Proof of the Innate Superiority of Private Health Insurance
Among recent winners of the Ig Nobel Prizes were Rebecca L. Waber, Baba Shiv, Ziv Carmon, and Dan Ariely for research about "Commercial Features of Placebo and Therapeutic Efficacy."
Two sets of volunteers were subjected to electric shocks after taking a placebo. The group who thought they were taking expensive medicine felt less pain than the group who thought they were taking cheap medicine.
The more it costs, the better you feel!
Q.E.D.
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It's teh humor!
October 3, 2009 4:24 PM | Reply | Permalink
In the reported study, the cost of the "medication" made almost no difference at low levels of inflicted pain (electric shock), and very little difference at high levels approaching the maximum tolerated doses. It was greatest at intermediate pain levels.
Translated to healthcare costs, this implies that when costs were a small fraction of family budgets (a very long time ago, if ever), families might have valued low cost insurance and even lower cost insurance more or less equally. Currently, they might be beguiled into believing the higher cost plans are better, even if they're not. On the other hand, when costs truly become intolerable (e.g., within ten years), families will no longer assume that costlier is better and will be more willing to evaluate plans on the basis of what they actually offer.
There are many other factors that make it difficult for subscribers to judge the quality of health insurance or health care, or their cost/benefit ratios, but the placebo effect is a variable that might also be considered in predicting future trends.
October 3, 2009 5:35 PM | Reply | Permalink
You're preaching to the choir, Fred!
And conversely, free blogs on the internet make me nauseous!
But my $2000 lifetime subscription to Penthouse...
That's some feel-good shit, and I feel good!
October 3, 2009 7:16 PM | Reply | Permalink
I'm not preaching to the choir, but pointing out that the "placebo" value of expensiveness operated only within a limited range. Once costs (or in the study, pain) became too great, their placebo effect diminished greatly. I expect we will see that with healthcare, and politicians alert to that possibility may be in position to take advantage of it in the way they frame the issues.
October 4, 2009 11:16 AM | Reply | Permalink
How many comments has this obtuse clown left on my diary?
13 and counting.
If anybody replies to a comment by zipperupus, for example, the clown Fred Moolten answers.
Who's talking to you, you jerk?
October 4, 2009 10:09 PM | Reply | Permalink
The converse of this proposition is also worth exploring, and if expensive medicine makes you feel better than cheap medicine, then...
Cheap medicine probably makes you feel better than free medicine, and...
Free medicine makes you feel better than medicine somebody pays you to take!
This suggests that paid volunteers in medical experiments experience the least benefit of any possible group, and Big Pharma's fine products probably work better for anybody who pays for them, and even free samples work better than the doses paid volunteers are paid to take!
This is great news for Big Pharma, and it's just their hard luck that those weasels don't read my blogs!
October 3, 2009 7:32 PM | Reply | Permalink
Or, as the Wired article says:
October 3, 2009 11:54 PM | Reply | Permalink
A similar experiment was conducted during the 2008 general election in the United States. Two placebos were offered to the public as the "candidates" vying for the highest office in the land. One candidate was labeled a "maverick" within his party and the other was labeled a "change" from the outgoing administration (as well as the "maverick's" party). The "change" candidate won, and once in office, continued the previous administration's policies.
October 3, 2009 8:04 PM | Reply | Permalink
quinn added a fascinating link on another site where this diary also sprouted...
But about that political analogy you made, gasket, again from quinn's link...
Don't say the P-word, gasket!
For all we know, Obama is a neuroscientist "hard at work concocting analgesic skin creams and methods for enhancing athletic performance."
Harharharhar!!!
October 3, 2009 8:27 PM | Reply | Permalink
Thanks for the link, RR. I'm almost done reading Understanding the Anxious Mind, so I'll take on quinn's article next. The juxtaposition of how some people are hard-wried for anxiety with how depression is "cured" in some people who take placebos ought to be an interesting pairing.
October 3, 2009 9:12 PM | Reply | Permalink
Okay, I have to say I'm not impressed with the Wired article (for several reasons that I won't bore you with). But it doesn't take much hunting to learn that Wired may be overemphasizing placebo effect for effect.
Pharma has a placebo problem? No, Pharma has a Wall Street problem. That's the story Wired touched on but otherwise completely ignored.
October 4, 2009 7:35 AM | Reply | Permalink
It seems to me that both the articles you linked are over-documented and under-thought.
For example, in this mess, the "researchers" reviewed 130 experiments and reached a crashingly obvious conclusion which was camouflaged by meaningless qualifications.
In their examples, an "objective outcome" was something like a cough.
"Are you still coughing?"
"Yes."
So the analgesic effect of a reassuring placebo doesn't cure a cough... and isn't that a surprise?
Why did these "researchers" prefer binary outcomes? Was there possiblya result they were aiming for?
Apparently there's a straw-man somewhere claiming more for placebos than I ever heard anyone claim, and wherever that straw-man may be, all sorts of grant-seekers can get their names in print by knocking him down.
In the other article, some "literary" doctors are eager to establish that medical interactions have meaning, and that's more than I can say for their jargoneering paper. More important than the text of it is the subtextual demonstration that someone mentioned Derrida in one of the few liberal artrs courses they could squeeze into their pre-med schedules, and they are accordingly much cooler than the average doctor.
Who isn't?
October 4, 2009 9:03 AM | Reply | Permalink
Who cares if my docs are "underthought"? I'm not a medical researcher. At least my links came from peer-reviewed journals and not Wired-fucking-magazine, which offers no citations whatsoever. The Wired author mentions the Michael J. Fox Foundation (I wonder why). So what? Not impressed.
The Wired article is even more underthought, yet you find it fascinating? Come on, Rootie! And quinn! Are you guys joking? Or do you happen to like the Wired article because it confirms your biases?
October 4, 2009 9:21 AM | Reply | Permalink
Hey, I didn't want a citation war! I read Wired for ideas and interesting stuff (not academic articles) and this one was/is interesting.
Anyhoo. The world spends a lot, in a massively organized effort, to find drugs which can be sold. Whereas the articles you linked to showed the authors failing even to DEFINE the Placebo effect. So for this whole range of human responses and methods of healing, this incredible world of potential - our medical establishment can't even describe an effect which shows up in thousands of their own trials??
So yes, I'm interested in the fact that the Placebo effect - if it WERE a pill - would be the most powerful multi-purpose drug known to humanity. I'm also interested in the (seeming) fact that the more Big Pharma hypes its drugs - and people believe - the more powerful Placebo becomes as well. And that Pharma is now wanting to beat down or get around Placebo. And ultimately, I'm incredibly pissed that monstrous levels of funding are going into the pills THEY want to patent - and almost nothing into determining how Placebo (and more widely self-healing techniques) works, how they can be improved, etc.
October 4, 2009 12:30 PM | Reply | Permalink
Hey, I didn't want a "citation war" either! And I didn't bring it up in the first place.
But the Wired article is inadequate and completely biased (in favor of pharma, if you didn't notice): It refers to the few studies it deigns to mention in the vaguest possible way, and it primes the reader by constantly invoking that there is a "placebo problem" for pharmaceutical companies. OMG! Poor pharma! There is no "placebo problem." It's an editorial invention barely supported by the facts presented in the piece.
What you bring to the article, quinn, is not relevant. The article itself is flimsy science reporting propped up with historical information and the details of one guy's work on jocks and a drug company's failure to compete in the marketplace. That's it. I certainly don't expect you to see how the writer could not deliver the article he may have originally proposed or was assigned, but I can see that he delivered an article that falls far short of the intent of the title, which is misleading to say the least. (For starters, depression has not been "cured"!)
Meanwhile, I didn't cite my articles to say, "Hey! Look at these great articles!" I cited them to demonstrate how LITTLE we know about drugs and the brain.
But I guess I have to spell that out to both you and Rootie because you are so enamored of the Wired piece. Okay. But at some later date, go back to the Wired article and look for the actual science in the piece. You might discover that there isn't much presented that can actually be called "scientific fact." Historical fact, exposition, supposition, and grasping at straws, yes, but scientific fact? Not so much. "Drug developers" say the placebo effect is getting stronger. Oh really? Merck and Eli Lilly say that? I wonder why.
October 5, 2009 11:16 AM | Reply | Permalink
Hey, I didn't want a "citation war" either! And I didn't bring it up in the first place.
But the Wired article is inadequate and completely biased (in favor of pharma, if you didn't notice): It refers to the few studies it deigns to mention in the vaguest possible way, and it primes the reader by constantly invoking that there is a "placebo problem" for pharmaceutical companies. OMG! Poor pharma! There is no "placebo problem." It's an editorial invention barely supported by the facts presented in the piece.
What you bring to the article, quinn, is not relevant. The article itself is flimsy science reporting propped up with historical information and the details of one guy's work on jocks and a drug company's failure to compete in the marketplace. That's it. I certainly don't expect you to see how the writer could not deliver the article he may have originally proposed or was assigned, but I can see that he delivered an article that falls far short of the intent of the title, which is misleading to say the least. (For starters, depression has not been "cured"!)
Meanwhile, I didn't cite my articles to say, "Hey! Look at these great articles!" I cited them to demonstrate how LITTLE we know about drugs and the brain.
But I guess I have to spell that out to both you and Rootie because you are so enamored of the Wired piece. Okay. But at some later date, go back to the Wired article and look for the actual science in the piece. You might discover that there isn't much presented that can actually be called "scientific fact." Historical fact, exposition, supposition, and grasping at straws, yes, but scientific fact? Not so much. "Drug developers" say the placebo effect is getting stronger. Oh really? Merck and Eli Lilly say that? I wonder why.
October 5, 2009 11:21 AM | Reply | Permalink
ARRRGGG! Sorry to post the comment twice. The fucking page wasn't loading and Movable Type determined that I wanted to submit the comment again.
October 5, 2009 11:25 AM | Reply | Permalink
Pish posh, this is just New York quality control and high standards speaking. ;-)
Truth is, Gasket, that when I read this kindof stuff now, within about 5 seconds I'm no longer paying attention to what the author's trying to argue. That's snotty, but not unreasonable. Because after people have read about 8.3 million articles like that, they tend to just scan the article for stuff that's new or interesting. Often it runs at a complete tangent to what the author's arguing, or is just a side fact or quote dropped into the piece. (Or at least, that's how I often read these days.) In this case, I found it interesting that perhaps the placebo effect may not be fixed in time - far more interesting to me that whatever Big Pharma was up to.
In short, what I bring to the article, find there, and take away from it, is what MOST interests me - not the quality of the article as "science article."
October 5, 2009 1:12 PM | Reply | Permalink
Yes, I know, q. What you just described about yourself is what I said about you—only I said it in shorthand. The interest you bring to the article and the info you glean from it (as well as the other stuff you ignore) is exactly what I meant by your "biases" and "what you bring to the article." Other readers do not bring your interests that piece.
The article on its face—sans the wondrous workings of your brain and Rootie's both—is not that great. In fact, it's almost propagandistic: It's definitely misleading (I can't figure out if the editors are just stupid, if they are trying to become Vanity Fair, or if they are deliberately misleading the audience) and it's manipulative in that it is pro-pharma without offering any other point of view. It made me wonder how much money Wired got in pharma advertising for running it. I was a little shocked by the one-sidedness of it, in fact.
However, if we're going to engage in a serious discussion about placebo effect, I personally want real articles, whether they align with my own biases or not.
Or if we're going to talk about bringing drugs to the marketplace, I also want a real article that gives more than just the drug makers' point of view. This article didn't provide much of use to me for either conversation.
Meanwhile, the drug companies have been quietly merging in order to disguise their failures to produce new drugs.
October 5, 2009 3:01 PM | Reply | Permalink
Yow! Did you notice that I actually bashed Big Pharma and the "researchers" who suck up to them in my comment about quinn's now famous link?
And I still say the Wired article is a better item than that survey of 130 tests of the placebo effect, which went over into outright bias when they decided to fold the outcomes of small-sample experiments into the large samples, apparently to avoid showing significant benefits of placebos in the small-sample tests for "objective" conditions.
October 5, 2009 7:26 PM | Reply | Permalink
Yes, I saw that, Rootie, and it made me laugh.
I think there is so much more to explore within the issue of biases, in the field of scientific research in general (as well as in the reporting of that research), and medical research in particular. We humans know so much (which we trumpet as if we had godlike powers), yet we can definitively explain so little (which we are never humble enough to admit).
After all this time on the planet, for example, we still can't identify the biological mechanisms of aging on the cellular level. We have several pet theories, some of which are in conflict with other theories of aging, and none of which are the definitive answer. (I bring this up because I happen to be doing some research in this field at the moment.)
When it comes to the human brain, we know and can explain almost nothing. I take issue with a general-interest magazine like Wired making so many definitive claims, as the Wired author does on this topic. I take issue because Wired's circulation is far wider than NEJM's, which has a "niche" (or specialized) audience. NEJM articles can be shot down if they are flawed, while Wired articles can't be shot down if its audience is not educated enough to do so.
From where I sit, I believe we don't have definitive data on placebos, let alone on the actual drugs themselves. (In other words, we assume a "control" that we don't fully understand. Wait! What do you mean you don't understand the effects of the "control"?) In a practical sense, if I were assigned an article on placebo effect, I am sure I would find myself in very deep water very quickly (based on what references I found easily, and inadvertently confirmed by Fred).
October 7, 2009 9:41 AM | Reply | Permalink
Yeah, but how convenient of you to leave out the SIDE EFFECTS and WARNINGS of Placebo. 'Tell your doctor if you experience shortness of beath, decreased appetite, bloody stools, suicide ideation, hives or other skin eruptions, nausea, vomiting, blurred vision, painful urination, or bad breath. WARNING: Do not operate heavy machinery while taking Placebo; If an erection lasts for more than eight hours, CONSULT YOUR DOCTOR IMMEDIATELY.
October 4, 2009 8:12 AM | Reply | Permalink
Like every normal adolescent, I suffer from all those side-effects you mentioned anyway, placebo or no placebo.
(But I usually wait until an erection has lasted two weeks before consulting a doctor.)
October 4, 2009 9:08 AM | Reply | Permalink
As an artist, you've probably noticed a similar effect with fine art, that being that the more expensive the artwork, the more satisfying ultimately, (for the patron). Har! Har! Har!
October 3, 2009 8:46 PM | Reply | Permalink
Twenty years ago, I spent considerable time with a neighbor who happened to be a Christian Science "healer." At the beginning of our acquaintance, my cynicism about her work knew no bounds, although I could see that she was earnestly involved, working hours and hours per day, seven days a week.
Over time, however, my cynicism diminished. Because it was hard to refute that people who believed in her power to heal tended to.... heal. She explained the phenomenon, not in religious zealot dogma, but in prosaic terms: "It's all about the belief system a person has," she said. "It doesn't matter whether one believes in Western or Eastern medicine, or simply in the power of the mind.
Whatever a person actually believes can support the healing of anything."
A few years later, this amazing, kind woman left Christian Science. When I asked why, she said that, although adults were perfectly capable of the focus required, she had come to the conclusion that children were not developmentally capable of such concentration; therefore, their healing rate was unacceptably lower.
Which might be another way of saying that the placebo effect only works in the mind of the believer, which is why BigPharma tests of same are blind,
October 3, 2009 9:34 PM | Reply | Permalink
William Blake says...
October 4, 2009 9:13 AM | Reply | Permalink
The placebo effect has been extensively studied in the medical literature. It is powerful, but limited. Despite anecdotal evidence to the contrary, the rigorous studies have shown it to be effective in relieving subjective symptoms, but mostly or totally ineffective in ameliorating objective abnormalities. It can relieve pain, depression, fear, or anxiety. It does not reduce blood sugar in uncontrolled diabetes, increase cardiac output in heart failure, make fractures heal faster, or cancers grow slower.
This is not to say that the mind cannot influence the body - it can, via classical hormonal and various other neurally mediated mechanisms. There is evidence, for example, that depression might slightly increase cancer risk, but this is not a placebo (favorable) or nocebo (unfavorable) result of medication reflecting a mistaken belief that one has been subjected to a powerful pharmacologic agent. Placebo effects of medication remain limited mainly to the province of psychological and emotional responses.
October 3, 2009 10:39 PM | Reply | Permalink
Hi Fred: Got any links to a "rigorous" study? I haven't searched rigorously, but I have learned (so far) that as of the early 2000s, there were no rigorous studies on placebos. I'm curious about this, so if you can point to any studies, I'd be interested in reading them. Thanks.
October 4, 2009 8:08 AM | Reply | Permalink
Thanks for replying to Fred, gasket, so I didn't have to, if I had had to, but don't expect to get much back.
Dialogue with Fred is like bouncing a penny off a blob of oatmeal.
And yes, Fred, oatmeal is ground oat groats or a porridge made from ground oat groats, and...
Mares eat oats and skiddly diddly doo!
October 4, 2009 9:22 AM | Reply | Permalink
I wasn't able to confirm the accuracy of a single thing Fred said in his comment! It's not my area of expertise, of course, but I don't have time (or interest, to be perfectly blunt) to refute him with panache. However, I am honestly curious about this topic, although I'd like a little direction if he can provide any.
Meanwhile, I think what's more important might be to investigate how the funding of medical research has changed in the last 20 years. In this country, it's always important to follow the money.
October 4, 2009 9:31 AM | Reply | Permalink
I appreciate your statement that you don't have the time, interest, or expertise, Gasket, but those who do are familiar with the data. Here is one source, among others:
http://content.nejm.org/cgi/content/full/344/21/1594
If data in the paper are thoroughly scrutinized, they demonstrate that significant placebo effects are achievable in some but not all conditions involving subjective outcmes (pain, anxiety, etc.), but not with objective outcomes, either "binary" or continuous - e.g., there were no significant effects on continuous variables such as hypertension or obesity, and surprisingly, little if any effect even on insomnia.
I've also observed the same findings in hundreds of papers I've read in the cancer research literature.
This is not to say that placebos aren't useful in circumstances where they are effective, but their effects can't be extrapolated to treatment in general.
October 4, 2009 11:07 AM | Reply | Permalink
It seems that the placebo effect might be a milder example of the effects that can be produced through hypnotism and that those effects may come about through different levels of the same mental stimuli. Any thoughts on this?
October 4, 2009 12:58 PM | Reply | Permalink
Is Fred Moolten trying to win some kind of prize for obtuseness and pomposity?
gasket asks him for some documentation, with her usual modest disclaimers of any expertise, and then "Mr. Obvious," aka Fred Moolten, huffs, puffs, and produces a paper which gasket already linked as a demonstration of his superior "familiarity with the data!"
Harharharhar!!!
What a tool!
And of course "Mr. Obvious" distorts the evidence in his already cited citation, but probably without "intent to deceive," which would imply at least a minimal comprehension of the "data" which his superior wisdom unearthed... after gasket had already cited it on the same thread!
Fred claims...
But according to exactly the same "research"...
So for both objective and subjective responses, in small trials with continuous outcomes, rather than either/or responses like "coughing or not," placebos had statistically significant beneficial effects, which only disappeared when they were submerged in trials with much larger samples.
Does this suggest that more extensive personal contact with researchers in small trials might enter into the equation, and increase the significance of the placebo effect?
Yes.
Did this possibility fly over the head of "Mr. Obvious" aka Fred Moolten, like distant planets in the dark?
Yes.
And did it occur either to "Mr. Obvious" or the miserable researchers whom "Mr. Obvious" obtusely re-linked that...
"A possible bias related to the effects of small trials" is only necessarily a "bias" and not an "effect" of the size of the sample if you're already committed to the idea that all differences between small and large samples are "biases" rather than "effects?"
No.
It didn't occur to Fred Moolten to question whether all differences between small and large samples are "biases" rather than "effects."
October 4, 2009 2:03 PM | Reply | Permalink
I can see the medication isn't working.
October 4, 2009 2:07 PM | Reply | Permalink
And I can see that you're a pompous, obtuse, and condescending tool.
And before you condescend to another commenter like gasket, who is ten times as intelligent as you are, you dim-witted tool, why don't you write your condescending comment on a sheet of toilet paper and shove it where the moon don't shine?
October 4, 2009 2:22 PM | Reply | Permalink
It's okay, Rootie. ;-)
I think some extremely interesting and valuable ideas came out of your post. So thanks for that as always.
October 5, 2009 11:28 AM | Reply | Permalink
I'm on an iPhone and posting is difficult so I'll be brief...
I have had a doctor or two call in a "prescription" for Placebo. One doctor even told me the "name" of the "drug" to put on the label... And said to be sure to put a sticker on the bottle which said "may cause drowsiness".... And to be sure to council the patient not to drive, etc...
We gave gelatin caps filled with starch.
The patient loved them and tried to get early refills often. We told her that we couldn't fill this kind of drug early as it was a very controlled substance.
We did this for probably 2 months or so.
October 4, 2009 10:06 AM | Reply | Permalink
I obviously don't know the details, Ickyma, but what you describe would be ethical only in very rare circumstances. Not included among them is the circumstance in which the doctor's goal is mainly "to get her off of my back".
October 4, 2009 11:34 AM | Reply | Permalink
Not so. A doctor may use placebo if he/she thinks it will be effective. It's ethical.
Admittedly, I haven't done this in over 15 years... But I have done it.
And it worked.
October 4, 2009 2:46 PM | Reply | Permalink
In a controlled trial comparing placebos with a potentially active medication, the placebos are typically pills, often capsules, disguised to look and taste like the test drug. Sometimes, it is hard to disguise the latter, however, particularly if it has a strong and unusual taste.
There are other difficulties. In one study, according to an anecdote told by the study author, a crossover design was used. Each patient received the active drug during one interval and was switched to the placebo during another - or vice versa, i.e., the order was different for different patients.
One patient asked the doctor, "Did you change the pills I was getting yesterday?"
The doctor inquired, "Why do you ask?"
The patient replied, "Well, until yesterday, when I threw them in the toilet, they sank. Now they float."
October 4, 2009 11:46 AM | Reply | Permalink
Mark Twain himself couldn't have done better. LOL
October 4, 2009 3:48 PM | Reply | Permalink
The problem is that the very concept of a clinical trial will affect a placebo's impact or lack thereof.
What is more important, imo, is the placebo ILLNESS. Those stress-induced diseases brought upon us through shock, awe and suggestion.
The "airborne toxic event."
In other words, when dealing with issues of auto and exo hypnotic effect, setting and observation invariably bother outcome. A clinician could no more analyze the Sai Baba faith healings than an anthropologist could analyze a clinical study. The occupation and beliefs of the observor determine outcome because consciousness behaves as both "particle" (stubborn) and a "wave" (compliant).
IMO, studies presented by Fred and Wired will fail to measure the actual placebo effect. When it comes to believing illusions and materializing effect through belief, the Iraq War would be a better study model than a sugar pill.
October 4, 2009 12:47 PM | Reply | Permalink
Hi Zipper - Your quantum-mechanical-military-anthropo-pharmacologic theory is interesting, but in fact, I believe it's easy to demonstrate placebo effects in clinical trials, as well as during uncontrolled circumstances. What seems clear is that this effect can alter, sometimes dramatically, the level of pain experience, without altering, for example the level of airway resistance in an asthmatic, or the caloric effect on body weight in an obese individual. The same individual who is absolutely convinced he or she is being helped is experiencing no benefit in terms of objective measurements of the relevant condition.
Faith healing does not appear to be an exception, and its inability to heal (as opposed to making people feel better) doesn't require formal clinical trials to demonstrate. All that is needed are prospective observations rather than testimonials claiming past benefits. Once the claimed healing is assessed starting at any given point, its miraculous powers seem mysteriously to vanish. I was being a bit facetious about the quantum mechanical analogy in my first sentence, but the failure of faith healing can't be attributed to QM effects at the macro level at which we operate. It's simply the result of fraud in some cases, and self delusion in others.
I think your point about stress-induced illness is valid and important. These are not really placebo effects (or more properly, "nocebo" effects, because they are adverse rather than beneficial). I say that because stress, being subjective, is always real; by definition, a person can't be fooled into believing he or she is feeling stress.
I'm not sure where the Iraq war fits in, except that self-delusion as a necessary step toward attempts to delude the public is not unheard of in the political arena.
October 4, 2009 1:21 PM | Reply | Permalink
This is more relevant to an exchange above than to your point, which is well taken, about the influence of trial participation on perceptions, but I bring it up here to avoid the shrinkage of column width that occurs when the "reply" function is continuously invoked.
The broadest review of the placebo effect literature is in the NEJM article already cited above by three of us -
http://content.nejm.org/cgi/content/full/344/21/1594
It confirms what is now generally recognized as the most reasonable interpretation of abundant data:
Placebo effects are demonstrable for subjective responses (pain, anxiety, etc.). Statistically significant placebo effects are not demonstrable for objective measurements (blood pressure, body weight, airway obstruction, etc.).
The absence of significant placebo effects on objective measurements is demonstable whether the outcomes are binary or continuous, and whether the studies are large or small - i.e., even with continuous outcomes in small studies. The last point was apparently misunderstood by someone above who may not have read the entire study but only the abstract.
Anyone who wishes to judge for himself or herself should visit the article to review the data.
In a sense, squabbling over some of these minor points obscures the larger issue that started this thread - perceptions of quality (including the value of health insurance) are influenced by how much something costs, but this influence diminishes when costs rise to very high levels. That's a circumstance we are now approaching in the healthcare arena.
October 4, 2009 2:35 PM | Reply | Permalink
My usual assumption that Fred Moolten is merely obtuse rather than obtuse and dishonest is beginning to waver.
For example, on this table, showing the effects of placebos in all trials, objective and subjective, binary and continuous, all the outcomes are positive for placebos.
Where a "pooled relative risk" below 1.0 indicates "a beneficial effect of the placebo," all the pooled relative risks are below 1.0.
Where a negative "standardized mean difference" indicates a beneficial effect of the placebo, all the standardized mean differences are negative.
For a dim-witted but condescending person like Fred Moolten, the conclusions of the researchers based on this data are the very last word, although there are numerous indications that they were arguing for a foregone conclusion, and selected just enough statistical "pooling" to produce that foregone conclusion.
But we can also choose to regroup the results into any number of different "pools," and calculate other confidence intervals based, for example, on the six different pools which all show beneficial effects of placebos in the table linked above.
In this regrouping, which is no more arbitrary than the researchers' submersion of small-sample tests into large-sample tests, the whole assignment of significance is shifted in favor of a beneficial effect of placebos.
Fred Moolten's claim that the one study which gasket found for him, (and which he used as a basis for pretending superior "familiarity with the data") is universally admitted as the very last word on this subject is also bullshit.
There are at least 33 other meta-studies of the placebo effect, as mentioned in Moolten's one and only source, and of those 33 other studies, Fred Moolten has read zero.
October 4, 2009 5:01 PM | Reply | Permalink
You don't lose gracefully, do you R? At this point, I think it's a waste of time to argue the point here, because readers can visit the article themselves to form their own judgments. I'll be surprised if any of them see evidence in any table or in the text for significant placebo effects on objective outcomes, particularly since the article states the opposite, but in any case, readers can decide.
October 4, 2009 9:21 PM | Reply | Permalink
Not that I know anything about science (and haven't read the reports linked here) but it seems the power of suggestion works even when quite aware that this “trick” is being played on the mind. V.S. Ramachandran (intriguing article) has done many interesting brain studies and developed therapies like mirror imaging to relieve phantom limb pain. It’s closely related to the placebo effect I think.
October 4, 2009 9:34 PM | Reply | Permalink
That's fascinating, Don - particularly mirror therapy for phantom pain. I see a partial relationship to placebo effects in that they both reflect profound somatic consequences of psychological phenomena. A difference resides in the dependence of the placebo effect on false beliefs - the individual is feeling somatically what he or she expects to feel as a result of treatment, even when the "treatment" is acting only on the mind and not on the body.
October 4, 2009 9:53 PM | Reply | Permalink
In every package insert (accompanying every bottle of medicine I buy) they list a bunch of information.
One of the bits is how this drug compared to Placebo.
All drugs, when being studied, are compared to placebo.
Placebo ALWAYS has "side effects" listed.
There was one drug... FLECAINAMIDE (I believe that was the one...) anyway... it listed 1 Fatality for the drug... and 2 fatalities for those taking Placebo.
No "cause/effect" established... It's just a number. But it's an interesting number.
Also. I can tell you with certainty that if a drug is "CHEAP", people will say it doesn't work. But if it's expensive they'll say "Man! That was some good stuff! Cured me in 1 day!" or some such...
I have actually gained some business from people who DON'T want to get their Rx's filled at Wal-Mart anymore because "Those $4 pills can't be any good."
No kidding.
October 4, 2009 2:52 PM | Reply | Permalink
You're correct about the package insert, Icyma. However, the presence of this information simply reflects the FDA requirement that for a drug to be approved, it must show statistically significant benefits in comparison with a placebo control group. It doesn't imply that adverse effects in the placebo group were due to the placebo, because a comparable group receiving nothing at all will also experience illnesses and symptoms simply as a result of the incidence of those conditions in the population.
I believe you regarding the Wal-Mart effect. There's obviously some public re-education that needs to be done to counteract drug industry propaganda.
October 4, 2009 3:02 PM | Reply | Permalink
Right... they have to show how the drug compared to Placebo.
But there are people taking placebo who don't know if it's the placebo or not. Actually, they believe the are taking the actual drug. They think they are actually taking something....
And then they report the drug effects.
I believe the placebo results reported are isolated and considered to be caused by the "drug"... non?
In any case... the placebo effect is real.
And, the cost of meds (due to pharma propaganda or whatever!) has an effect that is real.
I guess what we're discussing here is "to what extent" these very real psychological phenomena affect us.
October 4, 2009 3:48 PM | Reply | Permalink
You make a good point. In many cases, it's possible the placebo group will experience some subjective side effects (e.g., nausea, headache, drowsiness) that are due to their belief they are receiving an active drug. My only point is that one can't judge the entire list of adverse effects in the placebo group to be placebo-induced. In many cases, they are objective physical manifestations (e.g., epistaxis) or laboratory findings (e.g., a rise in creatinine) that reflect medical conditions that occur at low rates in any similar population and are unrelated to the taking of a sugar pill.
There is no question the placebo effect is real, and that it affects the way we feel. Since the way we feel is important for our quality of life, these effects are an inextricable element of medical practice, for better or worse.
Regarding our earlier discussion on the ethics of prescribing placebos, we would both agree that this might be justifiable on occasion, but perhaps not on the frequency of those occasions. Without trying to be too specific, I would just say that I see deliberate deception as a tool that might be needed for a patient's welfare, but only as a last resort. I would object to its use as a substitute for a doctor-patient relationship that would permit an honest discussion to help a patient tolerate the kind of subjective discomforts a placebo might relieve. Ultimately, there is always some danger in deception, because once discovered, it destroys trust.
October 4, 2009 9:42 PM | Reply | Permalink
You Say: Ultimately, there is always some danger in deception, because once discovered, it destroys trust.
And I couldn't agree more! It's a critical observation.
I should also note that by the time the Dr. has decided to use Placebo, it's very likely that the patient has already been very deceptive and violated the trust to begin with. The Doctor has not initiated the deception.
But you make a good point.
October 5, 2009 8:53 AM | Reply | Permalink