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.
Last year, Julian Savulescu of the Uehiro Centre for Practical Ethics here at Oxford debated Robert Sparrow of Monash University on the issue of using techniques like embryo selection to ensure one’s children have the best life possible. Savulescu has notably defended not only the permissibility but the obligation to select for the best children, while Sparrow has been more critical of enhancement via embryo selection. The transcript of their debate is now available, and their exchange helps clarify a key source of disagreement between proponents and critics of embryo selection – whether parents should be maximizing their children’s well-being, or simply giving them a good enough life. At its core, the debate is less about the intricacies of new technologies like preimplantation genetic diagnostics (PGD) and more about the ethics of parenting. I’ll summarize some of the key points of the debate below, but I encourage readers to have a look at the transcript to get a sense for how the dialectic plays out as well as how each interlocutor deals with a wide array of objections. Continue reading
Last weekend’s work was greatly enlivened for me by keeping track of the updates for Trinity Jailbreak. The challenge: 37 student teams had 36 hours to get as far from Trinity College Dublin as possible, without spending any money. They were, however, allowed to blag, persuade, and get corporate sponsorship to aid their “getaways”. Pre-contest, Donegal, Kerry, or perhaps Calais at a stretch seemed like likely winning destinations. However, this was grossly underestimating the resourcefulness of these students – with 1 hour to go, two teams were separated by less than 10km, frantically running in opposite directions – one in Indonesia, the other in Argentina, both >11,000 km from home.
From Trinity College Dublin’s website: “Medical students, Claire and Matthew were named winners of the competition on Monday when they reached the sunny Atlantic coastal city of Mirimar, south of Buenos Aires. They managed to fly to Buenos Aires and take a taxi down the Argentine coast without spending any of their own money and without speaking Spanish. Musician Chris de Burgh stepped in to pay for their ticket home… Many of the students persuaded travel agencies to sponsor them and made it to Paris, the Vatican City and Warsaw during the event… Lydia Rahill of the Trinity Law Society expressed gratitude to all who supported the event through sponsorship and offers of food, accommodation and help with travel expenses.”
The Challenge was organised on behalf of charity St. Vincent de Paul, which aims to fight poverty in Ireland, as well as Amnesty International, and had an original goal of raising €4,000 (~£3450). However, it caught the public imagination, and €10,000 had been raised by Monday, with €15,000 expected as a final tally. It’s apparently even made it into Time Magazine.
“Very impressed with @TCDJailbreak. Brilliant way to raise money for charity and amazing to see how far you can get by just blagging” tweets one Irish celebrity.
A great success!
Or was it?
I’m taking anyone’s best guess at how much all of these flights, accommodation, food and so on for the 37 teams would have added up to. It would take an age to find out, but it seems that it cost at least one team well over €4,000 (from Twitter: “@RoyalBruneiAir and Dermot Mannion are unbelievably generous, sponsored a @TCDJailbreak team w/ return flights to the tune of over €2000 each”). Now, only a few teams got as far as Indonesia, Brunei, Sydney (neither Brunei nor Sydney won due to missing the deadline) and Argentina – most stalled in Europe and some didn’t make it past Ireland. But it’s a near certainty that the overall cost of sponsoring this event is more than the expected €15,000 raised – I suspect a lot, lot more.
Which means the bottom line is: €15,000 to be raised for charity, >>€15,000 raised to sponsor “adventures for students”.
There are a lot of positives about this challenge – it encouraged a great deal of resourcefulness in those taking part, and showed quite how far you can get from a starting position of very little. But as a charity event? Can we say ‘the bottom line is €15,000 is going to good causes that wouldn’t have otherwise’? Or is this an example of a hugely wasteful resource-gobbling ‘charity challenge’ with only a small fraction of the funds making it to the intended charities?
- Perhaps this just counts as ‘good advertising’ for the airlines and travel agencies that sponsored it, and that this money would have gone into more television advertisement otherwise.
- Perhaps the personal individuals who covered flights, food and accommodation just like sending students on holiday, and wouldn’t have dreamed of sending this money directly to a charitable organisation if this event hadn’t taken place.
However, the public landscape is littered with good causes which need our support. And when we, or celebrities, or corporations support one cause, it means resources that can’t be allocated to another. When it comes to individuals, some literature suggests as well that biases such as “purchase of moral satisfaction” (Kahneman and Knetsch 1992) mean that people will spend just enough on a ’good cause’ to have that warm, fuzzy feeling – it may not matter how much actual good that donation does in the world; it would seem to follow that if a better target comes along they will not be inclined to support it. So a wasteful charity stunt may hurt other charitable ventures by diverting resources in inefficient directions*.
A contrasting charitable challenge taking place shortly is Live Below The Line. People challenge themselves to live for £1 or less a day for five days, raising money while highlighting how severe the poverty line is. And it doesn’t cost a huge amount to put on. If anything, those undertaking the challenge save money.
It’s hard for me to say with certainty without a lot more background work whether the ultimate charitable contribution of “Jailbreak” has a plus or minus sign attached – a growing number of organisations such as Giving What We Can focusing on these types of considerations could give a much more thorough and careful analysis. However, these types of event are unlikely to represent the best way to do the most amount of good.
If you want to climb Kilimanjaro, climb Kilimanjaro. If you want to raise money for charity, find a challenge that doesn’t cost large amounts of money and get sponsored for that. Then give the charity your Kilimanjaro travel money.
Responsible charities need to move away from association with costly, resource-gobbling stunts.
(Although in fairness, Argentina? That’s some pretty good blagging.)
*It has also been pointed out that this event had a dinosaur-sized carbon footprint that is perhaps worth factoring in, but further discussion on issues such as these is outside the scope of this blog post.
D. Kahneman and J. L. Knetsch, Valuing public goods: The purchase of moral satisfaction, J. Environ. Econom. Manage., 22, 57-70 (1992).
This is a brief note to alert the readers of Practical Ethics that research by myself, Anders Sandberg, and Julian Savulescu on the potential therapeutic uses of “love drugs” and “anti-love drugs” has recently been featured in an interview for the national Canadian broadcast program, “Q” with Jian Ghomeshi (airing on National Public Radio in the United States).
Readers may also be interested in checking out a new website, “Love in the Age of Enhancement” which collects the various academic essays, magazine articles, and media coverage of these arguments concerning the neuroenhancement of human relationships.
I’ve been to Cologne recently, one of Germany’s main Carnival cities. In the window of a shop I passed, I saw some residues of the just ended Carnival season for sale – amongst other things, a Native American costume. Like many others of the sort, it consisted of a brown faux suede suit, a colourful feather hair decoration, and a little fake axe. And – not to my surprise – it showed far more skin that it concealed. Unfortunately, I didn’t take a picture. However, “Indian” Carnival and Halloween costumes like that can be found all over the internet, may it be in the (sadly unavoidable) “sexy” women’s version like the one I saw, or in the male “warrior / chief” version.
Well, they say of Mussolini, at least he made the trains run on time.
Actually, that’s disputed, but that’s by-the-by. While watching the telly, I was struck by a remark of Scotland’s First Minister, Alex Salmond, on the resignation of the leader of Scotland’s Roman Catholic community, Cardinal Keith O’Brien following allegation of sexual misconduct. “It would be a great pity if a lifetime of positive work was lost from comment in the circumstances of his resignation”, said Salmond. Continue reading
Various news sources—including The Huffington Post, Gay Star News, and the London Evening Standard—are reporting a High Court case in which a campaigner for gay conversion therapy is fighting Transport for London (TfL) over a ban on its bus adverts that suggest that homosexuality can be ‘cured’.
Dr Mike Davidson is head of Core Issues Trust which, according to its website, is ‘a non-profit Christian ministry supporting men and women with homosexual issues who voluntarily seek change in sexual preference and expression’. Davidson, who is married with children, insists that his own gay feelings were removed by therapy. He told The Huffington Post that he had homosexual feelings ‘from the moment [he] opened [his] eyes’. Even so, he believes that ‘gay’ is a ‘late twentieth century political construction’ that people can reject. His adverts read, ‘Not gay! Ex-gay, post-gay and proud. Get over it!’—a response to similar posters by lesbian, gay and bisexual charity Stonewall which read, ‘Some people are gay. Get over it!’ Davidson’s adverts have been deemed ‘offensive to gays’ by London Mayor Boris Johnson, who is also head of TfL. Continue reading
Today I started writing for Quartz magazine, the Atlantic’s new on-line business magazine. My first article is on saving the world by funding charities rather than working for charities – a topic that I’ve written on previously for the Practical Ethics blog. The basic idea is that, often, one can do more good by choosing to fund not-for-profits rather than work for them directly – and that a good way to fund them is to ‘earn to give’, that is to deliberately take a high-earning career and donate a large chunk of one’s earnings to the best causes.
There has, in recent weeks, been a relatively vigorous debate over gun control in the US. This was undoubtedly precipitated by the horrendous Sandy Hook Elementary School massacre, in which 20 children and 6 adults were gunned down, but the issue has long been simmering in a country alternately outraged by gun violence and resistant to limitations on the people’s ability to keep and bear arms. There are a number of issues here, but perhaps the most general (and ethically interesting) is whether, in modern societies, the state should significantly restrict the ability of citizens to purchase and carry firearms. The New York Times’ blog The Stone ran a nice series of philosophical commentaries on guns; however, perhaps unsurprisingly given the typical liberalism of philosophers, all were to varying degrees in favor of gun control (or even prohibition) and not sympathetic to gun rights. I imagine those in the UK will be similarly disposed, but in this debate it is important to look for the strongest possible cases on both sides. For my own part, I find the most compelling defense of strong gun rights to come not from the need to check government or general libertarian freedom, but feminism. This may be somewhat surprising given feminism’s typical association with liberal causes, but on consideration it is not so strange. Continue reading