Placebos, antidepressants, and government mendacity

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.

Author: Michael O'Hare

Professor of Public Policy at the Goldman School of Public Policy, University of California, Berkeley, Michael O'Hare was raised in New York City and trained at Harvard as an architect and structural engineer. Diverted from an honest career designing buildings by the offer of a job in which he could think about anything he wanted to and spend his time with very smart and curious young people, he fell among economists and such like, and continues to benefit from their generosity with on-the-job social science training. He has followed the process and principles of design into "nonphysical environments" such as production processes in organizations, regulation, and information management and published a variety of research in environmental policy, government policy towards the arts, and management, with special interests in energy, facility siting, information and perceptions in public choice and work environments, and policy design. His current research is focused on transportation biofuels and their effects on global land use, food security, and international trade; regulatory policy in the face of scientific uncertainty; and, after a three-decade hiatus, on NIMBY conflicts afflicting high speed rail right-of-way and nuclear waste disposal sites. He is also a regular writer on pedagogy, especially teaching in professional education, and co-edited the "Curriculum and Case Notes" section of the Journal of Policy Analysis and Management. Between faculty appointments at the MIT Department of Urban Studies and Planning and the John F. Kennedy School of Government at Harvard, he was director of policy analysis at the Massachusetts Executive Office of Environmental Affairs. He has had visiting appointments at Università Bocconi in Milan and the National University of Singapore and teaches regularly in the Goldman School's executive (mid-career) programs. At GSPP, O'Hare has taught a studio course in Program and Policy Design, Arts and Cultural Policy, Public Management, the pedagogy course for graduate student instructors, Quantitative Methods, Environmental Policy, and the introduction to public policy for its undergraduate minor, which he supervises. Generally, he considers himself the school's resident expert in any subject in which there is no such thing as real expertise (a recent project concerned the governance and design of California county fairs), but is secure in the distinction of being the only faculty member with a metal lathe in his basement and a 4×5 Ebony view camera. At the moment, he would rather be making something with his hands than writing this blurb.