Probably the new definitive article on The Placebo Effect. Not just because Dr. hall tells us so much about the specifics of placebos, but because of what she tells us about psychoneurology in humans and animals.
The term “placebo effect” is unfortunate; it leads to misunderstandings. Placebos themselves don’t have any effect. They are inert: that’s what placebo means. The word placebo comes from the Latin for “I please.” You can think of it as the opposite of “I benefit.” What we really mean by “the placebo effect” is not some mysterious effect from giving an inert treatment, but the complex web of psychosocial effects surrounding medical treatment.
Or the placebo had no measurable organic effect. The “effect” is a psychological one that involves the altering of perceptions. Placebo isn’t just fun to say fast ten times after happy hour, it has become a standard part of scientific testing. All tests on new drugs include a group that receives the actual drug and a placebo group. This started with a study published by Dr. Henry Beecher in the 1950s in which he used a placebo group as a control. Almost all drugs or vitamins will show a false positive in test groups. It was not until 2001 that some scientists performed a study that used only a placebo group and a group that received no treatment. That 2001 tests showed what some had already figured out by logic. Placebos had no measurable effect. In Beecher’s study he could not account for people simply healing as the body has a way of doing given enough time with some ailments, people saying they felt better because they did not want to make their doctor feel badly or statistical regressions. The placebo effect does work, but its almost all a matter of medical situations in which perceptions play a large role. If you genuinely believe you just had an operation that healed your kidney stone, your stone might still be there, but how your mind manages the pain has changed. Injections of placebos are reported to work better then tablets. The size and color of placebo pills are a standard part of the perception, thus the effects differ. Still the effect’s reality is relative because giving an unconscious person a placebo has no effect, imagined or organic – in kitchen table debates that include suggestions of supernatual powers at work, this is an important facet of placebos, beliefs and validation of claims outside circular arguments. The patient has to at least be aware they are receiving a placebo and sometimes the placebo effects works even when the patient is informed it is a placebo. But wait, I took a placebo and my blood pressure actually went down or my breathing became less labored.
If you are asthmatic and are wheezing, any psychological factor that reduces your anxiety level or helps you relax might indirectly ease your breathing symptoms and even allow your constricted bronchi to dilate. In this view, the placebo effect doesn’t really cause objective effects, it allows you to have a different experience of your symptoms and it is that different experience that indirectly affects your physiology.
Sure one can make the case that giving an asthmatic a placebo in a medical emergency might be justified, that might be more an ethical bump in the road about a justified lie, then a medical concern or mystery.
If the placebo effect is real, what might the mechanism be? We can’t just write it off as delusions of hyper-suggestible patients. There’s evidence that several things might be going on. The main hypotheses are: expectancy, motivation, conditioning, and endogenous opiates.
Expectancy can include the same cut of steak, but the people who paid more for theirs say it tastes better. Motivation – if you’re feeling down emotionally you’ll get less of an effect then someone who is obsessed with getting well soon. For conditioning – doctor+pill. We’ve been conditioned to think that when a medical expert gives us something to make us better, we feel better whether it was medication or just a sugar pill. Endogenous opiates – naturally produced by our own bodies and placebos can be a trigger just like jogging or meditating.
Why then do animals respond to placebos. I mentioned the trained horse Clever Hans in another post. Our pets pick up on signals we give them even when we do not do so consciously. And the owner sees the pet getting well for the same reasons they would see themselves getting well.
So its OK if doctors just give out placebos. Its cute in movies when the cranky old doc with a heart of gold gives the patient with imaginary illness a B-12 shot, but strictly speaking its not ethical. In the extreme, one cannot give a placebo treatment for something obviously organically wrong like leukemia. There is always a very very rare chance of spontaneous remission, but withholding standard treatment in cases like that would clearly violate medical doctors ethics and the law. Still some doctors give their patients placebos for various reasons -“A 2004 study of physicians in Israel found that 60% reported using placebos for reasons like “fending off” requests for unjustified medications or calming a patient.”
Pepsi plans on investing $1 billion in China over the next 5 years and opening 5 more plants.
This reminded of the past week’s comparison by many bloggers liberal and conservative of the Iran protests to China’s Tiananmen Square protests. The liberal aspect of the comparison was a fairly simple one of the magnitude of the violence and the possible long term consequences for Iran’s people and form of government. The Right’s take was to use Tiananmen Square as a rhetorical club to beat Obama into doing or rather taking some provocative steps . Including imminently cutting off all possibility of ever having any kind of negotiations with Iran. Bush 41 obviously condemned the killing of the Chinese protesters and he suspended some sales of military equipment temporally. Ironically his son Bush 43 would cook up a war based on false pretenses a decade later in order to spread democracy as 400,000 people died in Darfur. Its a big internet and maybe there is some reputable conservative that wrote a column expressing an outrage at Bush’s inaction, but I cannot find it. The issue of China and its horrendous human rights record seem to have been reconciled in the conservasphere as the Pepsi story illustrates – we have business and diplomatic ties with China despite their history – money talks. The conservative comparisons between Iran today and Tiananmen Square were knowingly hypocritical and meant to be provocative in a way that the writers hoped would undermine Obama. The Chinese protesters in 1989 had no vote and very little hope that their leaders would embrace the reforms their Soviet neighbors were adopting. Conservatives like Bush 41 claimed that capitalism and freedom were joined at the hip, inseparable. Today, one billion Chinese still have no political freedom, but have been placated with money from a very aggressive western style market economy. In Iran the people had the right to vote and while naive, they did believe that vote carried some weight and consequences. A better comparison might be the Iranian Revolution of 1978. It took about a year, but they threw off the old regime and sadly adopted one that was a strain of Islamic fundamentalism. This new revolution may take as long to play out, but it has much more of a chance to have a lasting effect in terms of political democracy then Tiananmen Square.
“Who have persuaded man that this admirable moving of heavens vaults, that the eternal light of these lampes so fiercely rowling over his head, that the horror-moving and continuall motion of this infinite vaste ocean were established, and contine so many ages for his commoditie and service? Is it possible to imagine so ridiculous as this miserable and wretched creature, which is not so much as master of himselfe, exposed and subject to offences of all things, and yet dareth call himself Master and Emperor.” Michel Eyquem de Montaigne (B.1533–D.1592)