Placebos Show Care

Something similar to the placebo effect occurs in many animals. … Siberian hamsters do little to fight an infection if the lights above their lab cage mimic the short days and long nights of winter. But changing the lighting pattern to give the impression of summer causes them to mount a full immune response.

Likewise, those people who think they are taking a drug but are really receiving a placebo can have a response which is twice that of those who receive no pills. In Siberian hamsters and people, intervention creates a mental cue that kick-starts the immune response. …

The Siberian hamster subconsciously acts on a cue that it is summer because food supplies to sustain an immune response are plentiful at that time of year. We subconsciously respond to treatment – even a sham one – because it comes with assurances that it will weaken the infection, allowing our immune response to succeed rapidly without straining the body’s resources. … Farming and other innovations in the past 10,000 years mean that many people have a stable food supply and can safely mount a full immune response at any time – but our subconscious switch has not yet adapted to this. (more)

OK, but the key question is: why would getting a placebo pill ever have been a credible signal that you could safely turn on your immune system? If for our ancestors treatments like pills tended to be very effective at improving health, you might think that a pill would give you so much extra energy that you could afford to spend some of that extra on your immune system. But pills are rarely that effective, and your body would quickly notice that fact.

My showing that you care theory, that the main function of medicine is to signal concern, fits well here. The idea is that we are reassured by the fact that people take the trouble to take care of us.

The most severe part of our ancestors’ environment wasn’t the weather, it was other humans. When people were sick, they worried that their rivals and enemies would use that opportunity to hurt them. If such harms were coming, they had to be attentive, wary, and ready to act — they couldn’t afford to turn on their immune system, which would make them lethargic.

But if someone had caretakers, who spent time and other resources to take care of them when they were sick, why then such caretakers would probably also protect them from rivals. So they could afford to turn on their immune system. If your associates spend resources to buy you pills, and then take time to make sure you take certain pills at certain times, they probably care enough to protect you from rivals.

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  • AmagicalFishy

    Consider the situation wherein a sick person finds, steals, or acquires medicine in some way indicative of having no caretakers. This medicine, unknown to the person, is a placebo. He/she fully and wholeheartedly believes it to be the cure. Would you say there would or wouldn’t be a placebo effect?

    • dejour

      I like the original post a lot.  I also like your thought.

      I suspect a placebo effect would still occur.

      In the past a gene mutated so that one’s immune system would switch on when receiving a placebo.  In the vast majority of situations, the placebo was received in a caring environment.  So it was appropriate to turn the immune response on, and the mutation spread as it was useful.  The mutation was perhaps detrimental in the case of stealing a pill or some such ting, but this situation was relatively rare, and so on balance the placebo gene increased fitness.

      The “caring” technique would also explain why abused kids tend to have worse physical health outcomes.

      • http://juridicalcoherence.blogspot.com/ Stephen R. Diamond

         

        In the past a gene mutated so that one’s immune system would switch on when receiving a placebo.

        I think that’s farfetched, and AmagicalFishy’s thought experiment goes far to refute Robin’s explanation. Placebos  work by suggesting a favorable outcome, not by suggesting that you’re cared for–except to the extent that being cared for carries the same suggestion. So, the best hypothesis regarding how placebos turn on the immune system is something more directly connected with the belief that you’re going to get well, not that you’re being cared for. The two sometimes do coincide, but often not–as per AmagicalFishy’s point.The link to the immune system is more likely connected to the patient’s increased optimism. Optimism turns on the immune system.

      • Robin Hanson

        As I said in the post, it would only make sense to turn on your immune system as a response to a pill if you thought that pill was *very* effective at boosting your health. A mild health gain would not be enough.  

    • Silas Barta

      Research proposal: “We propose to replace the painkillers in a pharmacy with placebos (and leave the painkillers in another pharmacy unchanged), then noticeably fail to activate its security mechanisms, signaling its usefulness as a burglary target for addicts.  We then covertly track the addicts that break into the pharmacy and, once they are observed to take the pain-killers, covertly extract blood samples to determine if the physiological response is the same as that which obtains when addicts raid the pharmacies that weren’t replaced with placebos.  FOR SCIENCE.”

    • http://juridicalcoherence.blogspot.com/ Stephen R. Diamond

       

      Consider the situation wherein a sick person finds, steals, or acquires medicine in some way indicative of having no caretakers. This medicine, unknown to the person, is a placebo. He/she fully and wholeheartedly believes it to be the cure. Would you say there would or wouldn’t be a placebo effect? Or something else?

      I think most of us agree there would probably be a placebo effect in this case. But perhaps Robin’s hypothesis survives, even so, if the placebo’s critical feature isn’t that it show caring directly (which is too easy to fake) but that expensive resources are being expended.

      I think Robin’s point isn’t just that medicine is showing you care but that it is showing you care by the devotion of expensive resources. (This should stop any inferences that the solution to rising medical costs is just to provide cheap “caring” social workers instead of medicine.) Robin’s theory nicely explains why Obamacare is such a political flashpoint: on the one side, Democrats try to demonstrate they care; on the other, Republicans oppose the expenditures just to make the (more oblique) point that “we” ought not care (or are under no obligation to care) about some persons (the poor, the undeserving poor, racial minorities)–a choice between hypocrisy and malice that I decline.

      • http://juridicalcoherence.blogspot.com/ Stephen R. Diamond

          But perhaps Robin’s hypothesis survives, even so, if the placebo’s critical feature isn’t that it show caring directly (which is too easy to fake) but that expensive resources are being expended.

        That is, the psychologically critical features, through which evolution found its purchase,  can differ from the evolutionary “purpose.”

      • AmagicalFIshy

        I would question, then, whether or not there was a significant placebo effect in someone who believes a particular plant—picked and made into a tea—has healing properties, and this person goes out into the forest and finds the plant.

        Though, it well could be the case that whatever means of gathering the knowledge of the effects of said plant substitute for the “expensive resources.” Maybe it’s a revered ancestral custom, or a firmly held affinity towards a particular counter-culture.

        Apparently there is a larger placebo effect in children than adults. This could be that children really believe the placebo will help them more than adults, that children assume more of a “cared for” position when someone gives them medicine, or that they have ideas of a larger scale towards whatever went into creating/gathering/etc. the placebo.

        I don’t suppose there’s a way of testing the placebo effect that isolates either immediate care, belief in the placebo’s benefits, or ideas regarding what went into creating/gathering/etc. a particular medicine. I’m having a hard time thinking of any situations. Can you think of any?

        Anyways, I like the theory more when it encompasses the idea of “indirect care” signified by the resources spent, means gathered, etc. I hadn’t considered a person’s subconscious (if you’ll allow that word) processing that deeply into the situation. 

  • Doug

    So is the increasing cost of healthcare partially driven by shrinking families and fewer friends. We have to build giant expensive institutions where healthcare workers pretend to care because we have fewer loved ones than in decades and centuries past.

    • adrianratnapala

      I can believe it.

      I live in Germany, and today  I went to the doctor in order to fulfil a bureaucratic requirement.  This had trivial marginal cost to me or the doctor, because as whole big chunk of money has already been prepaid to my “insurer”.

      The doctor chatted to me for half an hour, inspected my upper body, and then referred me to another doctor, who presumably will fill out the form that I need filled.  I was very happy with this service,  and feel that I am getting much better service than I would have received if I had just cut out the bureaucracy.

  • Ilir Deebran

    Alex Gheg has a new consumer theory that makes more accurate predictions and allows the measurements of previously hidden thoughts, which means we can measure utility growth. Quantity, quality, variety and convenience in one equation. http://www.youtube.com/watch?v=u6tFLGpcOpE

    • http://entitledtoanopinion.wordpress.com TGGP

      You have posted this in multiple threads. You are off topic and basically spamming at this point.

  • Joshua

    What about the possibility that the absence of the ‘people care about me’ signal is really a signal in itself that the sick person is not useful to the group?  Evolution spawns some behaviors that are selfish for the tribe/species, rather than for the individual. 

    • rrb

      “Evolution spawns some behaviors that are selfish for the tribe/species, rather than for the individual.”
      Is that a view accepted by any reasonable fraction of scientists? After reading “The Origins of Virtue” by Matt Ridley, I got the impression that the mainstream view is that complex, functional adaptations only evolve when they tend to improve the number of offspring of the individual and close relatives. Helping the group doesn’t matter.

  • Blake Riley

    Sounds plausible, but it doesn’t account for nocebos, unless receiving medicine is a signal you are so sick you might as well give up. 

  • Robert Koslover

    Fascinating.  Might this also apply to the asserted “power of prayer” effect, i.e., if the sick person *knows* that many people are praying for his/her recovery, does that increase the odds for that recovery?

  • http://pulse.yahoo.com/_A4VNWL5SJ5TXC7NYQUGTNZGHSI Jim

    Hmm, I thought that you would go a different way with that.  Why not if people show support to you they can bring you food  so that you can afford to spend energy on the immune response.

  • weareastrangemonkey

    A couple of extra reasons in line with Robin’s explanation. Someone caring signals that:

    1) There are sufficient resources for the group that they can afford to take time off hunting/gathering in order to help another member of the group.

    2) That the group does not currently need to be on the move.

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  • http://www.facebook.com/profile.php?id=8795 Wallace M Forman

    So would a proper test to be to give some people a placebo pill, some people nothing, and some people a big hug and sympathy but no medicine?

    • Robin Hanson

      A hug and sympathy do not credibly signal a willingness to resist rivals’ attempts to hurt you. 

      • http://www.facebook.com/profile.php?id=8795 Wallace M Forman

        They seem more credible to me than bloodlessly handing a study patient a mystery pill.

        At least one primary care physician that I have talked to told me that the majority of his patients seemed to want mostly just sympathy for their mostly non-treatable minor aches and pains, and seemed rather off-put when they did not receive it. Many of them apparently spent a majority of their time with the physician complaining about non-medical problems in their life. Of course, the physician also was reluctant to prescribe medication for their imaginary symptoms, so this is not even anecdotal evidence for much.

      • Yaobviously

        A hug and sympathy credibly signal a willingness to resist rivals’ attempts to hurt you.

        I bet more readers agree with me than with you.

      • fburnaby

        Meh. I could go either way. Hugs and sympathy sound nicer to me, so based on introspection, I would expect to feel more cared-for if I received those.

        But hugs and sympathy are cheaper than more formal rituals would have been in the past. Sure, administering a sugar pill represents next to no investment in you nowadays, but it’s symbolic of the equivalent of calling in the shaman to do an exorcism ritual. High status people are called in to do specialist things for you.

  • http://www.facebook.com/daniel.carrier.54 Daniel Carrier

    This isn’t the first time I’ve seen this. I think it’s pretty common to mention the increased attention as one of the causes of the placebo effect. What your post does do is show why that actually would cause the placebo effect. I always wondered about that.

    I’ve also heard that as a possible reason therapy works, but you explanation doesn’t seem to apply. Am I missing something, or is that wrong/coincidence?

  • Zslastman

    Are you positing that there is a component of the placebo response that responds specifically to the social environment, or are you just positing an explanation for the evolution of a stress responsive immune system?

    A “being cared for” response would already be partially implemented by the simple means of having the immune system respond to stress, which would pre-date human social adaptation.

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  • Ryan Ballentine

    This survey article has the same thesis as you:

    http://www.cell.com/current-biology/fulltext/S0960-9822(12)00663-X 

    • http://juridicalcoherence.blogspot.com/ Stephen R. Diamond

       The article is by Nicholas Humphrey and John Skoyles. The macro-economic conclusion:

      So, Keynes discovered a placebo solution to the problem of wealth creation for a country whose citizens are inclined to conserve resources when they don’t need to. But our real point is that human culture discovered a Keynesian solution to the problem of health creation for human bodies whose healing systems were designed to play too safe.

  • Sharif Olorin

    Interesting theory. How would you propose testing it?