Don’t watch this video of Lorimer Moseley explaining the placebo effect. If you do, you’re likely to find a lot of your assumptions challenged.

Ok, maybe watch it.

Alright, definitely watch it.

After you’re finished, you’re likely to find yourself in a bit of an ethical quandary. I mean, the placebo effect is powerful! So powerful that one could almost make a living administering nothing but interventions they knew were not clinically meaningful … Thank goodness no one does this.

Now, you’re different. You believe in ethics, and you also believe that using treatments that are no better than placebo undermines your profession and your own reputation. I think you’re right, but let’s think about this for a minute, because there’s a confounder you may not have considered.

I propose that trying to eliminate the placebo effect isn’t possible. I think that’s true because the moment a patient walks into a professional clinical environment, the placebo effect is at play. The same exact technique administered by the patient’s buddy on a gym floor will unavoidably have a different effect when performed by you in a clinic.

What’s more, the choice is rarely between a favorable placebo effect and no effect at all, as that would require a patient that was unconscious. Instead, reality forces us to choose between placebo and nocebo. Between confidence and uncertainty. If you decide to overly qualify your clinical reasoning to the patient, you’ll likely swing the pendulum too far. In your attempts to abolish any trace of placebo effect, you will come across as so uncertain in the efficacy of your treatment that your patient’s inevitable doubts will lead to a nocebo.

Clinician affect is a prime example. If you are confident in your treatment, and believe it will work, that is likely to come across and increase the efficacy of your treatment. The converse is true. If you are ultrasounding your patient’s ankle, and think it’s worthless, it is likely to BE worthless. If you paid attention during Moseley’s video above, he talks about how, when clinicians were told that the drug they were administering was placebo, the intervention was less effective, even when they were actually administering the real thing. In otherwords, clinician doubt had a nocebo effect and blunted the real effects of the intervention.

Clinician beliefs matter, and I think the safe play here is obvious. Select interventions you can be confident in, and you are likely to be maximizing the placebo effect. Even if you make some errors in your treatment selection, the confidence you exude, which can only come from sincerity, will benefit your patients. Further, the more research you do into what the evidence actually says, the more confident you will be in your choices.

Be honest with yourself and your patients, and you’ll likely be taking full advantage of the placebo effect in an ethical and responsible way.