The Placebo Effect: Is it real, is it ethical?

[StevenLeonCooper]

I couldn't find a placebo-related thread that covered this topic within the last year or so. I thought it would be nice to revitalize the topic to see how people feel about it in 2014.

I have some questions and some suppositions. Before I begin, I'd like to define the term based on my understanding of it, to be specific as to what the thread is about and to provide an opportunity for anyone to correct me if I've misunderstood something.

Placebo Effect: When a person has a medical condition and is either cured or shows significant positive reaction to medication or therapy purely because the patient believes that it works and not because it has any directly observable effect or empirical evidence to imply it has an actual physiological effect by itself. The patient's belief in the treatment is what causes the benefit, not the actual treatment.

So that includes sugar pills given under the pretense that they are in fact actual medications, reflexology, chiropractic, Ayurveda, homeopathy, herbal remedies, acupuncture and a myriad of other medical treatments with no observable physiological benefits that directly relate to the conditions they allegedly treat.

My Questions:

1. Is the placebo effect real? I've seen evidence for and against the placebo effect; from the small bit of evidence I've seen I can't make up my mind yet. Some studies show an observable difference, some studies demonstrate no significant changes. Studies are hard to trust because there are many factors that don't get accounted for and any study will be biased by the will of its publisher.

2. Assuming that there is evidence in support of the placebo effect, evidence that indicates it works and that people believing in treatments is an effective way to help them, is it ethical? Can we justify lying to patients in order to better treat them? There's no intended spin on that question; providing placebo pills or giving inaccurate prognoses is plain and simple lying. Presenting a medical treatment that doesn't have credible evidence supporting it is lying through omission. Would the benefit justify lying to people?


My Suppositions

1. If the placebo effect is real then there should be a way of invoking it's healing properties without having to lie to people. There should be a way of stimulating the part of the brain that reacts to this belief via drugs or stimulation. We should be able to ascertain a physiological effect that is measurable and quantifiable. I believe that there probably isn't such a simple explanation, and that placebos can be explained by numerous factors of behavior that a patient carries out when under the influence of such a lie. These behavioral factors compound into a generally-positive effect but it is likely a combination of many things than simply believing that a treatment works. Also in play is likely the perception of pain and discomfort; the patient may not physically be any better but their perception of their condition may improve if they expect it too. This may make their lives easier but it doesn't imply that placebos actually heal people; in that way they would be no more effective than Dayquil for a cold.

2. It is unethical to lie to patients or misrepresent treatments as being more effective or credible than they actually are. Medical professionals have a responsibility to be honest with their patients because their patients often have to place full trust in them. There's no logical place to draw a line of when to stop when we suggest that doctors are allowed to lie about medical procedures for the good of the patient; the patient's bodily sovereignty is put at risk. Likewise it is unethical for people to provide alternative medicine without any substantiation because it tricks people into avoiding substantiated medical treatments that can actually help them.

I'm usually the first to say that results trump personal beliefs when it comes to saving lives (As I feel about Abstinence-Only Sexual Education, an ineffective mess) but this is a situation where I don't believe the ends justify the means. This is why I don't support the Truth campaign or Above the Influence. The goals are admirable: smoking causes a variety of health problems and is a waste of money; likewise the criminalization of marijuana makes obtaining the substance dangerous for many. Unfortunately both of these campaigns misrepresent information in order to peddle their messages and I can't stand behind that (which is why I feel the same about Abstinence-Only Sex Ed, it also promotes limiting of information).

What are your thoughts?

 

[casebro]

My thoughts are that the placebo effect affects those ailments, or parts of ailments, that are under mental control. Like how much pain you feel. NOT to cause direct physical changes like grow bones. Or improve an immune system.

No studies have shown any benefit is cancer cures, no matter how much positive thinking is involved. But the patient may have better mood before he dies.

 

[StevenLeonCooper]

My thoughts are that the placebo effect affects those ailments, or parts of ailments, that are under mental control. Like how much pain you feel. NOT to cause direct physical changes like grow bones. Or improve an immune system.

No studies have shown any benefit is cancer cures, no matter how much positive thinking is involved. But the patient may have better mood before he dies.

Yes, that's the only concession I think I would make for the placebo effect. Our state of mind certainly can affect how we perceive things like pain; in fact it can have a physiological effect on the chemicals and chemical receptors in our brains. All the same it's treatment of the perception of the condition, and not the condition itself.

 

[Akri]

For the ethics question, my understanding is that placebos* aren't used as regular treatment, but for testing against other medications. So any patients receiving placebos will be in medical trials, and they will have consented to possibly receiving a placebo.

*By which I mean medications that are intended to be placebos, and not things like homeopathy which are supposed to be real medicine but only work via the placebo affect. For those things the proper terminology isn't "placebo", it's "fraud", and it is indeed highly unethical.

 

[Loss Leader]

2. Assuming that there is evidence in support of the placebo effect, evidence that indicates it works and that people believing in treatments is an effective way to help them, is it ethical?

I don't believe it's ethical to rely on the placebo effect because it is impossible to determine which patients will be helped and which will not. If one could know ahead of time that a placebo would be effective for a specific patient, it would be ethical to treat by placebo.

If there is no significant risk to delaying treatment and if medical treatment is difficult or expensive (or comes with undesirable side effects) and a placebo is far less expensive, then I would consider it ethical to first try the placebo.

 

[Meed]

My Questions:

1. Is the placebo effect real? I've seen evidence for and against the placebo effect; from the small bit of evidence I've seen I can't make up my mind yet. Some studies show an observable difference, some studies demonstrate no significant changes. Studies are hard to trust because there are many factors that don't get accounted for and any study will be biased by the will of its publisher.

From what I remember, studies on the placebo effect have indeed been mixed. My impression has been that it works for some things but not others and when it does work it tends to be modest. I don't think there's any evidence that it can cure diseases or heal injuries, but it's not unreasonable to think that it could affect psychological symptoms such as depression, anxiety, perceived pain, stress and so on and I do think there is some evidence suggesting this.

The main use of placebos is in comparing a treatment group to a control group. And whether or not the placebo has an effect on the control group doesn't really matter to the experimenter, because the placebo having no effect won't hurt one's experiments any.

2. Assuming that there is evidence in support of the placebo effect, evidence that indicates it works and that people believing in treatments is an effective way to help them, is it ethical? Can we justify lying to patients in order to better treat them? There's no intended spin on that question; providing placebo pills or giving inaccurate prognoses is plain and simple lying. Presenting a medical treatment that doesn't have credible evidence supporting it is lying through omission. Would the benefit justify lying to people?

I don't think such lying would be ethical in the vast majority of circumstances. Maybe in some special cases. If you could lie to someone and get the placebo effect to cure their cancer, sure that would be ethical, but as noted earlier its effects seem to be modest at best.

My Suppositions

1. If the placebo effect is real then there should be a way of invoking it's healing properties without having to lie to people. There should be a way of stimulating the part of the brain that reacts to this belief via drugs or stimulation. We should be able to ascertain a physiological effect that is measurable and quantifiable.

Theoretically, perhaps, but psychological and brain sciences are not nearly so advanced as to be able to do this.

Also in play is likely the perception of pain and discomfort; the patient may not physically be any better but their perception of their condition may improve if they expect it too.

This is an important point to keep in mind and one that makes the placebo effect difficult to study. I don't think people are very good at judging whether their pain is worse than it was a week ago, for example, so they might guess and in doing so take into account the fact that they supposedly have been taking a pain reliever. Unlike real medications, an experimenter can't very well test the placebo effect by pitting it against a placebo control group. The best solution might be to use physiological measures (e.g. changes in heartrate in response to an anti-anxiety placebo.

2. It is unethical to lie to patients or misrepresent treatments as being more effective or credible than they actually are. Medical professionals have a responsibility to be honest with their patients because their patients often have to place full trust in them. There's no logical place to draw a line of when to stop when we suggest that doctors are allowed to lie about medical procedures for the good of the patient; the patient's bodily sovereignty is put at risk. Likewise it is unethical for people to provide alternative medicine without any substantiation because it tricks people into avoiding substantiated medical treatments that can actually help them.

Agreed.

 

[dlorde]

The placebo effect is a real effect - people report that they feel better than with no placebo. As I understand it, there are no clinical effects beyond those attributable to or associated with a subjective perception of improvement (e.g. stress reduction, etc). Nevertheless, these can be significant.

The ethics of using the placebo effect are debatable, particularly now it appears that it can work even when the subject/patient is aware they have received a placebo.

Your suppositions seem to indicate a confusion over what the placebo effect is.

 

[Pup]

Unlike real medications, an experimenter can't very well test the placebo effect by pitting it against a placebo control group.

Couldn't one split people into two groups: those who get no medicine at all, and those who get a sugar pill?

 

[StevenLeonCooper]

Couldn't one split people into two groups: those who get no medicine at all, and those who get a sugar pill?

I believe that has been done, or at least "no-medicine" control groups have been used to compare placebos to regular medication.

I guess your "placebo" in a placebo trial would be giving people the sugar pills but telling them that they are just sugar pills, right?

 

[dlorde]

I guess your "placebo" in a placebo trial would be giving people the sugar pills but telling them that they are just sugar pills, right?

No. Placebos can work even when you know they're fakes.

You'd need two placebo groups (knowing and unknowing) and a no-placebo group, at least. You could also have a group that has the consultation but gets no pills, and a group that has no consultation or pills, just a pre and post trial assessment... starts getting complicated.

 

[StevenLeonCooper]

No. Placebos can work even when you know they're fakes.

You'd need two placebo groups (knowing and unknowing) and a no-placebo group, at least. You could also have a group that has the consultation but gets no pills, and a group that has no consultation or pills, just a pre and post trial assessment... starts getting complicated.

Eh, the more you describe it the less falsifiable it gets, and the less credible it sounds.

ETA: Reading your article I find this little tidbit:

The researchers told participants that it could improve symptoms through the placebo effect.

So the researchers told participants that it could improve their symptoms ... that IS the placebo effect, in effect! That study is a bust. It doesn't prove that people can know it's a placebo, it just proves that telling people something will work can make them perceive results.

If I were running that test I would have said, "Here, this is an inert pill that you're body can't absorb. There's no physiological reason to believe it will do anything for you. Please take it for the duration of the test and give us the results." or maybe even make them think they're just part of the control group. The fact that they informed participants that their symptoms could improve is what pollutes the trial.

 

[Pup]

I believe that has been done, or at least "no-medicine" control groups have been used to compare placebos to regular medication.

I guess your "placebo" in a placebo trial would be giving people the sugar pills but telling them that they are just sugar pills, right?

I'd guess you could test for whatever effect you hypothesized would work, but I'd say the control would still be no medicine. In other words, if 20% of the patients would improve anyway, then you'd want to see if you could identify any kind of "treatment," including sugar pills with or without lying, an hour's sympathetic consultation, etc., that would cause more than 20% of patients improve.

 

[trebor]

The placebo effect is a real effect - people report that they feel better than with no placebo.
...

An increase in people reporting they feel better but not necessarily an increase in people actually being better?

 

[drewid]

No. Placebos can work even when you know they're fakes.

You'd need two placebo groups (knowing and unknowing) and a no-placebo group, at least. You could also have a group that has the consultation but gets no pills, and a group that has no consultation or pills, just a pre and post trial assessment... starts getting complicated.

And to make it even more complicated, people in trials can sometimes develop the side effects of the drug the placebo is "replacing" if they know about them.

http://en.wikipedia.org/wiki/Nocebo

 

[mummymonkey]

An increase in people reporting they feel better but not necessarily an increase in people actually being better?

Well that's the interesting question of course. But how could you tell?

 

[dlorde]

So the researchers told participants that it could improve their symptoms ... that IS the placebo effect, in effect! That study is a bust. It doesn't prove that people can know it's a placebo, it just proves that telling people something will work can make them perceive results.

Yes, they were given positive suggestion, and no, it wasn't a bust. The intention was to replace deliberate deception with positive but truthful suggestion, i.e. "1) an accurate description of what is known about placebo effects, 2) encouragement to suspend disbelief, 3) instructions that foster a positive but realistic expectancy, and 4) directions to adhere to the medical ritual of pill taking. It was about exploring an ethical approach to placebo administration, and it was surprisingly effective.

 

[dlorde]

An increase in people reporting they feel better but not necessarily an increase in people actually being better?

I guess that depends on the problem they have and how you view the outcome. If someone is complaining of pain and and after the placebo they say it has improved are they 'better' than they were? If someone says they are less depressed after a placebo mood-enhancer are they any 'better'? If someone's stress-related skin condition improves after a placebo treatment, are they any 'better'?

It seems to me that there's a need to identify more precisely which medical conditions are not measurably improved despite the patient reporting feeling better (or vice-versa), but for many relatively minor conditions, it may be impossible to tell.

It's quite possible that some popular drugs are successful more through the placebo effect than through physiological efficacy. This is part of the reason for the lobby to have all drug test results published and freely available.

 

[pantsorama]

Placebo Effect: When a person has a medical condition and is either cured or shows significant positive reaction to medication or therapy purely because the patient believes that it works and not because it has any directly observable effect or empirical evidence to imply it has an actual physiological effect by itself. The patient's belief in the treatment is what causes the benefit, not the actual treatment.

I don't think this is a complete description of the placebo effect. Especially the highlighted parts. There is more to it than altering of perceptions. Things like sampling bias, experimental bias, population variances in biochemistry, spontaneous remission, the observer effect, conditioning to acquiesce to authority, subjective measurements, the difficulty with self assessment, and other reasons.

Thats not to discount patient perception's part in the placebo effect. It is probably the largest part, truth be told. Although I have no idea how one would measure the size of each effect. But to say that it is all patient perception is too narrow a definition, IMHO.

 

[blutoski]

I'd guess you could test for whatever effect you hypothesized would work, but I'd say the control would still be no medicine. In other words, if 20% of the patients would improve anyway, then you'd want to see if you could identify any kind of "treatment," including sugar pills with or without lying, an hour's sympathetic consultation, etc., that would cause more than 20% of patients improve.

That's about it. This was the thought behind Hrobjartsson's literature review: find and evaluate all studies where placebo suggestion effect itself is isolated by comparing a placebo arm against a nontreatment group. They did a follow-up study in 2004.

Reference: [Is the placebo powerless? Update of a systematic review with 52 new randomized trials comparing placebo with no treatment.]

CONCLUSION: We found no evidence of a generally large effect of placebo interventions. A possible small effect on patient-reported continuous outcomes, especially pain, could not be clearly distinguished from bias.

So, to answer the OP, in my opinioni:

• The placebo effect defined in the OP (*) is very minimal and restricted to symptoms whose improvement cannot be objectively verified.
• I believe it is unethical for physicians to prescribe placebos because the ethical compromise of lying to a patient is not justified by the small chance of benefit.

Having said that, my opinion is not the consensus view within medicine, even among medical ethicists. Many physicians disagree with Hrobjartsson's findings. Surveys reveal that most physicians prescribe placebos, although this doesn't mean they do it often.


(*) I don't think this definition is quite correct, but wanted to address the OP using his own definition, which is widely used

 

[blutoski]

I don't think this is a complete description of the placebo effect. Especially the highlighted parts. There is more to it than altering of perceptions. Things like sampling bias, experimental bias, population variances in biochemistry, spontaneous remission, the observer effect, conditioning to acquiesce to authority, subjective measurements, the difficulty with self assessment, and other reasons.

Thats not to discount patient perception's part in the placebo effect. It is probably the largest part, truth be told. Although I have no idea how one would measure the size of each effect. But to say that it is all patient perception is too narrow a definition, IMHO.

It is a narrow definition, and that's part of the reason there's confusion among laypersons... the definition in the OP is more what I call a 'placebo expectation effect' but unfortunately the body of literature does contain a mix of definitions for the term 'placebo effect'.

This is part of the elegance of Hróbjartsson's approach: their reasoning was that if a person being billed for a placebo with expectations and the whole ball of wax had as much improvement as a patient put on the waiting list, then whatever's happening, it's not being caused by anything associated with the placebo.