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Placebos as performance

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Monday, Jun 29, 2009

Paul Kedrosky links to this article by Harriet Hall at the Skeptic about the placebo effect. The upshot is that placebos don’t do anything physiological but instead shift a patient’s awareness of their own symptoms. In the article’s terms, it separates pain from suffering. So placebos are less substances than performances staged by creditable authorities (or at least people we are temporarily willing to credit, if we are delving into the world of Reiki healing or homeopathy (“the ultimate placebo because its remedies usually contain nothing but water”) or macrobiotics or what have you) to persuade us that something transfiguring has taken place. Placebo effects are essentially rituals to distract us from our pain, keep us preoccupied while our body tries to repair itself.

The article mentions a recent study that intended to debunk the placebo effect:

In 2001 two Danish researchers, Asbjorn Hrobjartsson and Peter Gotzsche, published a paper entitled “Is the Placebo Powerless?” in the New England Journal of Medicine.3 They reviewed studies that included a no-treatment group, and they compared the improvement with placebos to the improvement with no treatment. They “found little evidence in general that placebos had powerful clinical effects.”
For studies with a binary outcome (improved versus not improved) there was no significant difference between the placebo and no treatment groups. For studies with continuous outcomes, there was some apparent effect of placebo; but not so for objective outcomes that could be measured by someone else, such as blood pressure, but only for subjective outcomes that depended on self-reports, such as pain. They weren’t even sure about that, however, because the effect was greater in smaller trials, indicating possible bias.

This seems to reinforce, though, the hypothesis that placebos distract us from pain, that they are in essence conjuring tricks staged by a (witch) doctor.

And some tricks are more persuasive than others:

We not only know placebos “work,” we know there is a hierarchy of effectiveness:

  * Placebo surgery works better than placebo injections
  * Placebo injections work better than placebo pills
  * Sham acupuncture treatment works better than a placebo pill
  * Capsules work better than tablets
  * Big pills work better than small
  * The more doses a day, the better
  * The more expensive, the better
  * The color of the pill makes a difference
  * Telling the patient, “This will relieve your pain” works better than saying “This might help.”
In one study patients were given the same aspirin in either a brand name bottle or an unlabelled bottle; it worked better if it was labeled as a brand they recognized. Our pharmacy used to stock two different brands of allergy pills that were made in the same factory and were identical except that one was green and the other was blue. When a patient said it wasn’t working any more, we’d switch him to the other brand and it would start working again.

That’s amazing to me. It’s like a grammar of analgesia.

The reason I’m fascinated by the placebo effect is that it reminds us how limited instrumental thinking is—the idea that this object has this effect. Instead, the context has enormous ramifications on our experience of things, an effect that sometimes we seek to ignore because it is impossible to control or even analyze thoroughly. As Hall points out, the pills are less important in treatment than the doctor-patient relationship. One could extrapolate and argue that this is true of objects generally. When we expect them to change how we feel, they are merely proxies for relationships, which ultimately have the most effectiveness in altering our moods. How we feel about ourselves, to a large degree, is a social construction—is determined by how the feeling is constructed in our interactions (real or imagined) with other people.

Also, I think that advertisements attempt to work in the same way as placebos, staging a performance that shifts our perceptions, so that inert products suddenly have magical effects. Cigarettes suddenly do make us manly; beer suddenly does “taste cold.” If that’s the case, then we need to trust the authority of advertisements to let them work. Authority could be established just through the sheer brute force of salience, spending tons of money to make a product prominent in the media. Ubiquity becomes its own argument for quality. But we may consent to believe in the authority of marketing, simply because it feels better to be fooled—much in the same way we suspend disbelief to enjoy magic shows or novels or Michael Bay films. It’s no accident that many of the earliest advertisements were for patent medicines—the ads lay the groundwork for the medicines to “work.”

The depressing conclusion I draw from this is that ads, as much as they seem contemptible, fulfill an important function in authorizing pleasure, conditioning us to its possibility, and staging the ritual that allows it to occur. They foster “expectancy” effects, whereby what we expect to happen seems to happen. Granting ads credibility makes it easier for us to find pleasure, but of a degraded sort—they supply simulacrum relationships that supplant our need for real ones. Another way of putting that: Ads allow for a kind of pleasure revolving around objects that perhaps crowds out other forms of pleasure that demand more from us but are ultimately more satisfying. With our willing consent, they teach us to enjoy ourselves in superficial, highly contingent ways and prompt us to forget that other more durable and self-nourishing ways exist.

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