Diego Caleiro

Philosopher, EA, and Biological Anthropologist

I’ve warned you! But I shouldn’t have

Among close friends, or even within the family, the use of SSRI’s (selective serotonin reuptake inhibitors) can be a delicate topic, it may come with connotations of depression, suicidal behaviour, and can be emotionally marginalizing. A new scientific review may further entangle this already vexing situation, in the study (Isacsson, G. & Alhner, J. 2013) it was found that the presence of suicide warnings in SSRI’s may have indirectly increased suicide rates due to an intricate form of cultural Information Hazard.

Despite being a review, the study only faintly points toward a certain interpretational direction, but it doesn’t clearly guarantee it. With that prior caveat in mind, Isacsson and Alhner gesture that the warnings mentioning suicide risk have caused a plateau in SSRI consumption in Sweden, and that during this period, the rate of suicides among those who didn’t take SSRI’s increased, and more so than among those who did. Once the label was in place, it made the decision not to take SSRI’s worse than it was before. This is a complicated process, and it is worth analysing it further.

In both the no-warning, and the yes-warning situations, you had three populations, A, who wouldn’t take the prescription regardless of anything else, B, who would take it as long as no suicide warnings were inscribed, and C, who would take them anyway. A comparison was made between C plus B and, separately, A, in the no-warning case, factoring out of course as many irrelevant variables as possible, and it was concluded that warning the C plus B population would be a good move to avoid suicides. Yet, in the yes-warning situation, it turns out that group B (those who would actually shift from taking to not taking) ended up more likely to commit suicide, contrary to prior expectation.

In this case, the warning itself can be considered an Information Hazard, and can be qualified as belonging to the following categories developed in the linked paper above by Nick Bostrom:


Temptation hazard: The warning tempts group B, who should not make the shift, to make the shift from accepting to denying prescription.

Knowing-too-much hazard: Knowing that SSRI’s can downstream into suicidal behaviour, despite true prima facie, is an undesirable piece of knowledge to have, making one more vulnerable to the very problem the knowledge should help with.

Although unusual, this is not an unheard of situation, its reverse even has a popular name: self-fulfilling prophecy. This is a case where a prophecy is self defeating. Not very frequently Medical Ethics intersects the field of logic and philosophy of language in relevant ways, but in this case, a comparison with the liar’s paradox is worth a note. In the same vein as “this sentence is false” is false when it is true, and true when it is false, so a suicide warning appears to be ethically desirable when absent, and ethically undesirable when present. Unfortunately, in this case, what results is not a beautiful paradox like Newcomb’s, but the worst of possible worlds.

As the quantifiable data on human cultural transmission increases, we are likely to find more and more “ethical conundrums” of this kind, and it would be well advised to educate ourselves with a vocabulary and intuitions to deal with these preventively, because sometimes, it is better to find ways to deal with what’s inside the box before finding out it belongs to Pandora.

Links:

Bostrom, N. (2011). Information hazards: A typology of potential harms from knowledge. Review of Contemporary Philosophy, (10), 44-79.

Isacsson, G. & Alhner, J. (2013). Antidepressants and the risk of suicide in young persons – prescription trends and toxicological analyses. Acta Psychiatric Scandinavia, 1-7.

The Cultural Cost of Placebo

A recent poll says that nearly all General Practitioners in the UK have given placebos to at least one of their patients.

The story can be seen here: http://www.bbc.co.uk/news/health-21834440

 

Everyone loves placebos. If you are a scientist, placebo shows an incredible feat of the human body, and interesting interactions between our psychology and the biology that underlies it. A doctor can rest assured that placebos won’t cause a chain of undesirable reactions in their patients, while still helping them. Even a new age pro-herbal unscientific mind favours placebo, placebos not only aren’t the allopathic evil kind of substance, but with sufficient distortion of argument, placebos can be taken as an argument in favour of whichever branch of neo-medicine that particular mind would like to enforce. So everyone loves placebo, and placebo helps everyone.

Or does it? Here I’ll outline some of the reasons we should be wary of placebo effects, and sketch some cultural costs that are being unconsciously left under the rug by the placebo enthusiasm in which we, or at least General Practitioners,  find themselves.

Reason 1) Placebo doesn’t mean what we think it means.

Under experimental conditions, placebos are supposed to be inert to the body. Very few substances are actually as inert as would be desirable, and many times we would find outrageous that substance X was considered placebo.  A striking example comes from Beatrice Golomb’s short essay on The Dece(i)bo Effect, where she mentions two studies which assessed the effects of corn-oil and olive-oil in patients who needed to lower their cholesterol. It seems a promising avenue of research until you discover that the olive-oil and the corn-oil were not the target of the study, which was a cholesterol-lowering drug, they were the placebos.  The first cultural cost that placebos pay is a labeling cost, once labeled, we lose track of the information of what they contained when studied in the first place.

Reason 2)Placebos don’t function as broadly as we think. Or would like to think.

Placebos are good for pain and anxiety, in the short term. Systematic reviews of general studies of placebo, on the other hand, shows very mild to no effects from placebo. As seen here. The second cultural cost that placebos pay is the cost of being likable, and therefore, less amenable to accurate scrutiny beneath the excitement field.  As is widely known, if an idea, meme, memeplex (group of annexed memes) or cultural item is the kind of thing that people just like to believe, it is extremely hard to eliminate it from culture. Placebo is a nice idea, and because of that, it is kept in a safer haven than it should, given how many lives it affects.

Reason 3)Placebos are mysterious, and mysteries are contagious

It is incredible that our minds are able to influence the body in the way they do (irrespective of one’s hardcore eliminative monism or Cartesian dualism). Even if the effects are mild, and more constrained than we think, they are still, in some sense, fantastic, belonging to a world of fantasy. To a mind with inclinations for Skyhook type explanations, they open the gate which parts the world of science from the world of fantasy. Doctors are not immune to aspiring that the world be magical and mysterious, in fact, given their high level of education in scientific matters, if any strong innate or childhood force compels them to look for mysteries and Skyhooks, then once the gate is open the diffusion of memes from one side to the other is likely to be uncanny. And here lies the most dangerous cultural cost of placebos. Placebos open the gate for Skyhooks and mysteries in the minds of those on whom our lives depend.  A well educated doctor has to go through a painstaking amount of cognitive dissonance if she is to enforce homeopathic treatment while knowing that nothing she was told while learning the profession indicates that it makes sense. But if there is this other mysterious thing that is well accepted and highly regarded among her peers, well, then the fact that we don’t know how it works should not be a decisive factor against homeopathy, right?

Reason 4) Placebos permit a diminished sense of responsibility by twisting psychological knobs

When administering a placebo, a doctor has more reason to sleep well knowing that he didn’t (really) act in relation to a patient while still helping than if he had (more) actively selected a medication which could have varied adverse effects for the patient, and legal consequences for the doctor. More than that, it permits the doctor to hold himself responsible only in case of success, which is an emotionally comforting position to be in. By psychologically thinking it is less of a directed action to administer placebo, the doctor can ease his sense of responsibility by believing that it was not so much his decision that played a role.  Even if in the real world he can be indicted for giving placebo in a condition in which it was wrong to do so, at the decision moment  the major players are his self image and internal representation of the event, and these are likely to prefer a story in which he bears no responsibility, except, ironically, the responsibility for infusing the sugar pill with the magical quality that will aid the one in need.

 

There are good reasons to administer placebos under many circumstances, and the claim here is not that 97.5% of General Practitioners are doing wrong. Instead, it is a call for a sober assessment of which exactly are the circumstances in which placebos ought to be administered. For one thing, in the cases in which placebos are effective, their effectiveness depends on patients actually believing their effectiveness, and for this very reason, it would be a great loss if they became ubiquitous enough that patients stopped believing their effectiveness.

Many cultural items pay the same cultural costs as placebos, being likable, permitting ease of conscience, having ill-defined conceptual borders, and annexing themselves with mysteries are memetic strategies familiar to researchers of cultural evolution, and the items that use those pernicious strategies frequently escape our sight, where I think placebos should be attentively kept.

 

 

 

 

 

 

 

 

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