YouTuber and physician Rohin Francis, MBBS, does a deep-dive on the power of placebo.
The following is a partial transcript of this video; note that errors are possible.
Francis: The placebo effect. Well, you know what that is, right?
Ted Kaptchuk: The placebo effect is the effect of an inert substance, the effect of something that has no effect.
Alia Crum, PhD: The things that shape our mindsets, which in turn activate our bodies' natural healing abilities.
Francis: Except, I promise you it is way more fascinating and weird than you think. In fact, I would say the placebo is maybe my favorite topic in all of medicine and I have been meaning to make this video for ages.
[Crowd]: We need a cure! We need a cure!
[Hibbert]: Why? The only cure is bed rest. Anything I'd give you would only be a placebo.
[Woman]: Where do we get these placebos??
[Man]: Maybe there is some in this truck. I'm cured! I mean, ouch.
Francis: Not only will we explore the placebo effect and its evil twin, but I might do something rather unexpected and pivot to becoming a life coach and guru who is going to make some bold promises to improve your health because I'm going to share with you that one weird trick that doctors hate me for.
Man: That's not why doctors hate you.
Francis: I'm pretty sure it is.
Man: No, it's because they know you and you're a d***head.
Francis: Really? Using a format that I have in no way ripped from Wired's YouTube channel, I'm going to turn it up to 11 and explain the placebo effect in 11 levels of complexity, kind of. This video is sponsored...?!
At the most basic level, the placebo effect is the brain adjusting how you feel. When my son falls over and hurts his knee, he starts crying. When I give him a kiss better and a cuddle, he immediately starts smiling and runs off. Do I have any magical healing chemicals in my saliva? No, or I would have made a fortune setting up a clinic where I lick patients. Oh God. I think I have just given a quack an idea, haven't I?
Did the kiss better actually change my son's injury in any way? Of course not, but his perception of the pain was reduced and he carried on playing. This is the placebo effect. A person is given something, which doesn't have any actual active healing ingredients, that's a placebo, but they feel better, that's the placebo effect, which is really the power of the mind.
What's actually causing the placebo effect is expectation. Now, because my son is a 4-year-old maniac, let's not use his brain as an example of an average mature human and instead assume that you are normal. It's a big assumption, I know.
A kissy on your booboo might not give you much of a placebo effect because you are a sensible grownup that doesn't believe in silly things like that. No, no, you spend £5 buying the branded Neuro-Oxy-Turbopain XXL Extreme, the Doomslayer, disrespector of discomfort painkillers, instead of the chemically identical, generic ibuprofen or paracetamol because you swear it works better than the cheap stuff.
Neil deGrasse Tyson suddenly bursts into the pharmacy to laugh at you and says, "They are the same, you fool," before walking into a local cinema to tell everybody watching "Avatar 2" that the Na'vi's blue pigmentation would suggest overwhelming levels of cyanin and he would relentlessly postulate at people who just want to watch the damn movie, telling them that Pandora and pomegranates might have chiral-coloration.
But is Mr. I'm-Rational-Science-Man actually right? Well, repeated studies show that people do derive more of a benefit if they are told a painkiller is more expensive than an identical one that they are told is cheaper. If it comes in a fancy box, it has a bigger effect.
You've probably heard little curiosities about the placebo effect, like a large white placebo pill being more effective than a small white placebo pill. Two white pills are better than one white pill. A red placebo painkiller is more effective than a blue, but a blue placebo sleeping tablet is more effective than a red, except in Italian men, according to one study that I read, where it was the other way around. Possibly, they claimed, that most of us are excited by the sight of red, so that doesn't work as a sleeping tablet, but blue invigorates Italian men as it's the color of the national football team. Yeah. I'm not entirely sure about that one, either.
A placebo injection of something like water is more effective a painkiller than a placebo pill and a fake surgery is more effective than an injection of water. If you've never heard of fake surgery or placebo surgery, stay tuned.
All of this is because of expectation. For example, if a patient is administered a real painkiller by a nurse in uniform coming to give them an injection, they get double the effect compared to when the exact same medication is infused via a pump without their knowledge. The more ritualized and apparently extreme a placebo is and the sign posting that you give, at least to the recipient, the more effective it can be. This includes the consultation itself, but we'll come back to that later.
This is an example of classical conditioning. We are conditioned to associate certain things with an improvement in our health, just like Pavlov's dog was conditioned to salivate upon hearing a bell, although one could argue that the real Pavlovian conditioning is that every time I say Pavlov, you think of a dog.
We anticipate that these things will cause pain relief or improve our mood, or allow us to sleep better, or help us focus, so our brain can actually cause those effects. Even though the thing itself is inactive, the placebo effect is about expectation.
If you've heard the placebo effect being talked about in the media or online, chances are you've heard it referred to in a negative way, which I believe is a shame. I think there are two reasons for this.
The first comes from medical trials, where we are trying to establish if a treatment works. Let's say Smarty McScientist comes to me with a new compound that her lab has created called Flatulex, which she claims reduces uncomfortable and embarrassing gas. But governmental drug regulators aren't just going to take her company's word that her new treatment works or every health influencer with a tub of white powder they claim enhances your brain would get official clearance and be on sale in regular shops, instead of boring you with a 5-minute ad full of ridiculous promises before their scientific podcast where you should definitely trust whatever they say. No, you need to prove what you're hawking works, and this is done using a placebo.
Randomized controlled trials are the cornerstone of medicine and they show us what works and what doesn't, so Smarty McScientist needs to recruit, let's say, 100 people. She randomly allocates each person to receive either Flatulex or a placebo, which should look and apparently be identical, but doesn't have any active ingredients. People often refer to placebos as sugar pills, but actually placebos can be very varied and come in different forms.
As a quick aside, I know from a trial that I was involved with that placebos can be extremely expensive, which is kind of ironic if you're testing a new use of an old medication, the actual drug might cost pennies, but the placebo can be tens of pounds a pop.
Anyway, Group A in Smarty McScientist's trial gets Flatulex and group B gets the placebo. Neither the patients nor the doctors know who got what, which is the double-blind part. Group A reported that their wind got 50% better. Well, that's a score for Smarty McScientist. She can ride that gas gravy train all the way to the windy bank.
But hold on, group B reported that their wind got 40% better. Hmm. The majority of Flatulex's observed effect was not actually a true effect. I'm stopping short of saying 40% was placebo because it wasn't and I'll explain why a bit later. But it is now clear that Flatulex is far less impressive than had Smarty McScientist just given her medication to a group of people and asked if they felt better, which is often the format of TV adverts for things like beauty creams or toothpastes: "62% of women reported firmer skin."
But we would have never known about Flatulex's deflated effect without a control group, who are randomly assigned so you can't pick and choose who goes into which group, and without that control group getting a placebo. So the placebo effect can be regarded as problematic or talked about in a negative way because it muddies the water of testing new drugs. But as you can see, placebos are essential in research.
Rohin Francis, MBBS, is an interventional cardiologist, internal medicine doctor, and university researcher who makes science videos and bad jokes. Offbeat topics you won't find elsewhere, enriched with a government-mandated dose of humor. Trained in Cambridge; now PhD-ing in London.