How Doctors Can Ethically Harness the Placebo Effect

By Guest Blogger | June 26, 2012 9:47 am

pills

Howard Brody, MD, PhD, is the John P. McGovern Centennial Chair in Family Medicine and Director of the Institute for the Medical Humanities at the University of Texas Medical Branch, Galveston. 

For years, doctors thought that placebos like sugar pills were totally inert, just something to be given out to mollify a demanding patient without any expected health benefits. Gradually, both physicians and medical researchers came to realize that such treatments can sometimes cause substantial improvement of symptoms, even when there’s no chemical or other biomedical explanation for what occurs—a phenomenon called the placebo effect. In a recent commentary in the Journal of Medical Ethics, Cory Harris and Amir Raz of McGill summarize the data from recent surveys of physician use of placebos in clinical practice in several nations.

They find that prescribing drugs like antibiotics or supplements like vitamins as placebos is now a widespread practice. This is happening without any public guidelines or regulations for placebos’ use, which raises an important question: How, exactly, should physicians be using the placebo effect to help patients?

This discussion is necessary because the understanding of the placebo effect is changing, and fast. In the past decade, scientists have used brain-scanning to see just which parts of the brain, and in what order, become active when a patient takes a placebo pill for various conditions. Other investigators have looked more closely at the treatment environment and sorted out what parts of that environment rev up a placebo response. For example, seeing a nurse inject a painkiller into your IV line gives you roughly twice as much pain relief as having the same dose of medicine administered by a hidden pump. Getting acupuncture treatment from a warm and friendly practitioner works better than the same treatment from a cold, distant one. There’s even some preliminary evidence to suggest that patients experience positive placebo effects even when told frankly that the pills they are taking are placebos, with no active chemical ingredients.

This research—and perhaps personal experience—has changed the way doctors view the importance of their patients’ mental states. Surveys from 20–30 years ago found a general belief among physicians that placebos were completely inert and powerless, and that if any good effect occurred, it was only in the patient’s imagination. The newer surveys, one of which I participated in, show a small revolution in physician thinking about mind-body relations. Physicians today generally agree that placebos can actually have a positive effect on the patient’s body, and that mind-body medicine “works.” That’s important, and has not been sufficiently noted.

If placebos work, what are the implications for daily medical practice? I agree with Harris and Raz that physicians and patients shouldn’t think that just because these surveys show they are widely used, so-called “impure placebos”—like antibiotics or vitamins given to people without bacterial infections or vitamin deficiencies—are now just fine.

There are at least two reasons to be very wary of prescribing impure placebos. First, you don’t want to sow false ideas: Will patients understand that this drug is indeed intended solely for its mind-body effect? Or will patients continue to be miseducated that antibiotics are good for colds (they are not) and that everyone should take vitamins for extra energy (they should not)? Patients should be able to trust their physicians as sources of up-to-date, valid medical information.

False ideas about what works in medicine lead to the second problem. There are real risks—several of the categories of impure placebos favored in some of the recent surveys, namely antibiotics, sedatives, and analgesics, can cause serious adverse reactions. Most studies of the placebo effect suggest that it’s an iffy sort of thing; it may occur when you want it to, or it may not. To expose a patient to a low but real chance of harm to secure an uncertain benefit seems highly questionable, especially without something resembling real informed consent or shared decision-making.

Knowing all this, let’s ask what a physician would have to do, to maximize the chances that either a pure or an impure placebo would work for the patient’s benefit. As I read the current research literature, (and as I wrote about a decade ago in The Placebo Response: How You Can Release Your Body’s Inner Pharmacy for Better Health), the physician would do several things. She’d listen carefully to the patient and be sure to explain the patient’s medical problem in easily understandable terms. She’d demonstrate care and concern while doing so. She’d help the patient feel more hopeful about and in charge of the bothersome symptoms. And she’d do everything possible to create positive expectations about the effects of the treatment. All these are proven ways to turn on the mind-body pathways that we believe to be implicated in the placebo response.

So my question is—why not do all that anyway and avoid giving out phony pills at all? It does not matter whether the preferred treatment for the condition is a pill or other therapy that really works via chemical or physiological means; or just waiting it out and drinking lots of fluids; or getting more exercise. Whatever treatment—pharmaceutical or otherwise—that the physician is going to recommend, it can be accompanied by the same mind-body “pep talk”.

What you are left with, then, is no patient deception, and little risk of any serious drug side effects; rather you are left with an excellent patient-physician relationship. That’s (so far as we know) the best way to stimulate a positive placebo response. It’s also what all patients deserve, and would deserve even if we had never heard of the placebo response.

Two ancient articles about the placebo effect drive this message home in an eloquent way. One, the title of a medical journal article of 1938 (forgive the sexism of the day), is “The Doctor Himself as a Therapeutic Agent.” The other, a comment in a 1953 paper, is: “The physician is a vastly more important institution than the drug store.”

Image courtesy of Jason Tromm / flickr

  • Chris

    I’m surprised drug companies haven’t started selling sugar pills for $100 a bottle.

  • Margaret Maxfield

    Good solution, also available for parent-to-child.

  • http://JamesEdwardTracy.com James Tracy

    I fear medication after going through 7 months of pure hell from Seroquel withdrawal (have 1+ years to go) and now have the exact opposite feeling about medication as the placebo effect.

    I fear artificial chemicals. They terrify me now.

    Perhaps I’m better off too.

  • HeatherT

    Back when I was 14, I started to get migraines. I had, as it turned out, a really smart doctor. He scanned me for tumors etc. Then, he sent my Mom out of the room (first time, ever! I remember that!) and said: “Look. We don’t know what causes these. But there is a trigger. It’s up to you to figure that out. It might be ice cream, or flashes of light. Track it.”.

    I did that, for 30+ years. It turned out to be dairy. I still dunno why, but I avoid dairy, and no more migraines.

    Point is … part of it is about suggestion. Part of it isn’t. We *do not know* what is going on, still, with our bodies. Placebo works to a degree, but the overall problem is that we don’t know how to raise or feed human beings.

  • Tony W

    You can buy “sugar pills” called “Obecalp” (placebo spelled backwards) on the internet. Hundreds of people swear by them.

    I work in the medical/pharmaceutical research world. Don’t underestimate the complexity of the placebo effect and don’t laugh at it. The body’s ability to heal itself simply because it seems to think it is supposed to is a remarkable thing.

  • Svein Berge

    So, to sum up the article: The etical way to harness the placebo effect is to listen and talk to the patient, but not hand out placebo. Sure, there are no ethical problems there and sure you end up with an excellent patient-physician relationship. But does it harness the placebo effect?

  • Bob Roehr

    The ritual of physically taking something can be an important part of the placebo effect — try to imagine religious communion without water and wafer but only words from the priest — and trying to disentangle that physical component runs the risk of diluting or even destroying the effect.

    The search should be to identify a chemically inert placebo that is safe but still delivers the effect.

  • Karen P

    This issue of placebos is central to the approval process for the pharmaceutical industry. Often when meds go through the process for FDA approval, the placebos (as is the case in psychotropic meds) are “active” meaning they produce some sort of physical response (dry mouth or something) to give the recipient the illusion that they are receiving the real thing. Funny thing is that drug companies often have a tough time proving efficacy, since the placebo recipients often feel better. That’s why many of our most widely prescribed drugs may have had test “failures” before they met the minimum threshold that the FDA requires. And then these drugs are prescribed on a much wider basis than the studies ever indicated (for example depression, the meds were developed and studied on people experiencing severe depression.)

  • George F

    There does seem to be some exaggeration as to the ‘real’ impact of placebos, and a failure to take account of patient’s desire to please practitioner whom they like by emphasising how helpful they have been.

    Having a good ‘builder-client’ relationship will lead to clients reporting being more pleased with the building work done than is they found an equally competent builder personally unpleasant, but that does nothing to indicate a sophisticated interaction between mind and mortar.

    Many claims about the value of the placebo effect rest upon subjective questionnaire scores, or short-term responses to suggestion. While the human mind can be manipulated in all manner of interesting ways, it is important that medical practitioners remember that they have a responsibility to speak as honestly and clearly to their patients as is possible.

    In the UK, we are now seeing how biopsychosocial pragmatism, and a desire to manage the cognitions of the sick in order to pragmatically promote functionality, is being used to justify reforms to the disability benefits system which have pushed many seriously sick and disabled people into poverty. Any justification for paternalism or the imposition of power over the weak tends to end badly, and be looked back upon with a sense of shame.

  • Anonymous At Work

    Question: Why don’t physicians take a page from quack homeopaths and simply give out pills that contain 1 ug per gram or some ridiculously low amount of an active ingredient? Avoid the idea that you are just giving sugar but give too weak a dose to induce side effects. That, combined with furrowed brows and a physical examination and medical history, should induce the placebo effect because patients will feel appreciated.

  • Plamen

    So, essentially, this is implying that religion does, in some cases, work. Taking holy communion in a supportive, caring, and pious church setting can have measurable medical effects. I’m an atheist, but I’ve seen doctors prescribe antibiotics enough times to know that they, in many ways, fulfill the function of holy people of previous eras.

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