Here’s your starter for ten as we continue our new Saturday slot posing a view for debate:
In the lively discussion about homeopathy and placebos following an earlier op-ed piece several people made comments about treatments which rely purely on the placebo effect such as: “If a placebo works and is safe and cheap, why on earth should we stop funding it?”
The more general issue of placebos was raised by Lynne Featherstone in an op-ed back in early 2008:
The placebo effect is seen when people are given treatment, such as pills, where the psychological impact of thinking that the treatment will make you better actually does – even if the pills are inert, containing no health-giving recipe at all. Give people a “medicine” that is really nothing such, but tell them it will make them better – and, lo, it can do.
It’s a weird display of the power of the mind when given a suggestion; a happy flip side perhaps of the power of the mind over the body you so often see when one of a couple who have been happily married for decades passes away – and then the other slips away shortly afterwards as if their mind simply no longer has any desire to keep their body going.
Of course it doesn’t work for all people in all circumstances (that would make the NHS’s job easy if it did!), but it’s a real, solid, verifiable effect – and one that medical scientists have to take into account when testing new medicine because, without allowing for it, their tests may otherwise fool them into thinking that some possible new medicine really does have health-giving properties when in fact it is only the placebo effect at work…
Which brings me to the dilemma. If a GP telling me that a treatment is extremely likely to work makes it actually more likely to work (because of the placebo effect) then shouldn’t they perhaps lie to me and tell me that even if it isn’t really that likely to work?
Ben Goldacre (I think) made the point well in The Guardian a little while back that this perhaps helps explain some of the popularity of alternative medicines compared with traditional medicine. For traditional medicine, GPs have shifted hugely in their outlook – being told to tell patients the full range of information about possible treatments, their chances of success and possible side-effects – and thereby sowing doubt into patients’ minds. But alternative medicine is often presented by its practitioners with absolute confidence – and so (regardless of any other benefits) scoring an immediate win on the placebo front.
Now – there are all sorts of benefits about keeping patients properly informed, including keeping a checking on conventional wisdom or vested interests getting out of control.
Yet here is the riddle: if doing that means they are actually less likely to get well in that immediate here and now case, who wouldn’t be tempted to shade the information? Would you be tempted to tell you child or partner a small fib about how sure you are the treatment is to work even if you know otherwise? And would that really be wrong?
There are lots of issues here so over to you and the comments thread…
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22 Comments
Lying is wrong & is always the servant of Power, of the strong against the weak. I always liked that quote from The Bible that the CIA adopted as their motto – “The Truth will set you free”. That could be a Libdem slogan.
It should be noted that this would appear only to be a problem for those of you who believe that *I* should be made to pay for *your* medicine. If we didn’t have the medical ponzi scheme known as the National Health Service, with all its inbuilt economic rent, protectionism and barriers to entry, closed shops and so on, and we were thereby all more able to afford to pay for our own health care, it would of course be entirely up to the user and their physician – whether that was to involve homeopathic “treatments”, crystal “healing”, or the village medicine man.
Then again, Ben Goldacre in a post last week about which I blogged also pointed out that the actual *evidence* for efficacy claimed by manufacturers of quite a proportion of “real” drugs was doubtful and not backed by science and that the fuss about homeopathy is actually in some ways covering up a bigger iceberg, and that regulators and policy makers might appear to be focussing on an easy target (“alternative” medicine as it was once called).
I think I’m probably drifting anyway towards some of the ideas of Ivan Illich like latrogenic disease.
“Lying is wrong & is always the servant of Power, of the strong against the weak.”
Even when lying may get you or someone else out of being the victim of the strong – convincingly denying you have a family of Jews hiding in the attic, say?
Anyhow, the thing is the placebo scenario strictly speaking may be lying (but then it *is* possible that much of medicine is about *hearing* what you want to hear from the “expert” – in which case, if it works, it works and why change it), but in the case of homeopathy, for example, many physicians have themselves been persuaded/fooled (depending on which side you are on). My paternal grandparents were on homeopathic medicines for the last twenty years of their lives, prescribed by a bona fide and well thought of local GP who had become their friend when he cared for my grandfather after his first heart attack. Whatever the rights and wrongs of it, both lasted till well into their eighties, which, for working class Glaswegians (he was a miner), is a good run.
I think the “powerful placebo” narrative is worth questioning.
Kienle GS, Kiene H: “Beecher was the first scientist to quantify the placebo effect. He claimed that in 15 trials with different diseases, 35% of 1082 patients were satisfactorily relieved by a placebo alone. This publication is still the most frequently cited placebo reference. Recently Beecher’s article was reanalyzed with surprising results: In contrast to his claim, no evidence was found of any placebo effect in any of the studies cited by him.” Abstract: http://www.ncbi.nlm.nih.gov/pubmed/9449934
From a Cochrane review by Hróbjartsson and Gøtzsche: “We found no evidence that placebo interventions in general have clinically important effects. A possible moderate effect on patient-reported continuous outcomes, especially pain, could not be clearly distinguished from reporting bias and other biases. We suggest that placebo interventions should not be used outside clinical trials, also for ethical reasons, as the use of placebo often involves deception.” Abstract: http://www.ncbi.nlm.nih.gov/pubmed/15266510
I’ve discussed the research into the placebo effect here: http://jdc325.wordpress.com/2009/11/13/the-powerful-placebo/
If, knowing that many in the medical and scientific community believe that homeopathic remedies are at best placebos, I regularly take homeopathic remedies and feel better, I am not lied to. Nor have I ingested what are usually more expensive conventional drugs which may have potentially harmful side effects. I do not think that most Lib Dems (pace Evan) are arguing that I should not be able to make up my own mind about whether to do so. So should my choice be limited by whether or not I can afford to pay for homeopathic medicine?
Serena, yes, your choice should be limited by your own ability to pay for something if it’s not been demonstrated to work beyond the placebo effect. As James points out, the placebo effect isn’t something that can be relied upon, which is in stark contrast to how it was presented by Lynne in the OP. I begin to suspect that some kind of almighty ‘placebo effect’ is the new tool of choice for people who wish to push alternative medicines, without mentioning some of the salient facts about it:
(a) it doesn’t work every time
(b) it works in different ways for different people
(c) it has fairly low odds of actually working in any case
The knowledge that placebos are being provided on the NHS has the knock-on impact of making everything GPs say have the potential of being misleading, and would massively knock confidence in all prescriptions. it would therefore successfully remove any possibility of the placebo effect actually, well, working.
Jock, I fear you’re letting your politics stray across into your epistemology.
If Lynne Featherstone is willing to give me as a patient the choice – which isn’t at all clear from what she wrote – then I have no hesitation in saying that I don’t wish to be lied to by my doctor about any aspect of my medical treatment.
But if other people feel differently I see no harm in giving them the choice. When they turn 18 people could be presented with a form, giving them the option of signing up to some statement such as “In circumstances where the NHS considers it to be cost-effective, I give permission for my doctor to prescribe treatment that has no provable benefit apart from a psychological one, and to lie to me about its effectiveness”.
Adam:
As a non-schooled philosopher or whatever I do hate people using that word – I can never really grok what it means. Besides I am diabetic, not epistemic!
But I guess you mean that I am not treating the “science” with enough seriousness by simply saying that it ought to be up to the individual to use or not use, accept or not accept these things for themselves in a free-market.
It seems to me that there are two issues here:
1. Should the rest of us pay for others to receive things of dubious efficacy, however objectively you are able to describe that (my answer is no, in a free medical market)
2. Is it right for medical professionals to suggest, promote, whatever things that they believe or know to be based on placebo effect (assuming we have got the first question out of the way).
…and that only the latter touches on epistemology. You may feel that this is the main question in the debate, and I’d probably agree, but why let that get in the way of pointing out that “if you’re paying for it yourself, it’s up to you and you are not wasting my money in choosing these dubious remedies”…:)
Is it unethical to lie? Yes. Even if the user is paying? Yes. In fact, since it would then be a contract patients probably have better remedy through arbitration/contract/tort than they would under the NHS. Though I do feel that “placebo” and “homeopathy” are different things in that nobody claims a sugar pill has any treatment agent whereas people do believe that mystically homeopathic “medicines” do.
Personally, I am sceptical, but I am also sceptical of the “closed shop” of medical pharmacology also, and especially on reading the Goldacre piece I linked to previously and as I say, tend to think that perhaps, we deify conventional medical science as well a bit much and as a result, after Ivan Illich, we may actually be less well (and potentially getting worse – in terms of an evolutionary immune system deficiency and so on).
As I understand it, there may be three reference points here for assessing treatment effectiveness..
One. What happens if you do nothing and let the disease run its course. Many ailments are self-limiting and any intervention is actually irrelevant to the likley outcome
Two. You give a ‘Placebo Treatment’ and this leads to some measurably better range of outcomes than option one.
Three. You give an active ingredient treatment. If this leads to better primary outcomes than option two, do these outcomes outweigh any side effects? If the outcomes are no better than in option two do any side effects make placebo superior?
I agree with Jock (I think) that the Bigger Iceberg is where we should be concentrating attention.
If the NHS were simply funding cheap generic sugar pills with no active content that GPs could keep in their desk drawer and give away free to patients where appropriate, saying “Take one of these twice a day and come back and see me in two weeks’ time if it doesn’t go away”, it would be one thing.
However this is not what the NHS is funding. Instead the NHS is funding an entire homeopathic edifice that, to give it the benefit of the doubt, does not believe that it’s dispensing placebos: it thinks it’s providing real medicine, when em>in fact the treatments are no more effective than placebos. A very large difference.
The NHS should be providing evidence-based medicine and not quack remedies of any kind. In my view this completely rules out the NHS providing any treatments for which there is no clear scientific evidence, including homeopathy and many other “alternative” treatments. In my view there is no such thing as “alternative medicine”: it’s either medicine or it isn’t, and homeopathy, it appears, isn’t.
There is of course evidence that placobos work, and no doubt any effect would be reduced if the patient were told that there was nothing in the pills. Thus if the NHS were to prescribe placebos then you would not be able to tell the patient that this was what they were. However if the NHS were to use placebos, it would recognise that it was doing so and define the circumstances in which their use was appropriate. It should not be funding an edifice of quackery – that is something quite different.
“Is it unethical to lie? Yes. Even if the user is paying? Yes.”
Surely it’s like corporal punishment. If the customer is paying for it, it’s not unethical.
Richard Elen is quite right. The key point is that if the NHS is going to spend taxpayers’ money on any kind of medicine or treatment it should do so on the basis of reliable evidence that it works.
Looking at it the other way round – if someone is ill, or injured, they deserve to get the most effective treatment for their condition, not something which is less effective.
As Tim Minchim puts it: What do you call alternative medicine that works? ‘Medicine’.
If the NHS is to fund treatment that only performs as well as a placebo then it should at least fund the cheapest possible placebo and not fund the nonsense that is homeopathy.
A fool & his/her money are soon parted.
Don’t forget, your homeopathic remedy won’t work unless it’s been banged on that horsehair cushion.
Neil:
I disagree. I think there is a big grey area (and I am not saying that homeopathy falls into it by the way) between “medicine” as approved of by vested interests and many other quite possibly efficacious treatments of which the “profession” takes a disapproving or downright dismissive view because they don’t fit with those interests mainly I suspect.
I agree that physicians should not lie, and that “placebo medicines” like homeopathy, should not be provided at public expense.
However, assuming the placebo effect works then it becomes very powerful evidence of psychological impact on physical health. I draw two conclusions from this.
Firstly scientific medicine should immediately take account of the apparent benefits of longer more comprehensive consultations with practitioners.
Secondly the phenomenon of “mind over health” should be much more fully studied in the hope that it can be rationally harnessed in some way which does not involve deception.
There are two main reasons that people think that alternative remedies like homeopathy have “worked for them”, one is the placebo effect, which people have been discussing here, the other is “regression to the mean”. Its easy to overestimate the “mind over matter” aspects of the former compared with the more prosaic explanation offered by the latter.
Basically, some conditions, particularly chronic conditions, fluctuate over time. If you use a particular treatment when your skin complaint flares up, it may well subsequently get better. This might not be because of the treatment, or even the “mind over matter” aspects of the placebo effect, but just because that was what it was always going to do irrespective of the treatment.
It’s because scientists understand that these effects occur that they devised Randomised Controlled Trials. There’s even a latin tag that covers this “Post hoc ergo propter hoc” , which was also the title of an episode of West Wing!
To answer the title question – “what’s wrong with treatments that act like placebos?” – nothing. As the report from the Science and Technology committee said – there is no doubt that people should be able to get these treatments from shops or private hospitals or the like. It’s quite another thing for the NHS to fund it.
There seem to be two objections: choice, and ‘o it works anyway’.
To deal with the latter one first. The point of course is that it doesn’t. People are getting medicines that they believe to work but has no known way that it could help, or statistical association with improvement. The only reason that this is allowed is because the illnesses are not that damaging, with strong regression to mean, so that it actually doesn’t matter if people get proper medicine. But in some cases it will. Will you take resouces from real life saving/improving treatment to bankroll a lie, and a dangerous life-and-death lie at that? People will continue happily without knowing that they actually are not getting the treatment they need.
Indeed, in the case of homeopathy that support of the lie is used to validate the businesses who earn masses of money deceiving people about health and medicine. I cannot see how that is different from government sponsership of tobacco companies, (indeed, at least these days they don’t try and misinform people)
Secondly, What does it mean to say that the NHS should fund something that has, for some people, culturally imbued (i.e. not “real”) efficacy? That people have the “choice” because they may not be able to afford to buy the overpriced medicines themselves. I think people forget what the NHS is – it is not the only way to get health, but is is paid for by everybody, and consequently has a limited budget. In fact this repsonse beggars belief. The NHS is a great system (or at least, universal healthcare however provided) because it means that people no matter what their income have access to lifesaving and life-changing care. To say that people should have a “choice” to be able to get bogus treatment – at the expense of others getting real, vital treatment – is astounding. If people had to actually to the choice with real people, not arbitrary figures of money – and had to face their choice – I think everyone, everytime, would choose real medicine. Support of homeopathy is a farce.
That is not to say, (Jock, I believe you have mentioned this), that all ‘medicine’ is wonderous and effective, I agree! But that is the point: we need more openness and testing, with rigorous standards, so we understand what we are paying for. To say (as I don’t think you are) that well, homeopathy doesn’t work, but neither (maybe) does conventional medicine, so even-stevens, is a tragedy.
Harry:
Indeed I am not saying that, and I don’t think the Goldacre article is saying that either. But what he is saying, I think, is that the fuss about something as obviously quackery (pace my grandparents who seemed to feel it did them lots of good) as homeopathic “treatments” is actually hiding a much bigger scandal – that there are lots of approved treatments for some very serious ailments that are getting away with advertising to medical professionals in the best industry journals and the like, having been approved by regulators, for which the science does not prove their claims any more than it does for homeopathy. And that the proportion of such treatments is really very seriously large, it would appear – i.e. like a third in the sample evaluations of treatments vis-a-vis the science “backing up” their advertising claims that have been done.
NB – that is not to say that they aren’t effective treatments necessarily, just that the research evidence they produce does not actually back up their claims – actual use in practice may very well prove them effective.
I’ll have a look, Jock, at those things. Something of interest here is Irving Kirsch’s new book on psychiatric drugs which I’ve started reading. His idea is that most of the tests for those drugs are seriously flawed and most are useless.
Interesting you talking about having competing agencies: it immediately made me think of financial raqtings agencies, and thither ‘who pays?’. That’s the key. Perhaps autonomoous hospitals would have an incentive to get the best results, but they could easily be swayed be the interests, too.
HarryD:
I’m not sure that was in this topic was it? And it may be straying too far from the topic, but I will indulge myself with one response.
I think the financial ratings agencies are too simple a model actually. And that’s partly I guess because of the nature of the things they are “rating” – financial instruments for financial risk takers who also have other ways of mitigating their risk through portfolio diversity or hedging. But they do not have the sort of economic incentives that a system of competing medical insurers would have. I have never heard of a ratings agency having to pay out if their assessment proved inaccurate. Losing credibility and custom perhaps, but not actually compensating losers.
There are at least three, probably four, different groups of people or organisations who would require insurance in a free market medical system – the patient for insurable risks requiring treatment or savings for non-insurable foreseeable treatments, the practitioner requiring registration of his credentials and professional indemnity cover, the facility for indemnity cover, and the treatment producer for indemnity cover. They may all be provided by different specialist insurers, but the common theme is that if the insurer “approves” something – a doctor, a treatment, a hospital or advice for the patient, they would reasonably be liable if their approved option went wrong.
Compare that with the current system – there is no economic incentive on the part of NICE or the FDA in the US whereby if they approve something that then does damage they end up out of pocket. Yes I suppose increasingly people are taking to suing state organisations for compensation, but it is a zero sum game still – any payout is of course financed out of existing budgets and impacts on other areas of operations or takes more from the rest of us in taxes. IN fact, practice seems to be that if a state run agency does get something wrong, it’ll probably get a bit more money to recruit some extra people in an attempt to make sure it doesn’t happen again.
Indeed, on the other side, the state run regulators actually have an incentive to delay or be less efficient than they might be about approving some new treatment. An insurer who was actually facing paying out for someone’s treatment might well want to take steps to expedite treatment approval if it will enable their patient for whose treatment they are paying to be cured with one dose and cost them nothing more, rather than have a long period of treatment with a satisfactory but perhaps not exactly “leading edge” existing treatment.
Whilst you might point to a treatment that perhaps should never have been approved because it turns out to be deadly (thalidomide perhaps would be a good one) and say “that regulator ought to be liable for all the death, disability and suffering they cause by approving it” nobody really worries, perhaps except the treatment producer who could be making money out of it, about how many people die or suffer for want of a treatment that the regulators are slow approving.
Same goes for the General Medical Council or the Royal Colleges. They don’t lose if a practitioner they approve turns out to be a liability. IN fact it seems to me that they rarely even lose reputation and certainly not economically, such is their monopoly and the artificial therefore esteem in which they are held.
hmm, spam filters appear to be eating my comment on this thread, so I’ve posted my thoughts here on my blog – please feel free to digest them and come back here to reply 🙂
Alec Dauncey alludes to “mind over health”. In fact there is already a well established method for exploiting the phenomenon: hypnosis/hypnotherapy. Now don’t get me wrong: I am not here to proclaim that it is ‘the answer’ or that it is anywhere near to being well enough developed. However I would like to make a case for more consideration. A few years ago I trained and qualified as a hypnotherapist, but have never practiced. So I know at least a little of what I am talking about but do not have a vested interest.
First, and above all, get out of your heads the nonsense of stage hypnosis which is conjuring with minds for entertainment. Surgery may still take place in a ‘theatre’ but is no longer an amusement; I hope hypnosis will go through a similar transition. Also abandon any idea that therapists can ‘program’ victims: neither to rob banks, commit murder nor heal themselves. That’s the stuff of Hollywood. A fiction.
Hypnotherapy probably works by exploiting the placebo (or similar) effect – but it is honest about doing so, no lying is necessary. Even the language used is clear: it works by the power of ‘suggestion’; it works by exploiting imagination and fantasy; the therapist enables and facilitates – s/he is not like a mechanic ‘fixing’ a problem with a car. Certainly the therapist is positive and assertive about the value of their treatment – but then so is my GP. In fact saying “this course of hypnotherapy is going to work because it will exploit your placebo response” would probably be regarded by most hypnotherapists as a useful way of increasing the confidence of the client.
Hypnotherapy is already used by some conventionally trained doctors and dentists (although I was shocked to discover how superficial their training was compared to the longer program I went through, which itself was described by the tutor as only a beginning). There is some uncertainty about a systematic explanation of how it works, but that revolves around a lack of understanding about ‘the sub-conscious’, the mind, and even about an agreed set of concepts and words that can be used to discuss the topic. However – importantly – it does not posit an incredible mechanism (as homeopathy does) and it does lend itself to scientific trials. My experience of the people who were involved in hypnotherapy is that they were open to a rigorous scientific examination of the subject without any of the special pleading that most ‘magic’ medicine seems to wheel out: none of the ‘our method is special and can’t be tested by impersonal scientific studies’.
Does it work with ‘everything’? Certainly not. Does it work with ‘some’ things? I believe it does and I believe it could work with many more disorders and could certainly assist with many more issues around chronic disease such as pain management. Does it need more development, more research and more evidence? Definitely. Will it get it? Ah, there’s the rub: probably not because it is cheap. People can be relatively easily trained and are not highly paid (compared to GPs, surgeons, etc). Business is not going to make enough profit out of it to justify spending the money to carry out large-scale trials. Pity.