The Placebo-Singers

In medical school, I was always told that the word “placebo” came from the Latin “I will please”, because patients tried to get better to please doctors, or the pill was just there to please patients, or something like that.

But everything about placebos is controversial and fascinating, and the etymology is no exception.

The most common funeral rite of the Middle Ages began “Placebo Domino in regione vivorum” – “I shall please the Lord in the land of the living”. The rite itself became known as the Placebo, and those involved as placebo-singers.

At some point “placebo-singer” acquired an ill reputation and became used as an insult. In Canterbury Tales, Chaucer writes: “Flatterers are the devils chaplains, that sing ever ‘Placebo'”. And during the English Civil War, a cleric was described by one of his enemies as “a placebo singer at Lincoln’s Inn, and afterwards a turncoat at Bridgefoot”. An 1822 dictionary of proverbs defines “to sing placebo” as “to endeavour to curry favor”.

There are a couple of explanations of how exactly this came to be. I think the most likely is a sort of intersection between the old term “to sing placebo” as in a funeral, and the literal meaning “I will please” – thus someone who “sings placebo” gradually shifts from someone who literally sings a hymn to somebody who tries to please, sort of as a pun. One modern sort-of equivalent that comes to mind is the use of “gaylord” as a playground epithet for gay people because it sounds like it should mean that, even though originally it was a given name derived from the French name Gaillard.

A second theory says that it was meant as a sort of insult to priests, who were always saying incomprehensible things to impress the overly credulous. This one doesn’t strike me as very believable, but it’s worth noting that another priestly Latin saying, hoc est corpus meaning “this is my body”, might through a similar process have mutated into the word “hocus pocus” meaning “a dumb attempt at magic for the gullible”. But this is just as convoluted an etymology as placebo, and probably not much stock should be placed in it – though reading that article did teach me about a Norse demon I didn’t know about before, so it wasn’t a total loss.

A final theory, maybe the most interesting, is that unscrupulous people would show up at random funerals, sing the placebo with everyone else, and loudly mourn the deceased – intent on demanding a share of the post-funeral feast afterwards. As such, placebo-singer came to mean not only flatterer, but imitator or phony – with obvious implications for the medical usage. Wikipedia seems convinced of this one, but there’s no source cited and I can’t find it in any primary.

At some point in the late 18th or early 19th century, it became associated with medicine, although it’s not clear exactly how. It seems to have had the sense of a popular but not very effective treatment, either derived from the placebo singers of above or from an alternate translation of placere, “to be popular”. Compare to the word “nostrum”, which is the Latin word “ours” and indicates popularity without a whole lot of effectiveness in a very similar way. This is the British Medical Journal‘s position on the matter – at least in 1999. A 2013 update makes a counterargument from Latin grammar – why isn’t the name the more appropriate third-person “placebit”, meaning “it will please”? 18th century doctors were generally grim people who spent their days watching people die of cholera. They wouldn’t have come up with some cutesy word where the pill is depicted as talking about itself. So maybe it comes from the funeral rites after all.

Annnnnnnnnyway, this whole line of thinking started as a way of procrastinating on the research I should be doing: trying to figure out what the heck is going on with placebos in depression. Asbjørn Hróbjartsson, who presumably studies biostatistics in between quests to slay frost giants, finds minimal evidence of placebo effects anywhere, and particularly cites three studies on depression that found no difference between a placebo and an untreated group. Wampold et al disagree and reanalyze the data to find placebo effects in a couple places, but they’re not very impressive and Hróbjartsson is definitely not impressed.

Most antidepressant studies parrot the conventional wisdom that the d=1.5-or-so effect size of antidepressant treatment consists of a placebo effect of 1.0 and a drug effect of 0.5. But there is hardly any attempt to think critically about the placebo part. How do we know it’s a drug placebo effect, and not just depression getting better on its own if you wait long enough, or people feeling special and liked because someone is doing a study on them?

Irving Kirsch is the only person I have seen even try to address this, and his methodology is audacious to say the least – comparing no-treatment arms in psychotherapy trials to treatment arms in totally different pharmacology trials. He finds that about 2/3 of the apparent placebo effect is indeed due to a drug placebo effect and 1/3 to people-eventually-get-better. The question is whether we want to trust him over Hróbjartsson’s small but more focused trials finding no drug placebo effect.

This is pretty important because there are a lot of depressed patients for whom the benefits of antidepressants might not be worth the costs, or who just don’t want to take them. If the VERY LARGE observed placebo effect in depression is in fact a real pill-based placebo effect, then it becomes vital to get some pill into these people right away. Folic acid, which has enough evidence as a depression treatment to be believable but which is also dirt cheap and very safe, would be a good choice.

But if drug placebo effects don’t do anything and it’s just people getting better over time, then it’s not worth pushing folic acid or whatever quite so hard.

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29 Responses to The Placebo-Singers

  1. Phil Goetz says:

    While the placebo effect is real and significant, it’s hard to judge whether awareness of it has done more good than harm. M.D. culture teaches doctors to dismiss anything that contradicts what they’ve been taught as placebo effect (or whatever you call its opposite, when patients imagine something harms them). The Placebo takes the place in modern medicine that God took in medieval theology, providing an instant, thought-preventing explanation for any irregularity.

  2. Jack says:

    The latin word associated with placebo, “placo,” is closer to appease, assuage, pacify, or placate than “please,” making it a bit more directly related to the modern concept.

  3. Anon says:

    I wanted to hear one of these requiem’s and found this on <a href=""youtube.

  4. James Babcock says:

    While we’re on the topic of placebos and people faking grief to get free stuff, another possible source for the placebo effects is patient fraud. Someone enters a study that pays to recruit patients, falsely claims to have a condition, receives a bottle of pills which might or might not be placebos, and either throws it away or sells it on the black market. At the end of the study, they tell the experimenters that they got better, to head off any attempts to refer them for actual treatment. If there are a few people like this in each study, that generates a strong placebo effect.

  5. Anthony says:

    I’m going to guess that “people feeling special and liked because someone is doing a study on them” is a pretty powerful effect for depression and probably some other psychological conditions, partly because the Hawthorne effect seems to be real.

    Perhaps the standard protocol for depressive patients should be switching between melatonin and folic acid, varying doses each time the patient complains he’s not getting better.

  6. Elissa says:

    Asbjørn Hróbjartsson, who presumably studies biostatistics in between quests to slay frost giants

    Goddamn it Scott, post-surgery I’ve figured out a way to laugh without spiking my intra-abdominal pressure, but I have to see it coming >.<

    • Scott Alexander says:

      This is as good a place as any to mention how impressed I am with what you did. Good luck with the recovery!

      • Elissa says:

        Thanks! You’re an awesome person, so your good opinion means a lot. I’m actually feeling a lot closer to normal than I’d expected to be at this point in recovery.

  7. Thasvaddef says:

    >But if drug placebo effects don’t do anything and it’s just people getting better over time, then it’s not worth pushing folic acid or whatever quite so hard.

    Why? You might as well unless it has negative effects.

    • Anonymous says:

      Scott mentioned two groups to whom he wants to give folic acid: those who have bad side effects, and those who refuse to take pills. The second group is the ones where he is worried about how much to push folic acid. But it’s a continuum: some people refuse antidepressants because of past side effects.

    • Watchmaker says:

      All drugs have the negative effect of “being expensive.” Most have other negative effects, too.

  8. Nestor says:

    Professional mourners are definitely a thing.

  9. Alrenous says:

    Placebos are very low status because most doctors are in the biz for the prestige, and being told that 2/3rds of your job has nothing to do with you is extremely embarrassing. This produces strong biases in all fields for which I have data – roughly two or three times the amount of bias one would reasonably guess. See also: expert diagnosis programs and the history of hand-washing. Hand washing is particularly bad because it tells doctors that not only are they not helping, they’re making it worse. If they actually cared about patients they would feel guilt and sorrow like nothing else. Instead they cover it up; it’s callous altruism.

    While Hróbjartsson has a section on definitions, he does not define ‘no treatment.’ Is there a standard implicit definition you didn’t mention?

    How do we know it’s a drug placebo effect, […] or people feeling special and liked because someone is doing a study on them?

    The latter is a placebo effect. The obvious thing to do is work out how to get the effect without lying, isolate the active ingredient, and in the meantime pretend to enroll every depression patient in a drug study.

    That said placebos don’t work on everything. Cancer is resistant, for example. Hróbjartsson seems to want to disprove placebo per se, not e.g. placebo-for-depression. First, John P. A. Ioannidis might have something to say about that. Second, it’s entirely possible that depression is just resistant. I’m not going to break his study down by treatment, he would have thought of that himself if he wasn’t using motivated reasoning.

    This comment is supposed to have links to Seth Roberts on hand washing, Mencius Moldbug on callous altruism, and my twitter where I recently opined that placebos are treatments because they make patients better. The spam filter dislikes me today, however.

  10. Derek Lorian says:

    What I’d like to see is a study comparing various different kinds of placebo against each other. That would get closer to telling us something about placebo effects, rather than simply providing a control against a drug effect. We could compare different dosage schedules and different patient instructions (this is a one-time injection vs. take this once a day vs. take this up to 4 times a day whenever you feel bad, but no more because it’s really strong). Things like hypnosis or psychotherapy could be included, and then use the drug as the control. So long as only one form of placebo is used only as a control, matching the tested drug, no useful information about the placebo effect can be derived. I proposed something like this in an undergrad seminar on depression, but the professor didn’t understand. Of course, there is no financial incentive to improve the placebo effect, but there should be a medical one.

    • Anonymous says:

      It’s been studied a fair bit I think. According to Wikipedia’s placebo article hot-coloured pills work better as stimulants and cool-coloured pills work better as depressants, capsules work better than tablets, injections work better than pills and increasing the number, expense or size of placebo pills or adding branding can increase their effectiveness.

      • Scott Alexander says:


        My two favorite results from this field are:

        1. The placebo effect increases with the probability that the drug is real. People who are (falsely) told they are receiving the real drug get a better placebo effect than people who are told they are getting a 50-50 chance of drug or placebo, who get a better placebo effect than those who are told outright it’s a placebo (although even this does a little).

        2. Drugs considered stronger or more dangerous produce better placebo effects. In one study, a researcher produced a particularly strong effect by giving the drug to the patient with a pair of tweezers, saying it was so powerful he was afraid to touch it.

    • Paul Torek says:

      Along vaguely similar lines, Scott wrote

      How do we know it’s a drug placebo effect, and not just … people feeling special and liked because someone is doing a study on them?

      The latter deserves the name “placebo” I think. And it deserves a chance, alongside “drug placebos”, unless it proves far less effective.

  11. anon says:

    I’ve always wondered why the placebo effect isn’t thought to kick in more strongly for those who receive the real pill. If there are actual changes going on in your brain chemistry, even if they’re irrelevant, it seems plausible you’d notice the difference and the placebo effect would work stronger.

    • Anonymous says:

      Some people believe this. It’s called “active placebo.”

      • anon says:

        Thank you! I was hoping there was a name for it.

        How do they try to test for it?

        • Scott Alexander says:

          By giving a drug that produces some side effects but doesn’t treat the disease being investigated. In some depression studies, they’ve given people Xanax (an antianxiety pill) that produces an obvious change in mental state but isn’t indicated for depression, as an active placebo. Results were mixed.

  12. Anonymous says:

    Another Wikipedia article, “Placebo in history” gives “Semantics of the placebo” as a source for the claim “…a singer of placebo became associated with someone who falsely claimed a connection to the deceased to get a share of the funeral meal, and hence a flatterer, and so a deceptive act to please.”

    Psychiatric Quarterly
    1968, Volume 42, Issue 4, pp 653-695
    Semantics of the placebo
    Arthur K. Shapiro M.D.

    It’s paywalled so I can’t check it myself but maybe you can.

      • Anonymous says:

        Thanks, I read the first few pages including the etymology section and Wikipedia’s claim that placebo singers falsely claimed a connection to the deceased seems unsupported.

        Relevant passage:
        “This usage derives from depreciation of the professional mourners who were paid to “sing placebos” at the bier of the deceased in substitution of the family whose role it was originally. The professional mourners probably were derogated because of their low social status, deriving income from the dead, and because they were a convenient object upon which the living could project their guilt.”