The Political Economy of Lobotomies in the United States

The actual title starts with: “Gordon Tullock Meets Phineas Gage:”, and here is the abstract:

In the late 1940s, the United States experienced a “lobotomy boom” where the use of the lobotomy expanded exponentially. We engage in a comparative institutional analysis, following the framework developed by Tullock (2005), to explain why the lobotomy gained popularity and widespread use despite widespread scientific consensus it was ineffective. We argue that government provision and funding for public mental hospitals and asylums expanded and prolonged the use of the lobotomy. We support this claim by noting the lobotomy had virtually disappeared from private mental hospitals and asylums before the boom and was less used beforehand. This paper provides a more robust explanation for the lobotomy boom in the US and expands on the literate examining the relationship between state funding and scientific inquiry.

That is from Raymond March and Vincent Geloso, via the excellent Kevin Lewis.


The psychiatric field is burgeoning with new science and despite our unpopular POTUS, there seem to be ongoing developments funded by NIMH including stuff like tissue sampling/regeneration, neuronal writing and less intrusive than poking a hole in your most problematic lobe. Frontal lobes are probably the most underrated, responsible for stuff like executive functioning, insight and judgement. "Lobes R Us" opening soon with a BOGO sale; I wouldn't mind a fresh lobe.

This is an important study, and a reminder that opposition to public welfare often results in depraved conduct. It's the case with lobotomy, which was viewed as the solution to the increasing public cost of caring for mentally ill patients.

Lobotomies from public health institutions were an example of public welfare. Granted, it was an example of authoritarian bureaucrats doing horrible things.

But it was absolutely not an 'opposition to public welfare'.

It seems as if you'll take any set of facts and re-arrange them to suit your mental world view.

Isn't that exactly what you're doing? You can argue lobotomies were the result of an underfunded welfare provision, hence why private healthcare with superior resources used superior treatment.

Private healthcare generally outperforms public in the US, but that's a function of resources, not something intrinsically inferior about public healthcare.

Lots of European countries provide public healthcare that matches or outperforms private healthcare.

+1 and also It’s not just resources, but cultural differences and expectations for health outcomes

Oh yeah and “paternalism” - intervening in our most deadly diseases and dictating our healthcare decisions in a way that distances us from whatever “entity” that provides healthcare

"Isn't that exactly what you're doing? You can argue lobotomies were the result of an underfunded welfare provision"

No, because there's an implicit assumption that lobotomies were a direct result of the philosophy or actions of those who "opposed public welfare". Which is clearly false.

Public officials not being funded to a certain level does not justify barbaric behavior. Nor can you then blame that behavior on others. It's the fault of the person that did it and those who sanctioned it.

You might as well blame Nazism and the holocaust on the reparations that the allies demanded from WW1. It's the same type of second order weak argument that can be used to justify nearly anything.

Has anyone shown that it was proven ineffective and viewed as barbaric at the time?

Hell, it was on the heels of the eugenics movement, and somewhat concurrent with the syphilis and various ghastly other experiments with withheld treatments and radiation exposure.

From the source:

" In the 1930s and 1940s, several medical associations denounced the practice of lobotomy to treat mental patients. By the early 1940s, a consensus had formed that the practice was not helping patients. Yet,
the number of procedures soared after numerous medical journals and professional associations denounced it and the practice continued as late as 1967. ..In addition to debates over the efficacy of the practice, there were serious ethical issues raised about it."

Interestingly, JFKs family resorted to it in 1960.

And yet public healthcare receives more funding in the U.S. than any European country, and nearly any European country as a % of GDP, and indeed more funding than private healthcare in the U.S.

The US doesn’t have public healthcare, it has an insurance model where the state pays the private sector, which is why for more than double the cost of most European countries the US has worse health outcomes across the board.

You're not really right.

We have a highly constrained healthcare system. It really can't be called private. It doesn't really use markets. It hasn't functioned like a private market since the 1930s.

The majority of dollars spent on healthcare in the US flow out of the government.

It's not valid to make a flat comparison between all of the US against '''European countries''' because:

* Thank god for mississippi
* '''European countries''' are themselves a patchwork of demographics and healthcare systems
* Healthcare outcomes are a function of demographics at least as much as they are a function of outcome-improving healthcare
* A lot of healthcare spending in the US is useless overconsumption

Compare like to like (a wealthy US metro area against a similar wealthy metro area in Europe) and things actually look surprisingly similar in outcomes.

Healthcare is a private good. You can't really provision private goods effectively by nominating a bureaucrat to buy it for you by proxy. That's as true in '''European countries''' as it is in the US.

"You can argue lobotomies were the result of an underfunded welfare provision, hence why private healthcare with superior resources used superior treatment."

You could argue that, but you'd need to show data supporting that. The abstract quoted doesn't really make the case for it at all. It's just as likely it was the result of "overfunding", where lack of sensitivity to price (lobotomies and lobotomy care more expensive) and putting control out of family's hands led to the results seen.

This is not to make a case against generally putting high funds in and putting them outside of the control of customers, but to not be able to imagine that this can go wrong is itself a bias.

Opposition to public welfare (whatever that means) results in depraved conduct by programs supported by the Government?

“Support your own welfare or we’ll lobotomize the whole lot of you”

Thanks for the reminder, Ray.

Actually, it exposes a major weak point of government medicine: there will always be a conflict of interest between sound therapeutic choices and top-down cost effectiveness. So long as public medicine is making decisions based on QALYs rather than bio-markers, this is what you'll end up with.

I'll add that most people never see this side of socialized medicine, because most people don't have chronic conditions.

What an extraordinary claim. Public healthcare doesn't have a conflict of interests, that's the hallmark of the private sector. How can you suggest government medicine is more motivated by top-down cost effectiveness than private medicine? Profit motive drives cost cutting much more aggressively than public sector imperatives, and since the state has to clean up any negative externalities it has strong incentives for remedies that are actually effective in the long-run. Incentives that are completely absent in the private sector, because the more illness the better for profit seekers.

You ask, "How can you suggest government medicine is more motivated by top-down cost effectiveness than private medicine?"

I can suggest this because I lived it, and so have thousands if not millions of other people who have (a) chronic conditions, but (b) do not respond favorably to standard treatment regimens. Under this scenario, government doctors -- of whom I was a patient -- are in many cases legally barred from offering "off-label" treatments if they cannot be justified. In this case "justified" means legally justified, not clinically justified. Where such obstacles are not present, doctors are provided a sequential list of therapeutic chronology, and evidently, they are prepared to scream and yell and berate patients who appear at check-ups with empirical data documenting our physically worsening under the "recommended" therapy.

I have never experienced the equivalent under the care of doctors whose motive was profit, because they will support any therapeutic choice, so long as there is a credible medical justification for it, an opportunity for the patient to improve and the doctor to extract a service fee, and the insurance companies have their paperwork in hand.

Your shock is simply no match for my lived experience. The profit motive improved my therapy and added years to my life -- whether you believe me, or not.

You do realize at least, that arguing government services are too cost conscious is a rather novel argument for a libertarian blog?

I mean sure, peel back the onion and talk about innovation, customer centrism, and customization. But of course that only works for those who can afford it.

Be nevertheless, when it comes to caricatures of ruthless cost cutting despite the human impacts is generally associated with private health care

Yes, caricature.

Something I too like to invoke when arguing public policy.

Oh please Captain Literal

I'm not making an argument, I'm reporting my experience. My experience isn't of "cost consciousness," but rather a conflict of interest between adhering to bureaucratic medical procedure for "the average patient" versus treating the patient in accordance with what the patient's own chart demands.

We spend a lot of time criticizing market-based health care for ordering too many tests, but those "wasteful" tests do serve a purpose: they provide an empirical veneer to support a treatment decision that would otherwise be disallowed for lack of insurance reimbursement.

There is no such mechanism in public health care. Actually there is: You can write your member of Parliament for a special exception.

I'm not here to argue that private health care saves money. I'm here to point out that conflicts of interest in public health care reduce a patient's access to medicine. As soon as the US adopts a true government health care system (and I believe this to be inevitable), Americans will suddenly understand what the strain of advocacy called "access to medicine" is all about.

Let me explain the evidence of my own experience with a cost obsessed, one size fits all treatment system with massive built in conflicts of interest...

Please do. I'm sure we'll discover some very interesting common features. It would be a bad idea, I'm sure we would soon agree, to put the insurance companies in charge of the array of available therapeutic choices. Unfortunately, that is precisely what government health care does.

I am honest enough admit that this reduces health care expenditures. I am also honest enough to admit that it does so through a corruption of the doctor-patient relationship.

In a freer world, doctors would provide patients with a range of therapeutic options and their associated prices. Then, patients would decide which choice to make, based on medical considerations and affordability. That's how it's supposed to work. Medical care is not supposed to be a doctor/bureaucrat awarding us with a diagnosis, and then an insurer/bureaucrat handing us a formulary, and then a pharmacist/bureaucrat charging us a dispensing fee.

The problem with US health care is that is purports to act differently than socialized medicine, but looks more and more like it each year. I'm for solutions that make it look less like socialized care.

It's really not novel. I mean, that's why social healthcare programs work well at all - they redistribute medical cash from people who are old and have chronic conditions and are generally suffering from old age, towards young people who have relatively easier to treat conditions.

I think this is mostly understood and agreed.

It's not that social healthcare is particularly more conscious of the costs of a particular treatment exactly, but it has a lot more latitude to choose its patients and how it spends money on patients. While an insurance based private spend system is purely reactive, and targets old people with lots of wealth who were healthy when young, who unfortunately tend to be really tough to treat.

(The US is at a world extreme of this sort of situation, probably because of ideology about freedom and rights to life, where even most healthcare insurance systems tend to be regulated towards functional redistribution and against older people on the verge of death becoming a "money pit").

Now social healthcare does have some problems with lack of competition leading to lack of improvement and innovation (low levels of new drug and surgery development) and there are broader questions of choice. This is why virtually all healthcare systems are trying to incorporate private elements (with varying degrees of success). But the efficiency benefit, measured in QALYs or mortality, of moving most of your resources from old, chronic, hard to treats, to young, easy to treats, is pretty major. In certain circumstances, redistribution works!

In brief, the US is the country of physicians claiming more and more insurance money to play whack-a-mole with the hard-to-treat ailments of old, relatively rich folk and keep them alive, backed by high insurance premiums for young people and a good deal of state subsidy, and it has medical costs and physician pay to match.

No, the redistribution doesn't work, it merely looks like it works, due to the way QALYs are applied to outcomes. Putting a 35-year-old on statins looks like an amazing deal in terms of QALYs, but it doesn't actually save the health care system any money.

In fact, low-cost maintenance meds like statins are the major cost-driver in any health care system, both public and private. Consider that in light of the fact that statins have a high QALY value but absolutely no effect on patient longevity. It's all an actuarial game the public and private payers like to pay, because it makes them look good without their having to do much actual work.

This is why we should want to have doctors and patients in charge of the system, not insurers.

That seems like an indictment of QALYs, perhaps, but not really an indictment of redistributing healthcare resources between different classes of patients from rich, intervention difficult, to poor, intervention easier.

Move more slowly through the logic here. Suppose it is an indictment of QALYs. Then, on what basis are we to make redistributive decisions? Based on what epistemic certainty are you confident in saying that the redistribution works?

"Public healthcare doesn't have a conflict of interests, that's the hallmark of the private sector."

Just because government bureaucrats don't maximize profit doesn't mean that they don't seek to maximize their own pay, power, and prestige that creates its own peculiar set of conflicts of interest. Speaking of which:

"since the state has to clean up any negative externalities it has strong incentives for remedies that are actually effective in the long-run."

Because the Veterans Health Administration is model of good health care delivery.

The VA is a model of what happens when you underfund a difficult and expensive service. It is a model of bad budgeting.

(And yes of course also vulnerable to some of the criticisms re large public bureaucracy).

So isn’t everything a matter of being underfunded then?

With infinite resources you can do all the things!!!

We may spend way more on education than everyone else, but it’s not enough! With more money our kids will be geniuses!

We may pay more per mile of any given infrastructure, but if we only Increased the budget even more we would fix all the things!

Etc etc.

Maybe the US is just terrible at providing government services, regardless of cost.

Or maybe America is terrible at reconciling their wishes with their budgets

America allocates a bigger budget to the military than any other country and has the greatest military in the world. Is is really that hard to understand?

Depends on how you measure greatest. It's not much good at winning wars unless they last only one battle.

No, they are very good at winning wars. It get tougher when we go to war but try not to hurt anyone.

"Public healthcare doesn't have a conflict of interests, that's the hallmark of the private sector. "

I'm not sure how anybody can seriously make that claim. Public healthcare has plenty of conflicts of interest.

Public employee compensation versus capital and treatment spending is a classic conflict of interest. Public Union work rules versus demands of the healthcare work is another. Short term political gains versus long term positive effects is a conflict of interest.

I'm sure there are others that didn't occur to me.

Wrongly performed lobotomies had nothing to do with "increasing costs" and everything to do with the incentives created by government when it provisions something like healthcare.

If spending on mental health institutions had been zero, those lobotomies would not have been performed. But hose lobotomies would still have been performed even if spending on mental health institutions had been infinite.

Part of the reason so many people were committed in the first place is that an easing of commitment laws was lobbied for. A concurrent large spending increase took place to solve the 'problem' (more people committed) that those changes in law created. A final problem of "what to do with the patients" was solved as the government paid doctors to mutilate patients' brains. This of course, at a time when it was knowable that such a treatment was inhumane, wrong, and ineffective.

It's on the way back, slaves!

Under another name. We'll get it right this time!

Hmm... The recommended article of today was on vaginoplastys, now this. What is the Straussian reading?

Straussian reading is like meditation. To ask the question is to know the answer.

Red China has just attacked a peaceful Brazilian fishing boat! It was an unprovoked and dastardly attack. Brazil and America are both signataries of the Inter-American Treaty of Reciprocal Assistance (Pact of Rio). What will America do to support its allies?! Whats is the use of protecting the Taiwan Strait if America won't lift a finger to help a neighbour?!

What connections link the political economy of lobotomies in the US with the political economy of public education in the US? --with the respective political economies of the US Media Establishment and the US Tech Establishment?

despite widespread scientific consensus it was ineffective.

What 'scientific consensus'? Medical literature in that era consisted of case reports, not controlled studies. Walter Freeman's career as a neurobutcher was assisted by the general refusal of physicians and surgeons in that era to utter criticisms in fora where it could be broadcast to laymen. Paul Krugman benefits from similar guild privileges.

I have news for you. Every other blessed thing psychiatrists were doin in 1935 was ineffective. That's one thing that made psychosurgery an attractive prospect to Walter Freeman (whose medical training was absolutely conventional, BTW).

Psychosurgery came and went over a period of 20 years. Psychoanalysis was much more durable, and persisted as a clinical practice for a generation after controlled studies began to demonstrate that its effect was to transfer income from the patient to the provider, full stop.

The idea that there's an ethical limit to what sort of treatment that private companies will expose others to is laughable on its face. Any limit has long since been disprove as a breach of fiduciary duty over on the tobacco and pollution side.

However, it may be fair to wonder if private practitioners back in the lobotomy era hesitated to use the practice because their paying customers were in fact the families of the patient, not the patient themselves.

Lobotomies peaked in the late '40s? It seems that most of the guys I work with have had the procedure.

I'm not so sure that psychiatry falls completely into the domain of "public healthcare". We are also dismissing neurology, which is part of the medical education and required competency and accreditation for psychiatrists. Let's also remember these are pretty new fields. Psychiatry is a niche that offers little quantifiable data, and relies on subjective, Likert scales and inter-rater reliability (although this is slowly changing). Its uniqueness makes it the richest yet one of the most difficult fields to harness. It involves more discussion and collaboration in its clumsy attempt to classify symptoms, which supposedly for the purposes of treatment and not a general classification of "person-in-society". It receives little respect for various reasons, one of which is stigma. Ironically, sometimes the stigma is more painful than the disorder itself. More of an art than a science, it falls back on philosophical and ethical morals of the current time and closely trails medical-legal-ethical guidelines. And it continues to spark timeless and meaty discussions such as these towards a better understanding of human nature and reduction in human suffering.

High IQ is associated with envy, jealousy, competitiveness. So these high IQ people work hard, do well and find themselves at the bottom of the social hierarchy. That makes professors very, very, very angry. So they support a central command system...when them in command.

There is a very succinct and interesting history of the mid-20th century lobotomy craze in Paul Offit's book Pandora's Lab. Quack medical hucksters with forceful personalities played a very large roll. And it was a fad, although one with miserable consequences.

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