If Only You Could Bottle a Placebo

But now we are learning that while the placebo itself is inert, the act of giving a placebo is not: it can produce actual physiological effects through suggestion and expectation.

That’s from SBM. It’s easy for scientifically-minded people to scoff at placebos, which are pure evil to any card-carrying physics-evnying PhD. How do you control and test the effect of the communication/empathy skills of a practitioner? How about status or charisma? Can’t, so no point in talking about it.

That needlessly cedes ground to charlatans and worse, though. The human body is a pretty awesome drugstore. It’s one where the shelves are shrouded and nobody knows how to pay, but we should pay attention to it:

the take-home message for clinicians, for physicians, for all health professionals is that their words, behaviors, attitudes are very important, and move a lot of molecules in the patient’s brain. So, what they say, what they do in routine clinical practice is very, very important, because the brain of the patient changes sometimes… there is a reduction in anxiety; but we know that there is a real change…in the patient’s brain which is due to… the ‘ritual of the therapeutic act.’

Why not train doctors to be better at delivery? The SBM post frames this as a conversation about ethics, but I don’t think you need to go there. As pointed out in this post, there are a lot of different kinds of placebo effects and not all of them require lying to patients.

SBM agrees on that point, at least:

I think attempts to elicit a placebo effect should be only used in conjunction with an effective treatment. Words should be used carefully, and the focus should be on general measures that bolster the doctor/patient relationship and enhance the patient’s trust, like spending more time with the patient and showing a greater interest and sympathy.

Anyway, let’s talk about the liars.

Is it ok to lie to someone if it’s genuinely in their interest? Amazing as it is to say, this is an ethical problem that needs to be resolved to advance science (here is another one!).

I’d argue that it is a good idea, but proving that it’s in their interest is a really messy empirical question.

Here is what a placebo balanced trial looks like:

Dr. Benedetti is using “placebo balanced design” to tease out the influence of verbal suggestions — expectations — on the action of drugs. Subjects are divided into four groups. The first group of subjects receives the active treatment and is told it is the active treatment (the truth).  The second group receives the active treatment and is told it is placebo (a lie). The third group receives placebo and is told it is the active treatment (a lie). The fourth group receives placebo and is told it is placebo (the truth).

Not good enough, in my mind. You’ll need ANOTHER level of testing where you tell one group that you’ll be lying to some people. In the real world, patients would know placebos are fair game and so controlling that feedback loop is important, too.

And even then, some doctors will be better faith healers than others and so just get better outcomes. Bottle that!

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