City University of New York (CUNY) CUNY Academic Works All Dissertations, Theses, and Capstone Projects Dissertations, Theses, and Capstone Projects 9-2018 Demystifying the Placebo Effect Phoebe Friesen The Graduate Center, City University of New York How does access to this work benefit ou?y Let us know! More information about this work at: https://academicworks.cuny.edu/gc_etds/2775 Discover additional works at: https://academicworks.cuny.edu This work is made publicly available by the City University of New York (CUNY). Contact: [email protected] DEMYSTIFYING THE PLACEBO EFFECT by PHOEBE FRIESEN A dissertation submitted to the Graduate Faculty in Philosophy in partial fulfillment of the requirements for the degree of Doctor of Philosophy, The City University of New York 2018 © 2018 PHOEBE FRIESEN All Rights Reserved ii Demystifying the Placebo Effect by Phoebe Friesen This manuscript has been read and accepted for the Graduate Faculty in Philosophy in satisfaction of the dissertation requirement for the degree of Doctor of Philosophy. ___________ ____________________________________ Date [Peter Godfrey-Smith] Chair of Examining Committee ___________ ____________________________________ Date [Nickolas Pappas ] Executive Office Supervisory Committee: Peter Godfrey-Smith Jesse Prinz John Greenwood THE CITY UNIVERSITY OF NEW YORK iii ABSTRACT Demystifying the Placebo Effect by Phoebe Friesen Advisor: Peter Godfrey-Smith This dissertation offers a philosophical analysis of the placebo effect. After offering an overview of recent evidence concerning the phenomenon, I consider several prominent accounts of the placebo effect that have been put forward and argue that none of them are able to adequately account for the diverse instantiations of the phenomenon. I then offer a novel account, which suggests that we ought to think of the placebo effect as encompassing three distinct responses: conditioned placebo responses, cognitive placebo responses, and network placebo responses. Next, I consider implications of the placebo effect’s role in complementary and alternative medicine for discussions of how to demarcate between science and pseudoscience within philosophy of science. Finally, I offer a bioethical argument that maintains that the neglect of the placebo effect within medicine may be contributing to an increase in health disparities along lines of race and ethnicity. iv Table of Contents Introduction ............................................................................................................................... 1 Chapter 1. The Ubiquitous Placebo Effect: Evaluating Accounts Alongside Evidence ....................................................................................................................................... 5 I. Introduction .................................................................................................................................. 5 II. Traditional Roles of the Placebo in Research and Practice .............................................. 5 III. What We Have Learned About the Placebo Effect............................................................. 8 IIIa. Examples of the Placebo Effect ......................................................................................................... 8 IIIb. Placebo Mechanisms .......................................................................................................................... 10 IIIc. Individuality and Placebo Reponses .............................................................................................. 13 IIId. Revisiting the Two Roles of the Placebo Effect ........................................................................ 14 IV. Accounts of the Placebo Effect .............................................................................................. 15 IVa. The Outcome of the Placebo Arm .................................................................................................. 15 IVb. The Placebo as Inert ........................................................................................................................... 16 IVc. The Placebo as Non-Specific ........................................................................................................... 16 IVc1. Non-specific Mechanisms ............................................................................................................................ 17 IVc2. Non-specific Effects ....................................................................................................................................... 18 IVc3. Non-specific Treatments ............................................................................................................................... 19 IVd. The Placebo as Psychological ......................................................................................................... 21 IVe. The Placebo as Incidental ................................................................................................................. 24 V. The Placebo as Mediated by Meaning and Context ......................................................... 27 VI. Conclusion .................................................................................................................................. 29 Chapter 2. An Account of the Placebo Effect: Conditioned, Cognitive, and Network Placebo Responses .............................................................................................. 30 I. Introduction ............................................................................................................................... 30 II. The Goals of an Account of the Placebo Effect ................................................................. 30 III. Conditioned, Cognitive, and Network Placebo Responses ............................................. 34 IIIa. Conditioned Placebo Responses ..................................................................................................... 35 IIIb. Cognitive Placebo Responses .......................................................................................................... 38 IIIc. Network Placebo Responses ............................................................................................................ 41 v IV. Returning to the Three Goals ................................................................................................ 46 IVa. Demarcation .......................................................................................................................................... 46 IVb. Explanation ........................................................................................................................................... 47 IVc. Direction ................................................................................................................................................. 49 V. Conclusion .................................................................................................................................. 51 Chapter 3. Expanding The Demarcation Project: Protoscience, the Placebo Effect, and Complementary and Alternative Medicine ............................................. 53 I. Introduction ............................................................................................................................... 53 II. Placebo Responses within Complementary and Alternative Medicine ....................... 56 IIa. Features of CAM Practices ................................................................................................................ 57 IIb. Practitioner Views on the Placebo Effect ...................................................................................... 58 IIc. Conditions Commonly Treated within CAM ............................................................................... 59 IIId. Homeopathy .......................................................................................................................................... 60 III. CAM as Pseudoscience? ......................................................................................................... 61 IIIa. A Meaningful Difference .................................................................................................................. 61 IIIc. Diversity of CAM Practices ............................................................................................................. 62 IIIc. Capturing Distinctions ....................................................................................................................... 65 IV. Theories of Demarcation ........................................................................................................ 65 IVa. Theory as the Criterion of Demarcation ....................................................................................... 66 IVb. Practice as the Criterion of Demarcation ..................................................................................... 68 IVc. Critical Attitudes as the Criterion of Demarcation ................................................................... 69 IVd. Pluralist Theories of Demarcation ................................................................................................. 71 V. CAM as Protoscience............................................................................................................... 73 Va. Protoscience in Discussions of Demarcation ..............................................................................