15 November 2009

Extrapolating the Placebo Effect

Most people know what the placebo effect is, but few know how powerful it can be. Beyond that, it is all too common for a person to deny their own susceptibility to the placebo effect. Placebos come in many forms; some simple, some bizarre. The form we all know is the sugar pill, which is given to test subjects or to patients who beg for medication despite not really needing it. Have you heard of a placebo button? It is a button that people can press, but it does not do anything. Think: the close door button on most elevators or the cross-walk button. Clicking it makes you think you're in control, but you're really just soothing your own mind and reinforcing a habit.

Scientists (the ones who look for empirical evidence, as opposed to the ones who just call themselves so) agree that homeopathic medicine and other cures deriving from spiritual remedies are only successful because of the placebo effect. You may refute that these methods have been known to cure some serious maladies, but there are two things going against that argument: there is no empirical evidence to support this (or else even doctors would use these methods) and I repeat that you might not be aware of how powerful a placebo can be. Consider the world of arthroscopic knee surgery, which has been turned on its ear within the last 10 years after a published report that stated that the pain relief gained by a routine, invasive procedure was no more valid than a placebo pill. The study noted that patients receiving nothing but two little cuts to make them think that the surgeons actually did something reported the same rate of pain relief as those who got the whole saline wash and cartilage removal procedure that has been standard for decades. This was an embarrassment to arthroscopy surgeons everywhere, but an important step in understand how much power our mind has over our perceived reality.

If you sympathize with knee surgery patients who went under the knife unnecessarily, you should hear about angina pectoris sufferers before the 1950's who had their sternum cracked open and one of their arteries tied off, only for the procedure to be found completely ineffective in 1955. The actual source of the relief? Placebo. Beyond the remedies that we use to get things off of our mind, the amount that we pay for them also matters when it comes to their effectiveness. This is where placebo meets expectations. Like all products, we expect the ones which cost more to be better or last longer. In fact, some products are purposefully overpriced because nobody would trust their effectiveness if they were sold closer to cost. Conversely, higher prices have made reputations for some products, despite their lack of any real advantage over competitors (Monster Cables, anyone?). If you pay 10 cents for an asprin or $2.50 for a miracle pill, which one do you think will be more effective? Which one do you think you'll give the benefit of the doubt to? (If, for the sake of being contrary, you say "the 10 cent asprin," you're only kidding yourself.)

Cognitive dissonance says that the more we invest in something, the more we are likely to appreciate it, even if it disappoints us. If we extrapolate what we know about the placebo effect and apply it to other things, we can get a better picture of how we, as human animals, pad the walls of our minds with justifications and confidence in faith. While it is exhaustive to require empirical evidence for everything we believe to be true, matters of belief and spirituality are better understood with the knowledge of how easily we fool ourselves. This, in spite of how vigilant we are in keeping it real.

9 nibbles:

  1. placebo effect is one manifestation of humans gullibility or susceptibility to manipulation...but i dont think it's bad. sometimes, we need those things to get by. can i call it faith???

    anyway, your blog is getting more scientific every time i check it. how about your thoughts about 2012? i just saw the movie on its premiere.
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  2. john: You're right that sometimes we need it to get by, and you can call it faith - just don't call it "reality." For my thoughts on 2012, you can see my post about the event last week. I don't plan on seeing the movie, as it looks like a firehose of crap aimed right at your face.
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  3. Indeed the placebo effect is a valid tool for medication. And ironically it's very potency lies in calling it reality and not faith. Faith and reality are thus intertwined - to the chagrin of the realists of course.

    Equally interesting is the nocebo effect. And it is employed not only by voodoo witch doctors with documented success, but by governments in the age of terror (or whatever age they are peddling us to keep themselves in jobs/power). It too works precisely because we don't just call it faith but reality. It is real after all that you are more likely to be bombed by a terrorist than killed or maimed by or in a car is it not (judging by the funding each problem attracts)? (<- irony in case any literalists are reading).

    And in fact it is nocebo I think that is your real grip Andrew and it would be hard to deny anyone placebo benefits by quibbling over reality. Not impossible just hard. The difficulty lies in a our compassion, which is rather nice mundane human trait. What makes it possible to deny placebo benefits is two salient risks:

    1) The malintent problem. That is, if we permit falsehood peddling for patient/client benefits (placebo) how do we draw the line on falsehood peddling for personal/vendor benefits (nocebo)? This is .

    2) The error risk. That is if we permit falsehood peddling for patient/client benefits (placebo) how do we know it'll actually work? It's a shot in the dark so to speak and its potency relates to how convincing your theatrics around the (non existent) treatment.

    All-told it doesn't look easy to find a way to integrate placebo powers into our medical practice in an ethical and reliable manner. It would be interesting to speculate if such were possible, given the demonstrated benefits (cures without intervention).

    Others would argue that meditative practices are comparably useful, and I would be curious to read of comparisons on the efficacy of placebo and meditation. The latter is less problematic to institute in the medical practice as it does not rely on deception. It raises an even more interesting question, how much of the documented benefit of meditation IS in fact placebo at work! And if so, perhaps meditation is a useful vehicle for delivering placebo benefits?
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  4. "humans gullibility or susceptibility to manipulation"

    I'm wary of this. At one level I concur. At another I find it unnecessarily disparaging of our perceptive and interpretive systems. That is, we perceive, and we interpret incoming information. It is somehow channeled into figurative buckets labelled fact, falsehood. They are gray buckets of course, somewhat intertwined, but all the same somehow we categorize incoming information.

    There seem to be two broad methods of categorization at play:

    1) Seeing is believing and reproducibility
    2) The word of authority

    Interestingly, while science prides itself on the first, it indulges in the second almost as much as any other practice does. Conversely while the evangelicals pride themselves on the latter, they too indulge in the former as best they can (albeit a little less puritan in their methodology and more prone to use of decoys, smoke and mirrors than the scientists are).

    My point though is that you seem to disparage the second way of knowing by describing it as gullibility and susceptibility to manipulation. And a part of me accepts it's a very valid way of knowing. I have stated before that as I read the New Scientist, I practice only this second way of knowing ... I choose my authority, to be sure, to be one that favours the first way of knowing, but I myself employ the second.

    Do I have, in the end, any other option? I believe not. Simply because the first method of knowing costs one or more orders of magnitude more than the second. It's expensive and I can't afford it. I have to use the second.

    Is it fair then to call this gullibility and susceptibility to manipulation?

    Don't get me wrong, gullibility and susceptibility to manipulation feature strongly in when we look at critical thinking or the lack of it. But you don't need to lack critical thinking skills to benefit from placebo. You, I and almost anyone else have good reason to trust our surgeons and their claims. A critical thinker like me will seek a second and third opinion before going under the knife (and I have), and I will seek for them to be independent. This doesn't rule out collusion between the people I consult to deceive me, and test placebo on me, and for it to work. Ironically I am a candidate for arthroscopic knee surgery! I could have been on this trial! I wouldn't call that gullible or susceptible.

    No, I think it fairer to say that placebo is a manifestation of the minds power to affect perception and body chemistry, and that confidence in the result is one way to coax this power out of it. Perhaps placebo then is a manifestation of our insecurities - that if we don't believe something will work our minds proceed to undermine its actually working.

    What evolutionary benefit may such a trait have had? Would be it be politically incorrect to speculate blindly that it was a mechanism selecting in favour of positive proactive members of the species, against depressives, and to go way way out on a limb and nose dive to the speculation that perhaps the intervention of civilization in the evolutionary selection process has allowed the depressives to rise over time ... Hmmm. Anyone studied that? Or can it be shot down in the blink of an eye?
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  5. Bernd, a great piece of enhancement you've laid out. If I were to guess as to why our minds work the way they do, it is to fall in line with the second method of learning you pointed - authority. This is how 99.9% of the animal kingdom works and so all of the mechanics and synapses and structures exist in our minds until we breed them out through evolution (or revert back if our "smarty pants" method fails us). Of course, I'm a proponent of different thinking, but I realize that in order to be different, there needs to be a norm. We probably won't get away from learning by authority - ever.
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  6. I am fully aware of the placebo effect within myself. I can have a headache, take an ibuprofen and almost instantly feel better, even sometimes when I can still feel it in my throat. I know it's placebo, but at the same time it still works.

    I will have to keep an eye out for it in non-medical situations now though, I think you are probably right though.
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  7. the Bernd guy is too analytic! he can write a whole new post with his comments.. hehe
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  8. "too" analytical? Strange notion. Andrew's noble effort as far as I can understand it is to prompt you johnonline to be more analytical ;-). I'm just helping out a little.

    Too verbose, that I could understand ;-). I know how to type all right. And when words flow smoothly from the mind to the keyboard well, the effort in fact becomes one of editing down, not scanning around finding keys or searching for words.
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  9. Here's one that bothers me. I know that over the counter DXM cough syrup works no better than placebo at standard doses, yet when I take it, my cough improves. It works in DXM only, with phenylephrine (also no better than placebo and doesn't work on me,) and with guaifenesen, which does work better than placebo. I know it's useless, but it still works for me. It really bothers me that it does.
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