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the futility boundary

Well-known but still poorly understood, the placebo effect is where pharmacology yields to psychology and the power of illusion. Last year a study revealed that expensive placebo pills work better than cheap ones. Now according to Wired, 'Placebos Are Getting More Effective', which creates some interesting paradoxes.

The placebo effect can be achieved in many ways, from prescribing sugar pills to merely putting patients on a waiting list, or any type of 'sham' alternative medicine - basically anything where a patient may have reasonable expectations of feeling better. To illustrate this, its opposite effect, nocebo, also hinges on expectations: patients feeling worse just by witnessing other patients' pain.

In both cases, the subjective expectations produce real, objective results, i.e. people feeling better, or worse. In fact, as this Skeptic article describes, there is a "hierarchy of effectiveness" for placebos:

  • Placebo surgery works better than placebo injections
  • Placebo injections work better than placebo pills
  • Sham acupuncture treatment works better than a placebo pill
  • Capsules work better than tablets
  • Big pills work better than small
  • The more doses a day, the better
  • The more expensive, the better
  • The color of the pill makes a difference
  • Telling the patient, "This will relieve your pain" works better than saying "This might help."

Such psychological mechanisms have long been considered an embarrassment in the drug industry, where they have a great term for medication that doesn't work significantly better than placebos: the futility boundary.

Placebos already posed interesting ethical questions, like how does deceiving people relate to the Hippocratic oath, even when it does help them? Introducing price into the equation makes these questions even more uncomfortable, like wouldn't this effect be subject to inflation? And now it turns out that the futility boundary is getting higher - suggesting that for all our scientific sophistication, we're getting more susceptible to illusion...

Among the reasons cited for this trend is the fact that drug companies are attempting to cure more elusive ailments, like depression, which involve higher brain functions and therefore are more prone to psychological 'manipulation'. Another reason, however, appears to be that current drugs, like anti-depressants, have become so widespread (and at least in that sense successful) that people's expectations of their efficacy have risen. These expectations, stirred up further by media and marketing, influence trials of new drugs - and of the placebos they're tested against.

Taking this argument to its extreme, it looks like Western society, which has come to expect so much from pills, may end up being better off taking sugar pills, precisely because it has been trained so well in their expectations of them. Pharma, like everything else, is reduced to marketing - but in a very precarious feedback loop.

Update: Some related Dutch sources:

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