Character as Moral Fiction is DONE

UPDATE: I’ve taken down the link to the draft of the book, since it’s actually coming out in February, and some corrections were made in the proofing process.

This evening, I sent my book manuscript, Character as Moral Fiction, to Cambridge University Press to begin production.  Here’s a draft of the cover:


Towards a moral vindication of placebo in the research and clinical contexts

Factitious virtue bears interesting and important relations to the placebo effect. The placebo effect intrigues because the beliefs involved in it seem to violate the evidence norm initially yet satisfy it in the end.  This phenomenon is best characterized as a belief about oneself causing its content to be true.  These beliefs are typically not sui generis, but respond to some kind of intervention, which we then identify post hoc as the placebo.  Thus, it’s important to distinguish between the placebo itself, which is the material intervention that triggers the change in expectations, from the placebo effect, which is channeled through the agent’s psychology.  In their discussion of the placebo effect Daniel Moerman, an anthropologist, and Wayne Jonas, a medical doctor, argue that because placebos are by definition causally inert, it is best to understand the placebo effect in terms of the placebo’s meaning to the treated individual.  “Ironically,” they point out, although placebos “cannot do anything themselves, their meaning can” (2002, p. 472).  For example, Sarah believes at t1 that the pill she’s just taken will relieve her pain, and at t2 her pain is relieved, due at least in part to her believing it would happen.


Currently, using placebo as a treatment (not just for research) is taboo, but the dirty secret is that many doctors do exactly that. This is troubling, as it means that doctors not only engage in ethically dubious behavior but endorse norms that proscribe that behavior.  In some cases, they even prescribe real but useless medications, such as antibiotics for a patient with a viral infection, which both wastes scarce resources and contributes to the evolution of antibiotic-resistant bacteria.  One way to resolve this tension would be to improve doctors’ morals, somehow convincing them to stop using placebos as treatment.  I aim instead to vindicate the use of placebos in some cases.  The strategy is to identify the types of patients who would be genuinely helped by placebos (because they or their medical problems are especially susceptible to the placebo effect) at least as much as by non-placebo treatment, and to constrain the prescription of placebos in such a way that deleterious mutations of bacteria are avoided.


This strategy is promising for two reasons.  First, the placebo effect cannot in general be avoided, nor should it.  Even when people are given genuine treatments, it’s undeniable that part of their recovery stems from their expectations, not from the medicine itself.  Second, it may not be necessary to deceive people when prescribing them placebos. Some fascinating recent studies have found that placebos do not lose all of their power even when patients know they’re just “sugar pills.” Perhaps it’s possible to justify the use of placebo as treatment in some cases.  A team of researchers led by Ted Kaptchuk (2010) showed that an announced placebo treatment (no deception) for irritable bowel syndrome improved overall health, symptom severity, and ratings of relief in their patients.  The pills for the study were labeled, “placebo pills made of an inert substance, like sugar pills.”  If congruent results can be found for patients with other disorders and diseases, it may be possible to vindicate the use of placebo as treatment in those cases.  This is the question I wish to explore from both ethical and empirical points of view.