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Revisiting Daniel Moerman and “placebo effects”

About three weeks ago, ironically enough, right around the time of TAM 9, the New England Journal of Medicine (NEJM) inadvertently provided us in the form of a new study on asthma and placebo effects not only material for our discussion panel on placebo effects but material for multiple posts, including one by me, one by Kimball Atwood, and one by Peter Lipson, the latter two of whom tried to point out that the sorts of uses of these results could result in patients dying. Meanwhile, Mark Crislip, in his ever-inimitable fashion, discussed the study as well, using it to liken complementary and alternative medicine (CAM) as the “beer goggles of medicine,” a line I totally plan on stealing. The study itself, we all agreed, was actually pretty well done. What it showed is that in asthma a patient’s subjective assessment of how well he’s doing is a poor guide to how well his lungs are actually doing from an objective, functional standpoint. For the most part, the authors came to this conclusion as well, although their hedging and hawing over their results made almost palpable their disappointment that their chosen placebos utterly failed to produce anything resembling an objective response improving lung function as measured by changes (or lack thereof) in FEV1.

In actuality, where most of our criticism landed, and landed hard—deservedly, in my opinion—was on the accompanying editorial, written by Dr. Daniel Moerman, an emeritus professor of anthropology at the University of Michigan-Dearborn. There was a time when I thought that anthropologists might have a lot to tell us about how we practice medicine, and maybe they actually do. Unfortunately, my opinion in this matter has been considerably soured by much of what I’ve read when anthropologists try to dabble in medicine. Recently, I became aware that Moerman appeared on the Clinical Conversations podcast around the time his editorial was published, and, even though the podcast is less than 18 minutes long, Moerman’s appearance in the podcast provides a rich vein of material to mine regarding what, exactly, placebo effects are or are not, not to mention evidence that Dr. Moerman appears to like to make like Humpty-Dumpty in this passage:

‘When I use a word,’ Humpty Dumpty said, in rather a scornful tone, ‘it means just what I choose it to mean — neither more nor less.’

‘The question is,’ said Alice, ‘whether you can make words mean so many different things.’

‘The question is,’ said Humpty Dumpty, ‘which is to be master — that’s all.’

Let’s dig in, shall we?

The interviewer, Joe Elia, begins by framing the question of the significance of the NEJM placebo/asthma study as asking what matters more, subjective responses of patients or objective responses? Right off the bat, this is a problem for several reasons, the most glaring of which is that it’s a false dichotomy. Both matter, but for different diseases and conditions one can matter more than the other. For example, in the asthma study, as all the SBM bloggers who wrote about it pointed out, objective measures matter a lot. If, for example, a patient with asthma has a very low FEV1, he might still feel OK or have only mild shortness of breath and yet still be just a tiny push away from total respiratory collapse. Another example that comes to mind is diabetes, particularly type I diabetes. Before we had an effective treatment in the form of injected insulin to restore blood glucose levels to something resembling normal, many diabetics, other than symptoms such as thirst and frequent urination, felt more or less fine. Yet they could easily be just a piece a cake away from diabetic ketoacidosis. In such conditions, objective improvement matters, and it matters a lot—far more than subjective symptoms. That doesn’t mean that subjective symptoms aren’t important, but concentrating on the subjective and dismissing the objective can be dangerous. Moerman, not being a physician, seems not to recognize this and doesn’t even address the issue. Indeed, he seems blithely unaware that relying on placebo responses in diseases that produce a real, life-threatening physiological derangement is the way to kill at least a few patients. But they’ll feel great—until right before they crump.

Elia asks Moerman right off the bat what he sees in medical studies such as the NEJM placebo study that’s common to other human situations. Moerman responds:

…I see actors and responders. I see uniforms. I see symbols of power. I see authoritarian and all sorts of other kinds of interactions between people. I see lots of interactions between people. I see lots and lots and lots of meaning.

And I see dead people. (Sorry, couldn’t resist.)

Time and time again, Moerman returns to this word, “meaning.” But what does he—if you’ll excuse the awkward sentence construction—mean when he uses the word “meaning”? Elia asks him just that question, pointing out that the word featured prominently in the title of his book Medicine, Meaning and the “Placebo Effect”. Moerman responds with a bit of a waffle dance before he tries to actually answer the question:

…given that we’re talking to a bunch of physicians, let me start by saying why it is I put “placebo effect” in quotation marks. What we mean ordinarily by “placebo effect” is unproblematic. It’s an inert substance designed to mimic a medical procedure. The key thing is that it’s inert. If it’s inert, what that means is, it can’t do anything. That’s what “inert” means. But there simply can’t be such a thing as a placebo effect. It’s a contradiction in terms, sort of like “king of America.” So, I think that “placebo effect” is like “king of America.” It doesn’t exist. Now, at the same time we all know that if you give people inert medications they often respond dramatically, and they get a lot better. So, the only thing that we know for sure is that it’s not the placebo that did it. So what did do it? And what I argue is that what did it is all of the other meaningful stuff that’s associated with medicine, starting with the behavior of the parking lot attendant, going through the receptionist, to what’s hanging on the walls to the art in hospital. I said in the article, our hospital has two helipads.

When you walk into a place like that you know you’re in a place of great overweaning power. It’s incredibly meaningful. And I would argue that that meaning, that and all sorts of other kinds of meaning—the stethoscope around the neck, the uniforms, the funny white shoes, you know, on and on and on—all of that stuff goes together to create a generic system of meaning which is then sort of instantiated by the specific red or orange or blue pills that the doctor gives you and tells you when to take it this way and that way and to drink lots of water, which is a healing substance all of its own. And the meaning that’s attached to all of that stuff can be at least as powerful as whatever is in the pill, whether it’s inert or not.

Alright, I’ll give Moerman credit for a bit of a sense of humor. That line about his hospital having two helipads wasn’t half-bad. Of course, back when I was doing residency in Cleveland, our county hospital had three helipads. So there. (Actually, the reason it had three helipads is because it was the main base for Metro LifeFlight, where I actually moonlighted as a flight physician for nearly three years while I was in graduate school.) In any event, Moerman seems to miss a huge point. He seems to be arguing that placebo effects come from the atmosphere of medicine; i.e., the lab coats, the halls of “power,” the helipads, the medical jargon, the mysterious language that only medical personnel (the high priests or shamans of whom are, presumably, the doctors) can understand. Here’s the problem. In the NEJM article, the patients in the no-treatment, “watchful waiting” group in the asthma/placebo study experienced all of that medical awesomeness, yet they didn’t feel better. They only felt better after they got either active treatment or placebo treatment. In fact, all that medical awesomeness didn’t affect them very much at all. True, even some of those who received no treatment at all reported feeling better, but that’s not uncommon in a clinical trial, and it was a far fewer number who spontaneously felt better than those who were treated with an albuterol inhaler or placebo treatments. In this study at least, the aura of medicine didn’t do much compared to the actual placebo intervention. Moerman completely missed the point here.

He does a bit better, although not a lot, in one of his articles from 2002 to which he refers in his interview entitled Deconstructing the Placebo Effect and Finding the Meaning Response. After listing studies in which, for example, medical students reported feeling a stimulant response after taking a red placebo and a sedative response after taking a blue placebo; people with headache reported more pain relief after taking a branded aspirin as compared to aspirin in a plain bottle and after placebo aspirin in the same branded bottle compared to placebo in a plain bottle; and it was found that people who were told that exercise would improve their psychological—surprise! surprise!—reported that exercise improved their psychological well-being. In the article, he also tries to have it both ways. While arguing time and time again that placebos, because they are inert, can’t do anything, he takes pains to point out that placebo responses leading to pain relief can be blocked by an opiate antagonist, naloxone, concluding, rather disingenuously in my opinion, “To say that a treatment such as acupuncture ‘isn’t better than placebo’ does not mean that it does nothing.” This is, of course, a massive straw man. If, as Mark Crislip jokes, placebo effects due to CAM are the “beer goggles of medicine,” altering perceived pain and symptoms without actually affecting the underlying physiology, it is not surprising that the brain function might—oh, you know—actually change in response to placebo.

In the podcast, Moerman chooses two more recent studies to try to make his point—and misinterprets them both. First, he cites a famous article from 2009 in which patients were randomized to individualized acupuncture, standardized acupuncture, simulated acupuncture (twirling a toothpick against the skin), and usual care and makes exactly the same mistake interpreting it that CAM practitioners made in trying to promote the study. In essence, he concluded that because sham acupuncture (the toothpicks) did as well as “real acupuncture” and that both did better than usual care that acupuncture “works.” Wrong, wrong, wrong. Moerman then cites a famous German acupuncture study (the GERAC study, published in 2007) as evidence that acupuncture “works” as a “meaningful” intervention. Wrong, wrong, wrong, wrong, wrong as well. This latter study preselected patients with a long history of back pain whose pain didn’t respond well to standard treatment but who were naive to acupuncture. In other words, these studies do not show that “acupuncture works very well for low back pain, much better than standard care” (Moerman’s exact words). In actuality, they showed the exact opposite.

He then mentions a study on depression in which St. John’s wort, sertraline, and placebo all had similar results in depression and asks:

What do you conclude from that study? That nothing has any effect against depression because a placebo was involved. That doesn’t follow.

Actually, yes it does. It does indeed follow. Well, it doesn’t follow that nothing has any effect against depression; rather, it follows that in this study apparently neither sertraline nor St. John’s wort had any effect. This, by the way, appears to be the study to which Moerman referred. If this is the study, then it’s not entirely true that sertraline had no effect different from placebo; it only affected one of three measures of depression, but it demonstrated “much improvement” in that measure. Disappointing, but not “no effect,” and there were a number of potential explanations. The authors note that “Failure of established antidepressants to show such superiority occurs in up to 35% of trials, which illustrates the difficulties plaguing randomized placebo-controlled trials in this population.” They also noted that only 36% of the sertraline group had their dose maximized, pointing out that “if any protocol bias existed at all, it would favor hypericum [St. John's wort], which could be dosed to the maximum of its permissible range, whereas the maximum permitted dose of sertraline was only 50% of its highest recommended amount.” So, in this study, it is reasonable to conclude that neither sertraline nor St. John’s wort “worked” in this population at this time at the doses used, but when the totality of evidence and the shortcomings of this trial are taken into account, sertraline does have an effect.

Another issue that Moerman completely ignores is that placebo responses might very well also be largely influenced by artifacts inherent in the structure of clinical trials. It’s not as though these issues haven’t been heavily studied, including expectancy effects (people are suggestible), observer effects (people often report improvement just from the process of being observed, also known as the Hawthorne effect), observer bias, training effects from repeated testing, and cheerleader effects from being encouraged. One wonders what Moerman would say about recent research, including an (in)famous NEJM meta-analysis and a recently updated Cochrane review, that suggest strongly that, when all these nonspecific effects and experimental biases are controlled for adequately, the placebo effect disappears. I think it’s worth quoting each briefly.

First, the NEJM:

…we found little evidence that placebos in general have powerful clinical effects. Placebos had no significant pooled effect on subjective or objective binary or continuous objective outcomes. We found significant effects of placebo on continuous subjective outcomes and for the treatment of pain but also bias related to larger effects in small trials. The use of placebo outside the aegis of a controlled, properly designed clinical trial cannot be recommended.

Then the Cochrane review:

We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

Be that as it may, in a way Moerman (sort of) agrees with Crislip, just not in a way that supports his argument that the “meaning” behind placebos is this wonderful, powerful thing. Crislip makes a strong argument dismissing placebo effects as a myth. Moerman is dismissing placebo effects in a different manner, but in a way infused with his background as an anthropologist. He’s denying placebo effects by renaming them. In a way, they are (again, sort of) arguing the same thing. Crislip argues that placebo effects are an example of mild cognitive therapy in which the pain stays the same but it’s the perception of pain that changes. Moerman argues something similar, ascribing changes in pain perception to all trappings of “power” and interactions with health care providers in medical settings and the “meaning” that patients find in them. None of this is inconsistent with placebo responses being in actuality altered perceptions of symptoms. It’s just that Moerman seems to think that the “meaning” that alters these perceptions is far more powerful than it is. Unfortunately, while Crislip is rooted in hard-nosed “materialistic” science, Moerman seems more rooted in postmodern, relativistic thinking:

Practitioners can benefit clinically by conceptualizing this issue in terms of the meaning response rather than the placebo effect. Placebos are inert. You can’t do anything about them. For human beings, meaning is everything that placebos are not, richly alive and powerful. However, we know little of this power, although all clinicians have experienced it. One reason we are so ignorant is that, by focusing on placebos, we constantly have to address the moral and ethical issues of prescribing inert treatments (73, 74), of lying (75), and the like. It seems possible to evade the entire issue by simply avoiding placebos. One cannot, however, avoid meaning while engaging human beings. Even the most distant objects—the planet Venus, the stars in the constellation Orion—are meaningful to us, as well as to others (76).

One notes that reference #76 is a book by Timothy P. McCleary entitled, The Stars We Know: Crow Indian Astronomy and Lifeways. Perusing the information about the book, I see that the author states very early on that the purpose of his book was to “provide insight into a little known aspect of Crow culture—Crow ethnoastronomy. Ethnoastronomy, a fairly recent development in human sciences, attempts to elicit how non-Western peoples’ perceptions of cosmic phenomena are utilized in structuring behaviors, values, and mores.” All of this might be fascinating reading as far as learning about the history and culture of various peoples, but it would appear to stretch the bounds of what is a science and what it has to do with medicine I’m having a hard time grasping. It must be that reductionistic “Western” scientist in me. Is Moerman trying to say that because humans find “meaning” (whatever that means) in stars and constellations that placebos work? How would understanding “meaning” improve medicine above and beyond what we currently do to understand the effect of patient-provider interactions on health care delivery. Moerman either can’t or doesn’t specify, nor does he provide concrete examples of how his ideas would improve medicine. Maybe he does so in his book, but given that his article to which he referred is billed as the “abstract” or a “synopsis” of his book, somehow I doubt it. Worse, Moerman adds nothing new to the conversation, nor does he provide any testable hypotheses that would allow us to use his concept of “meaning” to better medical care by maximizing nonspecific effects as we use effective medicines.

The lack of specific examples aside, the problem remains for diseases for which there is a real derangement in physiology, such as asthma, diabetes, and the like. If placebo responses make the patient perceive his symptoms as being less severe, that doesn’t help the underlying pathophysiology or work to prevent the very real, very dangerous complications that can result from that pathophysiology. Again, nowhere in Moerman’s editorial or podcast do I see a recognition of that. What I do see is Moerman trying to make like Humpty-Dumpty and make the word “meaning” mean just what he chooses it to mean—neither more nor less, except that, now having read his NEJM editorial and his earlier paper and listened to his podcast interview, I’m still not sure he even knows what it’s supposed to mean.

The bottom line is that we as physicians are indeed called upon to relieve patients’ symptoms, but our obligation goes far beyond that. As physicians, we understand the pathophysiology of disease; we know the consequences of leaving a disease untreated. It is not enough for us to make the patient feel better. If that were the case, then there would be no reason not to give patients sedatives or stimulants for almost everything. Those certainly “make patients feel better”! But there are a lot of conditions where physiology trumps subjective complaints, or at least threatens to. Asthma, the topic of the NEJM placebo study from last month, is, of course, a classic example. A patient can be feeling fine (or at least not too bad) but be perilously close to a respiratory arrest. The same is true of diabetes, where a more or less asymptomatic patient can be on the verge of diabetic ketoacidosis. In these cases, our obligation as physicians is not just to make the patient feel better, but to make the patient better.

Posted in: Acupuncture, Basic Science, Clinical Trials, Neuroscience/Mental Health, Science and the Media

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35 thoughts on “Revisiting Daniel Moerman and “placebo effects”

  1. nybgrus says:

    Needless to say I have actually been discussing this very article and its ramifications a fair bit with my colleagues. It was actually raised as a point of contestation in a CAM lecture by Brian83.

    However, I had some interesting conversation with other colleagues and the concept of “treating the patient” vs “treating the lab value” came up. These were good solid students well versed in the material so far, with no predilection for CAM, no devotion to woo, but also no exposure to it beyond knowing it is garbage. The immediate response was “That shows us how important it is to treat the patient instead of chasing lab values.”

    It brought me to the realization that Dr. Gorski concludes with – you cannot divorce the two concepts. You must always treat both the patient and the lab value, to varying degrees depending on the situation. That is where clinical judgement comes in and a robot would fail as a physician.

    It seemed clear to me that Moerman is advocating for one or the other, depending on the case. That is also false, but I can see where it comes from – the anthropological ethos is one of cultural relativity and that is extended to the medical anthro side. We are taught, as medical anthropologists, that completely disparate “ways of healing” will work on different people and that there is no objective standard. TCM works in China because it is part of the cultural milieu. Ayurveda works in India for the same reasons. Interestingly enough my professors always said that “reductionist” medicine was the worst of the lot though.

    But I digress – the point being I wholeheartedly agree with Dr. Gorski. Certain conditions/disease states require more focus on a lab value than a subjective response from the patient, some the other way around. But one must always consider both in every patient.

  2. Tell it like it is says:

    Last week I presented ‘The General Custer puzzle’. The General is faced with a dilemma that will either cure the situation, or kill him – along with close members of his family, and his brave company.

    When faced with a disease – particularly one that will kill such as cancer, asthma, or diabetes – many people will seek ‘alternative medicine’ (is that an oxymoron?) but sadly, just like General Custer, they fail to ask the right questions, and then through ignorance and hope, they are blindly led astray – often to their own detriment – and the detriment of their loved ones.

    The same is true of placebo – a word, which here means ‘misdirection’.

    In my opinion, placebos are no more than ‘alternative medicines’ and application of either can lead to fatalities – but as I see it, giving a placebo is far worse than giving a ‘belief’ potion – because the person offering the placebo KNOWS it is a scam – and is therefore ‘deliberately’ misleading the patient. Even worse – some placebos have built-in ‘side effects’ to further fool the recipient. To me, side effects = HARM = SUE!

    The wording of the question General Custer must ask to determine the ‘correct’ gulch in which to lead his men reveals IMPOSTERS and CHARLATANS.

    One answer is (well my answer anyway): “If I asked your friend to point to which gulch to avoid, which gulch would they point to?”

    Applying this ‘inductive logic’ to the ‘alternative medicine’/placebo dilemma, I offer the following variations (switch the word ‘alternative’ for ‘placebo’ at your leisure):

    If I asked another doctor if what you are offering me (a placebo) will cure my condition, what would they say?

    If I asked a doctor if your ‘alternative’ treatment will cure my condition, what would they say?

    If I asked a doctor if your ‘alternative’ treatment would detrimentally interfere with a treatment ‘they’ offered for my condition, what would they say?

    If I asked a doctor if what ‘they’ offered to cure or stem my progressively debilitating condition would detrimentally interfere with your ‘alternative’ treatment, what would they say?

    If I asked a doctor if ‘putting off their treatment’ in favour of your ‘alternative’ treatment to cure or stem my progressively debilitating condition would likely be detrimental to my health, safety, and wellbeing, what would they say?

    If I asked the families of bereaved people who committed to your ‘alternative’ offering in favour of science-based medicine – and then died if, in hind-sight, they should have sought a proven scientific cure that had the potential to extend their life instead, what would they say?

    http://www.metacafe.com/watch/2223312/unmasking_the_masked_magician/

  3. David Gorski Quoted Moerman “Practitioners can benefit clinically by conceptualizing this issue in terms of the meaning response rather than the placebo effect. Placebos are inert. You can’t do anything about them. For human beings, meaning is everything that placebos are not, richly alive and powerful. However, we know little of this power, (snip, for better scrolling)One cannot, however, avoid meaning while engaging human beings. Even the most distant objects—the planet Venus, the stars in the constellation Orion—are meaningful to us, as well as to others (76).”

    David Gorski said about this and the enthnoastrology book “but it would appear to stretch the bounds of what is a science and what it has to do with medicine I’m having a hard time grasping. It must be that reductionistic “Western” scientist in me.”

    I just did a presentation on including “meaning” in my fine art medium, so maybe I can try to be of assistance in translation.

    I think when Moerman is talking about meaning he is talking about the cognitive process that we engage in in order to response to our environment, people, objects, etc. People instinctively tell stories about or make judgements on many of the events and objects we observe. So when you see a man in surgical scrubs holding flowers you think and feel a different thing than when you see a man in scrubs holding a saw. They have different meaning.

    The reason people are touched, provoked, inspired, etc by art is due to that cognitive process. (It’s all in their head, it’s not the colors or canvas). Clearly this cognitive process effects people’s emotions and by extension their sense of well being, energy or pain perception.

    So Moerman seems to be saying that doctors should be aware of how the environment that a patient experiences in a hospital or office can affect the patient’s emotions, sense of well-being, etc. via their cognitive response.

    Moerman also seems to believe he is saying something new. Maybe because he uses a different vocabulary.

    I don’t think he’s saying anything new. That is what all the talk about bedside manner is about. It’s one of the considerations of architect and interior designers when designing a hospital. It’s why you have programs that arrange art exhibits and music performances at hospitals. It’s one of the reason’s my son’s SP let’s him choose a special prize from her stash after he has a naseoendoscopy

  4. sorry hit the submit button by mistake….

    Hot wheel cars have lots of “meaning” to a five year old.

    Is there more to learn about how the patient experience affects their attitude and how they feel? Sure. But Moerman doesn’t seem to understand that “meaning” only goes so far.

    Sickness, disease, inflammation is not all in our heads.

  5. Diane Jacobs says:

    > “That doesn’t mean that subjective symptoms aren’t important, but concentrating on the subjective and dismissing the subjective can be dangerous.”

    Did you mean, “…dismissing the objective” ?
    (I.e., is this a typo?)

  6. qetzal says:

    I’m not sure what Moerman thinks he’s getting at with all his talk about meaning, and how the placebo itself can’t be doing anything because it’s inert. As far as I can tell, he’s not saying anything that hasn’t already well described in more conventional terms.

    My biggest objection is to this claim:

    Now, at the same time we all know that if you give people inert medications they often respond dramatically, and they get a lot better.

    That’s just wrong. It’s part of a mythos that placebos can trigger powerful, mind-over-body healing responses. But of course, the evidence belies such claims, as Dr. Gorski has explained above.

  7. cervantes says:

    Well, all this doesn’t mean that medical anthropologists don’t have useful things to say to you. What this guy is doing is not medical anthropology. He’s just blathering about stuff and he happens to have a Ph.D. A degree in astrophysics would be just as relevant.

    The take home message is not that medical anthropology is wacko, it’s that this guy should stick to medical anthropology.

  8. WilliamLawrenceUtridge says:

    It seems like medical anthropology would be well-suited towards enhancing the nonspecific effects Moerman seems to find so powerful. There’s absolutely nothing wrong with enhancing nonspecific effects when accompanied by an intervention that genuinely decreases morbidity and mortality. The contribution of medical anthropology to bedside manner would seem to be a worthwhile synergy and one way of addressing the gap believed to exist between CAM and medicine in terms of patient satisfaction. You would essentially be training doctors to adopt the mannerisms and trappings of CAM that enhance placebo, a neat reversal of how things normally go.

    Naturally, of course, this just helps patients feel better while the medicine does acutal good. As opposed to helping patients feel better while the sugar pills do nothing and/or the patient dies.

    If Moerman feels that medicine is little more than ritual and faith, perhaps he could have a Christian Scientist lay on hands the next time he has a heart attack. Since, you know, quantum means we create our own reality and such the like.

  9. daedalus2u says:

    The biggest problem in the interface between science and the public isn’t the overt fraud, it is the hyping of results to the point of fraudulently misrepresenting their importance.

    There was a recent post about how to deal with the problems of overt fraud over at Respectful Insolence.

    http://scienceblogs.com/insolence/2011/08/in_which_i_disagree_with_brian_deer.php

    Not to try and minimize the effects of fraud, but hyping results that are not worth hyping is (IMO) a much bigger problem than overt fraud.

    This is what Moerman is doing. He isn’t adding any insight, what he is doing is hyping his idiosyncratic framing of placebos in a frame that is free from any data about actual disease, actual effects of disease, physiology or really data about anything.

    He is hyping his idiosyncratic (and demonstrably wrong) idea that how people feel subjectively is more important than objective measures of health.

    What he is doing is prioritizing his idiosyncratic (and wrong) ideas in his narrow non-medical field over the broad consensus of genuine health care providers. His ideas may align with the quacks and frauds in health care, but that is not a good thing. 100 years ago there were lots of patent remedies that treated symptoms, with cocaine, opium, alcohol and heroin. All of those things made people feel better by what are now well-known physiological pathways. Radium made people feel better too. All of this occurred before there was a good understanding of physiology and before there were instruments to measure what was actually going on. All health care providers had to go on was the feelings of their clients.

    Moerman wants to abandon the science of the last century and go back to the patent medicine era where the only thing that matters are the patients’ feelings.

    Why the NEJM gave him a platform to spout his nonsense is unconscionable and shows that the editors of the NEJM are not competent. Sorry to be so harsh on the NEJM, but when you try and pass yourself off as big and important and you screw up this badly, your reputation takes a hit. The NEJM could recover some of their lost reputation by retracting this editorial and explaining why it was wrong, but they likely won’t. The paradigm in medicine and medical publication is shifting to a profit motive, and there is more profit in acting like a health care provider by giving placebos than in actually providing health care by giving effective medicine.

  10. David Gorski says:

    Moerman also seems to believe he is saying something new. Maybe because he uses a different vocabulary.

    Ack! Exactly!

    I wish I had said that somewhere in my post…

    He really isn’t saying anything new. He’s like the newbie taking a look at a problem for the first time who discovers things that have been known by the experts for eons and crows about it as though he’s the first one to have noticed.

  11. David Gorski says:

    That’s just wrong. It’s part of a mythos that placebos can trigger powerful, mind-over-body healing responses.

    Ack, again…I wish I had made that point a little better too and not let Moerman’s statement go unchallenged.

  12. “He’s like the newbie taking a look at a problem for the first time who discovers things that have been known by the experts for eons and crows about it as though he’s the first one to have noticed.”

    ..and telling those experts they don’t understand or appreciate their field as much as he does.

    Among all the factors that comprise the placebo effect(s)/ response(s)/ influence(s)/ factor(s), etc, mind over body healing (essentially vitaliasm) is the least plausible factor. Mind over body healing only seems plausible because it’s so widely accepted.

  13. DU2 “What he is doing is prioritizing his idiosyncratic (and wrong) ideas in his narrow non-medical field over the broad consensus of genuine health care providers”

    Moreover, he seems to think he is speaking for me (the patient) when he says thing like “What is the more important outcome in medicine: the objective or the subjective, the doctor’s or the patient’s perception? “*

    Well hell, I went to the doctor to get the ‘doctor’s objectives perception’, not getting in a pissing contest over who’s perception is more important. As long as the doctor is treating me when I report symptoms (not telling me that I’m fine when I feel sick) I’m good with finding out ways to avoid danger and discomfort in the long run based on objective tests. That is what we patients are paying for.

    *quote from editorial used in MC Beer Goggles post.

  14. windriven says:

    “Moerman seems to be arguing that placebo effects come from the atmosphere of medicine”

    An alternative reading would be that he is arguing that placebo effects come from the expectation that the medical intervention would work. The test would be to treat a population with placebo at a high tech medical center and treat a similar population with the same placebo at a free street front clinic.

    But really, who cares? To my mind the much larger question is: given the many profoundly powerful interventions available in the modern medical armamentarium and the miniscule subjective benefits credited to placebos (and their often quackery-based delivery systems), why is there even a debate?

    Can Moerman – or anyone else – name a single placebo that will treat, say, cellulitis as well as cephalosporins? Is there a chiroquackter out there who can repair an inguinal hernia with a spinal adjustment? How about a reiki practitioner who can repair a defective valve by waving their hands? Does it matter if an asthmatic feels better but collapses and dies walking to the metro station?

    I’m sorry folks but absent some earth-shattering new information I don’t see how this rises to the level of serious discussion in The National Enquirer much less the NEJM.

  15. “He’s like the newbie taking a look at a problem for the first time who discovers things that have been known by the experts for eons and crows about it as though he’s the first one to have noticed.”

    Heh. Sometimes I feel like I am that person. Oh well. I openly admit to this, at least.

    My first thought when reading this post — recalling just how difficult it is to explain to people the difference between subjective and objective improvement. There are a great many people in the world that don’t believe there is a difference, or at least never thought about it before because they equate feeling better with health, and equate their personal experiences with Truth.

    The purpose of trying to explain that difference is to show that placebo effect does not actually indicate the ever popular “mind-body” connection, but my words often fall on deaf ears.

    Also, I’m becoming increasingly aware from reading this blog and other skeptic writing that I am not the only one noticing a disturbing anti-intellectual trend in the social sciences. This blabbering on about “meaning” as this groundbreaking perspective was humorous. It is as though Moerman is trying to become known as “The Meaning Expert” through the use of repetitive marketing. He says “yes yes I see lots of meaning…meaning this…meaning that.” Wow, meaning? Really? Shucks. I’ve always thought people would respond the best when they actually get concrete help for their health problems.

  16. “I’m sorry folks but absent some earth-shattering new information I don’t see how this rises to the level of serious discussion in The National Enquirer much less the NEJM.”

    Do you think they might have been going for the ‘even negative publicity is publicity’ plug? It least a lot of people are talking about it.

    Maybe their readership is slipping and this is the medical journal equivalent of popping out of an egg semi-nude.

  17. nybgrus says:

    @nobodyyouknow:

    Also, I’m becoming increasingly aware from reading this blog and other skeptic writing that I am not the only one noticing a disturbing anti-intellectual trend in the social sciences. This blabbering on about “meaning” as this groundbreaking perspective was humorous.

    Indeed. I didn’t realize it myself till well after I had gone through the whole degree. It all seemed perfectly reasonable to me during my education. I guess I am just more willing than your average medical anthropologist to change my mind when presented with the evidence and hold myself to scientific rigor.

  18. daedalus2u says:

    I think this is an example of “branding”. Moerman has coined the term “meaning” to explain the placebo effect (which he does not understand). His hope is that others will adopt his terminology so that he seems like an “expert” when people start using the same terms that he uses.

    This adoption of idiosyncratic terms for poorly defined or for things the coiner of the terms does not understand is typical of quacks. The adoption of quantum-woo terms is a classic example (quantum example too ;).

    He doesn’t know what the placebo effect is or what the terms mean, so he fills the empty space up with his own meaningless terms, the “meaning” of medical treatments. This really is a post-modern approach to medicine.

  19. qetzal says:

    I could forgive Moerman’s claim that the patient’s subjectively perceived improvement is perhaps the most important thing, if he considered that over an appropriate time frame. Taking the asthma study as an example, a patient may perceive short term improvement after placebo. But if that leads to objective decline over time – because the underlying physiological deficit is not being addressed – we can be sure that the patient will perceive a much greater decrease in subjective status in the future.

    Even by Moerman’s terms, surely a large, long-lasting subjective decline in the future must outweigh a small short term subjective improvement now.

  20. pmoran says:

    I have said previously here many times that the Hrobjartsson metaanalyses (quoted by David) are not as strong evidence against the clinical potential of placebo in subjective and psychosomatic complaints as they are commonly portrayed. Below is a more expanded account of the findings of the most recent version.

    Note how the way the studies were performed influenced the reported outcomes, as would be expected.

    The usual conventional clinical trial tries to minimise placebo influences, as they could partly or wholly obscure the therapeutic signal being sought. Subjects may be sunsure whether they are “supposed” to get better or not, which will also limit placebo responses.

    The only strong argument against clinically significant placebo responses is the likelihood of reporting biases. Until we have direct evidence that this is the major source of what even these authors describe as “clinically important” outcomes we should we wary of strong commitment one way or the other –especially oens we are drawn to by prior biases.

    From the findings –

    Outcome data were available in 202 out of 234 included trials, investigating 60 clinical conditions. We regarded the risk of bias as low in only 16 trials (8%), five of which had binary outcomes.
    In 44 studies with binary outcomes (6041 patients), there was moderate heterogeneity (P < 0.001; I2 45%) but no clear difference in effects between small and large trials (symmetrical funnel plot). The overall pooled effect of placebo was a relative risk of 0.93 (95% confidence interval (CI) 0.88 to 0.99). The pooled relative risk for patient-reported outcomes was 0.93 (95% CI 0.86 to 1.00) and for observer-reported outcomes 0.93 (95% CI 0.85 to 1.02). We found no statistically significant effect of placebo interventions in four clinical conditions that had been investigated in three trials or more: pain, nausea, smoking, and depression, but confidence intervals were wide. The effect on pain varied considerably, even among trials with low risk of bias.
    In 158 trials with continuous outcomes (10,525 patients), there was moderate heterogeneity (P < 0.001; I2 42%), and considerable variation in effects between small and large trials (asymmetrical funnel plot). It is therefore a questionable procedure to pool all the trials, and we did so mainly as a basis for exploring causes for heterogeneity. We found an overall effect of placebo treatments, standardised mean difference (SMD) -0.23 (95% CI -0.28 to -0.17). The SMD for patient-reported outcomes was -0.26 (95% CI -0.32 to -0.19), and for observer-reported outcomes, SMD -0.13 (95% CI -0.24 to -0.02). We found an effect on pain, SMD -0.28 (95% CI -0.36 to -0.19)); nausea, SMD -0.25 (-0.46 to -0.04)), asthma (-0.35 (-0.70 to -0.01)), and phobia (SMD -0.63 (95% CI -1.17 to -0.08)). The effect on pain was very variable, also among trials with low risk of bias. Four similarly-designed acupuncture trials conducted by an overlapping group of authors reported large effects (SMD -0.68 (-0.85 to -0.50)) whereas three other pain trials reported low or no effect (SMD -0.13 (-0.28 to 0.03)). The pooled effect on nausea was small, but consistent. The effects on phobia and asthma were very uncertain due to high risk of bias. There was no statistically significant effect of placebo interventions in the seven other clinical conditions investigated in three trials or more: smoking, dementia, depression, obesity, hypertension, insomnia and anxiety, but confidence intervals were wide.
    Meta-regression analyses showed that larger effects of placebo interventions were associated with physical placebo interventions (e.g. sham acupuncture), patient-involved outcomes (patient-reported outcomes and observer-reported outcomes involving patient cooperation), small trials, and trials with the explicit purpose of studying placebo. Larger effects of placebo were also found in trials that did not inform patients about the possible placebo intervention.

    Authors' conclusions
    We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

  21. pmoran says:

    I abhor cultural relativism. It seems to be another way of saying there are no truths worth seeking.

    But it is correct to say that every culture has felt the need to understand illness, has come with their own primitive prescientific theories of illness and systems for treatment, AND they have almost certainly derived the same generic medical and paramedical benefits from them e.g. satisfying the compulsion to “do something”, assuaging feelings of helplessness and hopelessness, and, with some certainty, genuine symptom relief from placebo and other non-specific influences and perhaps even the resolution of some kinds of psychosomatic illness.

    To this extent the anthropologists are correct. They may have an exaggerated perception of the therapeutic range of these cultural medicines, and annoy us with their search for appealing ways to describe these influences (“meaning”, “mind-body healing”,etc.) but there is an element of truth to it all.

  22. Tell it like it is says:

    The word avrakadavra is an ancient word that means ‘I speak (avra) – it happens (ka davra)’ – let there be light – and there was light – and you could see for miles.

    Many would have ‘got’ my ‘masked magician’ allegory – that of ‘revealing’ the ‘magicians’ who persist in using ‘spells and potions’ to delude – which, in chronic and terminal circumstances, can ultimately lead to despair and a feeling of vulnerability.

    The second part of my allegory is to highlight the necessity to reveal the ‘tricks’ – call them ‘methods’ if you like – so as to drive forward the search for betterment.

    Cancer screening of women brought down the mortality rate – not because of the screening – but because what the screening revealed prompted us to address the issues and come up with viable solutions or solid advice on when to leave well alone.

    Putting ‘faith’ aside, all the time we are willing to use or endorse pointless spells and potions – which include placebos – in a vain attempt to fool because we do not know of or possess a cure, we are hampering our own progress by not – to quote pmoran – “seeking a truth worth seeking”.

    Now there is a good knock-down argument for you.

  23. TILIS “Cancer screening of women brought down the mortality rate – not because of the screening – but because what the screening revealed prompted us to address the issues and come up with viable solutions or solid advice on when to leave well alone.”

    citation needed

  24. pmoran, I’ve always been interested in anthropology and in terms of medicine it seems that doctors and patients are going to be more comfortable and treatment will be more effective when the doctors understand the cultural perspective of the patient they are working with.

    But I think being aware of the boundaries of your expertise is a sign of craftsmanship in any profession. This spreading out into medical commentary without understanding the condition he is speaking on leads me to believe that Moerman is a poor craftsman, sloppy, in fact.

    I don’t think this anthropological commentary on fields outside their expertise is limited to medicine. A family member who is an economist was just raving about how she hates anthropologists and their tendency draw conclusions on consumer spending behavior, markets, etc without little or no supporting evidence. Her concern was with how these conclusion are then cited as sources in articles and papers by some economists, giving the impression that the conclusion is a proven fact. (She wasn’t very happy with those economists either).

  25. David Gorski says:

    Cancer screening of women brought down the mortality rate – not because of the screening – but because what the screening revealed prompted us to address the issues and come up with viable solutions or solid advice on when to leave well alone.

    I must confess, I have no idea what you’re talking about here, so confused is your sentence.

  26. nybgrus says:

    @michele:

    IMO, that is because anthropologists are so endeared to their “just-so” stories. This stems, at heart, because the very nature of anthropology is to put small pieces of evidence together to form an explanation of a culture. This is from whence cultural relativity is born – the realization that if you take the hegemony and cultural bias of your own culture and apply those principles to the evidence you would come up with the wrong story. However, this was taken to an extreme, and nobody properly understands that there is no way to verify which is the right story. Insofar as anthropology attempts to describe these extinct and extant cultures, that is quite fine. We can only do our best and we are likely right on a number of points. When discussing the ancient Mayans for example, we fill in a lot of blanks with what we think makes sense (based on artifacts and comparative anthropology with both other extinct cultures of the time and extant descendants). This makes for an interesting and worthwhile qualitative understanding of the culture in question, but it does not give a solid scientific basis for which to base actual tangible research outcomes on. However, the anthropologists (particular of the “medical” ilk, in my experience) do not think this to be the case. This leads to the phenomenon that you are describing. Of course this is fueled by the human tendency to think our expertise can translate to other fields, as evidenced by Michio Kaku’s abysmal foray into trying to explain biology and human evolution. He is a great physicist, but biologist he is not.

  27. nybgrus – What is the word for the opposite of cultural relativism? I see a lot of negative comments on culture relativism on this board, and I can see why that might make some sense in the context of other people’s lives, regions, etc. But in my life, my region, the thing I see that concerns me more is people deciding that any aspect of a another culture that is different from the majority one is inferior or outright threatening.

    I was brought up differently, I was brought up with a general idea that if one accepted the differences in another culture that don’t really impact your life and cause harm to anyone, then you would likely garner enough good will to have a good chance of working through differences that do impact people’s lives or cause harm.

    Of course I have no proof that works.

    But, respecting someone’s rights is different than buying into their reality. Until a culture can defy the law of physics through belief, I’m inclined to believe that natural laws don’t really care what any of us think and should be considered separately.

    Perhaps the anthropologists need some sort of organizational method for separating facts that are not culturally dependent from those that are?

    But now I think I am acting “like the newbie taking a look at a problem for the first time who discovers things that have been known by the experts for eons…” (DG)

  28. daedalus2u says:

    Michele, it is extremely difficult to not denigrate that which you don’t understand. It is an extremely common human trait.

    “Cultural relativism is the principle that an individual human’s beliefs and activities should be understood by others in terms of that individual’s own culture.”

    http://en.wikipedia.org/wiki/Cultural_relativism

    I think it is ironic that Moerman is not understanding the culture and practice of Medicine in terms of how those who practice medicine understand it. He is applying his own provincialism and interpreting it as performance art.

    That is what CAM practitioners do too. They don’t understand SBM so they denigrate it.

  29. DU2 “I think it is ironic that Moerman is not understanding the culture and practice of Medicine in terms of how those who practice medicine understand it.”

    HeHe, I hadn’t thought of it that way, but good observation.

  30. nybgrus says:

    Actually DU2 I’d disagree slightly. The medical anthros are trying to look at the practice of medicine in the terms of those who practice it. They are using the principle of cultural reletavism to claim that each practice of medicine is equal and valid when viewed through the lens of the culture within which it is practiced. Of course, in my experience, that means that they like every other type of “healing practice” (I was taught that there is a distinct difference between healing and practicing medicine) and hate the evil reductionists of “Western Biomedicine.” But to them, TCM works when viewed the the Chinese cultural lens, Ayurveda in India, etc.

    As for what is the opposite of cultural reletavism… not sure – absolutism perhaps? The issue with CR is that anthros take it to an extreme. It is one thing to embrace the differences of a culture and realize it is OK for the Brits to drive on the left side of the road and a different one to claim that you can’t evaluate the moral implications of child rape because it is the norm of the culture. They do the same thing with medicine and take that relative to an extreme where for them, a lab value means very little. Notice that Moerman talks endlessly about “meaning” – that is very much a facet of the training he received – but doesn’t seem to think that objective lab values carry much “meaning.”

    As I said, anthropology is actually a very interesting and useful field. It is just taken to ridiculous extremes at time and applied in very wrong ways.

  31. woo-fu says:

    @nybgrus

    They are using the principle of cultural reletavism to claim that each practice of medicine is equal and valid when viewed through the lens of the culture within which it is practiced.

    Not only is that totally unscientific, IMO, when determining efficacy, that argument actually undercuts the endorsement of CAM. I have heard at least a couple of Asian friends claim that their therapeutic systems wouldn’t necessarily work for non-Asians because they aren’t brought up in the culture. So, even though they practice one or another form of TCM, they don’t endorse the proselytizing of it.

    Furthermore, if each culture’s techniques were equally effective (perhaps not what they mean by “valid”?), why do so many people from so many different cultures compete to earn positions at prestigious modern medical schools? Surely, the ease of entry, cost of study, and the low overhead of practice are attractive features of simply staying in a CAM tradition, so there must be something even more compelling to draw them into modern medicine. Gee, I wonder what that could be?

    As for what is the opposite of cultural reletavism… not sure – absolutism perhaps? The issue with CR is that anthros take it to an extreme. It is one thing to embrace the differences of a culture and realize it is OK for the Brits to drive on the left side of the road and a different one to claim that you can’t evaluate the moral implications of child rape because it is the norm of the culture.

    Yikes–a harsh comparison, but a sad reality. It reminds me of how some of the same individuals fighting against same-sex marriage rights were simultaneously fighting for the rights to marry girls as young as twelve on the basis of “culture.” I know that’s taking it a bit OT, but these cultural arguments must have their limits.

  32. daedalus2u says:

    Nybgrus, I don’t disagree with you, but Moerman was writing in the NEJM. He was writing for his editorial to be read by MDs. He was writing for MDs without understanding the culture of MDs, or at least without understanding the culture of the subset of MDs that practice SBM.

    He was applying his “beer goggles” of CR to medicine and asserting that CAM is just as good as SBM. It is not true that all MDs share the assertion, that according to CR, that CAM is as good as SBM.

    I think the opposite of cultural relativism is looking at practices without a subjective filter of culture; that is being completely objective. This is difficult to do, just the way that science is difficult to do while maintaining a filter of subjective bias. Individual experiments can be done blinded so there is no opportunity for subjective bias. Most people simply can’t do it, so they have to default to what their feelings tell them and that is purely subjective. It takes a great deal more information and data regarding what the practices are to be able to analyze them in a culture-free context.

    Child rape is a good example. Depending on what the goals of the society are, child rape might be a good way to achieve those goals. If the goal is to have “leaders” who are sexually satisfied with no consideration as to the harm that might cause to their victims, then child rape (if done by a “leader”) is compatible with those goals and might be the only way to accomplish that goal. If the goal is to have adults that are physically and emotionally healthy, then preventing child rape is the only way to accomplish it.

    The same is true of CAM. If the goal of society is for CR to be the guiding principle, then using CR to say that CAM is just as valid as SBM is a way for people like Moerman to accomplish their goal and acquire more support from CAM practitioner. If the goal is to have a healthy population then CR and CAM is not the way to accomplish that.

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