Source: Wikimedia Commons – Original work of the US Federal Government – public domain

Placebos are medicines or procedures “prescribed for the psychological benefit to the patient rather than for any physiological effect” according to the Oxford English Dictionary. Originating as a way of doctors to clear their consulting rooms of people they did not feel could be helped with real medicine, placebos’ status, as Ted Kaptchuk makes clear, underwent a dramatic fall from acceptability after the Second World War and the general adoption of the randomised controlled trial to establish the efficacy of medical treatments. The lack of research since into the various aspects of treatment collectively called “the placebo effect” (Kaptchuk is a notable exception to this) is bemoaned by Kaptchuk, who feels an important element of successful treatments is not getting the attention it deserves.

This may be changing. After all, the impacts of placebos and nocebos (from the latin meaning “I will do you harm”, these are as mysterious as placebos, but make you feel worse rather than better) can be dramatic. Ben Goldacre does a five minute routine on them here (warning: it’s a bit rude). A recent Horizon documentary also looked at placebos, with the suggestion that they might have had an impact on the UK Olympic Team GB cyclists as well as in more serious cases like those of Parkinson’s sufferers.

Why am I talking about them? Because, in a more general way, to quote Seth Godin: “A placebo is a story we tell ourselves that changes the way our brain and our body work”. Godin asks why, if a placebo can make wine taste better and improve the way your back feels, we should be squeamish about discussing them.

The main reason, of course, is the feeling that it is unethical to promote treatments and products which have no scientific basis. This also explains why people operating within professions – whether medical or otherwise – are so wary of them. Professions see themselves, in the Baconian tradition, as bodies of people with expert knowledge using that expertise scientifically for the benefit of society. Placebos do not fit into this world view at all.

Imagine two pensions actuaries: Actuary A is a very experienced practitioner, known for years by many of his clients and a trusted source of wisdom. Everything he says, which he conveys with a practised seriousness and sonorousness, interspersed with frequent not-completely-discreet stories about the antics of other people he has met in his long career, is accepted by his clients like tablets of stone brought down from the mountain.

Actuary B is a young relatively newly qualified actuary. He has just obtained his scheme actuary certificate after toiling away in the background providing much of the analysis and calculation work underpinning the consultancy provided by the more senior actuaries in the firm, including Actuary A. He is seeking his first scheme actuary appointment, and has been trouping along to trustee meetings behind Actuary A for some carefully selected clients which the firm would like to move from A to B. B realises quickly, confirmed by his first trustee meeting where one of the trustees looks him up and down quickly and tells him that he doesn’t trust anyone with shiny shoes, that these clients have been selected because of their particular reluctance to pay the elevated charge out rate of Actuary A. Unfortunately this does not mean that they are keen to see a cheaper actuary installed on their schemes, quite the reverse in fact. The trustees who are most incredulous about the fees associated with actuarial advice seem also to be those who set most store in the mystical wisdom of Actuary A and his booming voice.

Now if I say that I think there are placebos at work here I do not mean that these clients are not receiving carefully constructed advice, appropriate to their needs and in compliance with all legislative and regulatory standards. What I am saying is that, from the lack of shine on Actuary A’s shoes, to the gravitas (I think it used to be referred to by a different generation as “bottom”) brought to bear on any particular issue by Actuary A, there are many things which do not add anything to the quality of advice (which in some cases has been almost entirely constructed by Actuary B), but which are valued at least as much (if not more, in Actuary B’s view) by the client.

As Simon Carne has pointed out recently, supported by John Reeve in this month’s The Actuary, the physical advice is subject to an ever increasing body of regulation, to the point where some clients might be deterred from even asking an actuary the time. However, everything about the environment in which the advice is conveyed – from the tone of voice; to the way the actuary sits; to the degree of direct eye contact; to the choice of gestures used; to, where meetings are held at the firm, the whole experience of someone entering the building and being led into a room deliberately designed to make an impression – is not. In the same way that a presentation is not just the collection of slides put together on PowerPoint, we need to give more recognition to the fact that the advice that is valued by clients is a lot more than that which is written or even spoken.

Although, judging from the number of times I have had to be the bearer of bad news (with the expectation that that will be the case preceding me and therefore helping me in delivering that message in many cases), perhaps the more usual term for this element of actuarial advice should be nocebo rather than placebo.