Antidepressants seem to be only somewhat more effective against depression than placebos, and the finding has triggered a fair amount of discussion of health care costs (how much are we spending for drugs that don’t work much better than sugar pills?) and of course lots of technical back and forth about the studies themselves. Am I ever not going to weigh in on the fact question (you can read a summary here, and I don’t vouch for its objectivity if that’s what you care about) because how much better Prozac is than Tums isn’t the issue here and I have no expertise: the placebo effect is well known, repeatable, demonstrable, and real. Frequently something you think will ‘cure’ a real ailment will, with no possible physical effect. I first learned about this in connection with warts, which have a long history of susceptibility to all sorts of magic if the patient believes it. My college girlfriend’s mother was chief of pediatrics in a large New York HMO, with a sideline as the local wart specialist. Her wart cures – I remember especially ‘topical application of the patient’s father’s shaving brush’ – were an endless and hilarious sequence of stuff that could only make sense to someone with the imagination (and modest fact base) of a kid.
The effect is related to a paper I’m working on with a graduate student, proposing that worry is a real cost of risky policy that deserves to be counted, along with expected quality life years lost, economic cost, and all that “serious” stuff we normally recognize. (Depression is not at all the same as being worried!) The ethical conundrum in the placebo case is much larger than the ethics of doing double-blind studies, and concerns practice, not research: what are the ethics of doing medicine in accordance with placebo findings, especially if this very cheap mode of treatment is vitiated by public knowledge of it? If patients have a significant probability that a prescription is a placebo, won’t the effect be undercut? Should public discussion of the whole thing be shut down on exactly the same principle as we discourage misuse of antibiotics, to protect the efficacy of an important medical resource?
In the context of worry, an obvious possible policy for government is simply to lie (and of course, to manage the ‘real’ risk properly). And citizens would be wise to support the policy: “if you’ve done all you should to reduce the physical risk, then just tell us ‘it’s perfectly safe’.” Except that if the policy were known, it wouldn’t work, so a tangled web of deception is in order, one that raises the risk of hiding real mischief.
This gives me a headache, so I’m going to stop. But I think the issue is a real one and the costs and benefits are very large (in both cases), so we can’t just shelve it as an interesting class discussion puzzle.