The common saying, “You get what you pay for”, isn’t of course universally true, but it’s an appropriate comment in many situations. Its obverse ought to be much more commonly on people’s minds, though, with respect to public goods, things that belong to everyone and no one: national defense, roads, environmental quality, and the like.
There are also quite non-material yet crucially important public goods, for instance accurate and trustworthy information about important matters. Contemporary dishonesty and dysfunction in science and medicine include that we lack the exceedingly important public good of reliable information about such essential matters as prescription drugs.
In the good old days, professional journals in science and medicine could be relied on to provide information that the authors and publishers honestly believed to be the soundest available. That is no longer the case. Fraud by individual authors may not be uncovered for a long time. Medical journals from well established mainstream publishers may actually be underhanded advertisements by drug companies — for example, “Elsevier published 6 fake journals”); “Elsevier had a whole division publishing fake medical journals”).
Advertisements by pharmaceutical companies have become fatally misleading in manifest substance and by means of manipulative style. Thus the Food and Drug Administration (FDA) had occasion to warn manufacturers of antiretroviral drugs against showing such scenes as “three athletic men and one woman who have just scaled a dramatic mountain peak, an athletic feat that many perfectly healthy people probably couldn’t do” (“The ‘Joe Camel’ ads of AIDS?”).
But it is clear that advertising experts and their clients believe that a significant proportion of the public can be misled by showing happy, healthy people doing enjoyable things even when soft dulcet tones mention terrifying possible “side” effects of the recommended medication. Thus ads for Viagra refer to possible “changes in vision”, which doesn’t sound quite as worrying as “may cause blindness”; and it’s misleading because in rare cases blindness has actually been reported (“FDA was told of Viagra-Blindness link months ago”, 1 July 2005; “Viagra and Blindness: Now the FDA is accusing Pfizer of covering up eye problems”, 16 June 2010).
Listen closely to what is said in almost any ad for a prescription drug, and read the text carefully, and note two general points: First, nothing beneficial is guaranteed. Second, the possible “side” effects can be utterly frightening. Thus one medication for easier breathing only says that it may assist and that it can’t replace the chronic medication or emergency medications — while mentioning the risk of many nasty possible “side” effects, including suicidal thoughts or actions (“Are you taking these asthma drugs?”), and, perhaps most surprisingly for a medication aimed at helping breathing, adverse respiratory events in as many as 15% of those using the drug. But in TV ads these horrifying possibilities are recounted in softly lilting tones while the video shows, for example, a happy man able once again — obviously owing only to use of the drug — to take his son and grandson fishing once more.
That horrendous “side” effects are recounted in ads is obviously intended to forestall legal actions, because almost everyone understands how ludicrous it is to advise contacting one’s doctor immediately in case of an emergency. In my case, the doctor’s phone answers with a menu, in which the first, helpful (?) item is, “If this is an emergency, call the hospital” — which of course doesn’t have records of my history and medications. So what use is it to read [emphases added]:
“Headache, throat irritation, or stomach upset may occur. If any of these effects persist or worsen, tell your doctor promptly. Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects. Infrequently, this medication may cause severe sudden worsening of breathing problems/asthma immediately after use. If you have sudden worsening of breathing, use your quick-relief inhaler and get medical help right away. Tell your doctor right away if any of these unlikely but serious side effects occur: white patches on tongue/in mouth, signs of infection (such as fever, persistent sore throat), mental/mood changes (such as nervousness), trouble sleeping, vision problems (such as blurred vision), increased thirst/urination, muscle cramps, shaking (tremors). Get medical help right away if any of these rare but serious side effects occur: chest pain, fast/slow/irregular heartbeat, severe dizziness, fainting, seizures. A very serious allergic reaction to this product is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, sudden trouble breathing. This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist. In the US – Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088” [symbicort].
Conflicts of interest are a pervasive fact of modern societies (see Andrew Stark, Conflict of Interest in American Public Life, Harvard University Press, 2000). The public good is in the interests only of the general public. The Food and Drug Administration is beholden to drug companies for the resources to evaluate applications for new drugs. Drug companies are beholden to shareholders, and that vested interest swamps everything else. The public-relations motto, “Where patients come first”, is nothing but a lie, promulgated not only by Merck but by countless others in the “health-care” business: Google that phrase and you find hospitals, clinical networks, insurers all disseminating the same plain untruth.
It is fallacious to imagine that free markets will always attain the best overall arrangements in practice, because truly free markets do not exist in practice. I cannot choose in a free market among providers of all the services I want; I have effectively no choices for utilities (electricity, water, phone, etc.), for example; and precious little choice (if any) for health care and health insurance.
Conflicts of interest are nowadays pervasive in science and medicine (Ethics in Science). Researchers depend on for-profit entities for support. If we want the best disinterested, objective information about anything, then we must employ people whose interest is solely to ferret out that information. That requires institutions whose resources come from public funds or from patrons, foundations or individuals, who do nothing but give the money and then stay entirely out of it. In practice, government is the only possible source, but political attitudes in the USA have not so far permitted such an approach to be put into action.
As concerns matters of health, current circumstances make it very difficult to get reliable information. Consider how much evidence it must have taken for Marcia Angell, an editor at the New England Journal of Medicine, to conclude that
It is simply no longer possible to believe
much of the clinical research that is published,
or to rely on the judgment of trusted physicians
or authoritative medical guidelines.
I take no pleasure in this conclusion,
which I reached slowly and reluctantly
over my two decades as an editor of
The New England Journal of Medicine
(“Drug companies and doctors: a story of corruption,”
New York Review of Books, 56 #1, 15 January 2009)
Angell has called for an independent, publicly funded institute to assess drugs and other medical treatments (The Truth about the Drug Companies: How They Deceive Us and What to Do about It, Random House, 2004, pp. xix–xx, 244–7). So did Michael Crichton (“Aliens cause global warming”, Caltech Michelin Lecture, 17 January 2003) , who may be best known as a writer of science fiction but who was also very knowledgeable about science and medicine and indeed had graduated as an MD (see Crichton’s autobiography, Travels).
What you don’t know may kill you, as the saying goes.
What you think you know may also kill you if it happens to be wrong.
As to health care and medication,
trustworthy information is truly hard to come by.
Skepticism about science and medicine 