Thu Dec 15th @ 5:00am by Paul Ingraham
The opposite of rational, informed confidence is “wishful thinking” — and it is the single biggest threat to the health care consumer. When you’re in pain, it’s too easy to hope for a cure where there are only promises. Snake oil salesmen know this; in fact, they depend on it. They know that people are particularly vulnerable to wishful thinking when they’re suffering, and they exploit it. It’s a particularly scummy flavour of intellectual dishonesty.
The most familiar example of a rational, informed confidence cure is when you go to a good doctor frightened by a strange and unpleasant symptom, and she compassionately chuckles and authoritatively explains why you have nothing to worry about: the condition is common and easily treatable. She spells it out for you, and it’s obvious that she’s probably right: she is speaking from plenty of direct experience. If she says it’s not a big deal, it probably isn’t! You walk away not only with some “real” medicine … but you are almost certainly feeling much better before you even take it.
That’s not the “placebo effect,” even though similar forces are involved. A placebo is based on a deception. But there’s no sugar pill in this scenario.
There are various ways that the confidence cure works its magic on patients in pain, but the main one is that “pain is an opinion” (
Ramachandran) and “100% of the time, pain is a construct of the brain. ” (
Moseley). No matter what is happening in our bodies, it is the brain that decides how dangerous it is and whether or not it hurts and how much. Authoritative reassurance changes the pain equation in a meaningful way. In fact, it literally changes the
meaning of your sensations.
Authoritative reassurance literally changes the meaning of your sensations.This is why it is
increasingly considered real therapy to educate patients about how pain works: to deliberately induce a confidence cure.
Pain freaks people out. Many common painful conditions are characterized by strong patient fear and anxiety that — sadly — does not get relieved, because so few health professionals understand them well enough to offer credible reassurance. For instance, in the case of low back pain, fear is usually well out of proportion to the true severity or dangerousness of the problem — and not only are attempts at reassurance tentative and ineffective, many health care professionals will actually scare the patient by reinforcing any number of common, ominous-sounding myths about low back pain.
Effectively, properly reassuring a patient in pain does not create a “placebo,” per se — it’s not fake medicine and a comforting lie. There’s a genuine therapeutic effect there, but it’s based onrational, informed confidence.
But placebo also has a “genuine therapeutic effect,” doesn’t it? Aren’t we always hearing about the “power” of placebo? In both cases, the patient has been led to believe that they are going to be fine, and that belief in turn can actually reduce pain and suffering: so what’s the difference? Why is it fine to aim for a confidence cure … but sugar pills are ethically verboten? It’s complex, but the medical ethicists have been working on that question for a long while now, and there’s a strong consensus — it’s not okay to fool patients. In treating pain, there’s a particularly good reason for that.
A placebo is not a long term solution!
Placebo is not so powerful after all. Much of what is labelled “placebo” is actually just the
appearance of an effect created by statistical and research glitches, and what remains is relatively trivial.
Dr. Steven Novella:
Placebo effects are mostly just as much an illusion as precognition or talking with the dead. Pain is the notable exception, which makes physiological sense. Pain is a subjective experience, evolved to have adaptive features that are highly situational. There are times when pain should be very bothersome, and other times when it’s more adaptive to be able to ignore pain. So it is no surprise that mood and expectation have highly influence the reporting of pain.
So to the extent that you can change people’s moods and expectations about pain, they really will experience less pain and suffering — but often that is still not much better than an illusion. The big problem with placebo for pain is not just that it’s ethically wrong to get it by lying to patients, even for their own good, but also that it doesn’t work very well. The therapeutic problem with “fooling” people with a pure placebo is simply that most people rarely stay fooled for long! And then they usually end up more hurt and scared than ever before.
And bitter.
But if you can get the same soothing effect on pain without lying, not only are you morally safer, but — and this is the important part — you also get a much more robust effect.
For instance, consider the example of a true snake oil, a therapy that is expensive and totally bogus. (It’s so tempting to give examples! But I’ll steer clear of that, so that the point isn’t derailed by controversy. Or manufactroversy.) Initially, a placebo effect will be powered by mostly the charm and conviction of the seller, and the desperate hopes of the patient. But most patients — even many of the suckers — have that little voice pestering them: “Is this stuff crap? Did I just waste my money?” Most patients — even many of the suckers — have that little voice pestering them: “Is this stuff crap? Did I just waste my money?”Rather than true confidence, most people who’ve spent a bunch of money on questionable therapy are watching anxiously for the first sign that they wasted their money.
And of course those signs come quickly, because it’s a bogus therapy. That’s when hope rapidly turn to ashes — so much for that nice placebo effect.
The beauty of an ethical confidence cure is that you get a much more lasting effect — one that is much less likely to be taken away from you later by the discovery that you were being ripped off, or just told what you wanted to hear.That’s the difference: a placebo is not a long term solution, but rational confidence based on good information is. And it’s a huge difference. Therapy must not induce placebo through disingenuous means, or using that weak sauce to justify treatments that have no other effect.
Knowledge reduces uncertainty, which reduces stress and anxiety, which reduces pain. It is the job of shamans, not health care professionals, to bullshit their way into a placebo effect for their clients.
