Content warning: I accidentally got chiropractic treatment and felt better afterward, and I think talking too much about the placebo effect might be a mild cognitohazard, but less hazardous than not talking about it.
This is a story about being treated by a medical practitioner with poor epistemics, and the placebo effect that I experienced despite knowing that her medical treatment is no better than a placebo and has no medically sensible mechanism of action and despite the fact that the intervention consisted of gently tugging on my leg exactly once.
I developed an acute lumbar spasm on one side (7 out of 10 pain on movement) a while back after a heavy weightlifting session. I went to the ER of the U.S. health system that I belong to. They prescribed skelaxin and menthol patches and referred me to a doctor at the PT clinic a week later.
By the time of the appointment, the pain was 4 out of 10. The doctor had me demonstrate the movements that triggered pain. She stated that the spasm was probably due to an underlying "pelvic misalignment." Bullshit detector, go! Please note that I am doing my best to recall what I said--I was on point that day for some reason.
Informed consent (???)
SF: A what?
Doc: Yeah, the muscles around your pelvis are very strong, especially with your back squats [~300 pounds was my 1-rep max at the time, not high among trained members of my age/gender cohort], and if one side is stronger or tighter, they can pull the pelvis out of alignment.
SF: What does alignment mean?
Doc: So your pelvis is made of different bones--
SF: Yes, os coxae, ilium, pubis, ishium, sacrum.
Doc: Right, and they can get misaligned.
SF: So the bones move relative to each other? I thought it was all one big stiff system.
Doc: Yeah, it is. The whole thing gets misaligned.
SF: What does misaligned mean?
Doc: Your pelvis gets rotated.
SF: Like, if I'm looking at myself in a mirror, rotated from that perspective?
SF: Can you see it?
Doc: No, a lot of cases of pelvic misalignment don't show up on an x-ray.
SF: So it's misaligned enough to cause pain but not enough to be visible?
Doc: Yes, it's the most likely explanation [her exact words] for the unilateral pain. That's really unusual.
SF: So what are you going to do?
Doc: An alignment.
SF: What is that?
Doc: Lie down on your stomach here. [I did.] Now put your hand here [on my lower back] and press down firmly. [I did. She then firmly took hold of my leg, on the opposite side from the pain. By this time, I knew I was dealing with a chiropractic-adjacent person, so I was expecting something massive. But she tugged on my leg toward her, away from my torso, exactly once, with so little force that I thought she was just moving my leg into position for a larger yank.] Okay, you're done.
SF: That's it?
Doc: Yes. You should feel relief in the next hour to two days.
SF: That's quite a range.
Doc: Different people react differently. Call the front desk if you need to get seen again.
What the hell is an osteopath?
I left, and as I was reading the printout summary of my visit, I saw the doctor's name followed by "D.O." In the U.S., this is a doctor of osteopathy. Osteopathy started out, like chiropractic, as totally made-up bullshit about how bone problems (hence osteo-) were the source of all illness, but it's made a large move toward evidence-based practice since then. Many states license osteopaths to do just about everything that a doctor of medicine can do.
But the stain of the original sin remains on their souls. Osteopathy's status as bullshit-adjacent attracts healers who think "Western medicine" is suspicious.
I had already researched different back pain treatments and concluded, sensibly, that chiropractic adjustments are no better than a placebo. Pelvic misalignment, in particular, is woo.
But did you die?
I started driving to the office. While on the freeway, I was overcome by an extremely strong sensation of well-being. I have had two comparable experiences in my entire life: One, in middle school, when I briefly experienced what was, subjectively, the sensation of the existence of a personal God watching over me; and two, in my late twenties, when I took 1mg of clonazepam during a borderline panic attack and experienced rapid relief. I was driving down the freeway, knowing I'd just received sham treatment, and laughing with almost delirious joy at how much better I felt.
The well-being sensation passed after about five minutes. And the pain subsided to about a 1 of 10: "There is something wrong with me, your back, but it's barely worth talking about." This reduced pain persisted for several days before returning to a level I would have expected by that point without any additional treatment.
To be clear: There is no evidence that chiropractic adjustments are any better than a placebo at relieving back pain (see, e.g.), and I knew this at the time. I checked the citations again after this remarkable experience, and it didn't seem to dent it. The effect lasted for days.
I think this is super fucked up. It wasn't a true aspiring-rationality a-ha moment for me at the time, but it should have been. (I think this was before I encountered HPMOR.) The human brain! It's so stupid!
You felt better; who cares?
I think this points to a tension between epistemic rationality and instrumental rationality.
But more importantly--I think using the placebo effect to treat someone is wildly unethical because it promotes strong irrational belief and lowers the epistemic standards of the community. The practitioner is giving people un-ignorable subjective evidence that a treatment works when they know (or should know...) that it does not work in any meaningful way, and they know that most patients will nevertheless (reasonably?) conclude that it does, and spread that meme.
And yet naive instrumental rationality would tell me that the treatment works, and works better than skelaxin. Just do it! I guess true instrumental rationality would say, "Weigh the treatment benefit to you, and everyone else receiving the treatment, against the epistemic externalities."