Placebos as a Source of Agency: Evidence and Implications

Abstract

Bioethical discussions surrounding the use of placebos in clinical practice have long revolved around the moral permissibility of deceiving a patient if it is likely to benefit them. While these discussions have been insightful and productive, they reinforce the notion that placebo effects can only be induced through deception. This paper challenges this notion, looking beyond the paradigmatic clinical encounter involving deceptive placebos and towards many other routes that bring about placebo effects. After briefly describing the bioethical terrain surrounding the deceptive use of placebos in clinical practice, section 1 offers an examination of the various mechanisms known to contribute to placebo effects: classical conditioning, expectations, affective pathways, open-label placebo treatments, and additional factors that do not fall easily into a single category. The following section explores how each of these routes can be harnessed to bring about clinical benefits without the use of deception. This provides grounding for reconceiving of the placebo effect as a clinical tool that is not always in conflict with patient autonomy and can even be seen as a source of agency. In the final section, implications of the shift away from seeing placebos as necessarily deceptive are discussed. These include the necessity of looking beyond the clinical encounter and mainstream medicine as the primary sites of placebo responses, how important acknowledging the limits of placebo effects will be when we do so, as well as the difficulties of disentangling agency, responsibility, and blame within medicine.

Effects of open-label placebos in clinical trials: a systematic review and meta-analysis

“… 14 – 16 ) since the therapeutic encounter can still be beneficial to the patient. Others say that physicians are still lying to patients “in order to bring about positive expectations surrounding treatment outcomes” 17 p. 2 which might harm the fiduciary patient-doctor relationship. This dilemma raises the question of whether the deception in placebo treatments is coercively necessary for achieving a placebo effect.…”

What Should Clinicians Tell Patients about Placebo and Nocebo Effects? Practical Considerations Based on Expert Consensus

“…For example, the need to communicate about side effects in ways that do not induce nocebo effects is gaining more widespread recognition [30,32,[53][54][55][56][57][58]. Because of ethical considerations [40,41], tailoring information seems to be particularly imperative for nocebo effects, especially for those patients who may have a high risk of developing these effects [30-32, 43, 53, 59]. The consensus on communicating information about mechanisms is also reflected in studies showing that understanding the mechanisms of placebo effects may help to maximize these effects in clinical practice [2,20,42,[60][61][62].…”

“…Based on the broad evidence for placebo and nocebo effects in clinical, neurobiological, and laboratory outcomes [5-7, 19, 22, 29-39], the experts agreed that placebo and nocebo effects should be explained, and that patients should receive at least general information about these effects. Providing an outline of the neurobiological and psychological mechanisms could also be helpful, as could informing patients about the limits of placebo effects (e.g., placebo effects are likely to affect symptoms but not the progression of a disease) [40]. The experts recommended placing several stipulations on informing patients about placebo and nocebo effects, e.g., information must be evidence-based and should not overstate the size of placebo effects.…”

“…For both placebo and nocebo effects, the experts agreed that the information should be tailored to specific patients, conditions, and circumstances. For nocebo effects, this need was particularly emphasized, as a consequence of a delicate balance between following the ethics guidelines of informed consent (according to which patients need to be fully informed about risks and side effects of treatments as well as the possibility of treatment failures) and simultaneously preventing and reducing nocebo effects as much as possible [40][41][42]. Moreover, for nocebo effects, the need for informing should be considered, and, when deemed necessary, such disclosures should be made carefully in a manner that does not increase anxiety and is not perceived as blaming patients for negative treatment effects (i.e., side effects).…”

New Frontiers or a Bursting Bubble? Psychedelic Therapy Beyond the Dichotomy

“…Some researchers have called for more detailed measurement of the context of psychedelic therapy in order to better grasp its therapeutic mechanisms [cf. (38,41,42)], something the growth in survey approaches is endeavoring to do [e.g., (43)]. We wonder what it might mean to circumscribe the generalizability of research findings much more narrowly, acknowledging not simply that there are additional contextual parameters that need taking into account but that it may not be possible to determine intervention effects in any general sense, given the plethora of "experimental contingencies" (2:8) in any given context.…”