Animals and the Placebo Effect(s)…..

If asked (or poked by a stick perhaps), most skeptics would likely be able to quickly rattle off a personal top ten list of the silliest pseudoscientific beliefs that they have encountered. There would probably be much variation between theses lists, with perhaps a few universal standards, because many skeptics specialize. My particular area of interest/specialty is irrational thinking as it applies to the practice of medicine.

As a pediatrician who specializes in hospital based care, I see more than my fair share of it. In the early days of my medical career, my already skeptical mindset was further influenced by encounters with patients suffering great harm at the hands of unproven and unscientific therapies. One child, barely able to breathe through a swollen airway by the time she was brought to our facility, was having her rapidly enlarging abscess treated by the unblocking of her stagnant chi. Ironically, she may have responded to being needled had they been a larger and inserted into the growing pocket of pus in the back of her throat. Another young patient, also having great difficulty breathing but due to an asthma flare, was failing to respond to the correction of a fictitious misalignment of her spine.

More recently I’ve dealt with the inappropriate use of hyperbaric oxygen therapy in a disabled child, and risky chelation to remove non-existant toxic heavy metals in a child with an autoimmune condition effecting their kidneys. And almost daily my life is complicated by the well-meaning but just as nutty use of antibiotics to treat what amounts to parental/practitioner anxiety, an indication for which I’m fairly certain there is no FDA approval. Science-based medicine is what I do, or at least what I strive for on a daily basis, so my list is heavily weighted towards beliefs common in both users and pushers of unproven practices.

High on my personal list is the belief that animals are immune to the placebo effect, and that the anecdotally successful use of an alternative remedy in an animal proves that it works for that very reason. This belief is frequently touted by pushers of therapies that have failed to demonstrate effectiveness in well-designed studies that incorporate a placebo control group. And it is often credulously repeated by woefully unprepared, or maybe just uninterested, journalists in the many puff alternative medicine pieces churned out each year. A wonderful example, for educational purposes, is this January 25th article in The Bulletin, an online news source for central Oregon, on the expansion of alternative therapies into the care of animals.

The piece establishes the mood with the ubiquitous anecdote/testimonial, in this case the terrific success of acupuncture in treating a dog’s chronic inflammatory bowel syndrome. The owner reveals that the therapy is working but clarifies that after more than a year of acupuncture, a restricted diet and unspecified herbs, “she’s definitely improved.” Sounds great, right. Well, not exactly. With a reasonable understanding of the placebo effect, anecdotes such as this are more easily seen for what they are: unblinded and uncontrolled studies involving one subject. In other words, absolutely meaningless.

We’ll get back to placebo in the context of treating animals in a minute, but first I’d like to touch on a few of the standard canards presented in this article as if chiseled in marble facts. The author makes several unlikely assumptions and outright false statements, the most glaring of which being that homeopathy involves the use of small doses of natural substances and that alternative medical care of pets is both holistic and individualized.

On first glance to those uninitiated in the reality bending wackiness of alternative medicine, and in particular homeopathy, this may seem like a reasonable thing to say. Homeopathy does involve small doses of various substances in the supposed remedies, although what is meant by the term natural is, as usual, unclear. Both poison ivy and snake venom are used in homeopathic remedies, and are both quite natural, but most folks would probably wince at the thought of ingesting them. But wince though one might, there is nothing to fear because homeopathic doses involve such “small” doses as to render them undetectable and unable to have any effect, beneficial or otherwise. Homeopathic remedies are inert and no decent study has shown them to be effective for any condition. Belief in homeopathy is akin to belief in magic. In fact, ask the next homeopath you bump into how they can tell the difference between a vial of tap water and a vial of deadly rattlesnake venom diluted to the point where no molecules of the substance can mathematically be expected to be found. Sit back and enjoy the show.

The claim by practitioners of alternative medicine that they are “holistic” or that they practice individualized medicine is subterfuge. Many people are impressed by such statements, and they have opened the door to our most premiere academic institutions for some pretty ridiculous stuff, but they are integral in a rather clever ploy by proponents to establish a false dichotomy between the many disparate alternative medicine entities and conventional medicine. They are always meant to imply that those evil, big pharma worshiping regular docs just treat symptoms and don’t care about the patient as an individual with a multitude of biopsychosocial factors effecting their outcome. Ironically, it is the alternative medicine woo flingers that almost universally cling to a single cause for all ailments. The single cause changes, depending on the particular form of quackery, but it still boils down to a complete and utter lack of individualization. Every patient, regardless of symptoms, has unbalanced chi to an acupuncturist. Every problem is caused by subluxations in a chiropractor’s office. To some it is all about nutritional deficiencies, while others blame unnamed toxins that must be removed from the body. Is all illness caused by liver flukes, as was proposed by Hulda Clark, or is it acidosis? Or yeast? Depends on who you ask I guess.

When I see an ill child in the hospital, I take a complete history. Rather than just throwing drugs or surgery at a symptom, I probe for information regarding prior illnesses, the medications a patient is on or has been on, their diet, family history, social history, etc, etc. I perform a physical exam. I then ask the questions that inevitably arise from my exam findings. Knowledge obtained from any one of these areas can effect the treatment options for the patient’s condition. I often am aided by social workers and medical managers that work diligently to ensure that my patients can obtain the help they need, by dietitians who focus on assisting patients in meeting nutritional goals, and by various therapists that provide valued assessment of and treatment for patients with respiratory, physical, occupational, or speech/feeding related adversities. There are psychologists and child life specialists that are available to attend to the emotional wellbeing of my patients and even their families as well. I could see ten 6-week-old male infants with bronchiolitis in a row and they might each require a different approach to their treatment based on the above factors. This way of approaching patient care goes on day in and day out in hospitals and doctors offices around the world. Naturally some are better than others, and there are some abysmal physicians that tackle patient care in ways no better than the average naturopath, throwing prescriptions of zithromax at every runny nose, but there are constant attempts by the profession to weed out bad practices such as this. The same cannot be said for practitioners of alternative medicine.

Now back to the issue of placebo and its supposed lack of effectiveness on man’s best friend. It is common to make the error of thinking that placebo is a single entity, that it is some kind of mind-over-matter effect stemming from the expectation of the patient. If that were the case, then I would agree that animals are not susceptible to placebo. But, as tends to be the case, reality is much more complicated than the fantasy world concocted by the true believer. Instead of simply being mind-over-matter, the placebo effect consists of a number of different components, some of which are pure artifact, which can lead to the appearance of a true improvement. Among these components is the tendency for symptoms to regress to the mean, which is probably the largest component of any placebo effect and the most likely reason why Maggie’s owner believes that she has responded to acupuncture. People tend to seek care for themselves or for their loved ones, pets included, when symptoms are at their peak. Other components of placebo include investment justification, novel or complicated therapy effects, or simply the desire to please an authority figure to name just a few. None of these have anything to do with an actual physiologic effect from the intervention and they only require the pet owner and veterinarian’s biased and subjective personal experience and time.

It is easy to imagine how a dog lover might interpret their pet’s behavior differently secondary to a placebo effect. It usually takes the dog a whole week to get over a flare of his inflammatory bowel disease with conventional therapy, one might say, but with acupuncture it only takes 7 days. It’s all in how you spin it and how your remember it. Human memory, while arguably better than a dog’s, is notoriously poor when it comes to recalling details over long periods of time. In addition to pet owners and the potential for their biased evaluations, it is equally easy to see how an animal might act differently because of how their owner interacts with them. Maggie might actually act more energetic and appear to be feeling better simply because his owner is paying more attention to him in anticipation of a positive therapeutic result. Perhaps other changes, such as the mentioned dietary restrictions, might have lead to positive changes in behavior that do not stem from acupuncture. The owner also mentions using herbal remedies in addition to the acupuncture. Herbs, like all drugs, have the potential to impact the physiology of the person or animal ingesting them. Many pharmaceutical agents used today were derived from the plant world. It is more likely, though still not very probable, that the dog was given an herb which led to a clinical benefit rather than acupuncture having a specific effect.

It boils down to the fact that anecdotes such as this simply cannot be trusted. We don’t know what would have happened if the acupuncture had not been tried. We also don’t know what would have happened if conventional therapy had been tried. Perhaps Maggie, instead of having merely improved, would be symptom free and far better off. Or, just maybe, acupuncture does work. That isn’t likely, since acupuncture has thus far failed to be shown effective for any condition, but my mind is always open to the possibility however slim it may be. But any reasonable person should require more evidence than this to consider any therapy beneficial. We have to employ, in addition to rational thinking, a means of being able to quickly weed out the implausible and hone in on treatments that are likely to work, and to avoid being fooled by our inherent biases.  There is the reason why science-based medicine has led to such amazing advances over the past century or so and that is the scientific method.

19 comments so far

  1. P.K.Sethi on

    I am a vet.practicing homeopathy since last 20 years .more than 40% of my cases are those which do not response to conventional vet. medicine but get well with homeopathy .Cattle and buffaloes in critical condition suffering from H.S./B.Q./Anthrax respond quickly to given treatment .Is this due to placebo effect ? All skeptics are welcome to my clinic and witness the claim .Science has yet to understand how ultra homeopathic dilution works and how placebo functions.

  2. theredstickskeptic on

    Unless you subject your claims to appropriate scientific scrutiny, you cannot know if your treatments actually work. Many patients died because of the efforts of well meaning physicians who believed as strongly in bleeding and the use of mercury based purgatives as you do in your homeopathic preparations. They were wrong and so are you. Homeopathy has been put to the test and it has failed miserably. Science, and good old fashioned critical thinking, understands perfectly well why people can be fooled into thinking that homeopathy works, and it has nothing at all to do with ultra homeopathic (is that really different from regular homeopathic?) dilutions. There is zero, or perhaps homeopathic (ultra even) plausibility to homeopathy, and there are reams of negative studies to boot. If it doesn’t work, there is no reason to worry about how it works. It is a non-issue. A rational thinker would not just take your word for it that you have seen these amazing miracle cures, and going to your clinic would just be additional anecdotal evidence. I don’t hold up my ability to weed out the many confounding variables, personal biases and various placebo effects on my own any higher than anyone else. I leave that to the process of scientific investigation.

  3. P.K.Sethi on

    Do you mean every cured patient needs scientific scrutiny ?Is his cure not a sufficient proof that treatment has worked ? You do not need a mirror to see bangle on your wrist ! Your attention is drawn to a 1998 study reported in journal of American medical association which reported that in 1994 adverse drug reaction accounted for more than 2.2 million hospitalization and over 100,000 deaths, making A.D.R. one of the leading cause of hospitalization and death
    in United States !So sir what difference does it make for patients dying due to blood letting and evidenced based scientific medicine ? I request you again , come and see face to face weather my patients are cured or die due to my drugs

  4. theredstickskeptic on

    Every claim of a cured patient requires scrutiny, especially when the claim involves treatments based on principles that violate fundamental laws of chemistry. Homeopathy is such a treatment.

    This is basic critical thinking that I am talking about here. A patient may appear to be cured by a particular treatment for a variety of reasons other than the specific effect from that treatment. Placebo effects are myriad and make up the bulk of those reasons. There are also a number of biases that can lead a person to believing that the treatment they provide works when it does not, such as confirmation bias. In essence, your personal claims of success are as meaningful as the testimonials on late night informercials.

    Medication error is a complex topic and well recognised by physicians and researchers as a problem that stems from both individual and system based issues. There are literally thousands of people that work tirelessly to decrease the incidence of medication errors in hospitals and there has been steady improvement.

    Any medication with an actual physiological effect on the body, to differentiate it from homeopathy which is equivalent to giving plain water or sugar pills, can also adversely effect the body. Adverse reactions are not all errors by a long shot though. It would be an error however to not provide evidence based treatment because of the fear of an adverse reaction.

    The reason why, assuming the data from the meta-analysis you mention reflects reality, adverse drug reactions might rank so high on the list of causes of hospitalizations and death is because of the success of modern medicine in treating so many deadly conditions. To put things in perspective, over 300,000 people each year do not die from cardiofvascular disease because of evidence based medical management. When discussing the bad outcomes that can occur with modern medical treatment, you have to include the denominator, the fact that countless millions of lives have been saved, in order to be fair. But I don’t think fairness is what you are after.

    You, like so many believers in unproven and implausible treatment modalities, are grasping at straws when you attempt to use these scare tactics, as if the fact that medicine isn’t perfect somehow equates to evidence in favor of your particular belief system. We might both be right, or both wrong. Forcing a false dichotomy with straw man arguments is a common defense when you just don’t have the evidence to back up your claims. I predict that you will very soon resort to “Big Pharma” conspiracy theories or personal offense, the last resort of the scoundrel.

  5. P.K. Sethi on

    Yes you are very correct .Who else can be better than you to do the scrutiny of my cured cases ? The owners who pay me are satisfied once their animals start feeding , working ,and give milk !this is cure without if and buts of scientific community .People can be fooled one…ten …..twenty times but never for twenty years .” Vox Populi ,
    Vox Dei ” listen to peoples voice who do not pay for homeopathy from govt. grants but from their hard earned money .
    It sounds strange to link a.d.r. deaths to the success of modern medicine .

  6. theredstickskeptic on

    People were fooled for over a thousand years into thinking that bloodletting was an effective therapy. These people were every bit as confident in their cure rates as you seem to be. A fool and his money, as the old saying goes, are soon parted. I imagine that how hard it was to earn that money plays a minor role if any in the decision to part with it.

    I’m sure it does sound strange. I’m sure that a lot of what I have to say sounds strange to you, especially considering your apparent inability to read what I’ve written and actually address the criticisms of your comments. You’ve done nothing but repeat the same tired arguments.

  7. P.K Sethi on

    It is worth pondering who’s favourite tool was blood letting.The than conventional school with whom you hold linage.People were not foolbut had no alternative.It goes to the credit of Hahnemann who not only deprecated the barbarous practice but also gave alternative modality .Those who believe it’s effects are placebo , ignore the the truth that same applies to their shots also. Allen Rose world wide vice president of genetics with Glaxo Smith Kline , one of the biggest drug manufacturing company , while addressing a scientific audience , admitted that in general 90% of prescribed drugsworks only in some 30% to 50% of cases.Placebo too cure 30% to 40% .So why blame homeopathy only?Complex psycho biological phenomenon of placebo effect can be due to different mechanism which includes amongst other the expectation of clinical benefit . Do animals have the power to reason weather a given treatment is going to work or not as a person might have ? No study has yet concluded placebo effect in animals.
    I am sure your knowledge of homeopathy is very poor and you have never participated in any study using homeopathy !So leave aside arguments , references ,meta analysis , come and be a part of the process .

  8. P.K.Sethi on

    Reply continued…..
    The new study conducted by a team of scientists in Melbourene , Australia published in the journal Cancer Epidemiology Bio-markers and Prevention has shown that man who regularly take inhaled steroids to keep their asthma under control are almost 40% more likely to develop prostate cancer !The biggest danger appears to be among man with sever asthma who frequently need treatment with steroid tablets or injections , among this group the risk of cancer increases by 70% .This is a small study who knows what awaits for a bigger study ? I think blood letting was safer than this evidenced based medicine .

  9. theredstickskeptic on

    I imagine that believing my understanding of homeopathy, both history and practice, is poor allows you to more easily ignore my arguments. But my knowledge regarding homeopathy is more robust than yours. Take my daughter for instance. She believes in the tooth fairy. She can tell you where the tooth fairy lives, what her clothes look like, what she does with the teeth, her real name, how she got the job, etc, etc. I know none of these things, but I know that the tooth fairy is a fictional entity invented for the pleasure of young children. Though my daughter might be capable of writing an entire book on the subject of the tooth fairy, I have a more accurate understanding. The same applies to homeopathy. You have wasted your life on gaining the same degree of understanding of homeopathy that my child has of the tooth fairy. Congratulations.

    Medicine is not perfect but our knowledge is advancing rapidly and the overall benefit to mankind continues to progress. Did a team of homeopaths write the paper you’ve mentioned? No, a team of true scientists did, and if it pans out it may change the way we practice medicine. But small studies such as this are more often wrong than right. And asthma is a potentially deadly if not debilitating condition for most sufferers. Prior to inhaled steroids the lives of asthma patients were considerably more difficult and prior to steroids in general they were considerably shorter. Prostate cancer occurs 100% of the time in men if they live long enough. It is very often found incidentally during autopsies of men who died for unrelated reasons. There is debate, between actual medical experts not experts in make-believe, regarding whether to even treat many occurrences of prostate cancer. It is a complex issue. But I’m confused here. Do you accept findings of published scientific literature or do you think it is all a scam? Or is it that you just cherry pick what fits your world view and ignore what doesn’t?

    The subject of placebo is also quite complex and your limited understanding of it has led to jumbled arguments that make little sense. Of course conventional medicine benefits from placebo effects. It would be impossible for it not to. But conventional therapies have for the most part been shown in trials to perform better than placebo, or at least have a plausible mechanism of action and basic science support. Homeopathy has never been shown in decent trials to be of benefit above placebo for any condition at all. Not one. And it has zero basic science support or plausibility. Its proponents are left appealing to anecdotes and worthless case studies. Oh, and to use in animals. Once again, it may help you sleep at night believing that animals are not effected by placebo but it isn’t true. Both animals and their owners are susceptible.

  10. P.K.Sethi on

    Poor understanding and a robust knowledge – this is utopia like your daughter’s fairy tale .I have utilized best years of my life in learning and practicing homeopathy but you are wasting your days in debunking and branding it unscientific without even the fundamental knowledge.I am not a sectarian .Homeopathy is not a panacea of cure but as a therapeutic modality vis-a vis conventional medicine which i practiced for decades as veterinary surgeon with state .I do not hunt selective publication which matters to my view only. On the contrary you go witch hunting .What you call nice trials are in fact misleading because P.C.D.B.C. trials are not possible with homeopathic drugs and that is why results are insignificant or poorer than placebo.I repeat there is no placebo effect in animals but if you are confident please give details of the published peer reviewed work.

  11. theredstickskeptic on

    Once again you assume I have no fundamental knowledge of homeopathy. That’s fine. I’ll just claim you are wrong because you have no fundamental knowledge of science. Have we crossed the streams? Is all of science and pseudoscience about to destroy itself?

    So homeopathy isn’t amenable to being studied by science and yet it is scientific? You don’t cherry pick studies but you ignore those that are “misleading”? Perhaps because they don’t agree with what you believe. You are quick to hold up science as evidence against conventional medicine. You want your cake and to eat it too. And all you have to show as evidence is anecdotal treatment success. History has shown us time and time again that this method of determining efficacy is poor and often leads us down a false path. So you have weak evidence and zero plausibility. And you are confused as to why rational people who approach treatment of illness skeptically aren’t convinced.

    There is most certainly a placebo effect in the treatment of animals, you just have a poor understanding of what placebo effects are.

    So what kind of jewels does the tooth fairy wear in her crown?

  12. P.K.Sethi on

    Please quote the so called scientific study detailing placebo effect in animals which i have asked for .

  13. theredstickskeptic on

    So I am supposed to respond to your arguments while you have ignored every single one of mine? Besides, you have already established that science is irrelevant so what good would it do. Tell you what. You actually read this post and then see if you have any questions regarding animals and placebo effects.

  14. P.K.Sethi on

    I want a peer reviewed study published in some journal establishing placebo effect in animals.I always seek knowledge how can i ignore your arguments ? In actual practice palliation what you call regression to mean will not make a buffalo yield 15 liters of milk what she yielded prior to falling sick .At the most she will start feeding a little but the owner who is loosing $ will not be satisfied till she resumes full production and this is cure for which he pays .In my comparative experience homeopathy does it faster at a cheaper rate .

  15. theredstickskeptic on
  16. theredstickskeptic on

    I think that the author of that post, should you choose to read it or the provided references, misses the point. He is stuck on an incorrectly limited definition of placebo and thus says that there is no placebo. But he goes on to describe the many different reasons why an intervention may appear to work other than a specific effect from a therapy. All those reasons combined, not just an effect based on expectation, are placebo effects.

  17. P.K.Sethi on

    In my view based on personal observation there is no placebo effect in animals. You may if you like make a net search .Skeptics like David Ramey ,Ben gold Acre , Lancet editor ,Vet skeptic ,vice president of J. B.M.A.avoided direct observation how homeopathy cures animals with me .Direct treatment / effect relationship can be studied , both with low and high potency with sick animals .Human trials with homeopathic drugs are not possible but some over enthusiastic homeopaths do it and make it an object of criticism .

  18. João Coutinho on

    “o you mean every cured patient needs scientific scrutiny ?Is his cure not a sufficient proof that treatment has worked ?”

    So, you think thats enough to just claim and thatś all fine? And go against all sistemátic evidence?

    No, not at all… How do you know its a cause and effect relation?

  19. P .K. Sethi on

    Very simple disease ( cause ) suspended the feeding which resulted ( effect ) in loss of production …. Homeopathy reversed the process ….
    optimum yield is resumed back . Are you a vet ? pl. speak .

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