What Is The Harm Of The Placebo Effect?


An article posted by Cara Santa Maria about banning homeopathy for pets got me thinking about a recent conversation I had with my father about the placebo effect, specifically when it came to homeopathy. While it is well known in the scientific and skeptic community that homeopathy is garbage, and takes full advantage of the placebo effect and anti-modern medicine marketing for its success, my father took the stance that there is an inherent benefit of “prescribing” placebos to patients under certain conditions.

His reasoning was this: if you have a patient that is suffering from insomnia, which is not due to a hormonal imbalance but rather due to an unaddressed anxiety or stress, and a sugar pill helps that patient to sleep at night, isn’t that better for their health than taking potent sleeping aids? Similarly, if a sugar pill helps someone with a generalized anxiety disorder feel more relaxed, or relieve a tension headache, or help a hypochondriac wait out a common cold they are convinced is deadly pneumonia, isn’t that better than giving that person the pharmaceutical counterpart to the homeopathic remedy? While he agrees that placebos are harmful in the context of an ulcer, or cancer, or other conditions in which a patient thinking they feel better will only make them wait for proper treatment and worsen their condition, he posited that using placebos in certain contexts could do a patient far more good than going straight for the heavy duty drugs. After all, sugar pills and drops of distilled water, while being useless cures also carry no side effects, so if plain water helps the condition, why expose the patients to the inevitable side effects, however minor, of drugs with real active ingredients?

While this reasoning has some merit on it’s face, it also ignores some serious downsides to this approach, especially when it comes to homeopathy.

 

First of all, while there is some evidence that placebos can work even if you know they are placebos, they are still going to work better (especially for hypochondriacs or people with anxiety) if the patient does not know that they are taking a placebo. This means that doctors, while being fully aware of the useless nature of homeopathy, would still have to lend it an air of legitimacy when prescribing it to their patients. Homeopathic industries seize on this, and make no distinction between conditions which are unharmed by the use of a placebo, and ones which would be. If homeopathy works for some kinds of insomnia, why not for some kinds of ulcers? Or some kinds of heart conditions? Or some kinds of liver disease? Using the cloak of legitimate medical doctors, it would be unreasonable to assume that homeopathic producers would limit themselves to only those conditions that could be resolved without risk by a placebo. There is also the inherently scummy nature of charging patients the same, if not more, for a small bottle of water or a packet of sugar pills which have no effect as a packet of real medicine, but that is another aside.

The second point against this method is that taking placebos might not be as harmless as all that, and simply be a band-aid over an underlying problem. What if those tension headaches are actually a symptom of something more serious? What if you feel less depressed now by taking those sugar pills, only to fall into a much deeper and dangerous depression later because your doctor prescribed you sugar pills in an effort to figure out if you were “really depressed” or not, instead of sending you to therapy? While a responsible doctor could make sure to both give you the placebo and give you the necessary tests to make sure that there is not a more serious underlying problem, there is also the inescapable fact that people are less likely to follow up if they think they are already being treated for the problem. I was anxious, now I have this sugar pill and I don’t feel so anxious anymore, why do I need to discover the underlying root of my anxiety? I have a solution and I’m busy, more digging is not on the top of my priority list.

Finally comes the moral objection to perpetuating lies. Knowingly handing out sugar pills to patients who come to you for help is no better than treating them like toddlers. Lying to them smacks of laziness and condescension, of not even bothering to trust them with the truth of their health, their bodies, and the ability to make their own decisions in that regard. This does not mean that I think that doctors should prescribe the heaviest sleeping aid imaginable to the first person who complains of having some trouble sleeping, far from it. Rather, explain that the more potent the drug, the heavier the side effects, so lets start with an investigation of the problem. Let’s start with a sleep diary, a food diary, and some mild sedatives like Chamomile tea, or Valerian. Let’s see if changing your diet, or doing some stress relief exercises does the trick. If not, we can move up to the next step, and run the appropriate tests that are needed to discover the root of the problem. I know, that requires effort and follow up, but at least it’s honest.

While I came out on the side of getting rid of homeopathy completely, getting rid of homeopathy for pets is a no brainer. Pets don’t know they are taking a placebo, the placebo effect is for the owners, who think they have given their pet a pill and convince themselves that they look better, thus not bringing them back to the vet to get them sorted out properly. I can also personally attest to the fact that homeopathic remedies for dogs cost twice what the normal medicine for dogs costs. It’s a scam that needs to stop getting so much public and legislative support.

What about you? What are your thoughts on the use of the placebo effect in the medical world?

Comments

  1. schini says

    Two points:
    1) I think you are on the right track with

    Finally comes the moral objection to perpetuating lies.

    There the issue is a fundamental one: Should doctors be allowed to use placebos? A yes would be in stark conflict with the expectation, that the patient/ customer gets enough information, to make “informed choices”. The common complaint, that the medical lingo used by many doctors is obfuscating and that the diagnosis (and prescribed treatment) should be given to the patient in clear terms understandable to the laymen (assuming the patient is not informed of the placebo nature of the “remedy”).
    It is precisely because homeopathy maintains it is not a placebo (which in reality it is), that allows the homeopaths to use it and claim to be taking the patients seriously.

    If we would allow doctors to use placebos at their discretion, homeopathy would very likely not be the one to choose, since it is usually way more expensive than a colored sugar pill would have to be.

    2) placebos for animals
    I think you are wrong there to some degree. Some animals do react to the owners emotional state. The placebo effect might not be as direct as in placebos taken by humans, but there is something of a transfered effect.
    This is IMHO consistent with that sometimes the placebo effect is stronger in humans, when the prescribing doctor is not in on the fact that a placebo is used (hence the need for double blind studies)

    • thoughtsofcrys says

      I both concede you a small point and disagree with your reasoning in point 2.
      I concede that animals can react to the emotional state of their owners. If their owner is particularly anxious and smothering, and they stop doing that after they give their pet a placebo, and the anxious smothering was directly exacerbating the animal’s condition, then yes, perhaps the placebo could help. However, I think that these situations would be too far in the minority, (and you would get the same result with real medicine) for me to reverse my thoughts on banning homeopathy for pets.
      However, I disagree with your reasoning. The thing about the need for double blind studies is that the physician is the one usually both collecting, and interpreting the data. If they know which patient is on the placebo, they might subconsciously (or consciously) bias the data they are collecting in favor of their hypothesis. Blinding the doctor, I think, has more to do with the way they perceive the health of their patients, and how they record that, rather than the patients getting better in response to their doctor’s positivity

  2. says

    First, you and I are on the same page with that first point about giving it legitimacy. It’s much the same reason I am annoyed by liberal religious people.

    Your second point, though, doesn’t seem to have any connection to what you said your father’s reasoning was. You said, “he posited that using placebos in certain contexts could do a patient far more good than going straight for the heavy duty drugs.” That doesn’t seem to fit with these two prongs of your point:

    What if those tension headaches are actually a symptom of something more serious? What if you feel less depressed now by taking those sugar pills, only to fall into a much deeper and dangerous depression later because your doctor prescribed you sugar pills in an effort to figure out if you were “really depressed” or not, instead of sending you to therapy?

    In both of these cases, more investigation into the illness is what is needed, not “going straight for the heavy duty drugs.” But you didn’t say your father was against further investigation, making it look like you are beating on a straw man. (In that first case, would not “going straight for the heavy duty drugs” also have the same issue of covering up a more serious issue?)

    I will say what you say here may still fit in somewhat with your third point where you say, “Lying to them smacks of laziness and condescension.” There could be a potential problem of placebos encouraging laziness in diagnoses as well. This is mostly speculation, but I think this would have to happen for your point to be legit.

    • thoughtsofcrys says

      Mostly, I was trying to demonstrate that, in some cases, it is hard to distinguish between conditions which would not be harmed by the use of a placebo, and ones that would be. We agreed that some conditions, like ulcers or cancer, would only become worse if one prescribed a placebo. However, my father had set up a false dichotomy which I was trying to break through. Tension headaches, or anxiety, might be something that would not get worse by taking a placebo, but they also could be. Basically, my father’s position was this: Give them a placebo, if it doesn’t work and they come back, then go for real medicine. My counter was this: what if they take that placebo, feel better, don’t come back, and then it turns out that their condition got worse because there was something far worse going on? The conditions he was using as an example for the use of placebos are not ones in which you are sure that waiting will do no harm.
      Either way, I did say that a responsible doctor could, in theory, prescribe the placebo while at the same time monitor the condition closely to prevent this. Point 2 does not stand on its own, but taken together with the other points, the whole puts me on the side against the conscious use of placebos by medical professionals.

  3. says

    I would add two points:

    First, in my doctor visits I often see a different doctor each time. If any were to prescribe a placebo, how would they communicate that fact to each other?

    Second, I’m not sure how much the placebo effect actually helps with symptoms, and how much it merely improves a person’s self-reported symptoms. It’s possible for a person to fall asleep at the same time, but still think that they experienced an improvement. Of course there was an improvement, they think to themselves, they took drugs for it! I think there would still be a placebo effect for pets even if the only person who knows the pets took anything is the assessor.

  4. grahamjones says

    I’d just like point out how old this is.
    Forbes concluded that homeopathy is “one of the greatest delusions…of the healing art” and the only good that ensues from its practice is the reduction in “the monstrous polypharmacy which has always been the disgrace of our art – by at once diminishing the frequency of administration of drugs and lessening their dose.”
    That’s John Forbes FRS, writing in 1857

  5. Pierce R. Butler says

    [CW: anecdatum & argument from authority]

    … getting rid of homeopathy for pets is a no brainer. Pets don’t know they are taking a placebo, the placebo effect is for the owners…

    Several years ago, my dog developed a persistent skin problem which necessitated taking him to a veterinary allergy specialists. In the process of describing choices in medication, she mentioned – and confirmed, when I got all wide-eyed – that such drugs are tested using full double-blind procedures, and that meta-tests have shown this is necessary for good quality lab results.

  6. perodatrent says

    Many years ago it was showed that placebo analgesia does work. Then effect is more marked when physicians believe they are giving an active drug to patients, even if the pill is a placebo.
    So, when a physician (or a vet) uses an homeopathic “drug”, (s)he believes it is an active drug, and transfers this belief to the patient (or the pet owner).
    What we really need are gullible physicians -of course, only to treat self-limiting illnesses.
    Gracely RH, Durner R, Deeter WR, Wolskee PJ. Clinicians’ expectations influence placebo analgesia. Lancet 1985; ii: 43

    • thoughtsofcrys says

      That is the reason why clinical studies are double-blinded, if the physician thinks they are giving the patient a proper drug, then the placebo effect is more likely to work. However, gullible physicians did not enter into my father’s argument. Neither of us were saying that we thought homeopathic practitioners know they are selling placebos, most of them think they are giving efficacious medicine to their patients. Rather, my father was arguing for proper medical doctors knowingly prescribing their patients placebos, for certain kinds of problems, in an effort to see whether or not their problem was minor enough that a simple placebo could do the trick.

    • oolon says

      How much of that is reporting bias? Read an interesting article on science based medicine. Asthma placebo study where patients reported feeling better but their lung function was worse. Very dangerous that they thought they were better when they were not. Pain could be the same if giving a subjective opinion compared to week(S), or days before. Keeping a pain diary or similar might help reduce it.

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