Noxious Placebos

Noxious placebos

Posted on November 29, 2008 by jp | Edit

Placebo, originally meaning “to please”, has come to mean applications which are believed not to have a known biological effect. Since these applications (“placebos”) are assumed to be “inert”, and specifically not harmful, they have been used as a standard against which planned biological manipulations (“treatments”) can be measured objectively. In this way placebos are perceived to satisfyingly enhance a cause and effect chain linking postulated treatment to benefit.


However, although having no rationale, placebos themselves can produce a subjective sense of benefit. The reasons are not understood, but could include the effect of having been a centre of attention, or a mystical belief that some type of interference or intrusion into the soma must have a potential benefit. Intermediary pathways have been demonstrated with changes in dopamine and the endorphins and activation of brain areas demonstrated by imaging.


Although these intermediary phenomena are interesting as correlated observations, they do not advance any comprehensive explanation of the linkage between cause (i.e. the application/placebo) and any resulting benefit.


Subjective reporting by the patient is often used to measure the benefit of treatments. In some of these cases it may not be possible to distinguish between the benefits of placebo versus planned biologically manipulation (’treatment”).


Let us now consider applications (“placebos”) which have no comprehensible therapeutic value but are neither inert nor benign. There are many historical examples ranging from trephination and blood-letting to purging and emeticism. Many of these “non-benign” applications persist contemporarily, such as excoriation by witch doctors, bee-sting therapy, piercings and many more. While it will have been clear to all that these treatments were harmful, with obvious damage or perturbation to the body, they must also – in the long run- have been perceived to have been beneficial to have been continued (and often a monetary value). These forms of irrational treatment must be assumed to have placebo mediated (“placebo effect”) benefit, either objectively or (more likely) subjectively.


Some, no doubt, have their benefit more at a societal level and less at the level of the patient/subject. By this I mean that the beneficiary is a group, rather than an individual. Procedures such as trephining could have appealed to the bystanders (as a group) being praised as a “Don’t just stand there, do something” action, or alternatively as a protection to society by ridding one of its members of evil. (The evil will have been in the form of “spirits”, since the expectation was that the spirit was imperceptible, and therefore the release was not expected to be perceptible). Human sacrifice, judicial hanging and suicide bombing may well have been the extreme expression of a placebo producing a societal benefit.


Where the “placebo” produces physical damage occurs, then a biological response (and perhaps a psychological response, if a distinction exists) is to be expected. Pain will produce a humeral and neurological reaction, as also would loss of body fluids or extreme temperature changes.


I will call these noxious placebos.


If one progresses to formal surgical assaults, it seems likely that such placebo effects should also exist in that domain. This would be expected to be particularly so where the motivation for surgery is more subjective than objective, and where the measurement of “success” is a subjective evaluation. In these circumstances the objective measurement of the surgical benefit might be highly distorted. [See page “Is conventional forefoot surgery proven as beneficial”]. If this is the case it will invalidate most self (patient) reporting scales of benefit.


I am concerned that many areas of surgery of the foot might fall into the category of noxious placebos. This is because the rationale for many surgical procedures on the forefoot is obscure. Further, a single surgical procedure is often claimed to have a benefit for a number of anatomically distinct problems [see page “Weir 2”].

I am concerned to read about the high number of complications which occur following foot surgery, and yet the patient (and by extension surgeon) rate the outcome is “successful”.


Finally, the web has many diaries of people who have undergone surgery, and suffered extreme and prolonged discomfort, sometimes multiple surgeries, and although yet to recover are already “pleased with the outcome”. One example, amongst many, is man who is “Happy with the results…so far” below…


Junior Member(male) Join Date: Jun 2007

Location: New York, NY, USA

Posts: 31

Re: Flat Foot Reconstruction Surgery–Share your advice & experiences please!Just a quick update from me: I saw my surgeon yesterday, the foot looks good and he’s cleared me to start physical therapy! Any advice on what I should be expecting? I’ve been pain-free for a while but I know that’s going to change as I start to put weight on it again. Basically he said that the next 2 weeks I go to therapy but don’t do anything differently at home; every week after that, I put 25% of my body weight down, so that after 4 more weeks I should be fully weight bearing. At that point I should get out of the boot and into some sneakers!Hope everyone’s doing well.lori, has your son had his consultation with the orthopaedic surgeon yet? I know it’s scarely to contemplate surgery for a child, but based on what you say about how’s it is impacting his life it does sound necessary. I am happy with the results of the surgery so far, and while many of us complain here, it does seem that most of us are really, truly glad to have had the surgery in the long run. Best wishes to your son.

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