Five Reasons Why “Placebo Medicine” is Bullshit

Placebo Medicine is Nonsense

The alternative medicine movement constantly moves the goalposts and shifts the narrative to avoid admitting that their products are medical failures. First they claim that their fake treatments are effective. When it is pointed out that their products have not been tested for safety and efficacy, they deny that it is even possible to be run clinical trials on alternative medicine because it is so personalized.

When it is pointed out that many real treatments are also personalized and could be tested just fine, they insist that clinical trials will vindicate their quackery. When their products fail the tests, they try to spin the result in such a way as to portray the clinical trials as a success.

When it is ultimately shown that some alternative medicine practice is virtually indistinguishable from placebo, they switch the narrative once again. This time, they insist that even if their fake products and services are indistinguishable from placebo, the placebo effect is supposedly some mysterious new age woo that the mind somehow determines reality and that we therefore must “harness the power of placebo”. Here is why all of this is deeply misleading.

In reality, placebo effects are often weak, transient and largely ineffective for objective measures. Giving patients with real medical conditions placebos as a treatment would also require deception. Some quacks insist that studies show that placebos work even if you tell people they are only getting inert sugar pills, but when examined closely, those studies actually involve deception.

Using “placebo medicine” in a clinical setting would also force doctors to lie to their patients about important aspects of their treatment which is unethical. It would also boost monetary gains and perceived respectability of the alternative medicine industry. Some fake treatments can also be dangerous due to them being contaminated by heavy metals or even prescription medication.

“Placebo Medicine” is ineffective

Various alternative medicine proponents and new age woo promoters claim that the placebo effect is some mysterious effect that is caused by the mind allegedly controlling or determining reality. This is part of the victim blaming narrative of claiming that people who get cancer somehow have themselves to blame because they had too many negative thoughts or ate too much acidic food. In reality, of course, cancer is a disease that is characterized by cells growing out of control and has nothing to do with your thinking or the pH of the food you eat.

To test the idea that placebos have clinically powerful effects, one can perform a meta-analysis on studies that included both a placebo group and a no treatment group. Three such meta-analyses have been done: Hróbjartsson and Gøtzsche (2001), Hróbjartsson and Gøtzsche (2004) and Hróbjartsson and Gøtzsche (2010). The first meta-analysis looked at 114 outcomes, the second looked at 156 trials and the third looked at 202 trials with 60 conditions. Their overall conclusion? Placebo effects probably do not have clinically significant effects in the vast majority of cases.

Thus, the “placebo medicine” narrative is empirically false.

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“Placebo Medicine” is deceptive

Defenders of the “placebo medicine” narrative often make the claim that it does not have to be deceptive and that there somehow exists a clinically important placebo effect even when you explicitly tell patients that all they are getting is placebo. However, the studies they rely on explicitly involve deception. For some of them, this information is even provided in the abstract.

A study published in the journal PLoS One by Kaptchuk et. al (2012) randomized 80 patients with irritable bowl syndrome (IBS) to either an inert placebo pill or a no treatment control group (while ensuring the same quality). They told the patients in the placebo group that

placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes.

This involves active deception in two separate ways. First, as we have seen, placebo effects are typically weak and transient, not something that causes “significant improvement”. Second, the researchers wrongly characterized placebo effects as if it had to do with some mysterious “mind-body self-healing”. In reality, it is just the sum of all non-specific effects that is not attributable to the active ingredient.

The phrase also hints at new age pseudoscience that claims that the mind determines reality and that positive thinking can somehow cure diseases. Thus, it might have attracted study subjects who were already very likely to strongly believing the placebo narrative from the start, thus artificially boosting the observed effects in the placebo group compared with the no treatment control.

The observed effect is also not that impressive. The placebo group only had a small improvement compared with no improvement in the no treatment group. Is that really enough to claim clinical significance of their results? It certainly does not justify a strong belief in the power of “placebo medicine” and it does not at all demonstrate that you can harness the placebo effect without deception, as the study involve explicit deception.

The second study that is often trotted out by “placebo medicine” believers is Carvalho et. al (2016). It is essentially a regurgitation of the same flawed methods as in Kaptchuk et. al (2012), but this time for chronic lower back pain. Indeed, the Carvalho et. al (2016) write that the information protocol they provided to their patients verbally was taken directly from their previous study. Thus, their study involved intentional and direct deception, contrary to what they claim in the paper and in the media.

However, this second study is even stranger. This is because they only included patients with milder forms of chronic lower back pain by intentionally excluding people who had recently taken opioid pain killers, had surgery, certain forms of back damage due to age, infection, cancer and so on. Their justification was that “reduce potential heterogeneity from different causes of pain” and “might render our goal more difficult”, but it does not take an expert in clinical trial design to notice that this meant that they ended up with a patient sample that were most likely to respond and respond more strongly to placebo effects. The baseline characteristics table also shows that the participants in the placebo group where over three times as likely to take benzodiazepines compared to the control group and that was not adjusted for in their statistical analysis. This might have resulted in the placebo group getting a stronger reduction in pain compared with the no treatment control over time.

Finally, the last author of the Carvalho paper is Irving Kirsch, a known anti-psychiatry activist who has made several flawed attacks against the efficacy of antidepressants in the past. Although this by itself is not enough to call the paper into question, the combined impact of this and all of the problems listed above is sufficient. While one of the authors of the powerless placebo meta-analyses are also anti-psychiatry (Gøtzsche), those studies did not have severe methodological flaws that undermine their conclusions substantially.

These studies, and the “placebo medicine” narrative, is discussed in additional detail here, here, here, here, here and here.

“Placebo Medicine” is unethical

Because “placebo medicine” ultimately require deception, it would force doctors to lie to their patients. Because doctors play such an important role in society and for the health of patients, it would be incredibly damaging if they were to routinely lie in their profession. Medicine requires honesty and accuracy, not smokescreens and deception. Would you want your doctor to withhold important and relevant medical information from you? I do not think that many people who were reasoning correctly and without fallacies would come to that conclusion. The relationship between doctors and patients must be based on honesty, clarity and accuracy. It is your health. You should care about it.

By lying to patients, doctors would also deny them their right to informed consent. If you are intentionally being fed lies by quack promoters, it is not possible to be properly informed and this is one of the reasons why alternative medicine is so vile. This crumbling of informed consent threatens to undermine both medical ethics and the very system used to make sure that patients are not harmed. Who gets to decide which information should be intentionally withheld from the patient? Who gets to decide which lies are acceptable, and which are not? Clearly, the most defensible and easiest system to regulate is that doctors should not be allowed to intentionally deceive patients about important medical facts that are relevant to their treatment.

“Placebo Medicine” is pseudoscience

Relying on “placebo medicine” would also greatly benefit the fake treatment industry. Because so many people need medication and treatment as the grow old, this would lead to a massive monetary gain for the quack industry, which would further allow them to spread their dangerous nonsense and line the pockets of snake oil salesmen. Contrary to the popular belief that alternative medicine proponents are fighting international pharmaceutical corporations, it is actually a 34 billion dollar industry that sells millions and millions of doses of supplements, alternative and complementary medicine (SCAMs). We might call these companies Big Placebo.

By being let into the health care system without any restrictions, they would also gain a considerable boost in superficial credibility. It would be much more difficult for the average patient to tell real doctors from quacks. In essence, the health care system would have to both embrace the fake treatment industry and their practitioners and actively support pseudoscience.

Because encouraging people to accept fake treatments for their real medical problems, it would also lead to critical thinking being subverted. The average patient will not be able to navigate the confusing environment and there is a great deal of credulity among alternative medicine proponents.

“Placebo Medicine” is harmful

When people rely on fake treatments that are ineffective, they might be less inclined to rely on science-based treatments. This might be especially true if they have bought into the “pharma conspiracy” narrative so often pushed by alternative medicine proponents. If they are less likely to use real treatments, it is likely that this will be harmful to them compared with going through real treatments.

However, ineffective treatments can also be directly harmful. This is because they can be contaminated by dangerous amounts of heavy metals, pesticides or even prescription medication. Because the alternative medicine industry is largely unregulated, there are very few checks and balances for these products, especially if you buy them on the Internet. In some cases, the product might not even contain any of the substances that the seller is putting on the bottle or contain very different concentrations that the label says.

Conclusion

Giving patients placebo treatments for real medication conditions in a clinical setting is a terrible idea. Placebos are weak, their effects disappear within a short period of time, and have very little effect on objective measures. At best, you are merely suppressing subjective symptoms while objective symptoms remain or worsens. It would also involve deception and force doctors to lie to their patients, which violates basic medical ethics and denies informed consent. Falling for the “placebo medicine” narrative would also provide tremendous monetary gain to companies who produce fake treatments and give them a level of credibility they do not at all deserve. Finally, many alternative medicine products have found to be contaminated by heavy metals, pesticides or even prescription medication.

Emil Karlsson

Debunker of pseudoscience.

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