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Title
Placebos have many ‘side-effects’
Keywords
placebo effect, placebos, complementary therapies, empathy, informed consent,
psychosomatic medicine
Abstract
There is a general idea that placebos are harmless, and yet the power of the placebo is a fact.
If something is powerful, it can harm. Confusion arises when that harm is not sought at the
same level as the effect, namely the level of plain sugar versus the level of deeper meaning
and expectations. The latter makes the placebo also an ethical issue. Once one does start to
investigate the correct level, one can discern many ‘side-effects’ in a broad sense. The most
important of these may be the violation of truth and what this engenders inside a person who
is ‘deceived’ by a placebo. The question of whether or not to allow the use of placebos in any
form to ameliorate symptoms therefore touches in a profoundly ethical way the deepest
aspects of what it means to be human.
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Article
Many people, including caregivers, think pure placebos are harmless, since “they have no
active ingredients.” It is true that a pure placebo – be it pill or potion – has no
pharmacological effect and therefore no pharmacological side-effects (note that this is
different from a nocebo [1]). However, the power of placebo is a fact [2]. That power does not
derive from the sugar in the pill but from the broader psychosocial context in which it is
administered. In the end, what ‘works’ in the placebo phenomenon is the deep meaning to the
patient – their hopes, beliefs and expectations. Whether and how to acknowledge and use this
deep meaning is arguably the most important ethical issue in medicine.
One can look into the brain and see this effect of meaning. For instance, with an analgesic
placebo, there are visible and varied consequences, including endorphin release [3]. Since
meaning clearly has effects [4], it can in a broad sense also have ‘side-effects’ at many
biopsychosocial levels. This should be taken into consideration when considering placebo use
– for example, the current debate in Germany about whether to recommend the use of pure
placebos in clinical practice [5]. It is also an issue when a recommendation committee finds a
complementary and alternative medicine (CAM) depends largely or totally on the placebo
effect – leaving aside the empathy of the caregiver. In fact, many recent relevant studies of
CAMs make the conjecture – which is probably very wrong – that “at least there is no harm
involved”, a position that CAM organizations are also increasingly adopting.
This assumption that placebos are harmless is related to a confusion found in many current
placebo debates. When one looks at a pure placebo merely as ‘sugar’, there are by definition
no (major) side-effects. However, when looking at it as powerful placebo, one must not only
look at the sugar inside. Its side-effects must be investigated with the same rigor that its
effects are. One must not be lead astray by these two different definitions. The remainder of
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this text is a list of topics that may be used for a comprehensive study of the real and
important side-effects of placebos.
Comparing ‘placebo’ to ‘empathy’, one can see that both are related to ‘meaning’ – or ‘deep
meaning’, to distinguish this from a superficial definition of the term ‘meaning’. So, placebos
and empathy are related to each other – and sometimes confused – but ethically they are total
opposites. Placebos are by definition a kind of deception, whereas empathy is by definition
very open and therefore incompatible with deception. Of course, one can administer a placebo
out of compassion in a desperate situation, but when placebos are used for the long run – as in
functional syndromes such as chronic pain or depression – they diminish empathy due this
mutual incompatibility. Physicians who use placebos frequently do not have open
relationships, especially if they use placebos to get rid of ‘annoying’ patients and situations
or, even worse, use them to enhance their status as a caregiver without developing empathy.
This is particularly unfortunate, since empathy can make the use of placebos unnecessary in
the first place.
In the end, and going beyond the Cartesian distinction between mind and matter (in which
indeed physiological effects can be seen, as in Parkinson's syndrome [6]), the ‘placebo as a
lie’ can only diminish symptoms, taking away attention from underlying psychological and
medical problems that continue to fester and become very costly, both for the individual and
for society. One sees this in the burgeoning numbers of psychosomatic (or ‘functional’)
diseases. These tend to be much more costly to diagnose and treat than somatic diseases. In
case of children, taking away such due attention may be especially disconcerting.
A deep feeling of helplessness is one of the most important etiologic factors in psychosomatic
disorders [7]. Placebos make deceptive use of a person’s own inner strength, and so are not
just any deception. They act at a profound level where psychosomatic health and illness are
forged. They prevent people from looking consciously to their own inner strength, and so
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exacerbate their sense of helplessness. They entice the patient into thinking that there must be
“something else” that can help them, so that they take what is apparently the easiest route,
rather than taking responsibility for their own health. This creates an every-increasing
dependency on placebos, which, ironically, is a major factor in the commercial success of
‘placebo-based medicine’, as is the case for many CAMs. All of this makes placebos a deeply
ethical concern, as it goes to the root of self-respect.
Placebos also lead to an acute loss of confidence when people find out that they have been
given a placebo under the guise of genuine therapy. This can be personal (“I have been
deceived”), group-based (“The caregiver in this village is a deceiver”) or very broad (“This
governmental organization reimburses quack medicine”). This loss of confidence can be
conscious or subconscious, in either case leading to substantial consequences.
Without going into each of them in more detail, a non-comprehensive list of further possible
‘side-effects’ that need to be investigated are as follows: people losing confidence in medical
science if scientists generally accept the deception of placebos; placebos promoting anti-
science – leading to a spiraling conflict with rationality and science; patients forcing or urging
their caregivers to give them ‘something’ that fulfills the same promise as a specific placebo-
based treatment; a reduction in the effect of regular medications due to people not knowing
whether they are receiving an active treatment or a placebo – with doubt creating a nocebo
effect; wasting potential caregivers’ time and energy by educating them about placebo-based
medicines rather than developing their empathy skills; placebos becoming a legally
objectionable deceit in view of patient consent (a patient cannot consent to being deceived in
clinical cases of placebo use– it wouldn’t even ‘work’, nor does it work with open label
placebos [8], insofar as these are really ‘open’, i.e. ‘non-deceitful’ [9]); people becoming
vulnerable to quacks of all kinds, including those outside of the domain of medicine; the
material side-effects of the placebo vehicle itself; failure to diagnose real diseases; the sheer
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monetary cost of placebos under our hypothesis that ‘a lie can never provide deep treatment’;
the negative cultural consequences of placebos discouraging introspection; anger arising from
the debate between the “I do feel it work!” and “It is completely irrational!” camps; a reduced
ability of caregivers who reject the deceit of placebos to make a decent living; the
disappointment and sense of betrayal in those who find out after many years that they have
been administering pure placebos, which they absolutely would not have done if they knew –
and who is going to admit to them that they knew about this all along but still encouraged
them?
We urge a thorough investigation of these and other possible side-effects of placebos, whether
they are pure or impure. However, we think that these first steps should convince
policymakers to be careful when considering placebo recommendations or funding
reimbursements. One last side-effect – but by no means the least – is simply the deliberate
violation of truth. In the final analysis, that is not acceptable in the domain of health and
healing, since it is a violation of what the powerful placebo proves above all: ‘meaning’ has a
huge power to heal psychosomatic illness and that power naturally resides within all of us. In
the end, only truth can truly cure. This lends the phrase “getting better” deep significance in
both health and ethics.
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Acknowledgements
This research received no specific grant from any funding agency in the public, commercial,
or not-for-profit sectors.
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Declaration of Conflicting Interests
The Authors declare that there is no conflict of interest’
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References
1. Colloca L, Finniss D. Nocebo effects, patient clinician communication, and
therapeutic outcomes. JAMA 2012; 307: 567-568
2. Kisaalita NR, Roditl D, Robinson ME. Factors affecting placebo acceptability:
deception, outcome, and disease severity. J Pain 2011;12(8):920-928
3. Scott DJ, Stohler CS, Egnatuk CM, Wang H, Koeppe RA, Zubieta JK. Placebo and
nocebo effects are defined by opposite opioid and dopaminergic responses. Arch Gen
Psychiatry 2008;65:220-231
4. Moerman D. Meaning, medicine and the ‘placebo effect’. Cambridge: Cambridge
University Press, 2002
5. http://www.cbc.ca/news/health/story/2011/03/31/placebo-effect-doctors-
prescribe.html
6. Benedetti, F, Carlino E, Pollo A. How placebos change the patient's brain.
Neuropsychopharmacology 2011;36:339-354
7. Camacho EM., Verstappen SM, Symmons DP. Association between socioeconomic
status, learned helplessness, and disease outcome in patients with inflammatory
polyarthritis. Arthritis Care Res (Hoboken) 2012;64:1225-1232
8. Kaptchuk TJ, Friedlander E, Kelley JM, et al. Placebos without deception: a
randomized controlled trial in irritable bowel syndrome. PLoS One 2010;5:e15591
9. Mommaerts JL, Devroey D. 2013. Placebo to ‘Open-label placebo’ to open altogether.
[accompanying article]