Released June 12th 2014 - 1st update February 26th 2015 - 2nd update Sept 4th 2017.

This example demonstrates how the Non Zero Ratio toolbox supports paradigm-changing new perspectives.

Be warned: as Einstein said: problems cannot be solved at the level they were created: they require a paradigm shift.

A paradigm shift proposes by definition a deviation from the norm and is thus abnormal. So what follows will look absurd : a statement will be made that surely cannot be true. However, using a combination of known facts, a new logic will be presented that supports the absurd statement, and thus should be true also. So here you go : how do you feel about the following suggested paradigm change ... :

Preventive health care campaigns against smoking, cholesterol, high blood pressure, obesity, ... that stress the harm may well increase risk and cause additional victims contrary to the general expectation!

This apparent absurdity is claimed to be true because of the placebo effect :

When new drugs will be introduced by pharmaceutical companies, these have to comply with a legal framework to ensure that these drugs are working better than the placebo-effect, by successfully passing amongs others double blind clinical trials. This placebo effect is very frequently observed in clinical trials with drugs, and is understood to be associated with expectation and conditioning. Both from this understanding (expectation/conditioning) and from research, it is also generally accepted that the placebo effect works both ways : curing in case of positive expectations, and getting ill/side effects in case of negative expectations (in which case it is sometimes referred to as the nocebo effect.

At this point, the Non Zero Ratio process steps in, exposing a link between two phenomena that are considered not to be linked:

The current normative thinking by the entire medical and even scientific community is that the placebo effect does not have any effect on the efficiency of preventive health care campaigns.

From the Non Zero Ratio process, on the contrary, it follows that this normative (= standard way of) thinking is from a scientific perspective unjustified, and the placebo-effect should on the contrary be expected to have a major impact on the efficiency of preventive health care campaigns.

The reasoning along the Non Zero Ratio process goes as follows:

- Most health care campaigns focus on the negative effects resulting from bad habits, to try to convince people to abandon these bad habits. A clear case is the anti-smoking campaigns that emphasize the negative "deadly" risks associated with smoking (getting lung cancer etc).

- In the minds of the people with these bad habits, this reinforces the negative expectation that, if they continue the bad acting (smoking), the bad consequences will result.

- This is exactly what the placebo effect is about : when the patient does an act (take a pill), and the expert environment reinforces the expectation you will get better, some patients actually get better even if the substance of the act (pill) is inert (placebo). Replace pill with cigarette and better with ill, and this leads to: when the patient does an act (take a cigarette, and the expert environment reinforces the expectation you will get ill, some patients actually get ill even if the substance of the act (cigarette) is inert (placebo).

So the Non Zero Ratio process leads to thinking that with what we understand today about the placebo-effect, one should consider it possible that it somehow also affects the efficiency of preventive health care campaigns as their efficiency would thus be the result of two different effects:

1) If in the example as a result a percentage of people would stop smoking, the risk of people getting cancer would reduce, which is the key reason for these campaigns.

2) However, if there would be a placebo effect associated with the negative expectation, this would imply that in the example, for those smokers that do not quit smoking, the risk to get ill has been increased, in the same way that a patient that takes a placebo pill and expects to get better, sometimes indeed gets better.

So the insight resulting from this thinking process raises following two research questions:

1) Are scientists indeed disregarding the possible role of the placebo-effect in preventive health care campaigns?

2) If so, are scientists justified to do so?

1) Are scientists disregarding the possible role of placebo-effect in preventive health care campaigns? YES:

Yes, medical science is not considering at all it is possible that the placebo-effect plays a role in preventive health care campaigns: The placebo-effect is never mentioned in research on the effectiveness of health care campaigns, as if it were considered, it should be clearly mentioned:

1. If the possibility of the placebo-effect would be considered, one would start with trying to establish preventive health care campaigns by avoiding the mentioning the negative expectations (risks of lung cancer, being out-of-breath, ...), but rather focus the positive effects (better sports results etc). This debate is nowhere being considered, reflecting the conviction that stressing negative expectations does not possibly have any negative impact on public health.

2. Next, only if the mentioning of negative expectations cannot be avoided in the preventive health care campaign, one would thus assess the net result of both effects (i.e. what is the risk reduction due to people stopping smoking due to the campaign versus risk increase due to the negative expectation put into the minds of the smokers that cannot stop smoking through the placebo-effect), as this balance should be positive. This balance is completely abscent in all research about efficiency of preventive health care campaigns. And it is not hard to see that, if campaigns would not lead to a reduction in group at risk (for smoking campaigns that is the case now in many Western countries, and with obesity, the size of the group at risk is in any case increasing).

2) Are scientists justified to disregard the possible role of the placebo-effect in preventive health care campaigns? NO!

This is an example of an error of omission, similar to Wason's four card problem. The scientific community does not feel the need to justify why the placebo-effect can be disregarded: preventive health care campaigns are expected to work as a norm. When you would confront a medical professional with the above lack of proof, you will likely be suggested that it is up to you to prove this crazy idea that the placebo-effect is indeed playing a role in preventive health care campaigns. This is not scientifically justified for the following reasons:

1) Scientists should be able to justify why the placebo effect can be disregarded in the case of preventive healthy care campaigns, especially as from the current understanding of the placebo-effect, one should expect it to play a role by default. They likely put the birden on you, because they don't know themselves why this was assumed and this sounds scientifically correct.

2) Scientists however should not put the burden on you (or me), but on themselves, because, if the placebo effect plays a role in preventive health care campaigns (and we saw earlier this is a reasonable assumption), then the generally adopted principle of cautiousness in medical care is actually violated: It deteriorates the campaign effectiveness, possibly leading, in worst cases, to highly increased risk: what if smoking campaigns do not succeed at recucing the number of smokers (currently the case in many European countries), and thus increasingly focus on the negative consequences of the bad habits but thus reinforce the negative placebo effect...

So the cautiousness principle in combination with the reasonable logic (placebo = expectation; campaigns reinforce negative expectation) is sufficient to require justification from the scientific community. Health care policy makers thus not only have the right, but even the duty, to require justification from the scientific community, and the scientific community has the obligation to clarify. If the scientific community cannot justify why the placebo effect can be disregarded in preventive health care campaigns (and from above it appears that this indeed will be the case), the cautiousness principle should be expected to drive health care policy makers to forbid the use of negative expecetations in preventive health care campaigns with legal means the same way double blind clinical trials are imposed on pharmaceutical companies in the case of new drug development.

The Non Zero Ratio process also helps to understand why this thinking flaw was sustainable:

The thinking flaw (error of omission), as with any paradigm change, is facilitated strongly by the Groupthink in this case within the scientific community that belief does not work (the debate of science versus religion, "the God Delusion" cfr Richard Dawkins)

And the placebo effect has an aura of belief around it : scientists do not really understand the phenomenon, and it could be worded into "if you believe something will make you better or worse, it will actually make you better or worse : belief works", which risks to relate placebo to the highly charged science versus religion debate. Who would want to research the placebo-effect? Believers?

This downplaying of the placebo effect in mainstream medical science also becomes evident when looking to the conclusions drawn from e.g. double blind clinical trials: If in one of such trials, the drug cures in 40% of the cases while the control group (placebo) cures in 30% of the cases, the conclusion generally is that the drug works better than the placebo effect. In reality though, the placebo-effect is present in both groups, so the drug group is the sum of placebo effect and the drug (chemical) effect, and the drug only adds 10% to the 30%, so is contributing only 1/3 of improvement, and one cannot state that the drug works better than the placebo-effect. So in general, the effect in the drug group is considered to be fully attributed to the drug and is considered to be the most important effect even when it is hardly better than the result in the control group.

Fabrizio Benedetti developed alternative clinical trial set-ups to eliminate the role of expectation (see e.g. his book The Patient's Brain: The Neuroscience Behind the Doctor-Patient Relationship, Oxford University Press, 2010), and found that in those cases, when eliminating the expectation, the resulting drug did indeed work far less than previously expected, concluding that the communication factor (the expectation created by the doctor) is much more important than currently considered.

The bottom line here is that when interpreting the results of clinical trials, scientists appear to attribute (in their language) the "chemical" working principle to the full effect (in the example 40%), while in reality in many cases an important contribution is actually caused by different effects that are also in the control group (placebo effect, natural curing, ...). In cognitive psychology this error is referred to fundamental attribution error. This results in most research being oriented towards the adequacy of drugs and their development (the chemical component, one drug typically being developed for one specific disease, where the money is), and in comparison ample research being oriented towards understanding the placebo effect as an all-round healing mechanism that can work on many different diseases and thus deserves to be better understood.

It may be clear that the paradigm change proposed above leads to completely different (new) ways of:

- Defining health care campaigns (these should avoid stressing negative expectations of bad habits)

- Research towards improved drugs (much more focus on understanding and reinforcing the placebo effect)

- Testing of new drugs (focus on combining the chemical and placebo factor rather than viewing the placebo factor as an annoyance)

More information about this view:

(2015, English) White Paper(292 kB pdf), an example of a paradigm change developed using the Non Zero Ratio process