Placebos And Deception
Swift
Written by Dr. Steven Novella
Monday, 15 August 2011 12:05
"The first principle is that you must not fool yourself, and you are the easiest person to fool." - Richard Feynman
We (meaning people) are really good at fooling ourselves. Our brains excel at that task perhaps in excess of all others. I suspect this derives from one of the basic functions of our brains - consciousness, which is a constructed illusion of our own existence.
This is not to say that we do not exist, or that our consciousness is not constructed from real information about the world. Our senses have a practical relationship to reality that serves us well. But the end result, our stream of consciousness, is massively constructed. Information is filtered, interpreted, and altered, then stitched together with the gaps filled in seamlessly.
Our brains are constantly making assumptions about what is probably happening, projecting our vision into the future, and altering one sense based upon information from other senses.
At the highest level of functioning, our reasoning ability, our brains spend a lot of time and effort serving our basic emotional needs. So we construct a fictional reality from a highly egocentric perspective. The default mode of human behavior is to engage in "motivated reasoning" - to rationalize away the negative, and emphasize the positive.
Skeptics, to varying degrees, but generally, understand and accept this view of the human condition. We can rattle off examples of how hopelessly biased and mistaken people can be on a regular basis. There does not seem to be any practical limit to the degree to which people can fool themselves.
And yet, on an equally regular basis the skeptical position is often casually dismissed by grossly underestimating the human capacity for self-deception. We hear phrases such as, "so many people can't be wrong," "Where there's smoke there's fire" (referring to anecdotal evidence)," or "Do you think everyone is crazy or lying?"
The effort to promote science-based medicine (SBM), which is an inherently skeptical project (and is now officially supported by the JREF) encounters the same casual dismissal of our arguments. The most important specific manifestation of this dismissal is justification by "the placebo effect." This is why we have spent much time at SBM writing about placebo effects, and why that was our chosen topic for the SBM panel at TAM9 this year.
Essentially, the evidence strongly suggests that placebo effects are largely a manifestation of the same kinds of self deception that leads to belief in alien visitation and Bigfoot. People report that they feel better because of expectation, suggestion, confirmation bias, and a simple desire to get better. They interpret regression to the mean or random fluctuation in symptoms to a cause and effect from treatment. They do not properly isolate variables and will interpret non-specific effects as effects of a specific intervention.
The perception of symptoms in the first place is also highly susceptible to the full spectrum of psychological effects. And further, psychological stress can sometimes manifest as physical ailments, which of course can then respond to the mere suggestion of treatment, which can help alleviate stress.
Engaging all of these psychological effects, as well as distracting patients from symptoms, or getting them to focus more on the positive, and take better general care of themselves, is all part of the therapeutic ritual. This may even include real health benefit from stress reduction, improves lifestyle, and improved compliance with treatments.
When the subjective experience of symptoms improve with a physiologically inactive treatment, many people (I would say most) do not want to believe the apparent effects are due to placebo effects. They want to believe that they are benefiting from the specific effects of a treatment. There is a tendency to be insulted, as if this means the symptoms (or the improvement) was "all in their head" - a commonly used phrase that is meant to imply dismissiveness.
But it's not dismissive. It's no more dismissive than suggesting that someone who believes they were abducted by aliens simply had a hypnagogic hallucination, or that someone who believes they saw a ghost experienced pareidolia combined with suggestion. It's no more dismissive that chalking up the sense that a psychic was very accurate to confirmation bias and a reasonably well done cold-reading.
People are really good at deceiving themselves, even to the point of manufacturing false experiences and memories. This is not dismissive or insulting - it's the human condition.
It is also why we need science. Science is a collection of methods that are designed to control for the significant human tendency toward bias and misperception. If we want to know whether some people have psychic ability, we cannot base our conclusions on anecdotes alone. We need to observe the alleged phenomenon under tightly controlled conditions - conditions that do not allow for all the various methods of self-deception.
The same is true for any medical intervention. If we want to know if a treatment works, we have to test it in such a way that placebo effects can be controlled for. Only if there is a consistent effect in excess of placebo effects do we conclude that the treatment "works" - that it has a specific physiological effect.
More and more, however, proponents of treatments that do not appear to work when studied in controlled conditions are arguing that they "work" through placebo effects. This is like saying that psychic abilities "work" through cold reading.
Placebo effects are mostly, and in some cases entirely, psychological effects and self deception. But even skeptics are often left with the question -well, if it makes people feel better, then who cares.
I think an appropriate analogy is this - it's like saying, well, if people are entertained by a psychic reading, even if it's nothing more than a cold reading, than who cares. Sure, you can make an argument for doing a "psychic" reading for entertainment purposes only. But I think most skeptics understand the risks of doing a cold reading in order to convince someone that one's abilities are genuinely psychic, and then hitting them up for larger and larger sums of money in order to contact their dead relative.
In medicine the stakes are even higher. It is dangerous to use placebo effects to convince individuals, the public, and regulators that an inactive treatment is effective. If someone is convinced that homeopathy works because it "helped" their cold symptoms, they may be inclined to rely on homeopathy when they have a serious illness.
Further, placebo effects have been leveraged to get superstition-based ineffective remedies into medical schools, scientific journals, and funded by the government to be researched. Limited resources are being diverted to pay for and research nonsense. In other words - there is clearly demonstrable direct and indirect harm from confusing placebo effects for specific effects.
All of this mischief is largely due to the fact that people significantly underestimate how massively susceptible we are to self-deception. Feynman's observation is as relevant today as it has ever been
