.” Now, if you’re an economist, that’s the way you think. If you listen to Freakonomics Radio—which you do, you are—you probably at least appreciate, to some degree, that kind of thinking. But if you’re someone who comes from a Huntington’s family? Who’s seen a parent die, maybe, and who’s been tormented for years about whether the same future awaits you? The economist’s way of thinking can be hard to stomach.


WEXLER: I was just totally offended by the titles of these articles that came out.


DUBNER: That’s Nancy Wexler again. She’s the Huntington’s researcher whose mother and three uncles died from the disease.  


WEXLER: You know, “Genetic Adverse Selection: Evidence from Long-term Care Insurance and Huntington’s.” And it talks about…I mean, these are friends of mine. And I think every single one of these articles was terrible.


DUBNER: Wexler also understands why only 5 percent of the people at risk for Huntington’s decide to take a blood test, the blood test that she helped develop, to see if they will get the disease.


WEXLER: You know, I think this is something that is horrific information, very, very powerful information. If you’re somebody who has a 50 percent risk as most people at risk around the world there is nothing, nothing whatsoever that you can do that makes any difference whatsoever, nothing, nothing, nothing, nothing, nothing, nothing. There’s no treatment you can take. There’s nothing to forestall it. And if we actually had something that made a difference in treatment, I think that would make a huge difference.


[MUSIC: Niklas Aman, “Spring Days” (from Above the Clouds)]


DUBNER: Nancy Wexler is 67 years old. She has an older sister, Alice, who has written about Huntington’s disease within the Wexler family. Now remember, because their mother had Huntington’s, they were both born with a 50 percent chance of getting it.


WEXLER: Well, I think that both my sister and I, we both thought well wouldn’t be fun since we found the marker and the gene, wouldn’t it be fun being the first getting tested? So we all, you know luckily my father is a psychoanalyst and said what are you doing? What are you doing? Fun? What are you talking about fun? What kind of fun is that? And I think, you know, having him actually express a reality, you know, all of us could find out both of us actually might get Huntington’s and die. And that was terrible. You know, at least having a 50-50 hope, you know, that ambiguity would go your way, you know, was helpful. I think another big, huge stress that people do not appreciate enough is being watched, because once you’re a public figure like me, like my friends, everybody watches you. You know, “Oh does she have Huntington’s, does he have Huntington’s?” You know.


DUBNER: Now, and you’ve, I just want to clarify if you want to clarify for me, is it true that you’ve never taken the test yourself then?


WEXLER: Well I’ll tell you I usually say that is a private decision because it’s something that I think gives permission to everybody to say, I have privacy, I have boundaries, I have rights. But I think since you’re being very friendly, I haven’t, but again, I think it depends an awful lot on what kinds of treatments actually would make a difference.


DUBNER: Of course. Of course. So let’s imagine that there’s someone listening to this program, let’s say they’re 18 years old or so with a lot of, you know, decisions coming up about what to do, what kind of family to be involved with and so on. And this is a 18-year-old with one parent who has Huntington’s. Talk to me about what risks that person has in testing if the test is positive. You know, how does that affect this person’s life financially, societally, perhaps legally, labor-wise, and so on?


WEXLER: Well, the reality of our country is that if a person is known to have even a risk for a genetic disease, for Huntington’s in the future, they quickly become an uninsurable person. If they have a job, if it’s a job that requires education, or even dexterity, or skill, you can lose the job. And GINA, the Genetic Information Nondiscrimination Act, or GINA, is supposed to protect you against that. But actually you have to prove that it was Huntington’s that caused you to lose your job. That’s the bad part of GINA. People think, I think, everyone thinks really that in some secret soul of their bodies or their minds that they’re truly unattractive and that nobody if they know this, they won’t love them And so people will just get into relationships that are brutal, violent, disparaging. I know a woman who dated every single horrible person she could possibly find. No literally. She thought well nobody’s going to like me so I might as well lose my virginity on a shit. And that you know, I think that we do that. We have our identity very much tied to who we think we are. And especially, you know, when the outside world is saying this is repugnant, this is repulsive, then we act it out in bad ways. It is toxic knowledge, it is difficult. If we could have more conversations about the knowledge, you know, before people are saying okay well it’s too expensive for you to live in ambiguity so line up here. I mean, I think we have concentration camps where everyone has to line up here and behave themselves or not. I think you don’t want to do that. You don’t want to eliminate people who are in any way physiologically or genetically different. The only way we can make people feel comfortable about talking is if we really genuinely feel that it’s okay to talk about it, we genuinely feel that you’re not going to take away my health insurance, my job, my life, my kids, you know, and it’s not going to have this kind of incredible retribution. Then I think, well you know, that’s a world I want to live in.


[MUSIC: Two Dark Birds, “Black Blessed Night” (from Black Blessed Night EP)]


DUBNER: Nancy Wexler is a professor of neuropsychology at Columbia and she’s the president of the Hereditary Disease Foundation. Before that, Emily Oster, an economist at the University of Chicago. In the course of reporting this show, we also talked with a few other people who have a 50-50 chance of getting Huntington’s but haven’t been tested. We thought you might want to hear from them too.



MELINDA: My name is Melinda Maher, I’m 25 years old and I’m living at risk for Huntington’s Disease.


CHRISTIE: My name is Christie, I’m from North Carolina, I’m at risk for Huntington’s Disease.


SHANA: My name is Shana Martin, I’m from Madison, Wisconsin, I’m 33 years old, I’m a world champion lumberjack athlete. So I compete in the sports of log-rolling and boom-running. The downside is I’ve been living at risk for Huntington’s disease. My mother just passed away from the disease a few months ago.


MELINDA: Right now at age 25 I hope to get a teaching job and I hope to move away from home and I hope to be able to move out and be on my own and have my own life and independence. And still right now I feel like if I were to test positive I would be afraid of that independence.


SHANA: I’m getting married in a few months, and we’re starting to explore having kids. And we chatted about it, I’m still quite firm that I don’t want to know. So firm that I’m probably going to invest quite a bit of money in in vitro fertilization just to not find out and to make sure my kids don’t have it.


CHRISTIE: I get up every day wondering do I want to be tested for Huntington’s. And I’m 40 years old, college graduate, working for a large university, and very happy with what I’m doing, but I can’t say it doesn’t haunt me every day. And so the longer I procrastinate against testing, I guess the longer I can say, well, I don’t have Huntington’s. Does that make sense?


[MUSIC: Drazy Hoops, “Happy Birthday to Me” (from Into the Red)]


[CREDITS]

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Comments are moderated and generally will be posted if they are on-topic and not abusive.

 

COMMENTS: 39


  1. ? says:

    I took one of those. It offered risk diagnoses. So I altered my behavior re eating/exercise. As far as another test goes, I know the objective results of taking that one. It’s the other stuff that’s the problem. I say that I am not going to worry about it, but I do. But then I see how some people I admire respond to success. The fact that I know nothing about their private lives means, from my point of view, they succeeded. As my husband would say, who cares who Richard Gere is married to, you like his’ films. Well, not altogether true. I do like knowing about people as people. It’s very much a part of what I do. But not in the way we celebrate success here in the US. We raise some people so high up on a pedestal- as if not human. And then the result is some are so full of themselves. That, I can do without. As for Huntington’s disease, or any other disease, we all are going to die from something. My understanding of such tests is that they predict within a range of certainty and not absolute certainty. Left open is the matter of individual behavior and that, other than a gene altering pill, there’s what you do and how/where you live. I had a friend whose mom died `young’ from lung cancer. Her mom never smoked. My friend moved to warm climate. The question for me is of how to reduce such stress? Answer- my book is limited to science. For those with a serious interest, it will be of interest. For everyone else- probably boring. I mean- who really wants to know the future in advance!

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  2. Kristen says:

    As someone who underwent genetic testing for Huntington’s disease, this research is extremely relevant to me. This topic is controversial in the HD community, especially in regards to the decision to have children. However, it is extremely important to open the communication channels because there are many unspoken implications resulting from the test. These channels must certainly be more open between the generations, who have contrasting views on the decision. We won’t be able to improve the quality of life for those at-risk until the community itself can openly talk about it to each other and the general public.

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  3. Dan says:

    Take this one step further… if you could get enough clairvoyance to find out you will live until you are 90 years old, but you will absolutely not live a day a longer, would you take that deal to live until 90. I initially thought I would say yes without flinching. I’ve given it a great amount of thought… and I think the rest of my life would become a literal countdown and I would therefore prefer to take my chances and just see how long I may live. Im curious to know what others would do

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    • Geoff Clausen says:

      I took part in the prototype study in 1986 over 9 months with the result in return for my time and belonging to a family that has suffered greatly to Huntington’s Disease. My time at John Hopkins in Baltimore were well worth the reality.
      I was so afraid of the answer that I waited 3 years for the results. My reasoning was based on fact , not fiction. If I had important information offered to me would I accept the truth or would I live in wonder. Fact was the lever was then I could plan in real time based on real information and plan my life thus. I decided that to know was to defeat denial and the unknown. There was no other option and I needed all the info. I could take.
      I understand why some choose the option to remain in the dark , I believe one of the Wexler sisters or maybe both choose to not take the test they helped create because it would not change things and why get bad news if you can pick no news. One of this sisters said ” I would not be any happier in life if I got the good news but I would be devastated should the outcome be bad news” . To each there own as there is no answer that fits all mindsets .
      As for the % of is the test valid, I was told 99.something is the answer. It has not changed my life as I am still a caregiver and I live the demon everyday. As for the countdown theory I would not invest in it as it pays no dividends. Life lasts until it ends due to dynamics way beyond your control. You can make better choices with information. Look both ways before stepping off the curb.
      May serenity be your friend, Geoff

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    • Geoff says:

      Dan , You pay your money and you take your chances ! Information is a good thing because then you can make life decisions based on reality. Looking into the future to age 90 is not a good metaphor because it has no connection with a family disease that has many tangents as it involves a group of close , bonded , individuals.
      I took the test and won the coin toss but have been a caregiver for forty-five years changing my life in ways I cannot put in words. Putting off knowing that which is going to happen anyway only leaves you with no compass.
      Having said that , it is a complex decision based on different individual circumstances .

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  4. JK74 says:

    Coincidentally enough, just a few days ago I re-read this Robert Heinlein story:

    http://en.wikipedia.org/wiki/Life-Line

    My answer to the question? I’d get the test, you betcha. Maybe it’s because I’d expect pretty good news; both my parents are alive & in good health for their ages (74 & 81), all my grandparents lived to ripe old ages (70+ to 90+). The only downside is that based on their experiences, I’ll die of some form of cancer. (Although I tell the joke; when I go, I want it to be peacefully in my sleep, like my grandfather. Not panicked & screaming, like the passengers in his car…)

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  5. Meg says:

    Though I believe it is important to have open communication and honest debates about these topics, I do not believe it is fair to ask those who are not at risk whether or not they would take the test. I do not want to belittle or undermine their opinions, it is just similar to how a person cannot know what it is like to lose a parent or a child when they haven’t. Being at risk for HD myself, there is no way for me to truly impress upon anyone how much turmoil is brought about by thinking about the test, nor the vast amount of complexity that the very nature of this incurable disease adds to one’s life.

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  6. J276 says:

    It seems to me that this is an ethical issue and not an economic one.

    It’s difficult to understand why someone would choose to have a child with a 50% chance of such a horrible disease. Are there unfair rules prohibiting adoption to couples with one HD+ parent? It is understandable why HD has persisted in the population as it affects people after reproductive age, at least prior to the mechanism of transmission being understood. Though the researcher talks about the test as a tool on the way to a cure, it seems to me that in a ethical population the test IS the cure.

    Lots of talking about how having the information makes people feeeeeeel… No question it’s depressing…but isn’t? it also navelgazing? How about how your potential son or daughter will feel at 55? Obviously these comments do not apply to non-parents, but a 5% rate of testing? Really?

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  7. Steve says:

    I was very surprised and disappointed that your story didn’t refer back to a very recent episode that would have completely illuminated the subject and reinforced the power of the Wexler quote that ends the piece above. This discussion reminded me of the response to the start of the AIDS crisis in the 1980s. After several years of confusion and lack of information, HIV was identified as the cause and soon after that a test was developed for the virus. For a few years after that, there was no treatment available to fight the virus. There was a very vigorous debate in the gay community about the value of getting the test and most people I knew chose not to do it primarily because there was nothing to do with the information other than wait and worry. Safer sex practices were already being encouraged and whether you knew you were positive or not you knew what you needed to do to protect yourself from possible infection or from infecting your partner if you were positive. As soon as AZT, the first effective treatment for the virus was developed, everyone I knew went out and got tested. I think the critical issue is always going to be whether having the knowledge will allow you to do something to address the issue. Having the knowledge for its own sake, especially when it can be so devastating, really has no value and, in fact, can be nothing more than debilitating. But having knowledge that can inform your actions and allow you to take steps to do something positive to avoid an otherwise terrible result will always drive us to action. I’m sure you could have found many other examples of diseases for which there were tests before there were treatments and then treatments came along and you would find the same result.

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  8. Greg Stearns says:

    This issue is Prospect Theory (http://en.wikipedia.org/wiki/Prospect_theory) at work. Specifically, the Four-Fold Pattern’s top right quadrant. 50% is drastically higher than 1in 10,000 (the base population rate) and the potential loss is enormous when both physical and cognitive degeneration are at stake.

    I have a 50/50 risk for Spondylitis, which isn’t anywhere near as debilitating as Huntington’s and I haven’t been tested (though at 31 without symptoms, I’m likely to be in the clear).

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  9. coolsonh says:

    If I was at risk, I think I’d take the test. Because in my mind the potential positives out way the potential negatives.

    The podcast did not talk about what happens when people are tested negative, (will not get the disease). Getting this information would be amazing, because instead of living with uncertainty, you could live as preparing for a long life. There would be no questions about having a career, getting married, having children. All of which would still be in question had the test not been taken.

    While the cost is high, the benefits, in my opinion, outweigh them.

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  10. Ben Saunders says:

    Great episode! I have to admit, I was irritated listening to Wexler; the argument “you’ll never understand because you don’t have HD” just doesn’t fly with me. She needs to leave her emotions at the door; she’s a scientist, and the data collected on individuals like her and her sister are invaluable.

    One thing that shocked me (obviously, I haven’t thought a lot about HD until now) is that some of these people knowingly have children, despite the incredible risk they’re taking. Dubner, I’m surprised you didn’t show more outrage… this seems clearly unethical. I have a son; I can’t imagine exposing him to a 50% chance of Huntington’s. It’s selfish, plain and simple. I googled “why do people with huntington’s have children?”, and this is an excerpt from the top hit: “Deciding whether or not to have children who might be at risk of inheriting Huntington’s disease is a dilemma that still faces prospective parents. Doing things the ‘old-fashioned way’ remains an option, and is of course free of charge and fun!” Jesus! How is it a dilemma? Who cares if it’s free or fun? Exposing your child to a 50% risk of HD isn’t a dilemma, it’s just a terrible choice.

    I know I’m going to take a lot of flak for this, but is there some way we can incentivize these individuals not to have children “the old fashioned way”? I’m not even sure if this is legal, but can we (the government) pay for in vitro fertilization and any costs it may incur? I hate to sound like a eugenics monster, but I feel there’s a tremendous advantage to “breeding out” this gene…

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  11. Andrew Cockerham says:

    One word: hope. Thats what this whole thing is about. The reason this ‘uncertainty’ is valuable, is because it gives us hope. If we knew the dreadful news, we would lose all hope. And no one can live without hope. Hope requires uncertainty. Or put another way, certainty destroys hope

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    • Jan T Oakfield says:

      As an HD family member who has been a caregiver for the past 30 years, and who tested negative for the gene mutation many years ago while family-planning, I’d like to add a few things to the discussion:
      1. While there currently is no cure for HD, there are HD doctors (primarily neurologists and psychiatrists) who are very adept at managing HD and caring for HD patients. They individually, and collaboratively, care for HD families (the patients, the caregivers, the gene-positive but asymptomatic, at-risk (non-tested) adults, and children living w/ HD family members), research the disease, and share information w/ each other and the HD community. There are HD clinics that provide medical care and services including social work, psychotherapy, genetic counseling, speech therapy, OT, PT, nutritional advice and opportunities to participate in research. Short of a cure for HD, medical management of HD, and those who provide this care, are extraordinary. With good medical care, and support from family and friends, quality of life can be achieved by HD patients, depending on how they and their support network deal with HD.
      2. HD research continues to advance and be pursued rigorously. We know more and more each day. Unfortunately, brain science is complex, it takes time, for HD and most other diseases.
      3. While the laws against genetic discrimination have yet to be tested, they do exist and are there to protect us.
      4. I’ve always believed that a cure is not far off (I’m an optimist, as are my family members affected by HD). Therefore, bringing children into the world with a 50% risk of inheriting the genetic mutation for HD didn’t scare me. We would still have a generation to find a cure. What scared me was being a mother who gets sick while raising children…how could I care for my school-age children if I was sick?
      5. Information, communication and certainty is better than uncertainty and denial.

      Individual decisions to get tested or not are most influenced by our personal experiences. Public figures have a responsibility to maintain objectivity when speaking about such intimate topics as genetic testing, and should not allow their personal experiences to dissuade at-risk people from being tested, especially if one is the heroine of the HD community. Perhaps this is why so few people have been tested? The radio host and the economist should also hear from those who live optimistically with the knowledge that they will, or have, HD.

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  12. Steve C says:

    Here’s a thought. Let people take the test, then flip a coin to see whether you throw the results, unread, into the bin. If you don’t discard the results, you only pass on the results if it is good news.

    In this way, one in four people at risk get to hear they are safe, and can stop worrying. These people would be forever free. Three in four never hear one way or the other, but they now know their chances of having HD have risen from 1/2 to 2/3.

    I wonder if this 50-50 chance (info or no info) would have a similar psychological effect to the one described in the show. People know the odds of having the disease but seem to live optimistically until shown proof — the failed test results. But if you promised to never show the negative results, and still provided enough uncertainty for people to imagine themselves free of the disease if they didn’t hear, would that psychological effect still function to allow people to continue to live optimistically?

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  13. rae says:

    When my sister-in-law’s grandfather mysteriously came down with the disease, they deduced that he was not his father’s child. Because she was an old woman, the family did not confront his mother.

    We wonder about who the real father was. Three of his four grandchildren died of Huntington’s, one of their children got tested (negative) the other did not.

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  14. Greg Rozansky says:

    If you have HD you have an obligation to get tested. I worked in a pre-implantation genetic diagnostic (PGD) laboratory. Symptoms of Huntington’s disease may only present later in life, often well after carriers procreate. If an individual has a family history of Huntington’s they must get tested so that they can have children through PGD which would then ensure that their children would not acquire the mutation. This is a cure that would one-day completely eradicate Huntington’s. Dr. Wexler’s discovery took place long before PGD was being used and frankly, the ‘should one get tested’ question is quite old-fashioned. In countries like Canada and Israel, governments are fully subsidizing PGD as they recognize this as a means of eradicating genetic diseases that have been sequenced.

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    • Shutish Patel says:

      Greg Rozansky’s comment merits consideration by public health policy makers. There should be no difference in our approach to HD as compared to any other fatal genetic disorder such as Tay-Sachs disease. If PGD is a viable approach, it should be offered as a necessary prenatal screening test for at-risk individuals. At this time it would appear to be the only absolute way to eliminate the disorder.

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  15. masha says:

    This debate makes me think of the book “Never Let Me Go” written by Kazuo Ishiguro, a science fiction dystopia about the world in which clones are bred only to be used as organ donors around the age of 30. Although the main characters, all clones, know and comply with this fate, none of that matters too much. What truly matters to them is the relationships their form, friendships and romantic love, which make their life worth while.

    In a way, most of us will end up having rather predictable lives: we’ll work, have families, be more or less happy and die around the life expectancy age for our population. The clones in Ishiguro’s book would die around 30, I am (hopefully) likely to die around 82, HD patients around 60. The odds of a longer lifespan might be different, but our priorites and aspirations are probably quite similar. It is what we make out of the time we have that matters.

    In the end of the book Kathy says: “I remind myself I was lucky to have had any time with him at all. What I’m not sure about is if our lives have been so different from the lives of the people we save. We all complete. Maybe none of us really understand what we’ve lived through, or feel we’ve had enough time.”

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  16. Nicki says:

    I want you to start posting what music you are using in each podcast. You have such great selections, especially in this podcast, and you don’t leave enough non-voiced-over sections for me to shazam them :)

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    • Kyle says:

      I tried Shazaming the music used around the 11:40 mark and even with no talking nothing came up. Let me know if you find anything!

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  17. Krista says:

    I got tested for a kidney disease called Polycystic Kidney Disease when I was 23. My father had it and I had a 50% chance of inheriting it, which I did. This disease is also incurable and life-threatening and having lived 7 years with the diagnosis I would say I wish I hadn’t been tested. It has given me a perspective and strength I would not have otherwise, but ultimately I wish I just tried to live as healthy as possible without knowing, as it’s taken a toll mentally and emotionally. However, I’d say the biggest upside to getting tested is being able to participate in medical studies for possible treatments, which I’m doing right now. I’m grateful that I’m able to help the progression of research and speed up treatments for others with my disease.

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  18. Alec S. says:

    I just finished listening to this podcast, and I thought it was very interesting. I have a disease called Hereditary Hemorhagic Telangictasia (or HHT). It is similar to Huntington’s in that if a parent has it, the children have 50% chance of also having it, they know where it is in the DNA, and there is still no cure. It is not nearly such a scary fate as Huntington’s, but at the same time, I know that it will be the cause of my death. It was interesting to hear the questions asked in the podcast, because I’ve lived with the answers to them my whole life. Of course you don’t want to get tested! Why would you? You don’t just go into the doctor and say “hey, find something wrong with me” likewise, if you have a higher chance of having a disease, there’s no reason you should find out while you’re still feeling healthy. If there were a cure, or some way to prevent it, that would be totally different. With HHT, we have the possibility of developing faulty blood vessels in mainly our brains, lungs, and liver. If they develop in our lungs or brain, we could die of a stroke or heart attack in our early 20′s. Because of this, they do recommend that we get tested, and luckily, most of the AVMs (fautly blood vessels) can be fixed so we don’t die so young. Anyway, enough backstory. I am a new mother of a beautiful girl, and while I want to make sure she doesn’t have any AVMs, I also don’t want to have her tested. It is such a battle between wanting to make sure she’s healthy, and the fear of what might have to happen if she’s not. It’s just easier to say “look at her, of course she’s healthy” rather than agonize over medical bills and test results and whether she will develop AVMs as she gets older. It does not possess me every day of life, usually only when I get a nose bleed. I also don’t change my perspective too much, although I do think it will change the older I get. Since it gets worse as I get older, I can still lead a pretty normal life until I’m about 60. I imagine then I will be more likely to seize the day then because I know my life span will be possibly decades shorter than if I was not affected. Although it is a rare and humbling situation my family has, my mom frequently reminds me “everyone has something, we’re just lucky enough to know what ours is” most everyone has some hereditary medical something-or-other being passed down, and really, most just don’t have to face it until much father down the road. We all know we’re going to die, some are just made aware of the fact (and choose whether to ignore it or not) much sooner than others.

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  19. 21064a01 says:

    Stitcher feed on this show has failed so many times. Anyone TRIED to fix this problem yet?

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  20. frank says:

    I love freakonomics and huntington’s runs in my family. I was one of the 5-10% who have actually taken the test. Test came back negative. Really glad to see the disease getting attention.

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  21. Matthew says:

    Anyone know the name of the song playing around the 12:50 mark?

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  22. Mark says:

    The music is listed in the audio transcript

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  23. breh says:

    This is the first freakonmics podcast I have listened to, it’s great! And for me the topic sort-of hits home for me. I was diagnosed with a chronic autoimmune disease at 19 that I know will eventually probably be the thing that kills me, I’ve been living with it for 17 years now. I’ve always tried to “stop and smell the roses” knowing my time here is shorter than most. But I also feel like without knowing maybe I would have strived for more… Very interesting to hear my behavior is so typical that it can be quantified.

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  24. Bella says:

    I just recently took the test to know whether or not I have the huntington’s disease (my mother has it), and boy was it such a process…

    I am 21 years old, and the clinic found it controversial that someone my age would be tested for something so life altering. They continuously postponed my decision, making me go through several steps before I can finally take the test. They went so far, as to have all the doctors related to this field sit me in a small room and tell me they don’t think it’s a good idea unless I’m getting married or choosing to have a child. I thought this logic was incredibly flawed but that’s besides the point.

    For all it’s worth, I don’t resent the procedure. It allowed me to develop a mature outlook in life. I was not scared for the test. I thought that having the disease would just give me an alternative lifestyle that I could be happy with too, considering the fact that I’m a very independent person who enjoys delving deeply into my own interests and goals.

    I don’t have the gene. I got a tattoo that evening to celebrate.

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  25. Daniel S. Sax MD says:

    An excellent, informative, thought provoking discussion.But for the negative social, insurance, economic, legal and vocational arguments against knowledge of the presence of the gene one should consider the benefits from knowing the number of of CAG expansions, which helps explain anticipation and gives a n indication when HD might become manifest. Another point to consider is when when to get the test i.e. as early as adolescence or at 55 or 65 when the information might be beneficial not only to the person but to his/he offspring.

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  26. Eva Podietz says:

    Maybe some people don’t want to know if they have a gene for a disease because they don’t want to ruin their changes of getting insurance coverage.

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  27. Kenneth Hoffman says:

    The question of why 95% of persons with a parent who had Huntington disease opt not to take the test while knowing that if they have it and have a family they would pass on the gene to future generation. The reason they give is that it would affect their ability to make a living, being social outcasts besides the trauma of the disease itself. I would think that their ability to prevent their offspring from the agony of Huntington’s would be enough reason to say nothing of their personal responsibility. They could still keep their knowledge secret while saving future generations.

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  28. Khannea SunTzu says:

    In a few decades we have the ability to change genes and/or gene expression. In other words, genes will stop be deterministic in the onset of genetic diseases. We aren’t there yet, but many people alive now who receive a genetic test “sentence” may see such an outcome reverse and be cured.

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  29. Jyothi nayak says:

    I want know my future life

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  30. Shem says:

    I world get tested because I would like to know the future risk I’m going to be placing on my future kids. It is in no way about be. Weather it is Huntington’s disease or another horrible ailment like Sickle Cell anemia (completely different from Huntington’s but just as horrible in my eyes) I wouldn’t want my children too suffer because of my selfish notions. “Well hun there’s a 50% or 0% chance you will suffer in life because I didn’t want to bother myself to get tested. Cheers.”

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  31. Enter your name...krishna narah says:

    i want to know about my career and when will i get marrhage?

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  32. saikumar says:

    i want to know my furture

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  33. Nicki Marshall says:

    For 12 years I debated whether or not I should get tested for Huntington’s Disease. However, after reading an article about the work of Michael Hayden and his group of scientists at UBC I decided to take the plunge, as in their studies with laboratory mice, they were able to halt but not reverse emerging symptoms of the disease. Of course I had to prepare myself mentally for the possibility the results would be positive for the disease. However, I was completely caught off guard when I got my HD test results, which thankfully were negative for the disease. I had not prepared myself for that news and am still surprised at how overwhelming the news was….I was so choked up I was on the verge of tears and could not speak. To try to explain the reaction is still difficult…It was so much more than relief; it wasn’t guilt but I did make a commitment to help in any way I could to find an effective treatment.

    Since then I have participated with a family member who does have the gene in a study that tracks our motor, cognitive and neurological well being through a series of tests that are repeated annually. At the earliest sign of disease related symptoms, my relative will be able to participate in a drug study with the hopes of getting fast tracked ahead of the disease with emerging drug treatments.

    The knowledge as well as the lack of knowledge has a profound effect on anyone facing the 50/50 probability. My decision to get tested was predicated on the fact that the positive results on Michael Hayden’s break through were limited to halting the onset of symptoms, but not reversing them.

    To suggest that people who have the gene should not have children is harsh and unwarranted. First off, it is possible that none of their children will carry the gene.
    Secondly, Huntington’s often occurs later in life, so the gene carriers will have plenty of time to have rich, full lives and possibly contribute something monumental to humanity, as is currently happening in many ways and places around the world.
    Thirdly, a cure may be just around the corner. Science is moving rapidly and scientists around the globe are sharing what they are learning with the hopes of beating the clock for those who are not yet symptomatic.

    What is needed is the will to defeat Huntington’s Disease, which, as has been clearly stated, has no treatment to effectively minimize the relentless progression of this heartless disease. We need the drug companies to get on board to do the testing, but that is a very expensive proposition, and unlike diseases with higher casualty rates, the return on their investment is perhaps a little slower than say a treatment for Alzheimer’s Disease.

    My the Force be with us!

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  34. Lokendra solanky says:

    My dob 30 july 1994 at 9:45 min. I want to know that what will be the my future

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