The Top EconTalk Conversations of 2023 (with Russ Roberts)
Apr 29 2024
Russ Roberts, EconTalk Host

The favorite EconTalk episodes for host Russ Roberts are when he and his guest have an unusually powerful connection such as his recent episode with Charles Duhigg, and the ones where he learns something mind-blowing, like Adam Mastroianni's insight that you can't reach the brain through the ears. Listen as Russ explains how he chooses guests, and why EconTalk has evolved to focus on things other than economics. He also shares listeners' favorite conversations from 2023, and tells a story that shows the challenges--and opportunities--of applying EconTalk's lessons to our personal lives.

An Extraordinary Introduction to the Birth of Israel and the Arab-Israeli Conflict (with Haviv Rettig Gur)
Israeli journalist Haviv Rettig Gur takes us on a deep dive into the origins of Israel--how European Jew-hatred gave birth to Zionism and the founding of the Jewish state in 1948. He then turns to the rise of Palestinian terrorism and...
The Secrets of Great Conversation (with Charles Duhigg)
When EconTalk's Russ Roberts sat down with Charles Duhigg to talk about his new book on the art of conversation, Supercommunicators, Roberts tried to apply some of its lessons to his conversation with the author. The result is this special...
Explore audio transcript, further reading that will help you delve deeper into this week’s episode, and vigorous conversations in the form of our comments section below.


Apr 29 2024 at 10:56am

Subjective experiences like pain are real, even if they’re not objectively measurable. Often, subjective experiences are the most important for decision-making (love, fear, pain, hope, etc.).

For Russ’s mother, it sounds like the hesitation in treating her pain was that it didn’t do anything ‘real’. But it did!

If you were in pain and I told you I could solve the pain, but that it was all placebo would you do it anyway? If not, why not? Don’t you want the pain to go away? We know this works.

There’s some evidence that placebo is effective even when patients know they’re getting placebo. Indeed, placebo is one of the most powerful drugs on the market – particularly for pain. Sure, if there’s something better go with that, since it’ll have all the benefits of placebo with clinical efficacy. But if your best available treatment option is placebo, even in the face of some minor potential iatrogenic harm, often it makes sense to take it.

May 1 2024 at 4:08pm

Agreed. People can actually hypnotized into feeling tremendous pain.

A construction worker was an agony after a nail went through his boot, only to find at the hospital the nail actually went between his toes and didn’t go through his foot at all.

Also, soldiers and shark bite victims have not always felt the pain of missing a limb until later.

As for the direction Econtalk is taking, Russ I love it. Keep it coming


Adam Heironimus
Apr 29 2024 at 1:23pm

A study published after Cifu’s appearance on EconTalk found that, like most things discussed on this podcast, “it’s complicated”:

“…three of four positive studies required magnetic resonance imaging (MRI) evidence of edema and two of the four required point tenderness over the fracture in order to be included in the study. These requirements likely helped target those who would likely benefit from the procedure, i.e., patients with subacute but nonhealing fractures which were likely the source of the pain. In contrast, neither of the negative studies required evidence that the compression fracture treated was an active source of pain, meaning that patients with healed fractures and chronic back pain were more likely included. In this population, VA [vertebral augmentation] is less likely to be effective and sham procedures, similar to those used commonly for the management of chronic back pain (anesthetic injection), may be somewhat effective.”

It seems as if many people do not benefit from VA, but the intervention can still be a good idea for a subset of properly screened individuals. From the information provided in this podcast it is impossible to know if Russ’s mother was part of this subgroup, but it seems clear that VA isn’t a waste for EVERYONE, even if it may be over-utilized at the present.

The 2017 study is a good read for those interested in finding out more about this nuanced topic:

Mike Rollman
Apr 29 2024 at 1:32pm

My 4 siblings and I went through the exact same fall-and-fractured-vertebrae decision-making scenario with our 84-year-old mom within the last four months…nothing significant to add to your lived experience but had to chuckle at the brief discussion regarding the brace your Mom was initially issued which, by your description, was very similar to the device prescribed to our mom and, like your mom’s experience, proved to be unbearably unwearable, driving us to pursue the Vertbroplasty procedure which has been, thus far, successful…

Apr 29 2024 at 7:15pm

Russ, thanks for sharing the story about your Mom. Some great comments on it here already – just to chime in:

“But if it was all in my mind, so what? What is the goal if not to impact my mind? Our mind – our consciousness – is all we have! So why do people knock what might be the placebo effect?”
p. 210 of the pdf here

Kevin Johnson
Apr 30 2024 at 10:47am

Loved your best of episode.  I love where your interests take you.  While I might not love every episode, the chance to be surprised and educated is great.  I encourage you to follow your search and thank you for letting me share.  Roland Fryer was great.  Focus on Israel is called for and very useful given how many false narratives circulate as “news.”  Haviv Rettig Gur also great.  His weekly with Dan Senor (on brief hiatus) is gold.  I only joined you regularly 2 years ago after elusive praise from Jonah Goldberg over the years.  I’m pleased your search goes behind Econ now.  Thanks so much and may you and yours stay safe and flourish.

Jordan Henderson
May 3 2024 at 7:02am

This episode may get a vote from me for the best episode of the year.  We’ll have to see, but sometimes looking back is part of looking forward.

Shalom Freedman
Apr 30 2024 at 11:39am

I want to thank you for the many moments of insight and understanding I have had in listening to Econtalk. I am not an economist and so most enjoy your conversations in other areas. Your ability to truly listen to and dialogue with your guests makes the conversations serious quests for truth. May you have many more years enlightening and delighting your listeners.

Robert Allvord
Apr 30 2024 at 1:54pm


Ive been listening to your podcast since 2018. I listen to the show at different times.
I always learn something and most people f the time I learn many things. Please know that your program makes a difference.

I truly hope you and your family stay safe. I hope that Israel can find a way to peace.
Best Regards,

Robert Allvord

David Jeffcoat
Apr 30 2024 at 6:32pm

Congratulations on 943 episodes.  I realize this train left the station long ago, but I want you to know I still like the phrase “every episode we’ve ever done …”  Maybe the word “ever” adds little or no information, but to me the word adds a musical quality to the phrase.

Thanks for what you do.

Paul J Rosado
May 2 2024 at 12:57pm

I’m glad you mentioned the EconTalk, Oct. 9, 2023, discussion with Adam Mastroianni about how you can’t reach the brain through the ears.  I forgot about it.

Jordan Henderson
May 3 2024 at 7:05am

Of course you forgot it!  You only heard it through your ears.

Julia Ohl
May 4 2024 at 8:05am

Please read this article on the deterioration of cartilage caused by steroid injections. It would be great to have an episode on it.

I LOVE your podcast and recommend it to many people. I have no interest in economics or AI, but I enjoy your health and meaningful life episodes especially.

I most admire your humbleness/humility. Do you consider those two words synonymous? I think in the Golden Mean the latter is a vice in some translations.

Anyway, here’s the link. I’m an atheist, so I won’t pray for you, but I sincerely hope things get better for Israel and Gaza.

Thank you!


Neil McMullin
May 4 2024 at 7:28pm

Hi Russ

Huge congratulations on 18 years of quality discussions. The observation I would like to make on this episode is – as a retired surgeon I think reviews of medical procedures can suffer from inability to control significant variables like operator experience, training, fatigue, equipment, and just plain operator ability. If I wanted to have my portrait painted I would go to a lot of trouble looking at past works of an artist but especially of other portraits that person had done. The unquantifiable human factors in medical procedures are overlooked but in my view are relevant to outcomes. We are not machines.

David Gossett
May 5 2024 at 12:11am

I was pretty spooked when Russ started the podcast. He sounded quite down, and I thought he was ready to pack it in and close down Econtalk. I felt much better when he explained how tired he was from the night before.

I get that Econtalk has not been focused on economics for a long time. And I don’t care because Russ is one of the best interviewers out there. He takes the conversations in really cool directions.

With that said, I would love to see Russ ask economic questions of non-economic guests, which he already does occasionally. Every guest says they have an impactful message to share. Cool. But what are the economics of that message? What impact will it have on economies? What is the message’s economics? It’s great that you can make an AI simulation, but will these stall the economy and focus too much on the past and ancestor worship?

It would be a cool niche. Each guest has an impactful message. Russ asks about them about the “economics” of these ideas, both in delivery and reception.

Comments are closed.


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TimePodcast Episode Highlights

Intro. [Recording date: April 14, 2024.]

Russ Roberts: Today is April 14th, 2024 and we're going to do something a little bit different today. Last month marked the 18-year anniversary of EconTalk. If all goes as planned, this will be Episode 943. Which is kind of amazing, a little bit hard for me to believe.

That means that we're about a year away from Episode 1,000--barring any surprises to my health, the world, things I can't anticipate. I hope to do something special for that 1,000th episode if we get there but I thought it appropriate to mark the 18-year anniversary.

We started in March of 2006. The number 18 represents life in the Jewish tradition. The word for life in Hebrew is chai [pronounced 'hai'], which is spelled with two Hebrew letters 'chet' [pronounced 'het'] and 'yod' [pronounced 'yud']. 'Chet' is the eighth letter of the Hebrew alphabet; 'yod' is the 10th letter. Which gets you to 18--which is why Jews often make donations to charity in multiples of 18 and 180, 1800, and so on, 360. So, 18 years seems like a nice landmark and I thought it would be useful to do a little bit of reflection.

In addition, I want to give you the results of our annual survey and say some things about the EconTalk episodes of 2023, your favorites, and a few other things, as well as responding to some comments in that survey.


Russ Roberts: So first, some survey results. 1,105 people voted.

One bit of feedback I asked you for is: How do you usually listen?

  • 29% of you usually listen while commuting,
  • 17% while exercising,
  • 13% while doing household chores, and
  • 21% said there is no 'most of the time.'

Here are your favorite episodes as you voted. It's a funky list for reasons not worth going into. I'll do it in reverse order, tenth down through first, the top 10 most popular or favorite episodes of yours in your voting.

A couple of thoughts on that list of Top 10. There were two episodes with Vinay Prasad. There were two of the 10 on what we might call traditional economics or economists--Tyler Cowen and Roland Fryer. And, there were two episodes on Israel: the Haviv Rettig Gur, and the Yossi Klein Halevi.


Russ Roberts: I want to say something about the way I choose guests.

I choose guests based on stuff that interests me or that I want to figure out. My favorite conversations are when I make an unusually powerful connection or have a rapport with the guest, or I learn something important.

As an example of the former--of having that connection--certainly, this year's episode of 2024 with Charles Duhigg on conversation. We had a wonderful rapport. I don't know Charles--I've never met him before, never met him in person--but something was special about that conversation. I cherish those.

But I, also, of course, cherish the ones where I learned something important, and I want to give a couple examples of those.

Actually, an amazing thing happened to me recently. I was talking to an old-time listener, and he said he has never forgotten the lesson that he learned from Paul Gregory on Politics, Murder, and Love in Stalin's Kremlin. That's a 2010 episode with Paul Gregory. And, this person I was talking to said that what he learned from that episode that was so extraordinary is that you could wield power without being at the top of the pyramid. And, Stalin wielded power as the General Secretary in the Kremlin, and that he wasn't at the top but he had control of various things through that position. And it soon became, through his use of it and application, the most powerful piece, the most powerful position.

And, what this listener learned is that sometimes controlling the agenda or who is nominated to a board can be as important as who is the chair of the board. And I thought that was a fascinating insight that this person learned from a pretty obscure episode of EconTalk back in 2010--which was about Bukharin, who was an early Communist who Stalin eventually killed. It's a great book, Paul Gregory's book. It's a great episode. But that listener got something out of that that I'd forgotten; I never remembered learning it. And, I think what's amazing is that, if you made a list of the one thing or the two things--if there are one or two things you learn from an episode--it's probably quite different for different people.

I think it was A.J. Jacobs in an episode talked about the power of one thing: he tries to write one thing he learned from a book or one thing he learned from an interview. And I just wanted to share a few I learned this year, in 2023, that I thought were interesting or important for me personally.

One would be the insight from Adam Mastroianni's episode--not the one that was voted into the Top 10; that was a different one--but he also had an episode on how you can't reach the brain through the ears. And that's a very unintuitive idea. In fact, you would think the only way to reach the brain is through the ears. So, the idea that you can't reach the brain through the ears, that by telling people things or lecturing them or haranguing them doesn't teach them things, they often either ignore or forget that and focus on what they learn through experience or other methods of education, reading.

And, I like the idea, of course, of close reading in seminars because that's what we do here a lot at Shalem College as a way to have lessons be absorbed that are not absorbed when you're talked at. That's a--I mean, I've thought about that so many times after having that conversation. Of course, I read that originally in an essay by Adam but, having talked to him about it and then thought about it some more, it finally got into my brain. Of course, I'm pretty sure we talked ironically about the irony in that episode--pretty sure we talked about the irony of listening to someone tell you you can't reach the brain through the ears.

Another example would be the episode with Mike Munger, Obedience to the Unenforceable. That phrase, 'obedience to the unenforceable'--the idea that we can be loyal and obedient to norms that are not enforced through the state but are enforced--not literally enforced then--but encouraged through social forces was a very powerful idea. We've talked many, many times on this program about the difference between law and legislation--legislation being things that the legislature passes and law being things that, even though that word law is used sometimes for legislation, it's better, according to Hayek, likes to reserve it for norms and expectations of behavior that emerge rather than those that are passed by a top-down form like a legislature.

But, I love that formulation--obedience to the unenforceable. And of course, that episode and that conversation and the power of that and how it has diminished over time, that the unenforceable is less salient to us and those norms and social forces are very different than it used to be, it was a great insight for me.

And finally, I'd point to Haviv Rettig Gur's episode where he talked about most Israelis--more than half of the people who live in the country of Israel right now--were essentially refugees either from the aftermath of the Holocaust or were thrown out of Middle Eastern countries, Arab countries where they had lived for a long time; and that this did not--this reality, that most of the people who live here in Israel do not have any place to go home to, is an important reality that, according to Haviv--whether he is right or not is not the main thing--but, he argues that the Palestinian narrative and their strategy is often predicated on creating an unpleasant-enough environment here in Israel that people would give up and leave when, in fact, we have nowhere to turn to. I happen to: I have two passports; I have an American passport and an Israeli one. But most Israelis do not. Nasrallah, the head of Hezbollah, recently made a claim similar to the claim that Haviv is critiquing, saying that Israelis should go back to their other country: they should go back to Brooklyn, or wherever. But, most Israelis don't come from Brooklyn. They come from Tehran and other places--Yemen and post-World War II Poland--where they either don't want to go back or can't--literally can't--go back. So, I thought those were--it changed the way I looked at this country where I live.

So, those are the ones that are most precious to me. And I'm sure yours are different. What speaks to you and what are important to you are different.


Russ Roberts: I want to thank everybody who commented--and many of you did. And many of them were positive, and gracious, and nice--which, I appreciate about how EconTalk has helped you in your personal life and the way you speak to others who you don't agree with. And, it's fascinating and a little bit weird to me that much of this program has become--its value to you is a cultural value, not an educational value of the normal sense of learning about economics. I think that's wonderful and it's a beautiful example of an emergent phenomenon, of course.

Now, one of you commented in the survey that the focus this year on artificial intelligence [AI] and Israel, quote, "Bummed me out." I understand that.

And, another common theme in the comments is we should have more economics.

I should say, this show, which started off as literally 'econ talk,' and is now much more the subtitle of the program, Conversations for the Curious: Yeah, what it's really about are the things that I'm interested in or I'm trying to figure out.

So, typically, what I've been doing, I think, over the last--I don't know how long--five to 10 years of the program, is: If something happens--the most dramatic example might be the financial crisis--and I realize I don't know enough about it. And so I interview a lot of smart people and ask questions that I want to have answered, and I assume that you're interested in, so that you, too, can go on this journey of exploration and discovery with me and figure these things out.

So, we did a lot of episodes on artificial intelligence. I've got a couple more planned. Not too many more--don't worry, for those of you who are tired of it--but it's kind of an important issue, I think. Some people thought it's a threat to the future of humanity, so I wanted to figure out whether I should be worried about it or not.

The answer is: A little bit. Not as much as I think that most worried people are feeling. And we should be aware of it--we should be aware of its potential to do harm, as with anything else. But I thought that was important and I was curious about it.

And, similarly: yeah, I moved here into Israel three years ago. On October 7th, we endured an unimaginable attack of horror. And I wanted to understand the history of that better than I did. You'd think, as an American Jew who is interested in Israel, I'd be educated on the topic. I was not. I knew a little something; but I've learned a lot from the 10-plus episodes we've done on the Arab-Israeli conflict, the Palestinians, and so on.

One of the things that's striking when you live here is how hard it is to appreciate what it's like to live here unless you do. And, you know, it's funny: I'm recording this on April 14th--last night, Iran bombarded Israel with drones, cruise missiles, ballistic missiles. I awoke at 2:00 in the morning--excuse me, I didn't awake. The country awoke. I was actually awake. My wife was sleeping next to me. I was trying to figure out what was going on still; and I heard an incredibly loud boom. It did not wake up my wife but it sure scared me. I didn't know what it was. It sounded like a missile had landed. Then I heard two more and then the air raid sirens went off and, at that point, you're supposed to run--you have 90 seconds to get to a safe room. Our apartment doesn't have a safe room. It's an old building. And so we ran into the stairwell with our son and daughter-in-law and granddaughter who had been visiting us along with people in the apartment across the hall. And we huddled there and heard another boom.

And, those booms were Iron Dome and other defensive programs that Israel has. They also have David's Sling and Arrow. These are anti-missile defense systems which, as you know by now, worked incredibly well last night. It might not work well every time. Hezbollah in the north has supposedly tens of thousands of missiles-- not hundreds--that they could launch at Israel.

But, point being that--two points. One is that I really think it's important to understand some of what's going on on this issue for almost everyone, not literally everyone, but I think a lot of people are curious about it and realize, like myself, they don't know enough about it. And, secondly, I'm pretty tired. So I'm recording this sort of on fumes. I went back to bed--after the air raid siren stops, I think you're supposed to wait 10 minutes for debris to stop falling and then you can go back to your house.

So, we went back out of the stairwell after about 10 minutes and went back to bed. It wasn't my best night's sleep, obviously, and it's--well, we'll see what the next days bring. It's going to be a very interesting time.

And, I'm sitting--I like to call it--I'm sitting in the front row of history right now, which is both exhilarating and frightening. It was very scary last night, especially for my children and grandchild, but it turned out okay.

But, it seems like that's something I'm going to want to understand a little bit better. And so I'm going to do a little more on Israel than I am on, say, fiscal and monetary policy or Bitcoin. And that's just the way the program has gone.

I'm very grateful to Liberty Fund, who funds the program--that they've allowed me to follow my interests beyond economics. But that's the reality of the program.

I don't mind being told that you want more economics. I'm happy to hear it. But it's just--economics is not what I'm so interested in anymore. I'm more interested in what makes life meaningful. I'm more interested in the Israeli-Palestinian conflict. I'm more interested in human frailty. I'm more interested in decision-making.

So, you're on a journey with me--most of you. Some of you have just started. But many of you have been listening for a long time and you've been with me as I've explored these topics and you've heard my questions change depending on who I'm talking to. And I hope that's interesting.

It's not for everybody. I understand that. And, for those of you who miss the old days, that we were All Economics, All the Time. I'm sorry.

You know, it reminds me a little bit of Bitcoin. There are listeners who wish we did a Bitcoin episode every week. We don't, because I feel like I've learned everything that I can feasibly, reasonably learn from talking to smart people about it. It doesn't mean I know everything about it. I don't. But the marginal benefit of learning a little bit more is very small. I figured out, from the Bitcoin episodes we've done over the years, roughly how it works--not exactly, but roughly--what's the likelihood it's going to survive, what's the likelihood it's going to make it, how is it like money, how is it not like money, why it might be important, why it might be overhyped, and so on. And, at that point--you know, there are [?] few more things to learn.

Again, I don't mean to suggest I'm an authority on Bitcoin. I'm not.

And I'm not an authority on the Financial Crisis and I'm not an authority on the Arab-Israeli or Palestinian conflict. But I've tried to get smarter. And my goal is to help you get smart. So I hope that is of interest to you.

If I'm not interested, it's not going to be a good interview. I'm sure there are listeners out there who can tell when I'm not so interested in the topic or the speaker. Sometimes I'll invite someone on the program having read, say, the first chapter of the book only to discover that the remaining chapters are not as interesting as the first one. And it's hard for me to be enthusiastic about it. I don't ever want to do that. It happens from time to time, but I generally don't want to do that.


Russ Roberts: Some of you asked for EconTalk merchandise. We have it; we'll put a link to this for the notes for this episode of where you can find it. We have t-shirts, we have baseball caps. I think we have beach blankets, onesies--you know, the important things. So, they're out there, love for you to--coffee cups--we'd love for you to spread the word for EconTalk through our merchandise selection. They're priced to basically break even. So, we're not trying to make money on it. It's just a way for you to be part of the team and join the club.


Russ Roberts: A couple more things before I close this out; and the first is that I wanted to add something about last week's episode with Paul Bloom which was about immortality and living a digital existence rather than a, quote, "real existence." This--one of the issues that came up was the Experience Machine--the idea of Robert Nozick that you would tie yourself to a machine and you would imagine it would feel like you were doing all the things you had programmed the machine to make you feel but, in fact, you would just be plugged into the machine. So, while it would feel like you had cured cancer, or won the Masters, or become President of the United States, or you're a great rock star, you're not actually. You're just feeling what it's like to experience that. But in reality, you're laying on a table hooked up to the machine.

And, one of the things we talked about in the program, in that episode, was that, if you are a religious person or you believe in God, that there's something troubling about the Experience Machine. And I talked about the soul; and I also talked about that with respect to creating an avatar of one's loved one, or communing with famous people or dead people through AI avatars.

And, I missed what I wanted to say that was the most important thing so I thought I'd add it here. Which is that: If you lead a religious life or believe in God, you think you're supposed to achieve something with your life. Now, of course, you don't have to be religious or believe in God to feel that way. Many people who are not religious--purely secular atheists, lead a secular unreligious, non-religious life--feel that their life should have purpose and that they should try to do things to make the world better. But certainly, religious people feel that.

And, what I should have made clearer is the reason I find the Experience Machine interesting is that it forces you to recognize that. And, I think--I don't know where I saw this--but I'm pretty sure that people are more willing to be on the Experience Machine than they were when Nozick proposed it back in the early 1970s. When Nozick proposed it, if you did a survey--and, again, I saw this somewhere, I don't remember where, but it rings true--if you did a survey of people and said, 'Would you like to be on the Experience Machine and you could feel like you've done all these amazing things?' and most people would say, 'Oh, no, that'd be weird.' But, younger people today are more likely to be interested in the Experience Machine.

And, my only observation, which I think I was trying to make in that conversation with Paul [Paul Bloom] which I didn't do very well, is that: I think, if you aspire to a religious life or to a connection to the Divine, at least in the Judeo-Christian perspective, the one I know better than others, you're supposed to do something with your life. God put you here for a purpose. You may not know what it is, you may struggle to discover it; but laying on a table and feeling good but not actually doing good would be problematic for most religious people. Again, it would be problematic for many people, religious or not religious, but I think they're related. And that was the point I wanted to make. I don't think I made it--as far as I remember. That episode hasn't aired yet as I'm recording this but it will have aired last week.

Anyway, I wanted to add that. It's often the case that, in the aftermath of an episode, I think of things I should have said or should have said better and, if EconTalk was my full-time job, I'd be able to spend more time on these kind of postmortems. But it's not my full-time job so I do the best I can. But, I wanted to add that since it was just last week.

Before I forget, I want to thank the team at Liberty Fund and all the people who help me with EconTalk, Lauren Landsburg, Amy Willis, Katie Flavin, Les Cook, Marla Goldfinger, and to the Foundation for its support and, of course, to my sound engineer, Rich Goyette, who does the heaviest of the lifting. Many of those people have been with the program from the very beginning. Some have been added to help along the way. But I couldn't do it without them and I certainly couldn't do it with my responsibilities here at Shalem College, so I'm very grateful to that group for all that they do.


Russ Roberts: I want to close with a story. I think it will interest you; and I tell it with my mom's permission because it's a story about my mom and a recent challenge she had. And, it gets at many of the issues that we've spoken about on the program that I alluded to earlier--decision making, human frailty, self-deception, self-awareness, human flourishing, a meaningful life, and so on.

So, here's the story about my mom. My mom is 91 years old. She lives on her own, which is a wonderful thing, and she has her own house. Until six months ago, she drove her own car--which is amazing. But, now she's sold her car: she relies on Uber. And, I don't know, a couple months ago or so, she called me to say that she'd done something stupid--she'd fallen. But she was okay, she said. She was at a local emergency clinic and they were going to give her an x-ray and see if she broke anything, and that she was in some pain but she was okay.

I felt bad for her, obviously. And then she called me later and the pain had gotten dramatically worse. Although the emergency clinic had given her a clean bill of health--she hadn't broken anything--it was pretty clear that something was wrong. And so she went on to get an MRI [Magnetic Resonance Imaging]. She went to the hospital and got an MRI, to discover that she had a compression fracture--which is basically a crushing of the vertebrae in the back, in her back.

So, now the [?] question was what to do; and I thought, 'Well, hey, I'm an expert on this because we have had many episodes even on this exact problem.' These were the choices: Choice Number One was to do nothing, hope it got better. Choice Number Two was to get a special brace made that would allow the vertebrae to heal on their own, which I was told would take a couple of months but would avoid surgery.

And, Choice Number Three was surgery. And, there's different kinds of surgery in this particular situation; but they are variations on what's called vertebroplasty which we've talked about a number of times on this program. It's basically the injection of cement into the spinal column to solidify the vertebrae back to where they were before the fall.

And, I don't know if you, as listeners, remember this who were listening to the program back then, but I think we've done two episodes on why vertebroplasty doesn't work--that it's a failure. Let me just check, let me see this. The first one was back in--let's see, 2016. Adam Cifu had written a book with Vinay Prasad and the book was Ending Medical Reversal; and, basically, the idea of that book--which fascinated me and still does--is that many of the most common and implemented medical procedures which originally start off with some evidence in their favor, when they're looked at more carefully, they don't work. Or even worse, they are harmful.

So, in this case, vertebroplasty--which was this application of cement into the spine--was finally tested against a placebo at some point and was found to be no better than the placebo. And, the placebo was insane. The placebo was: half the patients get the surgery, where there's an incision made in their back and cement is inserted; and, the second group, they open the tube of cement so that the patient can smell it and believe that they're going to get the surgery but they don't actually do the surgery. All they get is the smell.

And, this study with controls found that the actual surgery didn't do better than opening the tube of cement. And, of course, the surgery is risky--get infections, things can go wrong; some people do it with anesthesia, anesthesia always has risk associated with it.

And, the implication was that this procedure was an illusion, or that the brain could fight the pain from the compression fracture on its own once you smelled the tube of cement and had a belief--the placebo effect--that something had happened.

I may have told the story--I'm going to make a side-note for a different story. A friend of mine is a pain doctor, and I went into his office: I was having shoulder pain. I had damaged my rotator cuff. And I went into his office for a steroid shot. And, it's a wonderful procedure: there's an imaging device that lets the doctor see exactly where the steroid is being inserted in the needle into the shoulder. And it's relatively painless, the insertion. And, while we're waiting for the doctor, I was talking to his nurse, and I said, 'What's your favorite thing in this office?' And she said, 'Oh, my favorite thing is when we inject cement into somebody's back[?]--into their spine--and they walk out pain free.'

And, this is right after I'd done the episode with Adam Cifu; and I wanted to say, 'You know, that's an illusion. That's just the placebo effect.' But I didn't say anything.

And, years go by; and then my mom falls. So now I have to make a choice with my mom and my brother and sister consulting, the three of us with her: What should my mom do? Should she wear a brace for a few months? Should she--and hope it just heals on its own which, of course, many times, things heal on their own which is why many procedures are overrated. Or, should she get the surgery which has--she's 91 years old; I'm thinking, 'This is insane. You're going to put an incision in her back?' And her doctor insisted on general anesthesia. It just seemed like a terrible idea.

So I called my friend the pain doctor, and he said, 'Oh, no,' he said, 'You got to do the cement. It's fantastic.' He said, 'Often they walk out pain free.'

And I thought to myself, and I probably even told him: 'Yeah, but that could be just the placebo effect.' But then the truth is, is that--well, maybe that's the best way to get the placebo effect. I'm not really going to call her doctor and say, 'Look, do me a favor. Instead of doing the actual procedure, would you just open the tube?' It just seemed ridiculous.

So, we chose the surgery. With great unease. Actually, we tried the brace for, like, a day because that one seemed like a really attractive--the brace works very well in studies versus the surgery, also. The problem is: it's really hard to wear the brace. You put it on, it's like, 'This is not so bad.' You wear it for 16 hours a day or maybe you have to wear it for 24, it's insanely unpleasant. And, to ask my 91-year-old mom to wear this brace for X months while her back heals seemed insane.

So we didn't do that; and we decided to do the surgery.

And, as we're waiting for the surgery to take place, my brother and sister and I are of course talking about it; and I'm also talking with my mom about it--and I didn't hide anything from her, that I had this evidence that this procedure was not necessarily effective on its own, that it was something of a sham with risks. But, I had to make a call--the four of us had to make a call--and we decided to do the surgery.

And, was that rational? Was it irrational? I mean, should I have trusted the evidence of the study that Adam Cifu and Vinay Prasad presented in Ending Medical Reversal, that it was enough to open the tube? Should I have trusted the brace to have the effect and avoid the risk of invasive surgery, even though it was relatively--it's a small incision, risk of infection, the risk with the general anesthesia? I went into the surgery--secondhand, of course; I didn't enter it personally but, loving my mom--I went into that surgery with some, actually, tremendous unease.

And, you know, I rationalized it by saying to myself, 'Well, I don't know how that study was done, that found it was no better than a placebo. Was it really true that the people who were given the surgery versus the people who got the tube of cement opened that they had the same level of pain beforehand?' I didn't know.

But I was forced to confront the reality that I've talked about a number of times on this program: that we feel very differently about omission and commission. That, doing things is different than--things that happen because we take action are different from things that happen because we don't take action. We've talked about the Trolley Problem as an example of this.

But the truth is, in this case, it just seemed really cruel to my mom, at 91, to tell her, 'Oh, yeah, this surgery doesn't really usually--it's really not that effective. It only seems to be. And it's risky. So, wear this brace for three months'--or whatever it was. It seemed absurd.

So, I bet on my friend, the pain doctor, who said it usually works. And, we did the surgery. And she walked out of that surgery pain free. Incredible.


Russ Roberts: So, was it real? Was it a placebo? I don't know.

I meant to mention--we did an episode with Gary Greenberg on the placebo effect. I think that vertebroplasty also came up in that episode--it's really crazy.

So, pain is a bit mysterious. The brain/pain connection is very mysterious. Was she just getting the benefit of the placebo effect and the incision and the anesthesia turned out to be relatively risk-free in this case? Did it actually do something that reduced the pain through stabilizing her back? Don't know.

But, that was the choice I made, and at least the position I advocated for with my brother and sister--who thought it was crazy that I would even consider not doing it.

For them, again, the commission part of it seemed the right way to go--not the omission, not to do--they wanted to do something rather than nothing. And so did my mom: She wanted the pain to stop; and her doctor assured her that it often would stop after this.

And so we did it. And got a good draw from the urn, as they say. So, I don't have--I don't have much more to say about that. I'd be interested in any comments you have and anything else you have to say about what I have said before.

I want to thank you for listening, I want to thank you for being along for the ride. Especially those of you who have been listening for 18 years. I would have never imagined this journey. And it's been a great ride. I hope it keeps going for some time. So, thank you.

This is EconTalk, part of the Library of Economics and Liberty. For more EconTalk, go to where you can also comment on today's podcast and find links and readings related to today's conversation. The sound engineer for EconTalk is Rich Goyette. I'm your host, Russ Roberts. Thanks for listening. Talk to you on Monday.