The Set and the Setting

While the specific term “placebo” didn’t enter the medical lexicon until the late 18th century, ancient physicians were intimately aware of the effect. The ancient Greek, Indian, and Chinese traditions all leveraged the capacity of belief, trust, and suggestion to facilitate healing. However, with medicine’s scientific turn, the placebo has garnered a negative connotation of ‘all in the head.’ It is equated with sham treatments – sugar pills and inert tonics – and trickery associated with conmen and snake oil salesmen. At most, it is an effect that is filtered via the methodology of the double-blind placebo controlled clinical trial. Nonetheless, in clinical medicine and outside the narrow confines of medical research, placebo effects not only roam free, but are clinically impactful. By some (unrigorous) estimates, 30-70% of clinical effects occur via the placebo. This is unsurprising because research into the placebo effect has shown that these effects are grounded in neurobiology and a type of psychological phenomena that includes the health and wellness effects of religious practices.

As originally known to the ancients, placebo effects are mediated by rituals, social learning, conditioning, belief, and expectations.  However, in contrast to the ‘all in the head’ association, placebo effects emerge from the “set” and the “setting.” Originally formulated in the context of psychedelic experiences, the (mind)set is the patient’s internal state – their mood, expectations, personality, and past experiences. It is a complex construct that has developed historically, biologically, and culturally via complicated associations and social learning mechanisms. In general, a patient who comes to an encounter with the healthcare system with trust, belief, and expectation of improvement will have better outcomes. The setting on the other hand is the external environment including the physical space, social atmosphere, and cultural context. A setting engineered to display care, show empathy, and promote privileged knowledge will be inherently placebogenic.  

Modern healthcare has taken the baton in promoting privileged knowledge. In terms of placebo effects, there is a direct line from ritualistic dances and incantations of a shaman to the priestly and authoritative physician robed in a white coat, performing a stethoscope enabled physical exam. Similarly, the belief in the shaman’s privileged knowledge of the healing properties in plants and herbs is equal to the faith that patients have in the all-seeing capacity of an MRI, the diagnostic magic of blood draws, the healing properties of IV delivered potions, the referral to a leading specialist at a top-ranked hospital, and the superhuman capabilities of AI. In (placebo) effect, the belief-in and expectations-from science and technology has replaced the rituals of shamanistic practices. Nonetheless, placebo effects are mediated by the same neurobiological mechanisms. The setting becomes placebogenic, especially when the set is right.

However, the display and promotion of privileged knowledge is not enough to right set. Humans are foundationally ritualistic, symbolic, and connection-seeking. For our well being, we need the feeling of being seen, heard, and cared-for. Thus in order to truly leverage the placebo effect, a setting must engender the feeling of care and empathy. It must value subjectivity and intersubjectivity. This is where modern healthcare falters. Although the importance of the “patient experience” is acknowledged and measured. Many healthcare organizations also offer empathy training and best-practices to physicians to improve bedside manner. In the face of larger socio–cultural–economic forces (future essays), these measures are ultimately feeble and half-hearted. Examples abound, but experiences such as revolving fifteen-minute appointment slots, incessant answering of genericized questionnaires, being subjected to standardized and metric-blinded care guidelines, distracted physicians consumed by the electronic health record are familiar to anyone navigating the healthcare in the United States. None of these experiences are placebogenic, and it is probably not far-fetched to claim they are even nocebogenic. 

If viewed from this framework, it is unsurprising that healthcare struggles with conditions that are more amenable to placebo effects – chronic pain and psychiatric conditions. It is equally unsurprising that complementary medicine modalities have gained so much market share. They provide exactly what is lacking in the conventional healthcare system – displays of empathy, care, and personalization. The setting is paradigmatically placebogenic. It is also unsurprising that AI chatbots are frequently perceived as more empathic than human health care providers. Patients are looking to be heard, they are seeking a connection. Even sycophantic chatbots are preferred to distant and distracted physicians (future essay). 

In contradistinction to its accumulated baggage, the placebo effect is a ubiquitous phenomenon grounded in neurobiology. It is a type within the larger class of phenomena that includes religious practices. Like religious practices, it emerges from the interaction of the set with the setting. Also like religious practices, it can directly impact health and wellness. Through most of human history, medicine and religion have been conjoined. In fact, only recently have medicine and religious practices diverged in scope. The medicine-men of yesteryear were direct forebears to the physicians of today. The rituals of care and privileged knowledge of the shamans were antecedents to the rituals  of privileged knowledge today. However, in its haste to dissociate from its religious roots and in response to socioeconomic pressures (future essays), healthcare has underinvested in actions that display care and empathy. In order to truly optimize the effects of medicine, healthcare must create a setting that values subjectivity and seeks connection. It must positively influence the set.