Destigmatizing the placebo effect

Abstract

Alfano’s reframing of the operationalization of the placebo effect (PE) in the context of informed consent (IC) has broader implications for clinical practice, particularly with regard to the employment of the concept of authorized libertarian paternalism (Alfano 2015). Stigmatization of people refers to the development of a value judgment declaring that a person with certain attributes is in some way of lesser status, diminished, or invalid, with resultant negative consequences for such individuals. Concepts may also be stigmatized, particularly those that are easily falsifiable, including, apropos of the subject of PEs, mesmerism, sugar pills, and sham procedures, and hence PEs have historically been regarded with great skepticism, exemplifying something dishonest, misleading, “unscientific,” or invalid (Gold and Lichtenberg 2014). While recent studies have revealed extraordinary insights into the placebo and nocebo effect (PNE), in many ways these insights have had only limited impact upon the practice of medicine or upon (negative) views of the PNE. There may be many reasons why this is so. It may be because of the inherent conservatism of medicine, the need for medicine to distinguish itself from nonconventional practices through its (scientific) method and its capacity to provide an account of mechanism, or the intransigence of firmly held views in any field of practice. Indeed, investigators have “long recognized that individuals tend to maintain rather than change their stereotypes, despite receiving evidence that counters them” (Lyons and Kashima 2003, 989). Enculturation in medicine, in particular, systematically reinforces that certain concepts and actions are “foreign” to valid practice through a process of stereotype maintenance. Conscious, deliberate, or incidental/unwitting utilization of the placebo effect is characterized as deceptive, unethical, unscientific, and unprofessional and hence an action that separates physicians from nonphysicians. However, as distinct from a modern correlate of mesmerism or purely charismatic practice, there is an extensive, well-validated evidence base demonstrating specific psychological and biological processes underpinning PNEs (Hall, Loscalzo, and Kaptchuk 2015). This emergent evidence base is not simply of passing interest but poses significant challenges to traditionally held beliefs about both the role of PNEs in medical practice and about medical practice more generally.