Placebo, attitude, and health

Mark has expanded this discussion into a larger sphere than I had in mind in my post.

(1) Meta-analysis

The record of amazing effects for which science cannot conjecture, never mind observe, a mechanism is extremely poor, from fusion in a beaker to Uri Geller’s spoon-bending. In case after case, an experiment or two is described but when done properly the effect cannot be replicated. Telepathy from one room to another, on the larger evidence, deserves the greatest skepticism until it is repeatable and measurable. And it deserves to be left on the curio shelf in any case until it can be used for something. One of my heroes, James Randi (who debunked Geller when SRI couldn’t – it’s a great story) has much more on this body of stuff that is very slightly possibly knowledge.

One good diagnostic for pseudoscience in my experience is the tiny or unimportant effects claimed for it. How big a heart rate increase can a screen lighting up in another room before your best friend generate? A pyramid will make your sandwich stay fresh longer on the counter…how much longer?; and anyway, if I have a refrigerator, so what? Is bending spoons without touching them something we needed done? Manipulating radioactive materials from a safe distance, yes, or fixing the Hubble, but it never went beyond spoons. In any case, let’s remember that randomness will produce p = .01 significant effects one time in a hundred.

(2) Compared to what?

Prayer for diabetic shock may occasionally have effected a cure. But therapy directed physically at blood sugar levels is a much better bet, almost infinitely better, to the point that not dialing 911 for a comatose child is properly dealt with by the courts as involuntary manslaughter, especially after several hours of prayer not doing the job and the child getting worse.

There’s an ocean of difference between a delicate, hard-to-observe, ephemeral effect that might lead to real scientific advance but will probably come to nothing, and treatments and practices that can be shown again and again to have big useful effects. It’s cruel to describe the former in a news context so that it might be confused with the latter.

(3) The placebo effect

The placebo effect is real, and comprises a very wide variety of things a patient thinks will help, like acupuncture, and that ‘work’ for that reason and that reason alone. In my post I was also intending affirmatively to recognize a therapeutic benefit (for the condition in question, not just feeling generally better) of affection, good will, concern, and the like; if expressed in prayer, fine. I’m not at all surprised that confidence and optimism, including confidence of faith, accelerate recovery and that the effects superpose on the effects of conventional therapy. This is very far from blaming patients for making themselves sick by impiety or doubt. (It’s thought-provoking that many of the conditions known to have a psychosomatic origin afflict the skin (including the skin of the alimentary canal), and that the nervous system originates from an infolding of the same ectodermal layer that forms skin.)

Except for love and affection, which have no downside except if they displace treatments that do work, placebos of all types raise a perplexing issue for the health system that I have never seen examined. We can’t just put them aside, because they do work sometimes, and sometimes when we have nothing else to offer. But they only work to the extent that we lie about them; a hospital that uses placebo treatment whenever it might help should have a sign over the door saying “placebo treatments are never used in this facility” and the health authorities must conspire never to uncover the scandal of this coverup.

But doing this as policy is an intermediate Russian doll; every context outside it has to maintain the same lie; one can easily imagine this leading to a tangled mess of unaccountable mendacity “for our own good” that ensnares an army, for example, to lie about Pat Tillman. If it’s OK for us to believe wrong things to maintain certain medical efficacy, is it OK for us to believe wrong things to maintain military effectiveness?

Author: Michael O'Hare

Professor of Public Policy at the Goldman School of Public Policy, University of California, Berkeley, Michael O'Hare was raised in New York City and trained at Harvard as an architect and structural engineer. Diverted from an honest career designing buildings by the offer of a job in which he could think about anything he wanted to and spend his time with very smart and curious young people, he fell among economists and such like, and continues to benefit from their generosity with on-the-job social science training. He has followed the process and principles of design into "nonphysical environments" such as production processes in organizations, regulation, and information management and published a variety of research in environmental policy, government policy towards the arts, and management, with special interests in energy, facility siting, information and perceptions in public choice and work environments, and policy design. His current research is focused on transportation biofuels and their effects on global land use, food security, and international trade; regulatory policy in the face of scientific uncertainty; and, after a three-decade hiatus, on NIMBY conflicts afflicting high speed rail right-of-way and nuclear waste disposal sites. He is also a regular writer on pedagogy, especially teaching in professional education, and co-edited the "Curriculum and Case Notes" section of the Journal of Policy Analysis and Management. Between faculty appointments at the MIT Department of Urban Studies and Planning and the John F. Kennedy School of Government at Harvard, he was director of policy analysis at the Massachusetts Executive Office of Environmental Affairs. He has had visiting appointments at Università Bocconi in Milan and the National University of Singapore and teaches regularly in the Goldman School's executive (mid-career) programs. At GSPP, O'Hare has taught a studio course in Program and Policy Design, Arts and Cultural Policy, Public Management, the pedagogy course for graduate student instructors, Quantitative Methods, Environmental Policy, and the introduction to public policy for its undergraduate minor, which he supervises. Generally, he considers himself the school's resident expert in any subject in which there is no such thing as real expertise (a recent project concerned the governance and design of California county fairs), but is secure in the distinction of being the only faculty member with a metal lathe in his basement and a 4×5 Ebony view camera. At the moment, he would rather be making something with his hands than writing this blurb.