Predictably Irrational

by Dan Ariely

  ARE WE DOOMED, then, to get lower benefits every time we get a discount? If we rely on our irrational instincts, we will. If we see a discounted item, we will instinctively assume that its quality is less than that of a full-price item—and then in fact we will make it so. What’s the remedy? If we stop and rationally consider the product versus the price, will we be able to break free of the unconscious urge to discount quality along with price?

  We tried this in a series of experiments, and found that consumers who stop to reflect about the relationship between price and quality are far less likely to assume that a discounted drink is less effective (and, consequently, they don’t perform as poorly on word puzzles as they would if they did assume it). These results not only suggest a way to overcome the relationship between price and the placebo effect but also suggest that the effect of discounts is largely an unconscious reaction to lower prices.

  SO WE’VE SEEN how pricing drives the efficacy of placebo, painkillers, and energy drinks. But here’s another thought. If placebos can make us feel better, should we simply sit back and enjoy them? Or are placebos patently bad—shams that should be discarded, whether they make us feel good or not? Before you answer this question, let me raise the ante. Suppose you found a placebo substance or a placebo procedure that not only made you feel better but actually made you physically better. Would you still use it? What if you were a physician? Would you prescribe medications that were only placebos? Let me tell you a story that helps explain what I’m suggesting.

  In AD 800, Pope Leo III crowned Charlemagne emperor of the Romans, thus establishing a direct link between church and state. From then on the Holy Roman emperors, followed by the kings of Europe, were imbued with the glow of divinity. Out of this came what was called the “royal touch”—the practice of healing people. Throughout the Middle Ages, as one historian after another chronicled, the great kings would regularly pass through the crowds, dispensing the royal touch. Charles II, who ruled England from 1660 to 1685, for instance, was said to have touched some 100,000 people during his reign; and the records even include the names of several American colonists, who returned to the Old World from the New World just to cross paths with King Charles and be healed.

  Did the royal touch really work? If no one had ever gotten better after receiving the royal touch, the practice would obviously have withered away. But throughout history, the royal touch was said to have cured thousands of people. Scrofula, a disfiguring and socially isolating disease often mistaken for leprosy, was believed to be dispelled by the royal touch. Shakespeare wrote in Macbeth: “Strangely visited people, All sworn and ulcerous, pitiful to the eye . . . Put on with holy prayers and ’tis spoken, the healing benediction.” The royal touch continued until the 1820s, by which time monarchs were no longer considered heaven-sent—and (we might imagine) “new, improved!” advances in Egyptian mummy ointments made the royal touch obsolete.

  When people think about a placebo such as the royal touch, they usually dismiss it as “just psychology.” But, there is nothing “just” about the power of a placebo, and in reality it represents the amazing way our mind controls our body. How the mind achieves these amazing outcomes is not always very clear.* Some of the effect, to be sure, has to do with reducing the level of stress, changing hormonal secretions, changing the immune system, etc. The more we understand the connection between brain and body, the more things that once seemed clear-cut become ambiguous. Nowhere is this as apparent as with the placebo.

  In reality, physicians provide placebos all the time. For instance, a study done in 2003 found that more than one-third of patients who received antibiotics for a sore throat were later found to have viral infections, for which an antibiotic does absolutely no good (and possibly contributes to the rising number of drug-resistant bacterial infections that threaten us all19). But do you think doctors will stop handing us antibiotics when we have viral colds? Even when doctors know that a cold is viral rather than bacterial (and many colds are viral), they still know very well that the patient wants some sort of relief; most commonly, the patient expects to walk out with a prescription. Is it right for the physician to fill this psychic need?

  The fact that physicians give placebos all the time does not mean that they want to do this, and I suspect that the practice tends to make them somewhat uncomfortable. They’ve been trained to see themselves as men and women of science, people who must look to the highest technologies of modern medicine for answers. They want to think of themselves as real healers, not practitioners of voodoo. So it can be extremely difficult for them to admit, even to themselves, that their job may include promoting health through the placebo effect. Now suppose that a doctor does allow, however grudgingly, that a treatment he knows to be a placebo helps some patients. Should he enthusiastically prescribe it? After all, the physician’s enthusiasm for a treatment can play a real role in its efficacy.

  Here’s another question about our national commitment to health care. America already spends more of its GDP per person on health care than any other Western nation. How do we deal with the fact that expensive medicine (the 50-cent aspirin) may make people feel better than cheaper medicine (the penny aspirin). Do we indulge people’s irrationality, thereby raising the costs of health care? Or do we insist that people get the cheapest generic drugs (and medical procedures) on the market, regardless of the increased efficacy of the more expensive drugs? How do we structure the cost and co-payment of treatments to get the most out of medications, and how can we provide discounted drugs to needy populations without giving them treatments that are less effective? These are central and complex issues for structuring our health care system. I don’t have the answers to these questions, but they are important for all of us to understand.

  Placebos pose dilemmas for marketers, too. Their profession requires them to create perceived value. Hyping a product beyond what can be objectively proved is—depending on the degree of hype—stretching the truth or outright lying. But we’ve seen that the perception of value, in medicine, soft drinks, drugstore cosmetics, or cars, can become real value. If people actually get more satisfaction out of a product that has been hyped, has the marketer done anything worse than sell the sizzle along with the steak? As we start thinking more about placebos and the blurry boundary between beliefs and reality, these questions become more difficult to answer.

  AS A SCIENTIST I value experiments that test our beliefs and the efficacy of different treatments. At the same time, it is also clear to me that experiments, particularly those involving medical placebos, raise many important ethical questions. Indeed, the experiment involving mammary ligation that I mentioned at the beginning of this chapter raised an ethical issue: there was an outcry against performing sham operations on patients.

  The idea of sacrificing the well-being and perhaps even the life of some individuals in order to learn whether a particular procedure should be used on other people at some point in the future is indeed difficult to swallow. Visualizing a person getting a placebo treatment for cancer, for example, just so that years later other people will perhaps get better treatment seems a strange and difficult trade-off to make.

  At the same time, the trade-offs we make by not carrying out enough placebo experiments are also hard to accept. And as we have seen, they can result in hundreds or thousands of people undergoing useless (but risky) operations. In the United States very few surgical procedures are tested scientifically. For that reason, we don’t really know whether many operations really offer a cure, or whether, like many of their predecessors, they are effective merely because of their placebo effect. Thus, we may find ourselves frequently submitting to procedures and operations that if more carefully studied, would be put aside. Let me share with you my own story of a procedure that, in my case, was highly touted, but in reality was nothing more than a long, painful experience.

  I had been in the hospital for two long months when my occupational therapist came to me with exciting news. There was a technolog
ical garment for people like me called the Jobst suit. It was skinlike, and it would add pressure to what little skin I had left, so that my skin would heal better. She told me that it was made at one factory in America, and one in Ireland, from where I would get such a suit, tailored exactly to my size. She told me I would need to wear trousers, a shirt, gloves, and a mask on my face. Since the suit fit exactly, they would press against my skin all the time, and when I moved, the Jobst suit would slightly massage my skin, causing the redness and the hypergrowth of the scars to decrease.

  How excited I was! Shula, the physiotherapist, would tell me about how wonderful the Jobst was. She told me that it was made in different colors, and immediately I imagined myself covered from head to toe in a tight blue skin, like Spider-Man; but Shula cautioned me that the colors were only brown for white people and black for black people. She told me that people used to call the police when a person wearing the Jobst mask went into a bank, because they thought it was a bank robber. Now when you get the mask from the factory, there is a sign you have to put on your chest, explaining the situation.

  Rather than deterring me, this new information made the suit seem even better. It made me smile. I thought it would be nice to walk in the streets and actually be invisible. No one would be able to see any part of me except my mouth and my eyes. And no one would be able to see my scars.

  As I imagined this silky cover, I felt I could endure any pain until my Jobst suit arrived. Weeks went by. And then it did arrive. Shula came to help me put it on for the first time. We started with the trousers: She opened them, in all their brownish glory, and started to put them on my legs. The feeling wasn’t silky like something that would gently massage my scars. The material felt more like canvas that would tear my scars. I was still by no means disillusioned. I wanted to feel how it would be to be immersed completely in the suit.

  After a few minutes it became apparent that I had gained some weight since the time when the measurements were taken (they used to feed me 7,000 calories and 30 eggs a day to help my body heal). The Jobst suit didn’t fit very well. Still, I had waited a long time for it. Finally, with some stretching and a lot of patience on everyone’s part, I was eventually completely dressed. The shirt with the long sleeves put great pressure on my chest, shoulders, and arms. The mask pressed hard all the time. The long trousers began at my toes and went all the way up to my belly button. And there were the gloves. The only visible parts of me were the ends of my toes, my eyes, my ears, and my mouth. Everything else was covered by the brown Jobst.

  The pressure seemed to become stronger every minute. The heat inside was intense. My scars had a poor blood supply, and the heat made the blood rush to them, making them red and much more itchy. Even the sign warning people that I was not a bank robber was a failure. The sign was in English, not Hebrew, and so was quite worthless. My lovely dream had failed me. I struggled out of the suit. New measurements were taken and sent to Ireland so that I could get a better-fitting Jobst.

  The next suit provided a more comfortable fit, but otherwise it was not much better. I suffered with this treatment for months—itching, aching, struggling to wear it, and tearing my delicate new skin while trying to put it on (and when this new thin skin tears, it takes a long while to heal). At the end I learned that this suit had no real benefits, at least not for me. The areas of my body that were better covered looked and felt no different from the areas that were not as well covered, and the suffering that went along with the suit turned out to be all that it provided me.

  You see, while it would be morally questionable to make patients in the burn department take part in an experiment that was designed to test the efficacy of such suits (using different types of fabrics, different pressure levels, etc.), and even more difficult to ask someone to participate in a placebo experiment, it is also morally difficult to inflict painful treatments on many patients and for many years, without having a really good reason to do so.

  If this type of synthetic suit had been tested relative to other methods, and relative to a placebo suit, that approach might have eliminated part of my daily misery. It might also have stimulated research on new approaches—ones that would actually work. My wasted suffering, and the suffering of other patients like me, is the real cost of not doing such experiments.

  Should we always test every procedure and carry out placebo experiments? The moral dilemmas involved in medical and placebo experiments are real. The potential benefits of such experiments should be weighed against their costs, and as a consequence we cannot, and should not, always do placebo tests. But my feeling is that we are not doing nearly as many of them as we should.

  Reflections on Placebos: Don’t Take Mine Away!

  A few years ago, a woman seated next to me on a flight to California took a longish white cylinder from her bag, opened it, and dropped a quarter-size tablet into her airplane cup of water. I watched, mesmerized, as yellowish bubbles fizzed and foamed wildly in the cup. After the activity settled, the woman drank the whole concoction in two large sips.

  I was very curious about this and, as she looked very pleased with the whole process, I asked her what she was drinking. She handed me the longish white tube. It was Airborne!

  The description on the tube truly impressed me. These tablets, it said, had the power to boost the immune system and help fight the germs that surround passengers during flights. If I took it at the first sign of cold symptoms or before entering a crowded, potentially germ-infested environment, I could prevent the awful colds that I constantly fought. I could not imagine anything better. And, unlike any other medication I have seen, this one stated clearly that it had been invented by a second-grade teacher! Who better to design cold medications than someone surrounded day in and day out by germ-laden children? Since teachers are continually catching colds from their students, this seemed like a natural connection. Besides, I loved the bubbling, foaming action.

  My seatmate could not ignore my enthusiasm, so she asked me if I wanted to try a tablet. I happily accepted one, dissolved it in my half cup of water, watched the fizzing and foaming, then drank the yellowish stuff in one gulp. I could see before me the image of my own beloved second-grade teacher—Rachel—and my fondness for her added to the experience. Almost immediately, I felt better. I completely avoided getting sick after that flight. Proof! Thus did Airborne become a staple in my travels.

  Over the next few months I used Airborne as the tube suggested. Sometimes I drank it during a flight, but more often I consumed it after the flight. Each time I repeated the ritual, I immediately felt better about myself and about my chances of fighting off the insidious airborne diseases surrounding me. I was 99 percent sure that Airborne was a placebo, but the bubbles and the ritual were so wonderful that I just knew it would make me feel better. And it did! Besides, taking it made me more confident in my health and less stressed about getting sick—and, after all, stress and anxiety are known to lower immunity.

  A few years later, just as I was beginning my book tour and had to fly constantly, I heard the tragic news that Victoria Knight-McDowell, the second-grade teacher from California who invented Airborne, had agreed to pay a sum of $23.3 million in a settlement for false advertising, in addition to refunding money to consumers who bought the product. The manufacturer had to change the statements and claims on the product itself. The former “miracle cold buster” had been demoted to a simple dietary supplement made from 17 vitamins, minerals, and herbs. The old claim that Airborne “supports your immune system” remained intact on the packaging, but was accompanied by one of those pesky daggers (†) indicating fine print. You have to search for it, but eventually you find it hidden away in the back corner: “These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any diseases.” How depressing.*

  So there I was, faced with at least three flights a week for the next few months, and the magic of my Airborne was ripped away from me. I
felt as if I had learned that a person I’d considered a good friend for many years had never really liked me and had been saying bad things about me behind my back. Maybe, I thought, if I went straight to the drugstore and got some of the old containers with the exaggerated and inflated claims, they might help restore the magical power of Airborne. But this seemed unlikely. I could not avoid the knowledge that my fizzy miracle was no such thing. It was just some dumb vitamin with neat Alka-Seltzer special effects. In the face of such disillusionment, I can no longer enjoy the wonderful placebo-immunity-enhancing effect of yesteryear.

  Oh why, why did they do this to me? Why did they take my wonderful placebo away?

  CHAPTER 12

  The Cycle of Distrust

  Why We Don’t Believe What Marketers

  Tell Us

  I’m not sure about you, but I get a lot of spam e-mail. People are constantly offering me the chance to make a lot of money or buy cheap software. They tell me I’m the one person they’ve always wanted to meet. They offer to enlarge or improve different parts of my body. I was even presented with the opportunity to get another Ph.D.—one that would not require another five years of hard labor. Instead, they would credit me for my life experience. So far, this is the only one that I’ve tried out. But after I contacted the organization offering this degree, they decided to drop me from their list of interested prospective students. Sadly, I never did get credit for my life experience.