Tuesday, March 23, 2010


Let me start by saying that I have argued the following since my introductory psychology class ten years ago, I continued to argue the following as a psychology major, and I continue to argue the following within the context of rhetorical theory (and in pragmatics):
Though recurring tummy aches from irritable bowel syndrome are among patients' most common complaints, drugmakers have had trouble coming up with a safe and effective treatment. But in 2008 Harvard's Ted J. Kaptchuk devised a safe remedy that helps far more people than any designer drug ever did.

His magic cure: fake acupuncture delivered with lots of warm talk from a sympathetic acupuncturist--but no needles. In a trial of 262 patients with severe IBS, 62% of those who received the fake treatment got better, according to results published in the British Medical Journal. By comparison, only 28% of a control group of patients put on a waiting list saw their symptoms improve markedly. A third group who got the fake acupuncture, but without any warm talk, showed in-between results: 44% improved.
This according to a recent Forbes.com story entitled "For Nothing."

Save this kind of research, I never quite understood why the placebo effect was so routinely dismissed by medicine. It is producing a "real" effect, but because it was not producing a "real" physical effect it was not treated as real, or, as one astute commenter to the story writes, it is treated as "noise."
However, my major problem is that traditionally any results generated by placebos is treated as noise in the experiment. It's a good control, in that it accounts for the role of the action of being treated as a separate variable from actually being treated. Therefore looking for meaning in placebos strikes me as a sort of data mining.
While there are certainly concerns about doctors misleading patients, these concerns privilege a certain kind of reality. If the pill works, then to what extent are doctor's "lying." In fact, many of the negative responses to this story expressed this discomfort with doctors "lying" to patients. (I kind of have Nietzsche's "On Truth and Lies in a Nonmoral Sense" in mind here. "Lie" and "deception" assume a reality I am uncomfortable with. I am also thinking about a collaborative project I am working on with a psychologists in Holland: we are investigating "manipulation" and "deception" as social technologies.)

This is not to say that placebos always work or work equally well for everyone, but in this regard they are like any other pill. What is to stop a doctor from lying about any and all treatments? When it comes to ethical medical practices we must rely on the profession and external auditors to review and promote agreed upon ethical practices. Again, such an arrangement is what we always already rely on. A doctor wouldn't (or could just as easily and dangerously) prescribe Tylenol to treat a brain tumor. So fears about placebos in this direction seem unfounded (or at least no different from common concerns about medical treatments and professional ethics).

I think one place the fear comes from (yes, here it comes) is a particular orientation to the real as only the biological/the natural. I have posted on this issue previously here and here. The placebo threatens this biological foundationalism that has been at work in Western thought for a few thousand years. For instance, I think this distrust of the placebo effect can be traced to Plato's treatment of rhetoric as cosmetic (rather than real health, which comes from medicine). In other words, I read into the mistrust of placebo a mistrust of rhetoric.

I hear both then in the following comments on this story as posted to BoingBoing:
  • There are massive ethical issues with doctors giving something to a patient, knowing that there is no active ingredient, and lying to make them feel better. I wouldn't want my doctor doing that to me!

  • The placebo is, regardless of the intent, a lie. Using placebos as a therapy could endanger the trust in their doctor or doctors in general. This trust is crucial, however, to the function of a doctor. [the irony of arguing that trust is crucial is not lost on me: how could trust possible matter if its is the real cure you are after?]

  • There is a real and distasteful paternalism in lying to your patients to make them happy and leave your office.
Again, I think we should always be concerned with how doctors communicate with us and what and why they prescribe: these are always concerns (a doctor telling you to lower your blood pressure is being no less paternalistic). Again, what I want to (get at) know here is why the placebo is perceived as "fake" because this understanding of the effect leads to the dismissal of an effect we might very well want to have available to us. In short, and in the end, I think it is "fake" for some because the placebo effect seems to be a function of rhetoric (ignoring the fact that rhetoric is hugely important in the production of pharmaceuticals themselves). And rhetoric can't be real, can it?

Update: Here is another story on the placebo effect.


  1. I love this topic. I'm only nervous that you're working with this model where you, an enlightened intellectual, are "in" on the deception. Am I wrong there? And not for the reasons you might think...

    See the problem isn't that it's unethical or anything. It's that, for those of us who are in on the placebo-effect secret, the placebo-effect won't work.

    So, I'm worried about your health. If one of the sheep out there who sucks his thumb needs treatment for irritable bowel syndrome, placebo-wielding doctors can treat him. But woe unto ye, Nathaniel, if IBS strikes you.

    --Unless, of course, you can convince yourself that the doctor you seek out isn't doing placebo practice. In any case, it's the faith that heals; not the mustard seed. Maybe you weren't reading yet at my blog a few months ago when I was wandering down this avenue:


  2. I think that is a concern - who is in on the deception? However, I don't know how enlightenment enters into it. I don't think people are sheep because the placebo effect works on them. I assume it works (or can work) on everyone. I would never place myself "above" this effect at all.

    I think we should instead frame it as a particular kind of treatment prescribed by doctors who are granted a certain trust-level based on their profession. Once we see it as treatment we can/should see it differently. Is a doctor unethical because they do not explain exactly how everything works?

    In terms of deception, I guess I am not as bothered by it in this case. I do not assume that more knowledge is always better. I think, in the case of the placebo effect, the work we should do should be improving the architecture around it and those who prescribe it. Like with everything, there is never any system that protects against deception (rhetoric typically plays the whipping boy in this regard). Even Plato enacts it to make his claims for rhetoric (his dialogues aren't exactly transcripts). However, it is not his "deception" per se is not what bothers me, it is its effects that bother me. Such would be the case with the placebo effect. "Deception" cannot be categorically removed or dismissed.

    Also, as an IBS sufferer I would be more than happy being deceived. Being in the cave is much better than an agitated colon.

  3. I guess my point is that the placebo effect only works if you don't think that what's working is the placebo effect. So, I too, have no problem "being deceived," but not because I'm okay with being deceived--instead, because, when I am being deceived, I don't know I'm being deceived.

    You seem to think you can go to a doctor knowing that he's gonna work some placebo magic on you. I don't think the treatment will work in that case. We have to believe that our doctors' treatments are coming from chemicals, even if they aren't.

    I can't resist citing my very favorite Melville bit of all time:

    "But, to demand the ingredient, with the reason for giving, is the mark of a philosopher; just as the consequence is the penalty of a fool. A sick philosopher is incurable?"


    "Because he has no confidence."

    "How does that make him incurable?"

    "Because either he spurns his powder, or, if he take it, it proves a blank cartridge, though the same given to a rustic in like extremity, would act like a charm. I am no materialist; but the mind so acts upon the body, that if the one have no confidence, neither has the other."


    So, I see this as a real problem, as these articles about how it's all placebo trickle into mainstream culture. It's like our shamans are telling us their trade-secrets... and if we know the secrets, the secrets won't work.

    Am I wrong here?

  4. Ah, I see now. I think, in many instances, you would be right. However, there is much rhetorical practice that is not ruined in this way. I just returned from CCCC where, during a dinner with friends (four rhetors and a poet - so five rhetors and five poets, really), I was treated to a magic show. The guy performed basic card tricks. Now, I do not really believe that this man was performing actual magic, but the tricks, nevertheless thrilled me. A table full of magicians in other ways were likewise thrilled even knowing the trick, so to speak. We later discussed this incongruence. And, poets and rhetors that we were, essentially agreed that we found the tricks magical not simply because we have been deceived but because we wanted to be thrilled by the magic.

    I guess, if had made my original post just for you (and why not since you are my audience most days) I would have treated the placebo effect like the effects of literature and film. I would have quoted Coleridge (right?) on the willing suspension of disbelief. That is, I think the placebo effect works not just because the doctor deceives the patient, but because the patient believes the doctor will make them feel better and because they want to feel better.

    Knowing the magic trick is a trick doesn't ruin it (at least not for me). Knowing the I am not really on the Pequod doesn't make the book any less moving. Could it be that knowing the doctor might be applying a "fake" treatment (for even someone who read these same articles might not know, at the moment of treatment, which kind of treatment it is) doesn't actually ruin the effect, so strong is the patients desire for regular bowels?

  5. That's the ticket: at the moment of treatment, the facade of "medicine" has to stay in place.

    I've argued before that even during those shamanic rituals in the rain forest where demons are cast out, it's not the Ayahuasca, but the willingness to drink a wretched-tasting-poison & the trust in the shaman, that makes the ceremony a success (i.e., that casts "the demons" out).

    But anyway, I'm with you now.

  6. I think the analogy with enjoying a magician's act is interesting, but it also invites a closer look at what is needed to sustain the placebo effect. When you watch a magician, you know you're being tricked, but if it's a good magician, you don't see how it's done, and no amount of skepticism will take away the surprise and the delight, the very physical effects of a good magic trick. I'm not so sure that something similar is true of the placebo phenomenon. I think Casey's fear might be justified, and it would crumble under a skeptical mindset. There actually might be empirical studies about this, I'll have a look.

    Sustaining the placebo phenomenon is also not just a question of willing to be cured, suspension of disbelief, self-deception, or individual psychological techniques like that, it is also requires a careful management of therapeutic practice and the education of doctors. I would think that the placebo phenomenon thrives as a semi-legitimate trick of the trade, something every doctor knows but mustn't tell anybody else, not something that is ever part of the official evidence-based treatment protocols. Imagine that a television consumer program starts a campaign to root out this deceptive and patronizing practice. Wouldn't patient organisations, the insurance companies and the general public kill the placebo phenomenon?

    So I think the question still is: how fragile is the placebo effect psychologically and socially?

    - a psychologist from holland

  7. This may be one of those interesting cases where manipulation is both the ornamental and the creative. Thanks for the post Maarten. For some reason, "psychologist from Holland" sounds chic to me.