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‘Placebos’ and the logic of placebo comparison

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Abstract

Robin Nunn has argued that we should stop using the terms ‘placebo’ and ‘placebo effect’. I argue in support of Nunn’s position by considering the logic of why we perform placebo comparisons. Like all comparisons, placebo comparison is just a case of comparing one thing with another, but it is a mistake, I argue, to think of placebo comparison as a case where something is compared to ‘a placebo’. Rather, placebo comparison should be understood as a situation which sets-up the treatment and control groups in a particular way; not as a case involving objects or procedures called ‘placebos’ employed in order to control for ‘placebo effects’.

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Notes

  1. The concern in this paper is with placebo comparison, and so the argument is about the use of the term ‘placebo’ in a research context. Clearly however, the term has uses in clinical contexts that may be valid for independent reasons. I would expect the argument made here to apply to the clinical context; since the general idea is simply that the term obscures what can be better explained in more precise terms. However I will not argue explicitly for this here.

  2. Although note that such a principle does not imply that we cannot know that a treatment is efficacious unless a placebo comparison has been performed. It simply equates efficacious treatments with placebo outperforming treatments. If we know a treatment is efficacious, that justifies the belief that it would outperform placebo, were such a comparison to be performed.

  3. Or more precisely, a pill with no therapeutically relevant contents (cf. Golomb 1995; Golomb et al. 2010).

  4. Actually I’m just assuming they were sugar pills. We are told in the Branthwaite & Cooper’s methods section (1981, p. 1576) that the pills not containing aspirin were the same size, shape, weight and colour, and that they were not designed to taste the same as aspirin tablets. The content of these pills is not disclosed.

  5. Note aside that only some aspects of a treatment can be controlled for by randomisation (if that is, any can. See: Worrall 2007, 2010). In practice randomisation and the subsequent adjustment of baseline imbalances helps to minimise, for example, the influence of patients’ differing expectations. However even in the ideal case randomisation would not help at all to solve the problem of treatment groups that were under the supervision of ‘nasty doctor’ on the one hand and ‘nice doctor’ on the other. The attitude and behaviour of the treating physician is something that we must seek to homogenise between groups through other means.

  6. Use of the term ‘placebo’ could also be important in a different way, if that usage created therapeutically relevant expectations in a patient. For example in a clinical context, through being told one is receiving ‘a placebo’; or in a research context, through being enrolled in a trial and told that one may be randomised to a placebo group. See for example: Kaptchuk et al. (2010) and Enck et al. (2011).

References

  • Adler HM, Hammett V (1973) The doctor-patient relationship revisited: an analysis of the placebo effect. Ann Intern Med 78(4):595–598

    Google Scholar 

  • Amanzio M, Pollo A, Maggi G, Benedetti F (2001) Response variability to analgesics: a role for non-specific activation of endogenous opioids. Pain 90(3):205–215

    Article  Google Scholar 

  • Blackwell B, Bloomfield S, Buncher C (1972) Demonstration to medical students of placebo responses and non-drug factors. Lancet 299(7763):1279–1282

    Article  Google Scholar 

  • Blasi ZD, Harkness E, Ernst E, Georgiou A, Kleijnen J (2001) Influence of context effects on health outcomes: a systematic review. Lancet 357(9258):757–762

    Article  Google Scholar 

  • Branthwaite A, Cooper P (1981) Analgesic effects of branding in treatment of headaches. Br Med J 282(6276):1576–1578

    Article  Google Scholar 

  • Cartwright N (2007) Are RCTs the gold standard? BioSocieties 2(1):11–20

    Article  Google Scholar 

  • Cobb LA, Thomas GI, Dillard DH, Merendino KA, Bruce RA (1959) An evaluation of internal-mammary-artery ligation by a double-blind technic. N Engl J Med 260(22):1115–1118

    Article  Google Scholar 

  • de Craen AJM, Moerman DE, Heisterkamp SH, Tytgat GNJ, Tijssen JGP, Kleijnen J (1999) Placebo effect in the treatment of duodenal ulcer. Br J Clin Pharmacol 48(6):853–860

    Article  Google Scholar 

  • Dimond EG, Kittle CF, Crockett JE (1960) Comparison of internal mammary artery ligation and sham operation for angina pectoris. Am J Cardiol 5:483–486

    Article  Google Scholar 

  • Enck P, Klosterhalfen S, Weimer K, Horing B, Zipfel S (2011) The placebo response in clinical trials: more questions than answers. Philos Trans Royal Soc B 366(1572):1889–1895

    Article  Google Scholar 

  • Ernst E, Resch K-L (1995) Concept of true and perceived placebo effects. Br Med J 311:551–553

    Article  Google Scholar 

  • Golomb B (1995) Paradox of placebo effect. Nature 375:530

    Article  Google Scholar 

  • Golomb B, Erickson L, Koperski S, Sack D, Enkin M, Howick J (2010) What’s in placebos: who knows? Analysis of randomized, controlled trials. Ann Intern Med 153(8):532

    Google Scholar 

  • Gøtzsche PC (1994) Is there logic in the placebo? Lancet 344(8927):925–926

    Article  Google Scholar 

  • Gøtzsche PC (1995) Placebo effects. Concept of placebo should be discarded. Br Med J 311(7020):1640

    Article  Google Scholar 

  • Grünbaum A (1981) The placebo concept. Behav Res Ther 19(2):157

    Article  Google Scholar 

  • Grünbaum A (1991) The Placebo Concept in Medicine and Psychiatry. In: Cicchetti D, Grove WM (eds) Thinking Clearly about Psychology, Volume I: Matter of Public Interest. University of Minnesota Press, Oxford

    Google Scholar 

  • Hahn RA, Kleinman A (1983) Belief as pathogen, belief as medicine: “Voodoo death” and the” placebo phenomenon” in anthropological perspective. Med Anthropol Q 14(4):3–19

    Article  Google Scholar 

  • Hill A (1951) The clinical trial. Br Med Bull 7(4):278–282

    Google Scholar 

  • Howick J (2009) Questioning the methodologic superiority of ‘placebo’over ‘active’controlled trials. Am J Bioethics 9(9):34–48

    Article  Google Scholar 

  • Hrobjartsson A, Gøtzsche PC (2001) Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment. N Engl J Med 344(21):1594–1602

    Article  Google Scholar 

  • Hrobjartsson A, Gøtzsche PC (2004) Is the placebo powerless? Update of a systematic review with 52 new randomized trials comparing placebo with no treatment. J Intern Med 256(2):91–100

    Article  Google Scholar 

  • Kaptchuk TJ (2002) The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance? Ann Intern Med 136(11):817–825

    Google Scholar 

  • Kaptchuk TJ, Friedlander E, Kelley JM, Sanchez MN, Kokkotou E et al (2010) Placebos without deception: a randomized controlled trial in irritable bowel syndrome. PLoS ONE 5(12):e15591

    Article  Google Scholar 

  • Kirmayer LJ (2004) The cultural diversity of healing: meaning, metaphor and mechanism. Br Med Bull 69(1):33–48

    Article  Google Scholar 

  • Koshi E, Short C (2007) Placebo theory and its implications for research and clinical practice: a review of the recent literature. Pain Pract 7(1):4–20

    Article  Google Scholar 

  • Miller FG, Kaptchuk TJ (2008) The power of context: reconceptualizing the placebo effect. J R Soc Med 101:222–225

    Article  Google Scholar 

  • Moerman DE (2000) Cultural variations in the placebo effect: ulcers, anxiety, and blood pressure. Med Anthropol Q (New Series) 14(1):51–72

    Article  Google Scholar 

  • Moerman DE (2002) Meaning, Medicine, and the ‘Placebo Effect’. Cambridge University Press, Cambridge

    Google Scholar 

  • Moerman DE, Jonas WB (2002) Deconstructing the placebo effect and finding the meaning response. Ann Intern Med 136(6):471–476

    Google Scholar 

  • Moerman D, Benoist J, Brody E, Giovannini M, Gracia M, Hall E, Heggenhougen H, Jonas D, Kearney M, Kedenburg D (1979) Anthropology of symbolic healing [and comments and reply]. Curr Anthropol 20(1):59–80

    Article  Google Scholar 

  • Nunn R (2009a) It’s time to put the placebo out of our misery. Br Med J 338(apr20 2):b1568

    Article  Google Scholar 

  • Nunn R (2009b) Preparing for a post-placebo paradigm: ethics and choice of control in clinical trials. Am J Bioethics 9(9):51–52

    Article  Google Scholar 

  • Ong L, De Haes J, Hoos A, Lammes F (1995) Doctor-patient communication: a review of the literature. Soc Sci Med 40(7):903–918

    Article  Google Scholar 

  • Papakostas YG, Daras MD (2001) Placebos, placebo effect, and the response to the healing situation: the evolution of a concept. Epilepsia 42(12):1614–1625

    Article  Google Scholar 

  • Price L (1984) Art, science, faith and medicine: the implications of the placebo effect. Sociol Health Illn 6(1):61–73

    Article  Google Scholar 

  • Price DD, Finniss DG, Benedetti F (2008) A comprehensive review of the placebo effect: recent advances and current thought. Annu Rev Psychol 59:565–590

    Article  Google Scholar 

  • Rabkin JG, Markowitz JS, Stewart J, McGrath P, Harrison W, Quitkin FM, Klein DF (1986) How blind is blind? Assessment of patient and doctor medication guesses in a placebo-controlled trial of imipramine and phenelzine. Psychiatry Res 19:75–86

    Article  Google Scholar 

  • Shapiro AK (1964) A historic and heuristic definition of the placebo. Psychiatry 27:52–58

    Google Scholar 

  • Shapiro AK (1968) Semantics of the placebo. Psychiatr Q 42(4):653–695

    Article  Google Scholar 

  • Shapiro AK, Shapiro E (1997a) The Placebo: Is It Much Ado About Nothing? In: Harrington A (ed) The Placebo Effect: An Interdisciplinary Exploration. Harvard University Press, London

    Google Scholar 

  • Shapiro AK, Shapiro E (1997b) The Powerful Placebo. Johns Hopkins University Press, London

    Google Scholar 

  • Stein HF (1983) On Placebos. Medicine after the Demise of” The Placebo”. Medical Anthropology Quarterly:4–17, To Cure, to Control, to Please

    Google Scholar 

  • Stewart-Williams S, Podd J (2004) The placebo effect: dissolving the expectancy versus conditioning debate. Psychol Bull 130(2):324–340

    Article  Google Scholar 

  • Temple R, Ellenberg S (2000) Placebo-controlled trials and active-control trials in the evaluation of new treatments. Part 1: ethical and scientific issues. Ann Intern Med 133(6):455–463

    Google Scholar 

  • Thompson J, Ritenbaugh C, Nichter M (2009) Reconsidering the placebo response from a broad anthropological perspective. Cult Med Psychiatry 33(1):112–152

    Article  Google Scholar 

  • Worrall J (2007) Evidence in medicine and evidence-based medicine. Philos Compass 2(6):981–1022

    Article  Google Scholar 

  • Worrall J (2010) Evidence: philosophy of science meets medicine. J Evaluation Clin Pract 16(2):356–362

    Article  Google Scholar 

Download references

Acknowledgments

Thanks to those at the 2010 ‘Progress in Medicine’ conference in Bristol who offered comments on a very early version of this paper, and thanks to Robin Nunn for comments on a much more recent version. Thanks also to the helpful comments of the anonymous reviewers.

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  1. Institute for Science & Society, SSP, Law & Social Sciences Building, University of Nottingham, Nottingham, NG7 2RD, UK

    Andrew Turner

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Turner, A. ‘Placebos’ and the logic of placebo comparison. Biol Philos 27, 419–432 (2012). https://doi.org/10.1007/s10539-011-9289-8

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