Here’s something I slopped together recently. I’m not really familiar with the literature on any of this, so maybe it’s all pretty well known (or well known to be confused). Anyhow, comments are welcome, and I apologize in advance for my usual pile of typos, grammatical errors, and other miscellaneous blunders.
W
Johnny Woulda, 45, has had chronic tendonitis in both of his elbows since he was about 30. He’s always been told that there’s no help for it except rest and steroid injections, but the rest hasn’t worked, and he’s afraid the injections will be worse for him than the elbow pain. He takes a bus to work every day and one day he sees a poster that says “Do you have tendonitis? We are testing a new non-steroidal oral drug, and if you are an otherwise healthy male between the ages of 18 and 48 you could earn $100 by taking part in our clinical trial.” The drug company, Montrezl, is interested in testing the effectiveness of their experimental product, Elbowftra©. Based on their tests on chimpanzees, which have no belief one way or the other whether they are being given a real drug, they believe that Elbowftra© drug would have at least a 50% effectiveness rate on humans people—higher if the person is credulous (the sort of person now spending a ton of money on herbal remedies). The FDA has assured Montrezl that if they can confirm that at least 30% more human volunteers are cured by Elbowftra© than are cured by a sugar pill placebo, as determined by blind reviewers, they should have no problem getting their drug approved. On the other hand, if there’s not much difference between Ebowftra’s effectiveness and that of a placebo, there isn’t much hope.
Let us suppose now, that there is something a little unusual about chronic tendinitis sufferers like Johnny Woulda. They happen to not only be extremely desirous of getting relief from their pain, but more credulous than a randomly chosen subject. If you even suggest to one of this group that you’ve got a pill that MAY work, a couple of doses is quite likely (about 70%) to provide them long-term relief from both their inflammation and their pain symptoms. The problem for Montrezl is that for this cohort there is no significant difference between the effects of Elbowftra© and the placebo: they both have around a 70% effectiveness rate. This means that a double-blind experiement will likely result in a determination by the FDA that Elbowftra is garbage and may not be sold.
This produces a paradox which may be put as follows:
Let S= people in the trial; X = any pill; E = Elbowftra©; and P = a sugar pill of no medicinal value. Assume too that the FDA is very careful and strict, only allowing curative drugs to be sold.
1. (X) (if X is safe and helps at least 50% of those taking it in double-blind clinical trials, then X should be allowed to be sold). [premise]
2. E is safe and at cures elbow tendinitis in 70% of those taking it in double-blind clinical trials. [premise]
3. Therefore, E should be allowed to be sold. [2 & 3]
4. (S) (X) (X is allowed to be sold, then it is rational for S to believe that X is curative of something). [FDA accuracy and stringency assumption]
5. It is rational to believe that E is curative of elbow tendinitis. [3 & 4]
6. (P) ~(P has the power to cure any medical ailment). [medical valuelessness of placebos]
7 E is no more effective than P in clinical trials. [premise]
8. (S) (X) (P) (if X is no more effective than P in clinical trials, it is irrational for S to believe in the power of X to cure anything. [What is no better than something useless must itself be useless]
9. It is irrational to believe that E is curative of elbow tendinitis effective on at least 50% more individuals than no drug at all.
We have thus proven that it is both rational and irrational to believe in the effectiveness of Elbowftra©.
It is easy to see the similarities between this paradox and Newcomb’s paradox of the money boxes. It is argued there that since it is irrational to believe that there could ever be less in both boxes than there is in one box, it must always make sense to take both boxes. This is in the face of the obviously rational approach of predicting that the future will be like the past.
The logical, apparently scientific sort—the type that believes that sugar pills cannot cure tendonitis—can always be expected to take both boxes: “How can it ever make sense not to? The money is either in the second box or it isn’t—my choice can’t affect the outcome!” But the credulous pragmatist, like Johnny Woulda, is more interested in the cure than the scientific truisms. He doesn’t care if it is his belief that is causing the success-creating effect or not: he just wants his elbow to stop hurting (or to become a millionaire if he’s playing the Newcomb game). The concern of how these apparently crazy results might happen, being purely academic, holds little or no interest for him.
The thing is, being just a thought experiment, there is no actual empirical basis for the Newcomb results, only a discussion of pragmatic versus academic dispositions. But there is plenty of empirical support for the existence of the placebo effect. One really can improve one’s elbows if one believes. This is not like Pascal’s wager, where there’s no basis for supposing that anybody has ever benefitted from what seems like a completely wacky supposition of the existence of some kind of diety. On the contrary, it’s a well-known fact that the credulous are more likely to do better in clinical trials. We even have a name for it—“the placebo effect.” We may say that the person who takes ginko biloba based on anecdotes of a couple of friends is just deluding herself, but—again assuming it’s completely safe—only good would seem to come from these kinds of “delusions.” And if a belief is really (not just in-pretend) success-producing, why is it more delusional to have it than not to have it?
I think the problem with assessing the Newcomb paradox is that those who insist on taking both boxes don’t REALLY BELIEVE that the past empirical results could have been as they are described by the one who sets up the story for them. As it seems impossible to this type that the single box taker has always (or almost always) gotten away with the big money and the two-box taker gotten screwed, they feel that their choice of both boxes is more rational than that of the (credulous, not to say stupid) pragmatist. But it is the pragmatist who is actually relying on the empirical results rather than the insisted upon theorems (“There just has to be at least as much money there for you if you take both boxes!” “There’s no way glucosamine can help tendons!”). These “musts” and “no ways” are not really science, however; they are simply denials of the accuracy of the actual empirical results based on a supposed knowledge of what must be the case—given the logical principles or scientific laws. So who is really the religious thinker here after all?
Thanks for tying the Newcomb paradox back in.
My sense about the argument you two are having regarding whether placebo effects are entirely psychological is that it’s playing on an ambiguity between:
(1) Entirely CAUSED by psychological factors; and
(2) Entirely CONSTITUTED by psychological factors.
I think (1) must be true of placebo effects, or the substance in question couldn’t rightly be called a placebo. But the available empirical information indicates that (2) is false of placebo effects. So I think you’re both right.
This reminds of a distinction sometimes drawn between “science based medicine” and “evidence based medicine”. The distinction is trying to separate conclusions based solely on isolated statistically analysis of double blind experiments from conclusions which also take into account the compatibility of the treatment with generally accepted science.
For example, a “science-based medicine” approach to homeopathic medicine would look for a scientifically-believable mechanism of its operation as well as statistically significant trial results.
The fact that we don’t understand how many drugs which pass trials work makes this a controversial view, I believe.
As for me, I don’t really care what choices a person makes, as long as when they make that choice they are free and informed.
But I don’t want my government health plan (I live in Canada) paying for treatments which are not scientifically proven.
Allan Miller,
Me:
Even more strongly, I’d recommend a book he actually wrote: *Bad Pharma 🙂
But this is the very problem that is made apparent by the Newcomb paradox, and it goes back to another argument on this forum where I argued that all data is interpreted, physically and conceptually, and arranged according to worldview. Placebo effects are called placebo effects in the first place because of the worldview currently being expressed by BK (and which you just demonstrated in the above statement). They are assumed to be driven by the psychology of the patient from a dichotomous perspective rooted in a worldview. IOW, we call them “Placebo” effects not because we have thoroughly examined and tested them and know them to be generated by psychology, but rather only because we assume that if there is no known physical relationship between the treatment and the change in condition, it “must be” the psychology of the patient that is affecting the condition (even if that change is physiologically detectable and objectively measurable).
We do not know if what we call “the placebo effect” is generated by the psychology of the patient, any more than we know that Newcomb’s success can only be generated by luck. Claiming that the placebo effect is generated by psychology simply because those who coined the term assumed it was doesn’t mean the placebo effect is actually generated by the psychology of the patient, any more than Newcomb’s predictive success is necessarily generated by luck.
Except BK’s claim that I challenged him to support wasn’t that the effect is entirely “caused” by psychological factors, but rather this claim:
The placebo effect is defined as the change in condition following “treatment”; not the treatment (cause) itself. The placebo is the treatment/cause; the effect is the change in conditions that follow. The change in conditions (placebo effect) is certainly not entirely psychological in nature.
BK’s assertion is wrong. He is free to rescind that assertion and replace it with the claim that the cause of the placebo effect is entirely psychological, but that would be difficult to support given that there is evidence that there may be a genetic predisposition for the experience of a placebo effect.
Apparently, what you mean here is that regardless of the empirical evidence otherwise, you don’t want the government paying for treatments that don’t fit in with the current conceptual paradigm of the consensus scientific establishment.
William,
You give the impression that you know the actual answer, but are unwilling to tell it.
If you are so very sure, write a paper and publish it. If it survives peer review then perhaps you are onto something that will advance the health and wealth of mankind for many years to come.
William wrote: ” Placebo effects are called placebo effects in the first place because of the worldview currently being expressed by BK (and which you just demonstrated in the above statement). They are assumed to be driven by the psychology of the patient from a dichotomous perspective rooted in a worldview.”
I think you’re confusing something that works, we know not how, with placebos. The latter are actually intended to be useless from the perspective of non-psychology. If there’s a chance that some drug might have effects other than from psychological causes, they’ll use something else. That’s why stuff that we already do know couldn’t possibly cure elbow tendonitis WITHOUT BEING BELIEVED TO DO SO may not be used as a placebo. So we use something like sugar, which we have solid independent evidence is not curative of tendonitis when eaten in the form of ice cream sandwiches.
But the placebo effect demonstrates that we can’t infer from the fact that some CAUSE is entirely psychological that the effect is not “real” (i.e., importantly physiological). Anyhow, my point is that if you think the cause of these effects is not psychological you’re not talking about placebos at all. You’re simply noting that a lot of treatments are effective for reasons we don’t understand, which is certainly true. Placebos are one purely psychological form of not entirely understood treatments. As you seem to be pointing out, there are others as well.
BruceS says, “But I don’t want my government health plan (I live in Canada) paying for treatments which are not scientifically proven.”
I think that’s entirely reasonable.
W
I think you are misunderstanding the use of the word “effect” in the phrase “placebo effect”. This phrase is generally used to refer to the observed difference between two experimental conditions, NOT the mechanism by which this difference arises. See also “Effect Size”.
No-one is disputing (well you might be, it’s tough to tell) that the psychology of the patient affects the physiology of the patient.
There is quite a lot of research exploring the placebo effect, some of it rather entertaining*. It all supports the thesis that psychology affects physiology.
Given that science recognizes that placebos WORK, but the law frowns on charging gobs of money for them, please provide the empirical evidence to which you refer, i.e. placebo-controlled demonstrations of efficacy.
*more expensive placebos work better 😮 (still hunting for the citation)
eta:
a citation and JAMA. 2008;299(9):1016-1017
[Not sure if this is the sort of thing you have in mind (pretty much EVERY definition of “placebo” and “placebo effect” require that they be artifacts of psychology). The following is from the American Cancer Society site]:
Placebo Effect
What is a placebo?
A placebo (pluh-see-bow) is a substance or other kind of treatment that looks just like a regular treatment or medicine, but it’s not. It’s actually an inactive “look-alike” treatment or substance. This means it’s not a medicine. The person getting a placebo does not know for sure that the treatment is not real. Sometimes the placebo is in the form of a “sugar pill,” but a placebo can also be an injection, a liquid, or even a procedure. It’s designed to look like a real treatment, but doesn’t directly affect the illness.
What is the placebo effect?
Even though they do not act on the disease, placebos seem to affect how people feel (this happens in up to 1 out of 3 patients). A change in a person’s symptoms as a result of getting a placebo is called the placebo effect. Usually the term “placebo effect” speaks to the helpful effects a placebo has in relieving symptoms. This effect usually lasts only a short time. It’s thought to have something to do with the body’s chemical ability to briefly relieve pain or certain other symptoms.
But sometimes the effect goes the other way, and causes unpleasant symptoms or worse. These may include headaches, nervousness, nausea, or constipation, to name a few of the possible “side effects.” The unpleasant effects that happen after getting a placebo are sometimes called the nocebo effect.
Together, these 2 types of outcomes are sometimes called expectation effects. This means that the person taking the placebo may experience something along the lines of what he or she expects to happen. If a person expects to feel better, that may happen. If the person believes that he or she is getting a strong medicine, the placebo may be thought to cause the side effects. The placebo does not cause any of these effects directly. Instead, the person’s belief in or experience of the placebo helps change the symptoms, or change the way the person perceives the symptoms.
Some patients can have the placebo effect without getting a pill, shot, or procedure. Some may just feel better from visiting the doctor or doing something else they believe will help. That type of placebo effect seems most related to the degree of confidence and faith the patient has in the doctor or activity.
No, that’s exactly what I’ve been reiterating. It is BK that is apparently trying to re-define “placebo effect” to mean “placebo”.
Claiming it is not providing it.
Quite so. And ironic.
Your wisdom will be lost to all once the page turns over. You should seek wider publication of your wisdom then a mere blog.
You appear to have a solution to the “placebo” problem. Please write your paper so that I may promote it.
A few years ago a meta-analysis was published on the efficacy of antidepressants vs placebo in the treatment of depression. IIRC , it found that there was a statistically – but not clinically – significant advantage of the drugs over placebo. In other words, much if not all of the perceived benefit of antidepressants is due to the fact that patients believe that they will help them.
This raises an interesting question. If antidepressants alleviate the symptoms of depression through the placebo effect, then publication of the research could deprive patients of that benefit. They will no longer have any effect if patients no longer believe they do. Normally, it would be considered unethical to suppress publication of research which shows a treatment is ineffective but in this case…?
I read something lately that indicated even if you have that knowledge, the effect is not diminished. That would have only been in a “New Scientist” magazine or similar.
That would have to be related to dosage. Modern antidepressants have dramatic effects at higher dosages.
Also side effects.
Perhaps the therapeutic effect could be hard to detect at minimal dosage. The desired effect is a functional person, not a zombie.
I believe the current scientific consensus incorporates the empirical evidence, but consistently with methods of science (eg replication, consistency with other relevant science, peer review).
But you knew I was going to say that.
It’s a democracy so we each get our vote. I try to make mine as informed as I can, and that includes consideration of all viewpoints.
So while I don’t agree with you on this, I definitely appreciate your effort in putting forward your views.
William J. Murray,
How is it that this is posted under my name? I didn’t post it.
Whoever posted that post, it wasn’t me. However,to respond, nothing in the material provided uses any language that constrains the placebo effect to psychology, and the material provided testifies against the claim in question:
First – “belief or experience” – experience is physiological, not just psychological. Second, “helps change” – which doesn’t mean that the change in symptomatic condition is claimed to be entirely caused by “belief or experience”.
The provided source once again contradicts the claim that:
… even if one agrees to redefine the placebo effect as the placebo itself. No definition I can find claims the cause of the effect is entirely psychological. That is an inference not provided in any definition or any authorized description yet offered.
What are you talking about, William?
WJM
That you provide this answer in response to my question of the unconscious individual clearly indicates you do not understand what the placebo/nocebo effect constitutes. The placebo/nocebo treatment only works if you can convey suggestive information to the individual. If you can’t, i.e., individual is unconscious, no placebo/nocebo effects will be observed. The placebo/nocebo treatment has a bit to do with dummy pills or sham treatments….but these are, mostly, just the props the handler uses to influence the individuals psyche during the conditioning process…..the placebo/nocebo treatment is the handler laying down the foundation of expectation(s) with/from the proposed treatment. The placebo/nocebo effect is the conditioning of the individual to these expectations. The placebo/nocebo effect can be manifested in varied, but limited, physiological endpoints. Decreases or increases in blood pressure are not placebo/nocebo effects nor are increases or decreases in perception of pain rather they are the manifestation of the placebo/nocebo effect within the individuals psyche. The placebo/nocebo effect is entirely psychological…….in can be nothing else…..the individual has not been given any treatment that will do anything at all outside of the suggestive conditioning.
Another way to look at is to consider why everyone who is given a placebo treatment does not show manifestations of the placebo effect. Some people are more prone to the conditioning while others aren’t. If it is, as you say, something more than a psychological effect the other patients should show some demonstrable manifestation of the placebo effect. But this is not what is seen and from what is observed it is obvious that the effect is entirely psychological. This is the reason why the polar opposite responses can be achieved by conditioning the patient with different expectations.
Also, WJM, there are quite a bit of data and studies on the placebo/nocebo effect (it has been recognized since the 18th century) not all of is of good quality but there are some very good studies out there contrary to your assertion that little research into the phenomena has been conducted.
Yes, well, I imagine that William has become “satisfied” with the state of the debate and will leave it at that, rather then address that rather inconvenient fact.
No, it just means that I disagree that your dichotomous conceptualization of what is causing the placebo effect is exhaustive of the possibilities.
As far as your claim that the placebo effect is “entirely psychological in nature”, I’ve already demonstrated from your own sources (and others) that this is a blatantly false claim.
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0048135
Catechol-O-Methyltransferase val158met Polymorphism Predicts Placebo Effect in Irritable Bowel Syndrome
From the abstract:
From a write-up about the research above in LiveScience
http://www.livescience.com/24222-placebo-effect-genes.html
If the high-dopamine gene is the difference between having a positive placebo effect and not having a positive placebo effect, then even the more modest claim that the cause of the placebo effect is “entirely psychological” would be false. From this research, the psychological aspect may be necessary for the greater placebo value, but it is not sufficient. It may be – according to this research – that the placebo effect requires a physiological component to be significant – the high-dopamine version of the gene.
It appears from this and other research that neither the placebo as cause or the placebo effect are “entirely psychological”.
Now, BK, notw how your worldview assumptions played out in your post:
IOW, the only thing you could imagine being “the difference” as to why the conditioning had effects on some subjects and not others was that it was purely psychological.
You erected a false dichotomy – either it is psychological in nature, or all patients would would experience some placebo benefit. You never considered the possibility that both a psychological and a physiological component were necessary – that psychology alone may not be sufficient to generate significant placebo effects. In the research, nobody that had the low-dopamine gene got virtually any placebo benefit regardless of the degree of expectation psychology implemented.
This directly contradicts your assertion, and demonstrates my point once again: you and others here are confusing your worldview interpretation of data for facts and reality.
“they are the manifestation of the placebo/nocebo effect within the individuals psyche.”
What does that mean? The manifestation is in the drop in blood pressure, no? Yeah, the cause has got to be psychological (what else could it be?) but the effects often are not psychological. I mean if you call the actual shrinking of a tumor or decrease in blood pressure something within the cancer patient’s psyche, either you’re not using words the way most people do or what the hell, fix my psyche, doc!
No, the cause doesn’t “have to be” psychological, as my post above shows. That’s like saying “light must either be a particle or a wave! (what else could it be?)”. Reality is not constrained to the limitations of your imagination rooted in a particular worldview that interprets data into various dichotomies.
So we take this back to the Newcomb money boxes to find the salient point: people with an entrenched worldview interpret the empirical facts presented in the Newcomb challenge like they interpret the facts available concerning the placebo effect; according to conceptual constructs they hold virtually as absolute.
When the Newcomb empirical facts are processed through their conceptual construct, the success rate – if true – **must be** because of luck, and there is simply no reason whatsoever not to take both boxes. IOW, their current choice simply cannot make a difference as to what is in the boxes right now.
Similarly, in the minds of some here, there can only be one valid interpretation of the facts available concerning the placebo effect; the placebo effect is “certainly” caused entirely by psychology. This interpretation of facts is so certain to them that they don’t even recognize it as an interpretation at all – to them, it’s a factual account of reality – more than that, it’s tautological.
I don’t think the key issue is whether the effect is psychological or physiological since both are physical in the end, unless you are a dualist of some sort.
But there are ethical issues: should doctors deceive patients to achieve placebo effects? Some do, as BK mentioned in passing, but there is an obvious conflict with informed consent.
Can placebo-like effects be achieved when someone knows they are taking a placebo? I don’t believe that possibility is generally accepted. This piece criticizes a study which claimed to show that possibility, eg there were blinding issues with the descriptive materials given to subjects: Kaptchuk versus placebo effects
Can one achieve psychological effects ethically? I guess CBT versus drugs for depression could be considered one possibility. But there is a more intriguing one reported in a recent Economist article: Dealing with the yips for musicians
You do have to register to view the article; the gist is that a treatment for cramping in musicians fingers used to be based on a drug but it was not a permanent solution. A different approach was found by studying the patterns of the neural activity in the brain, recognizing a pattern associated with the disease, and using fingers splints, cranial stimulation, and feedback from changes in that neural pattern to correct the problem.
My point is that the treatment involves understanding the brain correlates of a disease and how they change during treatment, and that is a precursor for manipulating the physical effects associated with the psychology of placebos.
I’ve dealt with chronic pain and with severe trauma. In my life, the worst part of pain is not the pain itself, but the accompanying sense of dread. Psychologically, it is the sense that the body is decomposing and degenerating — a sense of helplessness.
Once this dread is overcome, the pain itself is tolerable.
There are lots of ways of overcoming dread, but the touch of another person seems to be very effective. Doctors know this. Faith healers know this.
I would submit that the placebo effect is precisely the effect of relieving dread, of assuring a patient that something is being done.
How surprising can it be that depressed people are helped by assurances that something is being done? Dread is the primary presenting symptom.
As for people with organic diseases, some will get well and some won’t. Even with cancer, some will experience remission.
As for the ethics of placebos, I don’t see anyone advocating placebos instead of prosthetic limbs, or instead of hernia surgery or instead of antibiotics. The placebo effect is important when we don’t really have a cure.
Well, there are purported treatments for phantom limb pain involving mirrors which could be considered psychological and hence maybe bear some distant relationship to placebo effects. I don’t know how rigorously they have been tested.
Mirrors as a painkiller for amputees
But of course I agree that the ethical issue only applies for cases where the placebo effect might improve the patients life (as the patient defines “improve”).
I’m not sure what the relevance would be to phantom limbs. My point is that the placebo effect does not work on ailments that have obvious physical causes. It will not cure rabies or tetanus. It will not regrow limbs.
It only works on problems where there is no effective treatment. And where the most important symptom is pain or distress. There are lots of diseases where there is no cure and where treatments are mostly palliative. There are heart and circulatory conditions where drugs relieve the presenting symptom, but do not appear to prolong life.
I understand it is not the placebo effect and of course I agree with your point.
It just occurred to me that it was related to missing limbs and was psychological as the placebo effect has been characterized on this thread.
That’s why I thought it might be somewhat relevant.
I agree it is a bit of a stretch.
I think you’re right that there are ethical issues–and I wish I had something of interest to say about them. In my own case I try to remain a smidge credulous…..but only a smidge. I mean, I’d like to be bettered by any treatment I use, whether or not there’s a reason scientists understand for my improvement. But I don’t want to be bilked by snake oil sellers any more than the next guy. It’s hard even in one’s own case, I think.