Talk:Sham treatment/Related Articles

Placebo?

Placebo should be counted a subtopic of sham treatment only if every placebo is part of a sham treatment. But since this does not seem to be the case, both placebo and placebo effect belong under related articles. Right, or am I confused? --Larry Sanger 19:14, 9 January 2009 (UTC)

It's not a clear hierarchy. A sham treatment is generally considered a subset of placebo, and there are subleties depending if the use is research or therapeutic. Abstractly, a placebo-controlled clinical trial has the control arm using something that has no expected physiological effect. The ideal trial is double-blinded; not only the patient but the person administering the procedure does not know if he is doing the experimental or the control treatment. The double-blinding allows placebo effect, but prevents observer bias.

That's easy enough if the treatment is a pill. If it's a minimally invasive physical treatment such as acupuncture or therapeutic touch, the person doing the treatment cannot be blinded, because they have to know whether the patient is experimental or control -- they literally cannot act without knowing whether or not to perform a sham treatment or a real one.

Sham treatment, in some cases, carries the additional implication of causing risk but no benefit. That might be approved, in a research protocol, with something minimally invasive, such as joint aspiration under local anesthesia, but no one is going to authorize cracking a chest to do, or not do, heart surgery.

Can there be a role for sham treatment in clinical practice? Look at the articles about the ethics of use of placebo in treatment. That's written with respect to medications, but, hypothetically, I can picture a practitioner of some manipulative technique "laying on hands" with the same ethical intention as the practioner that injects saline with the suggestion it may relieve pain. Howard C. Berkowitz 19:33, 9 January 2009 (UTC)

Erg, I don't need to know all that! My question was a simple one. It is not the case that every placebo, or every placebo effect, occurs in the context of a sham treatment. Right? In that case, these are overlapping topics. The placebo topics are not subtopics. Is that not clear? If not, explain briefly the logic why not, without telling me all about how placebos etc. work. That's not relevant to my point! --Larry Sanger 22:00, 9 January 2009 (UTC)

Larry, "sham treatment" is a term of art, but there is not a pure hierarchical relationships. If I had to force the situation, I would say all sham treatments are placebos, but not all placebos are sham treatments. Sham treatments have attributes including the inability to blind the practitioner if it's a research study, and often have the additional connotation that they subject the patient to pain or risk that would not come from a "sugar pill".

Sham and real treatments/drugs can have placebo effect. Placebos may or may not have placebo effect.

Not all placebo effects come from placebos. In the placebo article, the patient, with clinical depression, who is appropriately given a pharmacologically active antidepressant (e.g., nortriptyline or fluoxetine) and reports immediate relief, is experiencing a placebo effect from a drug that is not a placebo. The drug takes 2-4 weeks to have an actual effect on disease, so the only reason for improvement is placebo effect. Neither of those drugs are completely benign, so there are technical and ethical challenges on what to do next. What if the patient, a few days later, says that their depression has been relieved, but they now have sexual dysfunction, a known side effect of fluoxetine? The Principle of Double Effect gets very complex here--if you are reasonably sure the relief of depression is due to placebo effect, do you substitute a different inert pill that shouldn't have side effects? What if that patient doesn't get placebo effect from an inert pink pill, rather than a white fluoxetine pill? Mind-body relationships are very complex.

Interested on weighing in on the ethical issues here, which I would argue get into philosophy? Howard C. Berkowitz 22:15, 9 January 2009 (UTC)