Placebos Show Care

I’ve suggested that the main function of medicine is to show that we care. I’ve suggested that we spend a lot on medicine to signal our care, and that this can explain the placebo effect, wherein the mere appearance of care increases health. Some apparently confirming evidence:

Parkinson’s Disease patients secretly treated with a placebo instead of their regular medication performed better when told they were receiving a more expensive version of the “drug,” … While most people think of a placebo as a sugar pill that replaces a real medication, the impact more commonly comes from “the engagement between patients and clinicians,” in particular the way doctors create expectations that their efforts will help, Kaptchuk said. That includes a good relationship between doctor and patient; certain medical rituals, such as taking blood pressure and a medical history; and the “color, shape, number and cost” of the placebo drug. (more; the study)

Now this study is hardly definitive – it had only twelve subjects, and the placebo difference is only significant at the 3.4% level. But I guess that it will be verified in larger trials.

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  • Ilya1981

    Prof. Hanson: the first link doesn’t work.

  • IMASBA

    Signalling that you care is an important motivation for people who are aware of the costs of different forms of medical care, do not see an opportunity cost in that, favor high amounts of spending on the kind of care that’s not very cost effective (chemo for a 90 year old) and believe it feasible for that kind of spending to be rerouted to other things that benefit the non-rich (instead of just being converted into tax cuts for the rich). However a lot of people do not meet those criteria. High amounts of medical spending are also at least partly the result of the huge voting power of older voters.

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

    I’ve suggested that we spend a lot on medicine to signal our care, and that this can explain the placebo effect, wherein the mere appearance of care increases health.

    I don’t think this follows. If we seek medical care to feel we’re cared for, why would we feel healthier after receiving the care?

    It actually suggests the reverse: we want to feel cared for because it promotes health when we’re sick–sickness itself being considerably more unpleasant than feeling uncared for. (Was it Pascal who said the greatest distinction that could be found between folks was sickness versus health?)

    • Anonymous

      > If we seek medical care to feel we’re cared for, why would we feel healthier after receiving the care?

      You’re looking at this backward — I think we seek medical care to feel we’re cared for BECAUSE we feel healthier after feeling cared for.

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

        Then the ultimate function of medicine isn’t to feel we’re cared for but to feel healthier, which is what Robin denies.

      • IMASBA

        Does he deny that? I think he just looked at modern medicine spending massive amounts of resources per added qaly and then made a theory about that. I doubt Robin denies that the effectiveness of basic medicine (which people subconsciously extrapolate to all medicine), fear of death and ignorance about the true costs play a role of well.

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

        Of course he doesn’t deny the effectiveness of basic medicine–qua medicine. But what he minimizes is the effectiveness of basic medicine as the motivator of health spending, both private and public. Medicine has produced miraculous cures, but psychologically our attitudes toward seeking and giving health care largely remain those of foragers signaling care. The same attitude toward the physician (largely) prevails as our ancestors devoted to witch doctors.

        Is this plausible? I only challenged the claim that placebo effects support the theory. I think Robin is clearly correct that giving and receiving medical care is irrationally infected with signals of caring. But it seems he also clearly overstates the case–sometimes I’m not sure if I’m overreacting to mere hyperbole. More importantly, he neglects alternative explanations. We seize upon medical treatment to signal caring, I think, because sickness in others evokes strong empathic feelings. We pity the sick as we don’t necessarily pity the poor (for example) because we have all been sick and know what it’s like. Since it evokes genuine strong empathy, it also becomes a target for hypocritical empathic signaling.

    • UWIR

      It does seem like, notwithstanding lost purposes, the ultimate ground for behavior should be reproductive fitness. Feeling cared for would, in that model, not be a terminal value. On the other hand, if the purpose of being healthy is to stay alive to pass on one’s genes, and the purpose of wanting to feel healthy is to seek conditions of actual health, and the purpose of feeling cared for is to seek conditions of feeling healthy, that would make sense.

  • istvan

    But the ultimate source of it all is still a rather direct chemical/physical effect of medicine on the body, like vaccines, antibiotics, anesthetics etc. This is at the core of today’s medicine. We know that these work for a fact, so a layer of placebo can be built on it, even for rational, science-minded people. We expect the treatment to work because it comes from a place that has produced clearly working cures. Then those who know about the placebo effect, can add another layer of expectations due of the placebo effect, so the effect on health increases, etc.

    Interestingly, you can also invoke the placebo effect out of seemingly nothing, by truly telling the people that they are receiving placebos, *but* telling them at the same time that placebos work even if you know they are placebos. The trick is that this still builds on the core of medicine’s reputation, so the patient believes this claim, so he has the expectation and now the placebo effect kicks in. This effect cannot be attributed to the pill’s reputation, it’s due to the doc saying that science shows that the placebo will work.

    • IMASBA

      How ethical is it to have people pay for a placebo (and what kind of incentive would this give to the party that gets to keep the difference)? Then again, when a placebo works, your illness can’t have been that severe and making you pay money for real mwdicine is somewhat unethical too.

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

        I was surprised–maybe even shocked–to learn that 62% of internists and rheumatologists find placebos ethically proper. This is quite an anomaly in today’s supposedly transparent medicine.

        I’ve worked in medical environments but have never heard of placebos being used. I wonder who does get to keep the surplus. Are the insurers willing to pay for placebos that give the doctor or pharmacist (or whoever) a pure windfall?

        To me, to prescribe a placebo without the patient’s general consent to this practice is (in ethical terms) to commit fraud.

      • UWIR

        How do you know there’s a windfall? Why can’t the insurer demand that it be sold at cost? And if the placebo does in fact work, how is it fraud?

      • IMASBA

        Paying for placebos at cost would show up on bills if there’s any level of private insurance involved. Only an NHS-style system could hide it but imagine the scandal if it were to leak to the press.

        Send people to a meditation class, but don’t go prescribing sugar pills behind their backs.

      • UWIR

        So, you think people will look over their bills, notice that there’s a charge of only a few dollars for a bottle of pills, and their reaction to that will be to make a stink about not being charged an arm and a leg? And what counts as “behind their back” as far as giving sugar pills? If the label on a pill says “pentahydroxyhexanal”, is that “behind people’s backs”?

      • IMASBA

        Other doctors, insurers, government inspectors, etc… might, and then it only takes one. When your bill suddenly increases because your doctor decides to give you the real stuff from now on you might also raise some questions yourself, that would also happen in the case Robin mentions, where doctors tell you you’re getting something really expensive and fancy but it doesn’t show up on any bills. And yes, it is behind your back when doctors hide behind names of products that ordinary people cannot be expected to understand. Finally they’re taking a risk by just assuming the placebo will work for you when it might not (the placebo effect doesn’t work for everyone, and doesn’t work the same for everyone).

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

        You think, then, that’s there’s a widespread practice of prescribing placebos, which evades detection by patients and discussion by the public because no one has an interest in challenging it and patients are gullible about accepting arcane labels?

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

        And if the placebo does in fact work, how is it fraud?

        True, no harm no foul, in law as well as basketball. (But I’ll leave it to you whether the maxim applies to ethics.)

    • UWIR

      “But the ultimate source of it all is still a rather direct chemical/physical effect of medicine on the body, like vaccines, antibiotics, anesthetics etc.”

      No, it’s not.

      • istvan

        Hm. I think for many people it is. At least for educated people. For others it’s more of a custom or a tradition to trust medicine. But still that custom originates from the fact that the state and educated people endorse and back medicine.
        Of course the placebo effect also comes into play in homeopathy and alternative (i.e. unproven) medicine but I think even those people steal from the reputation of real medicine. You know, pseudoscientific words, white coats, pills.

        But it all depends on how much one is willing to believe. If someone expects health improvements from speaking magic words, they may also benefit from the placebo effect. And that would not be built around the reputation of working medicine.

      • UWIR

        You said it’s the ultimate source. If respect for medicine is the source for only some people, then it can’t be the ultimate source; there must be some deeper brain process that’s being triggered by the particular cultural phenomena of the West.

  • istvan

    Having a trusted, knowledgeable, parent-like character that cares about you (this would be the doctor) may in itself result in some sort of social, hormonal, feeling-important-and-safe reaction from the brain, that it legitimately helps health. It doesn’t necessarily has to be the result of an expectation. Might be just the result of a type of social contact.

  • Fran Finney

    Agreeing with Istvan here. I don’t find this study surprising at all. The placebo effect is certainly real. It has been demonstrated over and over. And the placebo effect could be simply an excellent example of the power of confirmation bias and selective perception. But why is this placebo effect so powerful? Being in the medical field myself, I have had a discussion on this topic with other medical professionals. We as a society really don’t know much about how disease, immunity, healing, and other physiological processes work.There is however an established correlation between stress levels and various hormones and biochemicals. Perhaps one of the most effective weapons we have in our current healthcare arsenal is (sadly) the ability to somehow guide people towards letting their bodies best able to deal with whatever condition they incur. But then the ethics of cost come up. Will the placebo be less effective if it is labeled a “sugar pill” or “sham treatment” and is given at minimal charge? For most people, yes.