The Oohs and Aahs of Placebos

By Dr. Phoebe Friesen
Printed in Issue 21

The placebo effect will never cease to amaze me. I’ve been researching it for a few years and it blows my mind all the time. There is something of a scientific resurgence going on around the placebo effect right now, so I’m definitely not alone in my enthusiasm. Dedicated labs have recently popped up at Harvard, Stanford, and a new international scientific society has been established. Brain scans of the placebo effect are showing up left and right, offering our favourite 21st century proof that something is really real. Research is showing that all sorts of placebo factors, like how a nurse speaks to you, how much a treatment costs, and how messy a doctor’s office is, can all make a difference to clinical outcomes. Once you start thinking about placebo effects, you start to see them everywhere. You begin to try to trick yourself, leaning into illusions and building up rituals, in hopes of harnessing the magic of these bizarre bodily responses. 

But how do placebo effects work? It seems like there might be a few different things at play. Expectations and beliefs definitely make a difference. Patients who know they are being given something for pain relief, or who expect that what they are being given is going to work, experience a lot more relief than those who are given morphine without their knowledge or who don’t expect to feel relief. What’s even more fascinating is that, in cases where no morphine is given but patients expect pain relief, the body releases its own opioids that look and act just like morphine.

There also seems to be some pretty cool stuff going on related to conditioning and rituals. Just like the classic Pavlovian case of pairing a bell with a bone enough times that a dog starts salivating at the sound of the bell, our bodies behave the same way. If a medication is paired with lavender banana syrup (or any distinct flavour) enough times, the body can start to react as it does to the medication after a taste of just lavender banana syrup. Some researchers are trying to use this technique to taper medications that are expensive or have terrible side effects, without reducing the effect. Another thing that seems to make a big difference is how care is provided. When you feel like your doctor is warm and competent, that you can place your trust in them, you are likely to heal faster and feel better. This feels both deeply intuitive and deeply mysterious to me. 

One of the most amazing things that researchers have found is that one doesn’t need to be duped in order to benefit from the placebo effect. Recently, research into “open label placebos” has found that even when patients are told they are taking a placebo, they often experience immense symptom relief. At the end of these trials, some patients end up begging for more sugar pills, despite knowing they are just sugar pills. Something fascinating is going on there. Crucially, placebos don’t work with any medical problem. There is no evidence that they can shrink a tumour or kill a virus. Instead, they work well with experiences often felt in both the body and mind—symptoms like pain, nausea, anxiety, or conditions like chronic pain, migraines, depression, irritable bowel syndrome, or fibromyalgia.

While placebos make me really excited, they also keep me up at night. One reason has to do with this limited range of impact. Since placebo effects seem to appear most often in conditions characterized as “psychosomatic,” they collapse the dualism of body and mind that medicine relies on so fundamentally. While I think this is outrageously cool, not everyone sees it that way. The conditions that tend to be responsive to placebo effects are among the most stigmatized in medicine. They tend to show up more often in women than men, and are tied up with stereotypes related to hysteric, attention-seeking patients whose problems are “all in their head,” which placebo research risks reinforcing. So while on the one hand, an increasing recognition of the placebo effect can lead to novel forms of care and justify the importance of respect and empathy in treatment, it can also backfire, propping up unhelpful beliefs about the legitimacy of some patients and conditions. 

Another reason is that placebo research sometimes stinks of positive psychology. While positive psychology was, in many ways, a welcome shift when it arose in the 90s, pushing for a focus on things like happiness and resilience instead of just problems people have,  is double-edged. While positive psychology might reveal promising connections between your health and your enjoyment of your job, they highlight some pathways of responsibility and blame and neglect others. Given the entanglement of placebos, deception, and charlatans throughout history, a lot of researchers are looking to rebrand them, and several are looking to positive psychology for help. One placebo researcher speaks about the healing potential of “mindsets” and seeks to show how it’s not just eating right and exercising that matters, but also how you think about what you’re eating and whether you believe you’re getting enough exercise. This might sound appealing to some, but it also narrows our attention in a dangerous way. Mindsets, like positive psychology, highlight personal responsibility, and leave out structural factors that also play a role in impacting health outcomes, not to mention eating well and exercising. Locating the source of ill health in mindsets can easily slip into blaming people for their own suffering. 

Can we find a way to harness the remarkable potential of placebos, without taking the problems they introduce on board? Can we appreciate what they teach us about how our bodies and minds are entangled, but avoid reinforcing biases and redistributing blame? I hope so. In the meantime, try pairing one sip of lavender banana syrup alongside your favourite feeling twice per day. Then taste just the syrup and see what happens! 

Doctor Phoebe Friesen is a philosopher and bioethicist.
Read this story in print, in Issue 21