Placebos Don’t Require Deception?

Estimated read time (minus contemplative pauses): 17 min.

I love a good dismantling of common wisdom as much as anybody. Here’s one I’d put up there with vegetative means unconscious and jazz means improvised: placebo means deception.

From the abstract of a 2010 paper:

Placebos administered without deception may be an effective treatment for IBS. Further research is warranted in IBS, and perhaps other conditions, to elucidate whether physicians can benefit patients using placebos consistent with informed consent.

In other words, some placebos may work even when you know you’ve been given a placebo.

The abstract is from a paper called “Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome,”1 by a team led by Ted J. Kaptchuk, who lists these titles on his website: Professor of Medicine and Professor of Global Health and Social Medicine at Harvard Medical School and Director of the Harvard-wide Program in Placebo Studies and the Therapeutic Encounter (PiPS) at Beth Israel Deaconess Medical Center.

I learned about Kaptchuk’s work on the Hidden Brain podcast episode “A Dramatic Cure” (4/29/20; transcript here).

The episode begins with the usual sort of fascinating stories one hears about placebos.

Anne-Marie Marvin (I’m unsure of the spelling) successfully administered an ongoing placebo treatment to her headache-ailing son in what amounts to a real-life reenactment of that one episode of MAS*H where the morphine’s no good.2 That bit of TV was almost certainly my first exposure to the placebo concept, and was Marvin’s inspiration as well.

Next up is the even more striking story of surgeon Bruce Moseley, who describes the success following arthroscopic surgery for arthritic knees as “a pretend surgery effect.” This opinion—from a practitioner whose credits include the 1996 U.S. Olympics Dream Team III and the NBA’s Houston Rockets (he’s seen a lot of important knees)—follows from the baseline study documented in this 2002 paper, of which Moseley is lead author: “A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee.”3

Moseley added a placebo control to the study on a colleague’s suggestion. “When I pitched it,” says Moseley, “she was the one that said, ‘Well, how do you know it’s not all a placebo effect?” The question hadn’t previously occurred to him, as “almost no surgeries have a placebo control group.”

The study’s placebo-positive findings initially sparked some bitter pushback from other surgeons but eventually inspired further confirmatory research and became widely accepted. Now the American Academy of Orthopedic Surgeons does not recommend the procedure.

More recently, placebo controls seems to have begun catching on among surgeons drawing inspiration, at least to some degree, from the work of Moseley’s team, while addressing, as show-host Shankar Vedantam puts it, “a range of pain-related and chronic conditions, from back pain to obesity.” None of these folks is saying that surgeries aren’t often helpful or absolutely necessary. The claim, rather, is that an invasive procedure is simply not worth the risk when a placebo works just as well. And the only way to find out which procedures are which is to conduct properly controlled studies.

But does this mean someone scrubbed and smocked will need to at least pretend to do the surgeries sometimes so the placebo effect still works? We’ll get to deeper questions of this sort in a moment (to asking them, that is; don’t expect good answers).

Moseley’s study was meticulously regulated to ensure that, though participants knew they might receive a placebo procedure, they could not know whether their time in the surgical unit was real or theater (Moseley himself didn’t know until given an envelop in the operating room). About halfway through the podcast episode, we’re introduced to the aforementioned Kaptchuk, who, as he himself aptly phrases it, “turned the apple cart over on placebo studies” by giving away the ruse. Sort of.

Disclaimer pause. My knowledge of placebo in surgery starts and ends with what I’ve heard on this episode of Hidden Brain. I have not read the relevant professional literature and I certainly know nothing of the field’s unpublicized conference-room goings-on and insider gossip and so on. This is true, in fact, of most of what I touch on here. Though I have over the years encountered, as I bet you have, many stories from awestruck researchers genuflecting before the wonders of placebo. But none so wondrous as Kaptchuk’s.

Due, apparently, to some insights or intuitions afforded him by bringing into a rigorous, Western-medicine research environment a certain perspective he had acquired as an herbalist and acupuncturist—that is, as a student of Chinese medicine, of whose literature he notes, “there were statements like, ‘the medicine should start working before the patient takes the herbs'”—Kaptchuk was motivated to “pivot” from studying alternative medicine to covering unexplored ground.

That is, he was tasked with determining the extent to which “alternative treatments are more than a placebo effect,” but instead began treating placebo effect as an area of study in its own right. Most apple-cart-upsettingly, he began asking whether placebo requires deception.

One of his key insights was that the rituals in which both healer and the ailing participate may play an important role in helping placebos work (flashback to Moseley’s surgical theater, in the dramaturgical sense of that word). From Vedantam’s melodiously voiced introduction of Kaptchuk:

…most people in medicine do not believe their job is to harness their patient’s imaginations. Ted Kaptchuk is an exception. He believes the drama embedded in the doctor–patient relationship is deeply connected to healing. It’s a focus of his research.

We are also introduced to one of Kaptchuk’s former patients, Linda Bonanno (not sure about the spelling), who shares her story in candid and colorful terms and with an air of enduring astonishment. Upon being accepted into a Kaptchuk-led study on irritable bowel syndrome (IBS), a condition she had been suffering from for ten years, she was told that she was to be given a placebo. “I was disappointed, I knew it was a sugar pill,” says Linda, but she followed the script: “I just took them and went about my day. I said, ‘this is not going to work if it’s a sugar pill.'”

On the fourth day, her decade-long suffering stopped. “I said that this can’t be. For three weeks I felt fantastic, I had no IBS, I wasn’t sick, I was taking those pills every day, and I couldn’t believe it.”

Vedantam reminds us that the insight grounding the study was that “the placebo effect wasn’t just about the pills. It was about an edifice of drama, rituals, and the trust between patients like Linda and their doctors.”

The reason Bonanno’s relief lasted only three weeks was that her participation in the study came to a close. No more sugar pills. Despite trying to be optimistic, her suffering—”worse than labor pains,” Bonanno says of the worst of it—soon returned. She went back to ineffective self-treatments and to organizing her life “around the inevitability of pain,” as Vedantam puts it.

Eventually, after some years of this, she reached out to Kaptchuk, who again put her on a placebo treatment. Bonanno’s skepticism somewhat reemerged (I can’t imagine it not), but again her IBS vanished. “When I think about it, I’m stunned. I don’t understand it. I’m at a point, to tell you the truth, I don’t even care anymore. I just want it to disappear and that’s it.” Bonanno then gives us a hint of what it’s like to work with Kaptchuk. She likens the effect of talking with him to that of a “complete body massage.”

She took sugar pills for about a year this time, before one day missing a round by chance. Her IBS stayed quiet, so she ceased treatment. She was still IBS-free as of this Hidden Brain episode.

Bonanno’s is not an isolated case. And, since his IBS work, Kaptchuck has found similar or better results for other ailments (e.g., for low back pain and cancer-related fatigue).

There is of course much research to be done yet on placebo, and many questions—medical, psychological, sociological, philosophical—to ask about what that research means. Far more than I can ask here, where my central aim is to spread the word. Tell everyone you know. This is one of those happy revelations that makes the world more rather than less mysterious. And its call for warm doctor–patient exchanges might help improve our culture of healing.

That said, I’ll now indulge in a moderate sampling of searching questions and thoughts, snacks for more contemplative appetites. While reminding you that I haven’t read Kaptchuk’s papers.

(Were I to delve into the literature, I’d start with this 2017 meta-analysis by Chesterton et al.: “Effects of Placebos without Deception Compared with No Treatment: A Systematic Review and Meta‐Analysis.”4 The Hidden Brain show page’s “Additional Resources” list for this episode is also interesting: “All The World’s A Stage—Including The Doctor’s Office.”

Even better, maybe one of these researchers will show up on a longer-form podcast. In my experience, researchers avoid venturing in their papers into the sorts of yet-untested questions I crave, but they’ll do so on long-form podcasts, especially one that involves booze.)

For starters, two nice morsels from Vedantam (and here ends the food metaphor, before I embarrass myself by asking for a “side of Kaptchuk with that”; why I need an editor): “Would we get less impressive results if placebos became a common treatment rather than a novel one? What if patients obtain placebos from a pharmacy rather than from a kind doctor in a clinic?”

I’ll add a few more.

Does effective placebo without concealment require the concept of placebo? Bonanno was skeptical. But it’s widely understood that placebos sometimes seem to work, somehow. This understanding may have influenced her response to treatment, somehow, particularly the second time around. But also baked into the placebo concept is the need for concealment, which is intertwined with the (increasingly in-tension) notion that placebo treatment, in itself, is used precisely because it doesn’t do anything medicinal—or, if it (somehow) does, it is because the patient expects their treatment to work (which, again, requires concealment).

Would placebo without deception work just as well were the healer to push hard on—really stress-test the most slippery points of tensions in—the above complex of ideas?

An example will help clarify. Suppose Kaptchuk gets the ritual right, but at the end says, “Ah, I see we forgot to bring in the placebos today. But I’m obligated to give you something. So here’s some fake medicine that won’t work. Some empty gelatin capsules used in movies, left over from a promotional TV spot we did last weekend. Harmless, but I wrote ‘fake/prop medicine’ on the bottle to be safe.” Might something like this work, as a kind of placebo placebo—where the placebo is framed as not even a placebo in order to strip away, if possible, the aforementioned awe-inducing properties of placebo as such?

If so, is placebo of the sort Kaptchuk enacts really a placebo? I ask this without being pedantically petty about what placebo denotes; that is, I don’t assume that any effective treatment is by definition not a placebo. I accept that something can simultaneously have the ontological status of placebo, while also (somehow!) working, though I say this with recognition of, again, an inherent tension in the idea. A tension that Kaptchuk himself acknowledges on Hidden Brain, when he says:

I would ask my mentors, “so what is this placebo effect?” And they said, “it’s the effect of an inert substance.” And I said, “that’s an oxymoron.”

That tension is in part what led to his aforementioned pivot, in fact. I’ll now take a step back to raise the placebo–placebo (as many placebo as you like) question from another angle.

Though placebo without deception is news to me, a quick look around shows that informational websites do generally make at least a quick and carefully measured reference to the phenomenon. If it gathers more evidential support and becomes better known, there will be baked into the idea of placebo that placebos are a treatment in themselves. Indeed, this is how Kaptchuk talks about it—where it’s the interaction itself, the interpersonal ritual, that is at least as important to the placebo effect as the sugar pills are, themselves a kind of ongoing reminder of those interactions and perhaps the principle connection between the interpersonal ritual and the expectation of internalizing that ritually corporeally (for the herbalist its herbs; for the typical Western patient, it’s a pill coming out of an orange bottle with a sticker with our name on it).

Now back to the placebo–placebo question. If extracting the core concept of placebo—i.e., these pills can work despite being inert—from the pretend pills renders them ineffective, then it seems that the effect placebo itself is a placebo effect. Maybe that’s just a tautology, but I’m not sure. I can’t put my finger on it. I suppose my point is that to really test the placebo-without-deception effect might require a placebo-control of its own. A concealed one. More tension. I’ll leave that idea fester as I move on to a related thought.

Again, this Hidden Brain story emphasizes the importance a certain kind of doctor–patient interaction involving a kind of warm attentiveness from the clinician (see again Bonanno’s characterization of Kaptchuk). And the more elaborate the interaction, or ritual, the larger the effect. When Vedantam says of Kaptchuk’s bedside manner, “that sounds like acting,” Kaptchuk replies, “hey, it’s a drama, healing is a ritual and drama that everyone in the world knows, at least their cultural forms of it, that drama activates neurons and activates a neurological process that’s involved in what we call now in biomedicine at this point the placebo effect; you got it right on the head.”

So, there’s a kind of good-faith play-acting here that is taken as no more deceptive than when we tell each other we are doing fine when asked or say it’s no bother when obviously put out. The understanding, to some degree culturally grounded, of good-faith play-acting—of an invitation to collaborate, whatever that takes, in the healing process—warms into a crucial trust on the part of the patient. This all seems fine and good and understandable and is no doubt familiar stuff to those who rent out their attention by the hour (e.g., psychologists; I hope the characterization isn’t too cynical).

How would placebo without concealment work with a colder—what for some practitioners might count as more nakedly honest—interaction? It seems to me that this should be fine, given Kaptchuk’s reference to each patient having their own cultural expectations associated with healing rituals (see again Moseley’s surgical enactment, where, notably, placebo was concealed). For me, the healing ritual involves a cold, bright, sterile room where somebody in a lab coat probes and squeezes and peers and listens, or maybe just asks a few questions while hunched over a computer keyboard (finger-pecking prescriptions to send to Walgreens). Is the lab coat and so on what matter for the likes of me (as in the Milgram experiments, where subjects are sensitive to such signs of authority, and lack thereof)?

Or is this program too cold and impersonal? How important are the sugar pills in Kaptchuk’s treatment program? Perhaps they interject an air of lab-coat authority—of appeal to the scientific method and so on—that placebo generally requires (for patients of a certain background), while, again, serving as a kind of bodily ingestion of the treatment. (I suppose for some, the needles in acupuncture serve a similar function.)

From this follows another curious question, one that echos Vedantam’s. Would I buy from Walgreens shelves—whose perusal is its own subroutine of the healing rituals I understand—a bottle of pills marked “Placebo”? Only if it’s more expensive than the real thing. I’m not sure if this is a joke. I think you know what I mean.

There must be some salient spark to ignite the meaning-processing machinery responsible for the efficacy of placebo (without deception). I imagine, at least, that this is so, and that the machinery resides somewhere deep. Not preverbal, but in its own space and not directly accessible by what we imagine to be our conscious, executive, internal self. An entity of the sort responsible for split-brain phenomena and the overdosing of experienced heroin users in a foreign environment.

(The idea in the latter is that environment is integral to one’s drug-taking ritual. The act of preparing a dose for consumption—unwrapping one’s tools, etcetera—in a familiar space alerts one’s metabolic defenses to brace themselves for the drug’s onslaught. In an unfamiliar environment, those defenses are hit without sufficient warning. Unable to make up for lost time, the result is overdose from an otherwise unexceptional hit.)

Maybe it makes sense to conceive here—to talk in terms of—the influence of separate, deeper self. The self that didn’t quite get, in Bonanno’s brain somewhere, that she was regularly ingesting an “inert substance.” The self that responded to the placebo and to the ritual (if those two things are at all separate). It’s a commanding self, and appears mindless from the homunculus-eye’s view, but is not so easily fooled. I doubt that an attempt to self-treat by placebo would be any more successful than attempts at self-tickling or, unfortunately, at self-massage of the suboccipitals (though I’ll never give up trying).

Maybe it’s not just a conceptual other self, but a very real one. Just as real, anyway, as the one we already take ourselves to be (or, even more crudely and nonsensically, to have: what, exactly, is doing the having?).

Whatever’s going on, it involves meaning processing of a sort whose end expression, or culminating output, is best characterized as mind-body interaction (the driving force of which some dare to call mental causation).

An example I’m fond of sharing in such discussions is that of a phone call whose only words I now remember are: “Your mother was just hit by a car.” I felt my entire body change. Had the words been in Bulgarian, my body wouldn’t have changed. Had the call clearly been meant for someone else, my body wouldn’t have changed. Had my mother been sitting next to me, my body wouldn’t have changed. But as I believed “you” to mean me, my body changed. My insides imploded and the hole this left induced a kind of half-ethereal vertigo.

This is the magic of meaning. I cannot stress enough (and, as we’ll see below, Kaptchuk agrees) that this is no mere matter of imagination, deliberate visualization, or positive thinking (Bonanno’s explicit, or occurrent, belief was that the placebo wouldn’t work). I don’t know what the explanation is, but I tend to think it ultimately describable or model-able in purely physical terms, while simultaneously noticing that the mind-body problem grows only more intractably mysterious as the ever-swelling volumes of brain scans and information-age theorizing carry us no closer to a good theory of consciousness.

This is true for the placebo case, the language case, the too easily missed (for most of us) but still ferociously difficult case of the human thinking, raise hand, and the hand raises.

In light of all the foregoing, it’s unsurprising to hear Vedantam cite recent evidence that the placebo effect is stronger in outcomes involving patient report, like pain and nausea, than in those involving doctor’s measurements, like hypertension. Unsurprising not only due to the subjective nature of pain (my reported 6 could be qualitatively identical to your reported 3, though how on Earth to know?), but also due, it seems to me, to a certain disconnect—or dislocated and secluded otherness—about the meaning-processing apparatus. It’s powerful but in many ways primitive in terms of the scope of what it can make sense of (it is, after all, only human).

I can’t imagine a placebo doing the work of cholesterol or diabetes medication, or of a flu shot, or similar processes whose medically salient activities are firmly on the body side of the mind-body divide (what would be called the purely physical by the dualist).  In fact, it’s easy to imagine too strong a belief in placebo-without-deception leading to real harm in such cases. (Something like this may in fact already be going on, but without invoking the word placebo.) And a placebo certainly won’t amputate a gangrenous foot or straighten a deviated septum.

(A case that works towards making the mind-body distinction easier to see is that of the asthma patient who reports relief following placebo treatment, despite unimproved breathing test results. It strikes me as a potentially middle-ground example, as it seems that, if relief is felt, this may reduce the sort of anxiety or panic that could worsen physical symptoms. So long as you don’t light up a cigarette to celebrate. To test out this hunch, I did a quick search on “asthma breath test after placebo,” and the first hit was a 2014 paper by lead-author Stefanie Dutile, with Kaptchuk as coauthor [along Michael E. Wechsler]: “The Placebo Effect in Asthma.”5)

Given placebo’s association with conditions relying on self-report, some folks worry that placebo-positive research bolsters the idea that (say) chronic pain is only in the reporter’s imagination, which is to say imaginary or somehow not real—or worse, somehow fake: perhaps a product of hypochondriacal delusion. Kaptchuk quite rightly rejects such ideas. From the Hidden Brain episode:

The placebo effect is not a mind-body New Age mind cure. Those things happen not because you think, but because you do, you perform, and you enact. The placebo effect is embodied in what patients and doctors do. it’s way below and much stronger than thinking you’re going to get better, and you get better.

I’m lucky to have no chronic pain in my life, but I can relate in my own little way. I’ve been told more than once that my allergies are in my head. This was more common before rising peanut allergies spawned greater awareness.

To get a sense of earlier attitudes (as I met them). My grandmother was convinced my young parents had been duped when they told her of her new grandson’s egg allergy. How could anyone be allergic to eggs? (Why she couldn’t wrap her mind around this is in itself an interesting question that I’ll leave for another day.)  She then somehow involved me with eggs in the kitchen, but not for long. My reaction was immediate and my swelling was swift, as was my grandmother as she sped me–preverbal child and with no concept of allergy—to the hospital.

I of course do have a concept of allergies now. Interestingly, this enables a certain sensitivity to suggestion. If you tell me you put cat hair in my food, I’ll start to feel like I’m reacting. Or I might not be sure. I won’t get welts (or will I?), but I’ll feel something that I’ll be sure I hadn’t felt moments earlier. Recall the heroin overdose example. It’s not so implausible that something in me goes on the defensive when you say “there’s mold on the blueberries.”

On the other hand, if you reassure me that my cat-hair-laced food is safe, I will definitely still react. I know, because people have done this sort of thing to me, believe it or not (not this exact thing, but close enough). These days, most people I meet don’t need much convincing about allergies (the last time I flew, no nut snacks were served because of one of our fellow passenger’s allergies). The only exception is that I’m often told a dog is hypoallergenic, but I still feel something, for whatever reason. I love dogs, though, so I power through a petting or two when I can. (And a few years of immunotherapy helped a lot. I recommend it.)

I outgrew my egg allergies years ago, but as an adult developed a mild peanut allergy and moderately strong salmon and crab allergies. I was surprised to learn about the latter after eating a crab cake sandwich and getting flu like symptoms along with scalp-to-sole welts. A good day and a half in bed. (On a happier note my voice was deepened for a day—histamines are reverse helium, it turns out—so I effortlessly rerecorded vocals for a song that otherwise dips just below my resonant range.)

This suggests to me the final question I’ll ask about placebo today.

Recall the earlier “not even a placebo” example. Suppose Kaptchuk—or a less radically honest, in the relevant sense of the term, version thereof—tells a patient they’re getting a placebo. But then, oh, the placebos have run out. So they’ll get “fake/prop” medicine instead, which Kaptchuk persuades them to take as regularly as they would a real placebo. The twist, though, is that the patient isn’t handed an inert substance, but real medicine. What then?


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Further Reading

Footnotes:

  1. PLoS One. 2010; 5(12): e15591. Published online 2010 Dec 22. doi: 10.1371/journal.pone.0015591.
  2. “Major Topper,” aired 3/27/78.
  3. July 11, 2002. N Engl J Med 2002; 347:81-88, DOI: 10.1056/NEJMoa013259.
  4. Charlesworth, J., Petkovic, G., Kelley, J., Hunter, M., Onakpoya, I., Roberts, N., Miller, F. and Howick, J. (2017) Effects of placebos without deception compared with no treatment: a systematic review and meta-analysis. Journal of EvidenceBased Medicine, 10 (2). pp. 97-107. ISSN 1756-5383. https://doi.org/10.1111/jebm.12251.
  5. Dutile, S., Kaptchuk, T.J. & Wechsler, M.E. The Placebo Effect in Asthma. Curr Allergy Asthma Rep 14, 456 (2014). https://doi.org/10.1007/s11882-014-0456-2

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