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Comment by jonawesomegreen | Hacker News Reader

I listened to an episode about the placebo effect on the "Only Human" Podcast awhile back. Its truly fascinating, and has made me question the power of the mind in a way I hadn't before. It also has some really interesting ethical problems, is it okay for doctors to lie about placebo treatments if it actually helps?

> Kallmes performs vertebroplasty, a surgery he has helped to develop and standardize, that involves injecting medical cement into the fractured bone to stabilize the fractured area and relieve pain. He says he gets great results from his patients, and teaches the method to other doctors at conferences.

> But here’s the thing: he has no idea why vertebroplasty works. So a few years ago, he decided to test it against a placebo. Kallmes found that pretending to perform vertebroplasty – making it seem like he was injecting a needle into the spine but without the cement – had similar effects. About 40 percent of both groups experienced immediate relief from pain after the surgery. He published his results in the New England Journal of Medicine.

https://www.wnycstudios.org/story/real-doctors-fake-medicine...

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Thanks for sharing. Adding another podcast anecdote here — one that made me chuckle — from Scott Belsky in his interview on Tim Ferriss' podcast:

> I remember my father, as an orthopedic surgeon, when he was a resident, he was working in one of those crazy, New York City hospitals where people would come in with like overdoses and shooting wounds and stuff like that. And he was telling me that the most often kind of prescribed [medicine], especially on the psychiatric stuff that came in, was 100cc of Obecalp, which is, of course, "placebo" spelled backwards. And how as soon as someone would be like, "Obecalp, stat, 100cc," that would, suddenly, switch something in a lot of these patients’ minds, in terms of where they felt they were in their hope. And that always stuck with me.

Yes! I did my internship at Los Angeles County-University of Southern California Medical Center ("Big County") in 1974-75. In the ER, it was routine to give repeaters with no obvious source of pain (visits weekly, no other doctor) OBECALP BLACK. These were humongous (about 1" long x 0.5" diameter) shiny black capsules filled with powdered starch. We'd tell the patient, "These contain the strongest pain med that's legal." Worked more often than not in terms of relieving their pain in the E.R. Till next week...

In such instances, giving a placebo definitely seems better than an opiod, but in my opinion, it definitely isn't helping the patient and is likely hurting them by distracting them from the underlying emotional cause. At least when given repeatedly...

In the majority of those patients, the underlying cause was alcoholism and its myriad complications resulting from a store called Liquor Liquor being located across the street from the hospital.

Liquor Liquor? That sounds like a very healthy and reasonable store to have across from a hospital. Nothing unethical or distasteful there!

The irony was not lost on us. The first thing those patients did after discharge was head to Liquor Liquor. It had a huge flashing colored neon sign — ALL CAPS.

We have a bar here in Phoenix, located almost directly across the street from a hospital, called "The Recovery Room":

https://www.google.com/maps/@33.5240529,-112.1032385,3a,15y,...

  black capsules

This reminds me of the "black capsule", the mythical suicide drug in the original film "MAS*H".

> Is it okay for doctors to lie about placebo treatments if it actually helps?

I mean, their oath is to help people, not to tell the truth, the whole truth, and nothing but the truth.

Oh, no. It’s much more complicated than that. The ethical principle you describe might more clearly be defined as beneficence: acting in best interest of the patient. But what about when it conflicts with another ethical principle,namely autonomy: the right to decide what happens to your own body and what treatments you don’t get.

To my mind, there isn’t an obvious answer, but the conflict between these two is why there is debate about “using” the placebo effect as a treatment.

I figure the ethical debate extends into our societal issue of greed as well. Certain institutions would love to be able to give you no medication/treatment, charge you as though you had received it and you're none the wiser.

Which is interesting because presumably if they didn't charge you it would shatter the placebo effect. I wonder if cost of the procedure actually impacts the efficacy of the placebo?

Sane middleground:

"We did procedure X, but your insurance covered all of it."

Nobody sane would ever believe that.

Anyone with a decent HMO would, for broad classes of procedures.

I'm guessing you're in the US.

Nobody in the Western world outside the US would have any reason to question it.

https://www.marketplace.org/2015/03/03/health-care/how-cost-...

this is a small study - but yes, it appears that way https://www.ncbi.nlm.nih.gov/pubmed/25632091

They are still providing a service and even pills with starch in them cost something to make. I don't see any reason the doctor and hospital shouldn't charge.

If they're just administering placebos do you still have to pay for real doctors?

But then we go deeper into what placebo is. If the patient needs the psychological comfort of being seen and OK'd by real doctors, staying home mentalizing their own well-being won't do much. It's about taking responsibility for self-care--to the extent possible, of course--as opposed to externalizing any ill state to a sanctioned (sacred?) pill.

You could train actors to give out placebos for a fraction of price. Less work for doctors and more jobs for actors. It's a win-win.

I think placebo can be self-administered. I can make many pains decrease in intensity (or sometimes go away) just by thinking about it.

Last year I fell while mountain skiing and was in great pain at first (could barely move, standing up from lying down was excruciating, etc.)

The first day I didn't take any pain killer; the second day I did but it didn't really help. The third day I stopped taking the pills and just kind of "decided" I wouldn't suffer that much.

The pain didn't disappear completely, and it still hurt too much to get back on skis, but it stopped being so intense. When I got back home I did an x-ray exam and MRI and found I had broken a vertebra in two, that had lost 25% of its height. The doctor was super surprised I could walk normally and said: "do you not feel pain". I said I did but it was very manageable. She didn't investigate and just said "ok then, good for you!"

Also, I used to get hiccups that lasted a long time (30 minutes); and then I discovered you can make them stop very fast by being super calm and concentrating. Not only that, but since I found this out, I barely get hiccups at all anymore.

I think we can consciously control much more of our own body than we think, and we're only scratching the surface.

If it works, its treatment, even the right treatment. Would you know when its safe to give a placebo? That takes diagnostic skill.

Homoeopathy comes to mind.

I am in two minds about it. On the one hand it would appear pretty ridiculous and there is no way that it should be paid for. On the other hand if it works via the placebo effect in a cost effective manner, is that a bad thing?

The placebo effect isnt bad, lying about the effects (homeopathy) charging much more than the cure is worth (homeopathy), and outright selling poison to people (homeopathy) is not ok.

But isn't the lying necessary to be a placebo?

And what is the cure worth? How do you measure that?

Not necessary apparently, https://www.health.harvard.edu/blog/placebo-can-work-even-kn...

How is it supposed to work as a placebo if you're told "hey, this is a glass of fresh water: drink it. And by the way, it's free'.

In other words the lie is integral to the working of the placebo. This is the whole source of the issue.

It does work even without deception, which makes it all the weirder. It's covered in the article.

What's interesting is that it seems to depend on which truth you tell. To oversimplify, "take this, it's not medicine" doesn't help. "Take this, it's not medicine but it will help you anyway" does.

The weird thing about homeopathy is that it's advertised as selling poison, but actually isn't. One of the ridiculous premises is that "like cures like", so it should be poison, but then there's the other ridiculous premise of diluting it to make it more powerful.

except when it is selling dangerous levels of poison:

https://www.forbes.com/sites/brucelee/2017/01/28/fda-toxic-b...

I suspect that much of this issue is resolved by looking at how they sought consent for their study, since they had to inform participants about what they were going to do to them (though they could have phrased it as, I may do A, or I may do B).

Now, they can say, "I may do A, and I may do B, and there is evidence that both are effective"

A very interesting ethical discussion I had with a doctor friend recently is that in some cases where a doctor identifies that amputation is the right/only course of action, they will only present that as a soft option to the patient, if at all.

This is because studies have since found that amputations can cause a great deal of psychological harm and it can be better for the patient if they arrive at the conclusion to amputate of their own volition - even if that takes months of excrutiating agony spent realizing not having the limb is better than the pain.

It was an interesting additional dimension to consider - even if the doctor knows much better than the patient, sometimes the patient feeling a sense of autonomy could be important for their wellbeing, and that short term pain could be beneficial.

In some ways this applies to everything we do that we think might be helpful. Sure we could get patients to loose weight by locking them up and only feeding them 1300 calories of veggies, but for some obvious reasons that isn't really an option. We can encourage them to take medications, but they still have to take them.

Atul Gawande talks about how much we have discovered in medicine in the last century, but that the next century is going to be about how to effectively implement that knowledge to help people. This applies to both the first world and to the developing world, though the challenges in both are different.

(also we probably wont stop discovering new treatments that we will them have to deploy...)

> Sure we could get patients to loose weight by locking them up and only feeding them 1300 calories of veggies, but for some obvious reasons that isn't really an option.

Yeah, but a lot of patients would consent to an offered treatment plan where they're locked up (and unable to sign themselves out!) and fed only 1300 calories of veggies.

The weird thing is, there are private businesses willing to provide exactly that kind of service (see: de-tox centers.) But doctors and hospitals generally don't see this as a valid form of in-patient medical treatment. Why is that? Do doctors think that patients have an inalienable right to bodily autonomy? (If so, how would surgery ever work?)

(The annoying point about this difference, to me, is that if a doctor were to diagnose you with X thing that keeps you at the hospital for a month, unable to leave—then your insurance would likely pay for that, and your employer would likely consider you on sick leave. But if a private business like a detox center keeps you for a month, then you have to pay for that out-of-pocket and you're likely to be fired from your job if you don't have the requisite vacation days saved up. From what I can see, it is in the patient's long-term interest if doctors get into this business!)

Autonomy isn't a meaningful principle when it comes to medicine. Even patients who are doctors can't really give informed consent since they won't necessarily be knowledgeable in the specialty relevant to their treatment. And the vast majority of patients aren't doctors.

Not to invoke a slippery slope argument, but there are a lot of really horrible things that have been done without giving patients autonomy. We as a society need to consider it extremely carefully before any instance of acting against a patient's bodily autonomy.

It would be interesting to compare that against the horrible things people do because they do have autonomy.

If horrible things are being done to people, I'd pick the ones those people are doing to themselves almost every time over the ones being done to others in violation of their bodily autonomy.

The whole point of autonomy is that there is an ethical difference between doing something to yourself, vs. doing something to someone else.

Yes. Obviously you'd narrow things down and compare like to like. Anti-vaxers being the hot example of the day. Sometimes it's so obvious that we act on it, like with secondhand smoking, but I bet there's a lot more to dig into.

Autonomy means that you get to consent (or not) even if you are not informed.

Right, that's the problem. The fact that doctors must ask for the consent of people who don't understand what they are consenting to.

The idea itself isn't that controversial - age of majority laws for contracts, voting, and even medical treatment clearly acknowledge the idea that some people are too young to know what they are agreeing to, so the decision should be made by someone else who takes responsibility for them (most things), or there should be no decision because there doesn't need to be one (voting).

We just need to refine our understanding to reflect the reality that as old as you may get, you will never understand some things.

Autonomy is not a problem of medical treatment, it's a fundamental principle of an ethical society.

Without autonomy, the concepts of voluntary/involuntary lose meaning, which can enable some very nasty scenarios. Exceptions to autonomy are rare and come with stringent legal duties and obligations on the responsible party. Doctors are not responsible for their patients in that way; they are service providers.

Lack of understanding should not be sufficient to undercut an ethical principle like autonomy. Imagine if I had the power to decide that you don't sufficiently understand the concept of autonomy, and must be shipped off to a re-education center.

> Autonomy is not a problem of medical treatment,

Talking about it outside of the specific conflict, is disingenuous. Everyone understands how important Autonomy is. That's part of the issue, not a supporting argument to value it over the health of a patient. If there's no patient, there's no Autonomy either.

The GP comment was "Autonomy isn't a meaningful principle when it comes to medicine."

So, I do not agree with you that "everyone understands how important autonomy is."

Not agreeing isn't the same as not understanding.

If I legitimately didn't understand it, it would be right to teach me. That's why we have mandatory schools for children.

The point of autonomy isn't to treat the patient as the most knowledgeable person in the room, but to present the options, all considerations and drawbacks that you're aware of, answer any questions, and then ask them to make a decision. If you think that patients aren't smart enough to understand the implications of drug side effects and weigh the costs and benefits of treatment versus the original disease, then I really hope you're not a doctor. And I really really hope you're not my doctor.

> then ask them to make a decision

You don't see the irony in that, when talking about the Placebo effect? This discussion is about an implicit assumption.

Is uninformed consent meaningful in the first place?

IMO the power of the mind and attitude is really key to how people perceive and function with pain. I don't think that we adequately understand it.

We see that all of the time... I recall working in a bakery in the mall in high school and chatting with a Vietnam veteran with chronic pain from a lung issue and a missing leg who would walk 8-10 miles on crutches every day at 5AM and sometimes do push-ups in our cafe area. He was the most positive person that I have ever met, which was striking when you'd see other folks with very minor issues grouse and complain and be visibly ill.

My mom was taught "therapeutic touch" in the 1960s in nursing school, which I believe isn't considered pseudoscience today. For certain types of patients, it was helpful, but the technique was mostly placebo.

Fundamentally, changing how people think is ethically problematic if it becomes manipulative, but it's a key factor for our well being as well.

> We see that all of the time... I recall working in a bakery in the mall in high school and chatting with a Vietnam veteran with chronic pain from a lung issue and a missing leg who would walk 8-10 miles on crutches every day at 5AM and sometimes do push-ups in our cafe area. He was the most positive person that I have ever met, which was striking when you'd see other folks with very minor issues grouse and complain and be visibly ill.

This might simply be that the Vietnam veteran happens to have much better and more stable chemistry than people with, say, depression.

It seems one danger with this placebo discussion is that we may end up at square one, blaming depressed/anxious/ADHD/BPD people for their problems...

Absolutely... every question seems to open up a minefield of ethical problems, fraught with unknowns.

What about pricing and marketing? Is it ok for a doctor to create a new "placibo treatment" and market it as the real deal on late night tv just because some non zero percentage of people will mark that they had improved symtopms. What is the fair price for a sugar pill that the doctors and compaines are empowered to lie about. Ones mind and mindset play a big role in healing the body and we have far more powerful tools for effecting the mind then future doctor's lies and sugar pills. We have therapy, counseling and the love of family and friends. In my mind its all about hope which doctors can deliver to patients far better with smiles and compassion then sugar pills.

> What is the fair price for a sugar pill that the doctors and compaines are empowered to lie about.

$0.

Health care costs have ruined many, and that's frankly unethical. I don't see a point treating the unethical American health care system as a premise in these ethical debates.

What if it being $0 reduces to placebo effect so that it no longer is effective?

What if the opposite effect happens? https://www.marketplace.org/2015/03/03/health-care/how-cost-...

Why would you think manufacturing and distributing a sugar pill should cost $0? Many drugs are basically the same cost as sugar and those aren't free. How about $5 for a bottle of 100.

Precisely, what is advertisement and marketing if not creating an incremental value from a placebo effect?

The practice of medicine is at the service of the patient: the doctor should not make decisions for the patients unless he has to: the final say is always from the patient.

If the doctor lies to the patient, the patient cannot make a proper decision for himself.

So yes, it truly is an ethical dilemma.

> is it okay for doctors to lie about placebo treatments if it actually helps?

Well, if it actually helps, is it a lie? A placebo is something intended to have no therapeutic value, generally for the purpose of testing another treatment. Arguably if you intend something to be the treatment then it isn't a placebo. :)

> is it okay for doctors to lie about placebo treatments if it actually helps?

Let's sharpen the question: What if the lie is the treatment?

It sounds to me like the 40% who the placebo helps for have a different, mainly mental, problem than the 60% for whom it doesn't.

It was 40% effective for _both_ groups. Meaning the "actual treatment" might actually be doing nothing.

Yeah, I got that. The injection probably did nothing aside from a placebo effect.

> It sounds to me like the 40% who the placebo helps for have a different, mainly mental, problem than the 60% for whom it doesn't.

It's likelier that the 60% not helped are those who have a different, mainly mental, problem that the 40% for whom it does work.

If the cure comes from strength of mind, then it probably isn't correct to say that those with weaker minds and wills are healthier mentally.

Are you saying no fractured bone pain is physically based?

That seems overly radical. Then again, I suppose all pain is in the mind at some level.

No, I'm not saying that. My comment doesn't even come close to implying that.

Nope. Placebos can work even when you know it's a placebo: https://www.health.harvard.edu/blog/placebo-can-work-even-kn...

I wonder how much of that effect is due to subjects not understanding what a placebo. Would the effect remain if the study population was other physicians or scientists?

I think it's relatively unreasonable to assume that when the study says that participants are informed that they're taking a sugar pill that the participants don't understand what that means, nevermind assuming that no effort at all was made by the administrators to address this fairly obvious issue. If the entire point of the study is testing whether or not patients still benefit when they understand that they're not taking any medication, it seems self-evident that they would be required to ensure their test subjects understand that they're not taking any medication!

From the article, the guy who ran the study apparently still has reservations on this point: "And he can even be disparaging of his own work, wondering, for instance, whether the study in which placebos were openly given to irritable bowel syndrome patients succeeded only because it convinced the subjects that the sugar was really a drug."

Can you imagine a label on all drugs. "General surgeon reminds: your doctor might be lying to you as part of your medical treatment. This might not be a real drug"

> different, mainly mental

What evidence do you have that the placebo effect is 'mental'?

Absolutely correct. It's called Münchhausen Syndrome. What "helps" these patients isn't the placebo, it's the attention. (And it "helps" them in the same sense in which the next fix "helps" the junkie.)

> It also has some really interesting ethical problems, is it okay for doctors to lie about placebo treatments if it actually helps?

Given that it can still be effective even when you tell your patients you are giving them a placebo, I don't think this needs to be an issue (it's a worthwhile thought-experiment nonetheless, of course).

> when you tell your patients you are giving them a placebo,

Patients dont know they are getting a placebo in clinical trials. It's double-blind by design (doctors dont know either which one is placebo or active ingredient).

Since we assume placebo effect is partly psychological, if you tell a patient you are giving them placebo this could possibly lead to worse outcomes.

There have been "open-label placebo" trials, where the patient is aware they're getting a placebo... and it may still work.

E.g. https://www.health.harvard.edu/blog/placebo-can-work-even-kn...

Not saying it does not work. I am saying the effect is probably less.

I agree. Though it's odd that the placebo effect seems to be getting stronger over the years (according to the article) - I would have thought it would have weakened as the concept spread through the public.

Perhaps that serves to emphasise just how little we actually understand it.

So, it seems to be based on expectancies. The double-blind setup (while really useful in disentangling drug vs treament (i.e. placebo) effects), seems to reduce expectancies. See for example, this paper: https://www.sciencedirect.com/science/article/pii/S030439590...

The tl;dr is that if you lie to people about their treatment, they get better than those who get told they may or may not receive placebo.

Additionally, if you administer naloxone to people in pain trials, it appears to reduce the placebo effect, which suggests that the effect is mediated by endogenous opioids. (Except in IBS for some reason).

Finally, if you tell dentists that they may be administering placebo analgesics to their participants, the participants report significantly higher pain during dental treatment (even though all participants got an active drug).

So, to sum up, its pretty complicated, but the practical takeaway is that you should try to have faith in medical treatments if you want to get better.

> Finally, if you tell dentists that they may be administering placebo analgesics to their participants, the participants report significantly higher pain during dental treatment (even though all participants got an active drug).

Interesting, I had never considered that as a thing to research! But I can imagine it working like a placebo-equivalent of reverse-psychology.

Do you have a reference for the dentist situation, fascinating result.

There you go: https://www.thelancet.com/journals/lancet/article/PIIS0140-6...

Are you sure your interpretation is correct? You said

> if you tell dentists that they may be administering placebo analgesics to their participants, the participants report significantly higher pain during dental treatment (even though all participants got an active drug)

whereas the study seems to claim

> if you tell dentists that they may be administering an antagonist to their participants, the participants report significantly higher pain during dental treatment (even though all participants got a placebo)

The latter seems much more believable to me.

https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=%22C...

https://books.google.com/books?hl=en&lr=&id=8UMDAAAAQBAJ&oi=...

Whoops, its been a few years since I read that paper (I did my PhD on this, but finished a few years back). Apologies for the noise, it appears you are correct.

I agree that it is counter-intuitive, but I am not making this up! On top of what jsk13 mentioned, the NYT article itself mentions:

> You don’t even have to deceive the patients. You can hand a patient with irritable bowel syndrome a sugar pill, identify it as such and tell her that sugar pills are known to be effective when used as placebos, and she will get better, especially if you take the time to deliver that message with warmth and close attention.

There was an interesting article in the New Yorker covering this as well, for those who want to read more: https://www.newyorker.com/magazine/2011/12/12/the-power-of-n...

> , is it okay for doctors to lie about placebo treatments if it actually helps?

Placebo does not work on everyone. And it's not the best treatment even if you consider it "works somehow". So doctors will provide what work more often than not, hence an actual drug with proven efficacy vs a placebo.

It's also interesting to note that it may not be necessary to lie. In a number of studies, placebos have been effective even when the patient is told they're getting a placebo.

Note that "working" is ambiguous. In many disease where the condition is not entirely chronic, there is often the phenomenon of regression to the mean: i.e. you are recruited in the clinical trial at your worst state, and you progressively get to "average better" even if you don't take any drug. that can also partly explain placebo effect in many cases.

Shouldn’t that be controlled for in a trial?

Absolutely. That's why you have a control group which gets a placebo. Then you can test if the medication is more effective than the placebo.

At least that's how it worked until someone looked at the term "placebo effect" and got confused into thinking that's anything other than regression to the mean.

Yes, but if you're specifically studying placebos you should have a control group that gets nothing.

It's good to note that non-placebo treatments don't work on everyone for every problem as well.

How did he manage not to be sued into oblivion?

Probably because he was making an effort to understand the efficacy of his own treatment which any reasonable person would understand to be the opposite of negligent.

If you were a patient who paid for something and didn't get it.. this is malpractice. There's a chance that if you were in the 60% that had no positive effect, you might've had the effect if you had the treatment. A reasonable person would sue, and a reasonable jury would compensate.

It reads as if he conducted a study in which he got informed consent from its participants.

As is, they were told that they'd either receive an injection with the cement or a placebo injection, and they agreed to participate under those terms.

Hopefully that was the case.

I'd like to believe the journal he submitted his findings to has a rule about publishing papers that used unethical means to obtain data.

I thought testing against placebo was a standard procedure in medicine and without such testing treatments wouldn't even be approved.

Yes, but patients always consent to be randomized to the possibility of being treated with placebo.

in a clinical trial setting or in general? I'm not sure about everyone else, but I sure wouldn't want the possibility of getting a placebo when I'm at the doctors/hospital.

trial only.

you would have to consent.

> Yes, but patients always consent to be randomized to the possibility of being treated with placebo.

This is false as a blanket statement. For specific categories like Cancer treatments, nobody is given placebo in Phase III for example, because their life/survival is at stake. For such clinical trials you prove the efficacy by comparing with the typical survival in other studies/other treatments (overall survival chart) like this: https://media.revlimid.com/wp-content/uploads/mm-hcp-overall...

Right, more correctly I should have said:

Yes, but in trial where patients may receive placebo, the patients always consent to be randomized to the possibility of being treated with placebo.

jonawesomegreen linked to a story about an FDA-approved fake treatment.

Placebos also work when people know they are placebos. No reason to lie to the patient.

My intuition would be that a significant component of the effect is that the patient believes they have been treated. Until we see evidence otherwise, I see no reason to assume that the placebo effect is not weakened by the loss of that component.

I agree with your intuition, but I'm guessing the parent was referencing this: https://www.health.harvard.edu/blog/placebo-can-work-even-kn...

I have seen it. I do not believe that this test (or others, yet) compared known placebo treatments to unknown placebo treatments.

I'm a big fan of your music.

I see. Yeah, intuitively you're almost definitely right.

> Is it okay for doctors to lie about placebo treatments if it actually helps?

People do this all the time, it's called homeopathy

And it's not okay. It's fraud.

Homeopathic products cannot make claims about treating or curing diseases.

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