Urte Laukaityte

Rehabilitating Placebo

May 3, 2024

Listen to this essay on the Many Minds podcast.

Imagine you’ve been suffering from dreadful knee pain for quite some time. Your doctor volunteers a diagnosis – a torn meniscus owing to wear and tear. A particular surgical intervention seems like a promising option. It’s considered safe and effective – each year over half a million are performed in the US alone. And so, you undergo this procedure by the name of arthroscopic partial meniscectomy (or, APM). Happily, you start to feel better. You conclude the surgery reduced your pain, just as it had done for countless others.

Unless, that is, the surgery itself did no such thing. As it happens, what you had was placebo surgery – the experience of sitting in a room with sounds and sensations mimicking those you’d have during actual APM. You did have an anaesthetic injected into your spine and a small cut made in your knee. The surgeons asked for all the right tools at the right times and moved your knee in the right sort of ways. More elaborately, they pressed a mechanised shaver with its blade removed against your kneecap, while the rest of the medical team were busy splashing salt water and draining it into a suction pump to simulate the sounds of blood disposal. This was all just elaborate theatre, but in fact you’re better for it.

This scenario is not hypothetical – it describes a Finnish randomised controlled trial from 2013 named FIDELITY. Five years later the placebo group of this trial did not have more pain than the patients who’d had the actual surgery. What they did have was a lower risk for arthritis. And between these options you’d probably choose the same amount of pain relief with less arthritis. That is, you’d probably choose sham surgery.

The placebo effect has a somewhat unfortunate reputation among the scientifically minded. The phrase “no better than placebo” usually amounts to a lethal dismissal of any medical intervention under discussion. Often for good reason! But I’ll venture a guess that, for the most part, you only ever hear about placebo when something doesn’t work. It’s there to fill a sort of disqualifying role in clinical science. After all, if something is “no better than placebo,” it flunks the science test.

But in recent decades, placebo has been going through a reputational makeover. As we will see, the placebo effect produces measurable physiological changes that can be clinically helpful. So much so that I reckon we should start making better use of this effect, including as a treatment in its own right. And not for any of the fluffy reasons that you might expect. Instead, it will be the tools of hard-core empirical science rehabilitating placebo. 

To begin, let’s get clear on what the placebo effect is and is not. There are many other reasons why you might feel better after a sham medical intervention that are not the placebo effect. Unhelpfully, these are often all lumped together. First, it’s very common for symptoms to ebb and flow over time, even without treatment. This is known as the natural history of a disease. And so, spontaneous remission is a thing. Think of just waiting out a cold – all that is standing between you and perfect health could be, say, six days. With a torn meniscus, it may not be perfect health exactly, but at least some noticeable improvement.

What’s more, for someone to decide on surgery, their pain is usually exceptionally bad (much worse than average). In such cases, it will likely be better the next time it’s measured purely because that original pain score was exceptional. This principle is known in statistics as “regression to the mean.” In the 1800s the name was the blunter, yet more evocative “regression towards mediocrity.” Imagine measuring people’s height at random. If you come across someone over seven feet tall, the next person you measure will probably be shorter, that is, closer to average height – or, more formally, the mean. In clinical research, suppose you only select people with exceptional (very high or very low) scores of pain, glucose, blood pressure, whatever it is. Their subsequent scores are likely to move closer to the mean, and you have set yourself up for misinterpreting this as evidence for your intervention.

Another reason for lower pain scores could be a form of response bias. In social situations people tend to adapt their behaviour to what they believe is expected of them. To be polite, you might unwittingly give a slightly better score than you would otherwise. After all, a whole team of professionals went through the trouble of trying to fix your problem. The precise moment-to-moment contours of chronic pain can be ambiguous and open to interpretation. And so, you may genuinely believe your response to be fully accurate, even if it was influenced by a desire to please. The term “experimenter effect” captures this tendency.

All these incidental factors – the natural history of a disease, regression to the mean, the experimenter effect – may contribute to what’s called the placebo response. However, this is different from the placebo effect – a psychobiological phenomenon where you get better because you anticipate getting better. In other words, the placebo effect is the more general placebo response minus such incidental factors. A good way to think about it is this: any improvement in the placebo group of a standard clinical trial will be a placebo response, but it is not necessarily caused by the placebo effect. And so, funnily enough, if we wanted to truly separate out what’s what in a clinical trial, we’d need to add a (“do nothing”) control group for the placebo control group. There are calls for null control groups to become standard practice in study design, though we’re not there yet.

But so how do we know the placebo effect exists at all? Perhaps your placebo surgery cure wasn’t a cure and part of a wait-and-see strategy instead. Time could be the true healer of a torn meniscus.

Well, until we start having “do nothing” control groups in all clinical trials, it’s difficult to know for sure. But here’s what we do know about the relationship between the placebo effect and pain in particular – it’s tight. A landmark study from 1978 showed that placebo pain reduction relies on endogenous opiates. These are natural painkiller molecules our body produces that bind to the same receptors in the brain as morphine and other opioids. To confirm this, researchers first made sure a placebo lowered pain for a patient. They were then able to block this effect with naloxone – a drug that jams opioid receptors, preventing opioid molecules from binding. Because of this, naloxone can reverse, say, a heroin overdose and save lives. It can also, it turns out, reverse placebo pain relief.

Since the 1970s, there’s been plenty of follow-up research. The same kind of process can be demonstrated in animals. For example, placebo pain relief is negated by naloxone – the anti-opioid molecule – in rats, too. There are other revealing methods to tap into the phenomenon. For instance, CCK (short for “cholecystokinin”) is another naturally present signaling molecule in the brain. This one tends to hinder opioid activity, even when it’s just helpfully dampening pain. Now, suppose you selectively barricade CCK receptors and so prevent them from meddling with opioid action. Reducing CCK activity makes any opioid painkillers you take more potent. Could that affect the placebo effect? The answer is yes, blocking CCK receptors strengthens placebo pain relief in the same way. Brain imaging work has also shown matching activation patterns in pain reduction coming from placebos and opioid drugs.

At this point you might be thinking “right, so placebo for pain could be a thing, but that’s a bit narrow, isn’t it?”  Fair, but the power of placebos doesn’t stop at pain. To take a very different example, consider Parkinson’s disease. Parkinson’s is a neurodegenerative condition that damages dopamine-producing neurons in a brain region called the substantia nigra (Latin for “black substance”). The area has higher melatonin, so you’d recognise it as a darker little blob in the middle of the brain. Destroying these neurons mainly disrupts movement. The classic sign of Parkinson’s is tremor of the hands, but muscles becoming stiff and rigid is typical, too. Moving in general takes real effort; it’s slow and laborious. This makes it possible to take some objective measurements to probe the physiology of the placebo effect. To be clear, you won’t cure a neurodegenerative disease like Parkinson’s with placebo. However, studies have shown that placebos can help patients move more easily, as assessed by external examiners. And, just like in the case of pain, this improvement is rooted in changes to brain physiology. Remember, dopamine depletion is the ultimate problem in Parkinson’s. Well, for a time, placebos can increase dopamine levels in patients’ brains.

How is any of this possible? The textbook answer is that it boils down to the power of learning and expectations. By ‘learning’, people mostly mean conditioning here. In the 1890s, Ivan Pavlov famously demonstrated the basic mechanism in dogs by pairing their food with the ringing of a bell. The food here was an unconditioned stimulus because dogs naturally salivate to it. In contrast, the ringing served as the conditioned stimulus – they don’t normally have much of a take on bells. Over time, the dogs would water at the mouth as soon as they heard the bell, even without any food there. As it turns out, you can do the same thing with placebos and drugs. That is how it worked in the rat pain study mentioned earlier. At first, rats would get injections of morphine. But, after a time, an injection of mere salt water would have the same effect – their pain dropped down nonetheless.

Let’s take another example, a human case this time. Imagine being allergic to dust mites. It’s pretty serious, so you have to be on medication. But now, every time you take your antihistamine pill, you pair it with a strange green drink that doesn’t do anything. Your pill acts as an unconditioned stimulus, while your green potion plays the role of a conditioned stimulus. What will happen? After some time, the weird placebo drink will be enough to convince your body to reproduce the workings of the antihistamine. And again, this is not just something the patients report feeling. For your dust mite allergy, the placebo effect will show up as reduced activation on the skin prick test as well as the basophil test used to evaluate how bad people’s allergies are. This particular scenario comes from a 2008 experiment. But similar studies have demonstrated the placebo effect in other conditions affecting the immune and the hormonal systems.

You might wonder just how far classical conditioning could take us here. Surely it couldn’t mimic something like breathing – a critical life function. True, you couldn’t just inhale placebo all day long, skipping oxygen altogether, and survive. And yet, it turns out you can partially replace oxygen with placebo and get by. Researchers took people to the mountains in Switzerland, Italy, and Alaska where oxygen concentration drops quite a bit – at an altitude of 5,500 metres it is 50% lower than at sea level. Unsurprisingly, placebo gas does not increase oxygen levels in the blood. But it does affect the other symptoms of too little oxygen – in particular, the ones that the brain has control over. For instance, take hyperventilation. Rapid breathing is a common reaction to less oxygen coming in. Simply offering someone placebo gas without preamble won’t help much, but if you do some preconditioning, it’s a whole different story. Remember, this means pairing something neutral with an unconditioned stimulus that provokes a natural physiological reaction. In this case, the unconditioned stimulus is oxygen. If you set that up, over time, not only does placebo reduce hyperventilation, it lowers the heart rate and makes blood pH levels fall, too – just as oxygen does in cases of altitude sickness. Can we just stop breathing one of these days? No, but, despite all limitations, these results are a pretty intriguing demonstration of what conditioning can get you. More generally, if the brain is involved in producing a given symptom, perhaps it could be convinced to tone it down.

Now, many cases of the placebo effect don’t seem to have this kind of pairing process going on, though. The sham knee surgery, for instance, did not. Neither does the classic case of a nice doctor in a white coat offering a sugar pill. So how do we explain these? The standard answer is that it’s all about patient expectations, understood here as their conscious beliefs. The idea is that expecting improvement can in fact produce it – a type of self-fulfilling prophesy. You believe that kind nurses are there to help and the tools of modern medicine are up to the task. And so, a fancy-looking pill or a sterile needle can work their magic. Various psychological processes have been floated to account for this. Perhaps it’s the sense of hope that leads to the beneficial effects. Perhaps it’s the reduction in anxiety. Or maybe it’s the activation of reward pathways, where the expected reward is getting better. 

Alternatively, the cognitive mechanisms responsible could be more general still. After all, expectations can get you quite far, too. And, as it happens, you can see this same type of process outside of medical contexts. Let’s take food. What happens if you ingest a heavy “indulgent” milkshake of 620 calories? For one, you’d feel full quite quickly. Physiologically, this means a steep decline in the levels of a hormone called ghrelin, which regulates hunger. What about a zero-fat no-added-sugar “sensible” shake of 140 calories? Well, you’d feel lighter and your ghrelin levels wouldn’t drop as much. As expected, this is exactly what happened in a 2011 study. Except the drinks were in fact the same 380-calorie milkshake. The difference was the subjects’ mindset. It was enough to influence their gut hormone levels to line up with what they thought about the food rather than what it was. Their expectations won the day.

So, at least on the face of it, the placebo effect seems to be driven by two quite different mechanisms – one involving basic unconscious processes and the other relying on conscious expectations. On the one hand, there’s learning in the form of Pavlovian conditioning – pairing an active drug with some inactive placebo and conditioning a similar physiological response to both over time. On the other hand, there are these higher-level, more conceptual expectations that we have. In certain cultures, these are beliefs about the curative power of drugs, needles, surgeries, white coats, spotless hospitals – the whole therapeutic atmosphere. In others, the act of healing could involve dancing, chanting, drums, totems, or spells. Your mind takes into account all these contextual cues, whatever the cultural background. If all goes well, the meaning that the treatment ritual conveys is care, competence, safety. This, in turn, enhances the efficacy of the treatment, even if it’s ultimately just an inert placebo. In some cases, there’s no need for placebos as tangible entities at all – reassuring language from a trusted physician can be enough to elicit the effect. And so, the placebo phenomenon has also been called the “meaning response,” “interpersonal healing,” or “contextual healing”.

You might wonder, though, just how distinct the two suggested mechanisms – conditioned learning and conscious expectations – truly are. After all, where do these higher-level expectations come from? Could the type of learning involved in fact be kind of similar? A history of positive experiences with a particular treatment strengthens the placebo effect. A history of positive experiences with physicians in general does, too. Perhaps some of these beliefs could be influenced by the things you’ve heard from others – people you know, public figures, even fictional characters. As a result, over time, with repeated experiences, you might connect the concept of healing with the symbols of medicine. This sort of process wouldn’t be conditioning, exactly. But in a sense a continuum between learning and expectations seems to be a better metaphor to capture the varieties of the placebo effect. Perhaps especially so, once you learn about this: the expectations that really matter in placebo may not be your consciously held beliefs anyway. What I mean is your conscious self does not have to expect to get better for the placebo effect to work its magic. You can be convinced the whole thing is literally a sham and still reap the benefits. How come?

For context, ethically minded people have long thought placebo use of any kind is dubious, if not outright wrong. One of the first associations many have with the placebo effect is deception. Its use in clinical trials is generally considered to be just about okay. This is because patients can be informed of the setup of the trial and so they can consent to the possibility of ending up in the placebo group. However, plenty of theorists feel that its use in the clinic automatically violates informed consent, ruins the patient-doctor relationship, and undermines trust in the medical system – all bad. The idea that placebo equals deception comes from thinking that the only way some sham intervention could possibly work is if patients are made to believe it’s the real deal. And so, on the flip side, if someone knows they are getting dummy pills with no active ingredient, that just wouldn’t do anything. It couldn’t do anything. Well, it turns out, the world is stranger than all that. Open-label (or “honest”) placebo protocols, where the patients are fully aware they’re being given a sham treatment, work beautifully, too. You can print big letters on the pill container spelling out “placebo.” The patients can trash the whole enterprise as ridiculous, and the researchers might even agree. None of this makes a difference – the sham still works.

And so, honest placebo could give us the green light to set aside many of the ethical worries, especially since it turns out to be about as effective as deceptive placebo. So far, we’ve had promising clinical trial results using open-label placebos for irritable bowel syndrome, chronic low back pain, allergic rhinitis, migraine attacks, depression, ADHD, and even cancer-related fatigue. These initial studies are small and exploratory, so it’s difficult to extrapolate. But the preliminary finding would jive well with a more general recent trend in the mind sciences – a newly (re)discovered appreciation for the centrality of the unconscious. We’re not really talking about a full-on resurrection of one doctor Freud here. But as the philosopher Keith Frankish put it, unconscious processing is increasingly seen as “the engine of cognition.” Meanwhile, the explicit mind is merely, in his words, “a fragile superstructure.” The honest placebo phenomenon calls into question a clear-cut separation between learning- and expectation-based placebo processes. After all, if the expectations that truly matter are subconscious in most cases, the two are closer together than it would first seem.

Either way, it’s becoming clear just how important what’s happening in a patient’s mind can be in the clinic. As we’ve seen, positive associations can enhance the curative powers of treatment. However, the same kind of process can also go very differently. The evil twin of placebo goes by the name of nocebo (from Latin for “I shall harm”). To understand how that works, take much of what we’ve said before and reverse it. The nocebo effect captures our ability to get worse because we anticipate something negative. It is much more difficult to study. Part of the reason is that researchers don’t want to knowingly make patients feel worse. But there are a few things we can tell about placebo’s nemesis, too. Remember CCK? We’ve met it before as the molecule that doesn’t get along with opioids in the brain. Getting more action from one means less action from the other. It seems this molecule is involved in nocebo pain increase because you can dampen this nocebo effect by blocking CCK receptors. It’s likely that much of what we know about placebo has its problematic counterpart in nocebo. And it’s common – in clinical trials many people taking placebos report adverse side effects. These can get so bad that between 4% and 26% of the placebo control group drop out of trials investigating statin drugs, for example.

Where does that leave the whole project of harnessing the phenomenon for better clinical care? You’d find plenty of naysayers ready to bury it – understandably so. Suppose you get a sceptic to grant the placebo effect exists and is even powerful enough to be helpful. An immediate problem comes to mind: there’s always some risk that your well-intentioned placebo intervention ends up generating the nocebo effect instead. And so, you harm instead of help.

Another issue is there’s a lot of variability in who responds to placebos and how strongly. Studies show this again and again. The same applies to non-human animals as well. It’s not entirely clear what determines whether someone is a so-called “Good Placebo Responder.” Perhaps it’s their learning rate or how they process rewards. Or it may be previous experiences that bear some similarity to the intervention. Various personality traits could also be relevant – for example, the degree to which someone is suggestible or hypnotisable, optimistic versus pessimistic. There’s even research mining for possible genetic factors. Even so, it seems equally plausible that context-sensitive variability will rule the day here. With some exceptions, being a “Good Placebo Responder” may be less tied to certain individuals across all contexts at all times and more dependent on a combination of a specific person, plus situational factors, perhaps even at a particular time. This doesn’t mean there are no patterns that could be discovered. But in an important sense, not all placebos are made equal.

This is both an opportunity and a challenge. The opportunity lies in that acknowledging the reality of placebo calls for more individualised person-centred clinical attention. Care should be informed by things like the patient’s background, previous medical experiences, their illness beliefs, and so on. The challenging aspect is that we’d need a bunch of heavy-duty empirical research to bet on placebo treatments in any big way. However, gunning for universally or even just generally applicable scientific findings on placebo is tricky in light of this much variability. At least on the face of it, there’s some tension between the context-sensitivity of the placebo effect and its potential as a reliable means to improving actual patients’ lives.

What is more, a critic might add, there’s simply no point in expanding placebo use to the clinic. After all, modern medicine is a marvel – we have effective treatments and we should stick to them. Outside of clinical trials, it’s unclear what the use of placebos would even be! To respond to this imagined sceptic, let’s start to consider how clinical practice and the placebo effect could realistically intersect.

The history of medicine is, at root, the history of placebo. Until quite recently, most medical interventions were placebos at their best and rather deadly at their worst. If you’re lucky, you would be ingesting various combinations of feathers, hooves, hair, teeth, genitals, or, more fancifully, crab eyes, fox lungs, spider webs, and such. Perhaps you’d be treated with some moss from the skulls of skeletons known to have suffered a violent death. Another potent remedy could be found in a little rock-like object believed to be a crystallised tear of a deer that was bitten by a snake. On a less poetic note, your lot might have involved bleeding, blistering, puking, or leeching instead, assuming you don’t end up having an organ cut out – in whole or in part. With these treatment options, a non-believer physician offering no more than attentive care and psychological comfort would have been a godsend.

You might think modern medicine has completely moved past this sort of thing. Now, we have antibiotics, antivirals, antihistamines, antiseptics, and antipsychotics – it’s a completely different playing field! You’ll be relieved to hear this is true – in some cases, that is. As a counterpoint, in a 2017 book “Medical Nihilism,” Jacob Stegenga argues that modern medicine is quite underwhelming in how effective its typical interventions are. The magic bullets we’re most proud of, say, penicillin or insulin, are exceptions rather than representative examples of our medical prowess. Clinical professionals are often aware that many of the tools in their arsenal are subpar, even as they (understandably) continue to use them.

More straightforwardly still, studies also show our own physicians do prescribe placebos today. Although relatively few offer fully inert or “pure” placebos like sugar pills, most admit to prescribing so-called “impure” placebos and doing so routinely. These are clinical interventions that don’t have any specific effects on the patient’s actual condition, but do work for other diseases. Think of a doctor prescribing a vitamin for a patient who doesn’t have any vitamin deficiencies, or antibiotics when the patient is infected with a virus. 2018 saw the publication of a meta-analysis of surveys asking general practitioners in 13 countries about their placebo use. Between 16% and 75% of physicians reported prescribing such impure placebos at least once a week.

Reasons for doing so may vary. Some might intend to tap into the placebo effect, whereas others could be merely placating an insistent patient. As it happens, the word “placebo” itself comes from Latin for “I shall please.” This is not even getting into the widespread use of so-called Complementary and Alternative Medicine (or, CAM) among patients. Some of these procedures are reminiscent of the historical gamble between placebo at best and something rather worse, if your luck is out. However, CAM can also work quite well for certain patients. In studies of acupuncture it doesn’t matter much if someone gets real acupuncture or sham acupuncture. What does matter is whether the person believes they were getting the real thing and whether they have positive curative associations with it. Of course, CAM is mostly practised outside conventional medicine by definition. And yet, it remains true that placebos are still used in various ways across the medical system, as they have been throughout history. It is also true that the nature of these practices has mostly continued to be deceptive and sometimes even dangerous – a fertile ground for serious ethical worries.

I’d welcome a future where we can make informed and open use of the placebo effect instead. We don’t quite yet know the extent to which it could be harnessed fruitfully, but we do know of some good starting points – both to increase placebo and decrease nocebo. For instance, there’s evidence to suggest that for those steeped in Western medical practices at least, four dummy pills are more powerful than two dummy pills. The frequency with which some treatment ritual is performed is an important factor, too. So your multiple sugar pills should be spread out in time rather than gulped down all at once. Price and branding appear to matter quite a bit, in that more expensive medications with compelling branding elicit a more potent placebo effect. Similarly, your doctor seeming to believe in the power of the intervention makes a difference, as does social learning more generally – from your peers, celebrities, or ads. Healing also partly depends on the complexity of the intervention – multi-step intricate regimens seem to be much preferred by your unconscious. Could a simpler procedure produce the same placebo relief as the kind of elaborate sham surgery described earlier? Possibly not, particularly bearing in mind all the pre-operative preparation and post-operative rehabilitation that come with it. And so, despite the context-sensitivity and individual variability of the placebo effect, there may well be ways to move forward in an empirical and, if you like, evidence-based manner.

Thinking of the potential of placebos, a bunch of possible use cases come to mind – some more straightforward than others. For instance, they could be used to enhance the effects of treatment-as-usual. We’ve already known that the potency of otherwise pretty powerful drugs can be lowered, if you don’t know you’re getting them. It’s intriguing to think of that knowledge as an added placebo-like benefit. We could extend this principle further still with open-label placebos. It seems that adding honest placebos to treatment-as-usual can be more clinically helpful than the usual treatment alone. Furthermore, there are plenty of medications with horrid side effects, particularly for some people, and placebos could potentially reduce the doses required. Going further afield, there are conditions for which we don’t have anything much to offer at all. Some of these are conditions that could be extra responsive to the placebo effect. Could placebos be helpful in managing them?

The risk to raising the profile of placebos in this way is quackery claiming a proverbial stamp of approval. Lo and behold, the nightmare scenario goes, charlatans on every corner are selling energy field therapy for heart attacks or homeopathy to cure sepsis with patients buying these in droves – all because this essay assured them the placebo effect actually works! Let’s just say communication around this field of research would be vital. But strategy depends on where you think your likely audience’s bias may lie. And so, for now, I suggest we take these mental phenomena seriously first and then figure out how to make the best use of them, while avoiding the pitfalls.

More broadly, it’s worth picturing a future where the role of psychological expectation is not only begrudgingly acknowledged, but truly integrated into clinical practice. People have described medicine as an art for a long time – the phrase feels a bit cliché by now. There have also been plenty of calls for physicians to have the time, energy, and resources to connect with and so better care for their patients. I want to make it clear that quality social contact isn’t just a nice-to-have addition to an otherwise well-functioning clinical approach. It’s a must-have for a medical system to cut it.

To harness the placebo phenomenon, the use of sham drugs and surgeries is expendable, but social care is absolutely crucial. One proposal for why can be found in the Signaling Theory of Symptoms – a possible evolutionary explanation of the placebo effect. The idea is that in our deep past, some reliable way of mobilising help was essential for our survival. But how could your group members know you were in need of such care? The solution was for symptoms to evolve a dual function – private and public. Privately, immune symptoms, for example, often enable self-healing and defense against further damage. Publicly, they serve as a display or a signal, drawing attention to the sick individual. To meet both needs, the theory goes, our bodies have evolved to produce exaggerated symptoms. That is, to ensure social care, our symptoms are more serious than they would need to be to simply fight off infection or mend any damage. Think of immune reactions like redness, swelling, coughing, apathy, or even pain. This extra layer of visible illness serves as a call for help. And it is also what can disappear, as soon as the person (or their unconscious at least) feels like they’re being properly cared for and treated. According to the Signaling Theory of Symptoms, this extra layer of signaling is what explains the placebo effect.

How could the sick tell they’re actually receiving proper treatment? We don’t know too much about medical practices in our deep past and we can’t travel back in time to double check. We do know this though: the specifics of how, who, and when could have varied widely between different groups, but the universal feature would have been social contact with a trusted healer. And so, the theory continues, our immune system has evolved to respond to this kind of close, attentive social care. We all have particular ideas about medical paraphernalia and what a fitting treatment ritual looks like. We start off with an open mind though, which gets moulded by the culture around us.

If what I’ve said so far is on the right track, we have some work to do. Modern materialist medicine has underemphasised things like physician emotion, interpersonal connection, physical touch. Following on from scientific success stories like the germ theory of disease, we’ve been laser focused on helping out with the body’s defences, while not always tending to the patients’ social needs. Well, we’re finding that these needs are critical for healing.

Right around now, you might be expecting a set of recommendations for transforming the current medical system in light of the cutting edge of placebo research. Is it physicians spending more time with each patient (and, some may retort, even longer queues)? Is it just more doctors? In general, it’s unlikely a surgical team would go through with the full theatrics of the placebo operation we started with outside of a clinical trial. Would we even want them to do that? Probably not – specialists of that caliber are hard to come by and there are plenty of patients who absolutely need actual surgeries. As we’ve seen, even if placebos can ease cancer-related fatigue or pain, they will not get rid of the tumours. To increase capacity, should we be trying harder to bring in the best practitioners of complementary medicine to reap the benefits of placebo? After all, when it comes to effectiveness, actually receiving some homeopathic medication makes less of a difference than going through a homeopathic consultation – a long chat with an attentive healer-figure radiating confidence and hope. Is the answer perhaps: all of the above?

I don’t know and won’t pretend to. But growing research into the placebo effect is opening up a greater space of possibilities in the minds of many. There’s a sense in which we already know a whole lot about harnessing the placebo effect – after all, we’ve been doing it for thousands of years. But even if developed over centuries, key cultural practices can easily be lost, especially if we’re not sure which bits are crucial and why. Now, clinical knowledge that has been pushed aside, or altogether forgotten, is getting a fresh look. Perhaps this time we could do a better job preserving not just bits like the analgesic properties of poppies. This time we’d better also enshrine another foundational bit of the treatment ritual – the “meaning response.”

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