Alternative therapies are often written off by sceptical rationalists with the traditional refrain that they are ‘no better than placebo’. What little good research and meta-analyses exist on the topic do confirm this to be the case, thus debunking the holistic practitioners’ magical claims. What this dismissal glosses over is that the placebo effect is a lot better than nothing.
Vast swathes of research have found that the effect works across physical and mental conditions, using different forms of sham treatments, from sugar pills to surgery. Researchers have played with the properties of treatments, finding out that four sugar pills per day are more effective than two at removing stomach ulcers, and that injections of saltwater are more effective than pills at relieving pain. Even seemingly small details add to the effect: the effect is strengthened by pills that are bigger, branded, and more expensive.
Alternative therapies have already figured out these details, however. By being allowed to operate in an unregulated market, they can concoct whatever remedies take their fancy, and consumer tastes and demand selects the most popular. Incongruously, their business environment is closer to unfettered capitalism than that of the big pharmaceutical companies. In addition to identifying the most effective placebos, alternative therapies offer the added bonus of giving the patient his/her choice of treatment. The importance of feeling in control of one’s treatment is gaining currency at the moment, reflected in the emphasis on patient-centred care. Evidence shows that a feeling of control is associated with better outcomes. This suggests that patients who choose a certain placebo may do better than patients who are prescribed the same one. Open up the NHS to market forces, and increase patient choice: does this sound familiar?
The NHS currently funds placebos in the form of complementary healthcare, though of course neither party in this arrangement describes it in such terms. This includes paying for the pseudoscientific flourishes unique to each therapy, such as sourcing unnecessarily exotic ingredients. Surely then the NHS could save significant amounts of money by funding an in-house placebo program, pared down to the simple elements of the effect? Two objections spring to mind: perhaps the mystique of alternative therapies is essential to the effect, and at the very least the patient must be unaware he/she is taking a placebo, meaning the NHS would have to lie to patients. The latter option really isn’t an option, as it would erode trust in the doctor-patient relationship.
A paper published last year provides hope that these problems may not in fact exist. Researchers randomised patients with irritable bowel syndrome (IBS) to an ‘open-placebo’ group, in which patients were given pills they knew to be inert, or to a control group which was given no treatment. Crucially, the pills were presented as having been effective in the past, thus creating the expectation of an effect. Patients given the open placebo did indeed report significantly increased global improvement scores, adequate relief and reduced symptom severity. This finding urgently needs replication across other medical conditions, but the fact that the effect on adequate relief was even bigger than in double-blind IBS trials is very encouraging.
This then is evidence that the placebo effect remains, even when patients are told they are being given a placebo, without any explanation of how it may work. Expectation of effectiveness is the underlying driver, rather than belief in a treatment having a specific mechanism. This applies equally to alternative therapies – the stereotype of people trying them being new age types isn’t the whole story. Many people trying them don’t believe the claptrap, but are desperate and willing to try anything that appears so successful.
Similarly, the nocebo effect illustrates how the expectation of side-effects can lead to their existence when a placebo is taken. Clinicians therefore have the power to heal or hinder with the same placebo: whatever prediction they make of it becomes a self-fulfilling prophecy. Ethically, this seems to clear the way for clinicians to be able to say, truthfully, that the placebo they are prescribing should make you feel better.
Placebos on the NHS would put an end to the bizarre monopoly which alternative therapies enjoy over the use of the placebo effect. Current regulation means that this quite well understood scientific phenomenon can only be used by those who reject scientific input into their therapies. This disadvantages certain groups who don’t want to or can’t use alternative medicine – rationalists on principle, and people who can’t afford it. And for all the similarities, a commitment to placebos would be a commitment to a type of medicine which is the very opposite of alternative therapies: evidence-based medicine.
- Placebos And Deception (randi.org)
- If randomized clinical trials don’t show that your woo works, try anthropology! (scienceblogs.com)
- The Amazing Power of the Placebo Effect (psychcentral.com)