The placebo protest: under the microscope

Placebo pills

Protesting makes me feel good.

At the end of April last year, I wrote an essay on the rise of protest-based demonstrations as a means of engaging with the public on certain irrational beliefs. While the 10:23 homeopathy campaign and the so-called Boobquake protest were the two references I provided, other examples such as the atheist billboards in the US can be arguably included in the category of what I termed the ‘placebo protest’.

In its simplest terms, protests can be described as any collective’s attempt to coerce others into changing behaviour or taking action, making it a fairly broad category that can include many different forms of public engagement. However, the term also suggests the active opposing of an existing social condition, so is commonly negative or antagonistic in nature. A campaign that promotes the message ‘don’t eat pizza from Joe’s” is a protest, while ‘eat at Joe’s Pizzeria’  is less likely to fall into that category.

While academic literature varies somewhat in the precise boundaries of what constitutes a protest, there is a consensus amongst outreach researchers that any attempt to impact on public behaviour relies on specific environmental conditions (termed ‘opportunities’) to succeed. Identifying these conditions can make the difference between winning people over and wasting resources trying.

A good example of identifying opportunities involves understanding how a target demographic interprets a particular message. Using communication tools that convey subtle variations in meaning between sub-cultures risks losing key messages in translation; using stunts, demonstrations or slogans that mean one thing to the protester (or extend from a culture within that group rather than one understood externally) and another to an audience could make any effort to change behaviour somewhat impotent, or even counter productive.

A significant impediment to identifying opportunities in a demographic is a lack of  – or wide variation in – explicit goals. Terms such as ‘promoting education in…’ and ‘raising awareness of…’ are commonly bandied about without objective qualifiers or even a hint of an observable indicator. Often, the qualities of the target audience might be too broad or be presumed without good evidence. Without clear aims or targets there is an added risk of ad hoc justifications of success, typically relying on output (audience scope and reach) to represent impact (change of behaviour).

For a form of outreach to be a placebo protest, however, there is one last important feature – those engaged have to demonstrate little interest in evaluating the circumstances or effectiveness of their actions. Like placebo medicine, placebo activism is practiced not with a true desire to blind oneself to bias, but simply to feel better on having acted, regardless of the true impact of their efforts.

While I can’t accuse all individuals who are engaged in any single protest campaign of doing so for merely placebo reasons, there is some irony in that a number of people will happily offer explanations for their participation that aren’t unlike the same explanations many users of homeopathy or natural medicine offer; ‘soft science like sociology or psychology is too ineffective to study the effects of what I intuitively already suspect to be true’, ‘it takes all types of action to make a difference’, ‘doing something is better than doing nothing’, and ‘it might not work for all people, but what’s the harm in trying?’

Central to the placebo protest is the apparent assumption that sharing feelings is synonymous with sharing knowledge. An emotional reaction to a wrongdoing leads to encouraging others to see it as silly, immoral or dangerous. That’s not to say this is always ineffective (history is full of examples of fear campaigns that are immensely successful in changing behaviours), however when it comes to rational outreach, should it be the desired approach?

Boobquake was proposed as a scientific study, for example, however was presented more as a satirical exercise poking fun at an Iranian prayer leader’s claim that the exposed skin of females is positively correlated with earthquakes. Either way, it’s unclear as to what – precisely – the point of the exercise was, if not an outlet for indignation. Many people have their own view of the agenda, whether it was to promote scientific values, encourage people to understand more about tectonics, or to simply ridicule a specific view (thereby encouraging an emotional reaction in the population to an emotional claim).

The actual impact, regardless of the intentions, is unknown. Was it antagonistic towards the goals of many feminists? Did it polarise views or change them? Were a significant number of people more aware of the science of earthquakes, or of the importance of statistics in science? It’s not clear. Yet there was still a sense of ‘success’ given it had a large output.

When the sense of success carries more importance than a true understanding, however, science loses out. This is the placebo protest. For a community of people protesting in the name of science, it is a rather bitter hypocrisy.

Likewise, when the association of American Atheists launched a billboard campaign in time for Christmas, 2010, telling people ‘You know it’s a myth!’, it’s hard to know what the real aim was. At face value, it might serve as encouragement for members of the driving public who hold some theistic beliefs to abandon them. How successful was it? Are billboards an effective means for spending such funds, or could they have achieved the same (or better) results by spending it elsewhere? If they’re successful, how did it compete against the reciprocal billboard funded by Catholics stating ‘You know it’s real’?

What of the 10:23 campaign, now in its second year? Interestingly, one individual decided to take a closer look at the 2010 homeopathic ‘suicide’ stunt and seek some evidence of its impact.

As a part of a research project, David Waldock sampled reports from the mainstream and social media and analysed them in relation to the event. Focusing on a single objective of the campaign – ‘To educate the public about the full story of homeopathy, to cause them to question and become opinionated about homeopathy’ – he found that the context of the various forms of media discussion changed from being more scientific and clinical to being more political, tending towards language that reflected regulation rather than the specific mechanics of the practice.

Of course, this lays the foundation for a rather interesting discussion. Given evidence of a discourse that is leaning towards regulation, should this be the goal of future protests? Is it better to influence politics and act top-down, or should activists continue to focus on changing attitudes from the bottom-up? Are resources being well used if this is the response, or should they change?

The important thing is, useful discussion can now progress further on the back of potential evidence than on blind assertions. David’s work is by no means the final word on the matter, but it has at least provided grist for the mill and is a clear attempt at marrying observed consequences with actions.

For activism to be successful, it needs to be done with evidence, experience and expertise. Currently, protests and stunts seem to be performed more as a means of expressing frustration, anger or bigotry than a measured way of encouraging a change of culture. As such, success is measured by how many people know you’re upset.

Yet if we truly wish to combat the poor consequences of irrational thinking, we need to identify what makes outreach effective, and distinguish this from occasions when it is merely a way to placate the irate.

If you please – just don’t lie

Believe it or not...it still might make you feel better

When it comes to alternative medicine, there is arguably no greater misunderstood phenomenon than the placebo effect. It’s not uncommon to hear it feature as a defence supporting the efficacy of treatments that otherwise have no evidence for performing as claimed. It is the modicum of benefit that is proferred when it has been scientifically determined that a touch, tincture or totem has been shown otherwise impotent.

Much of the present common understanding of the effect stems from a 1955 book titled The Powerful Placebo by Henry Beecher – an American anaesthiologist who stressed the need for double blinding in clinical testing and was the first to attempt to quantify the placebo’s action. While the placebo effect is argued to be a significant confounding factor in determining useful from useless treatments, Beecher presented the placebo effect as clinical, citing data that demonstrated a percentage of patients were ‘satisfactorily relieved’ by sham treatments.

Since then, other studies have suggested the placebo effect is physiological – that in spite of having zero bioactive components, the act of treatment alone can still help improve a patient’s biophysical functioning. For example, in a 1977 study stomach ulcers were found to have decreased in size following a placebo treatment.

On such evidence, it seems that the mind truly holds sway over the body’s matter. By merely perceiving a treatment works, an individual’s biology will make a greater effort to fix itself.

Yet there is an increasing amount of evidence showing that the placebo effect – or at least, this interpretation of it – is a myth. Any influence a sham treatment has over the variables can be reduced to psychological factors, with past studies falling foul of poor methods.

However, in the very least, it still leaves room for inactive treatments to make patients believe they’re feeling better. And, given western medicine primarily concerns itself with the individual patient ‘s sense of wellbeing, it might be argued that placebos could be used to placate a patient where no other treatment is available.

Ethically, such actions are highly questionable. Few physicians would feel comfortable duping a patient into thinking they’re receiving a treatment, when in fact they’re getting a fake pill or potion. Not to say this has stopped some from administering fake treatments without patient consent.

A new study now shows we might have the wrong end of the stick altogether – that any psychological bias towards placebos comes as a result of its superficial resemblance to treatment. Giving rationality too much credence, it was assumed that a patient needed to suspect that their treatment was legitimate. Instead, it seems the same effects might arise regardless of whether the patient knows the treatment has no bioactive components, putting lie to the claim that ‘it’ll work if you believe it will’.

Ed Yong has a great write-up on the study at his blog. While the study’s method left room for plenty of questions, if its results are legitimate it demonstrates that simply engaging in medical ritual might be enough to bias a patient’s disposition towards their wellbeing. The patient needn’t be led to accept there is a biophysical foundation to the ritual – just that there is a semblance of medical intervention.

The precise limits of the placebo effect and its cultural relationship remain fuzzy. Whether it will ever be an ethical approch to medication is hard to ascertain. However, knowing that a personal rationalisation might not be necessary for a patient to benefit from medical ritual is a positive step to better understanding how the way a patient is treated can be as important as the treatment itself.

 

 

Published in: on December 23, 2010 at 8:15 pm  Leave a Comment  
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The mighty loopholes of the TGA

At first glance, there seems to be a rather effective safeguard preventing Australians from being sold anything that erroneously claims to treat illness or relieves us from discomfort. The Therapeutic Goods Association is the regulatory body responsible for assessing and monitoring therapeutic goods or materials that are marketed in Australia. It covers what can and can’t be said in advertisements, the necessity of clinical trials and the provisions for what can be termed a complimentary or alternative medicine.

For the most part the TGA’s regulations maintain a high level of safety when it comes to the types of medications we have available to us. Thanks to the national customs service, it’s also relatively difficult to procure medications that are deemed to be unsafe or illegal. Yet ever-present loopholes, both semantic and procedural, continue to threaten the health and hip pockets.

One such gap in this medical chain-link fence is both the scourge of scientists and the joy of scientifically illiterate journalists – what I term as the ‘proof paradox’. As far as science philosophy goes, proof is a provisional term. Indeed, certainty is so heavily reliant on context, the word ‘proof’ is typically softened to reflect a sense of probability when it comes to scientific conclusions. Things can be proven logically, yet such solutions are constrained by context of accepted premises.

Scientists consider their ideas as a sliding scale of confidence, approaching absolutes but never committing whole-heartedly. Such philosophical scepticism is useful for scientists, should new evidence ever arise that casts past observations in a completely new light. As such, all conclusions carry a silent caveat that says ‘given that the surrounding scaffold of knowledge continues to hold true’.

Colloquially, this reservation takes on a new weight and substance. The term ‘theory’ grows heavy in the public domain, anchored by doubts scientists would dismiss as merely provisional. All scientific ideas are painted in shades of mights and maybes, where evidence is regarded as subjective regardless of one’s epistemological values. With the caveat dropped, all things are indeed possible. No longer is a statement implicitly ‘false or misleading’ should it say a material ‘might’ treat, cure or alleviate symptoms.

There is no conflict in the eyes of the majority of people, who know of no such footnotes, caveats or hidden contexts. To the average citizen, that ‘might’ carries weight. To the scientifically literate, it is a weasel word that lurks in the shadows beyond abandoned hypotheses and weak p values.

The second gap is less philosophical. When an advertisement is challenged as false, the TGA is currently alerted to it as having broken its regulations. What happens there, according to ABC reporter Steven Cannane in this Lateline report, is something of a mystery.

Short of tightening up science literacy amongst the general public, it’s difficult to address the contrast between the public’s practical view of doubt and science’s provisional scepticism. It’s arguable that the TGA should be given the authority to mediate the use of weasel words such as ‘might’, ‘may’ and ‘could’ when it comes to not-so-subtle suggestions of dubious efficacy, treating even vague suggestions of treatment as if they are making solid claims.

When it comes to the reporting of obvious advertising breaches, however, lets hope changes are in the wind that will see to more forceful actions being engaged over matters of non-compliance. Having a watch-dog that barks but doesn’t bite is about as effective as a placebo authority.

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