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.
Gholson Lyon is on a crusade. It started last November, when he found out that a woman in a research study that he was conducting was pregnant. Lyon’s study had revealed that the woman carried a gene that causes a fatal disease. Yet he couldn’t tell the mother-to-be that she might be carrying a sick child due to the rules governing the study. The mother did give birth to a boy with the disease; he died in the same week that Lyon published his paper on the study, as I reported recently in Nature. Lyon was so disturbed by the situation that he is now trying to find a way for researchers to work within the rules so that they don’t face these same ethical dilemmas. And he is speaking and writing about the issue everywhere he can.
The issue of what to tell patients about their DNA is difficult enough for doctors who are treating patents rather than studying them. But it has become urgent for researchers as well, because genetic sequencing technologies are now cheap and fast enough that scientists are planning to sequence five thousand patients’ genomes this year, and as many as 30,000 next year. The US National Human Genome Research Institute will soon begin a program that will spend tens of millions of dollars to sequence the genomes of patients, like Lyon’s study subjects, who have rare genetic diseases. And researchers are also sequencing thousands of otherwise healthy people across the lifespan, from newborns to old folks.
Inevitably, researchers will find stuff in these thousands of genomes. Most of it will be difficult to understand. Some of it will clearly be linked to disease. Some of it will be newly linked to disease through these studies. The whole point of these studies is to link genes and disease. So it would seem like a good idea to tell the gracious volunteers who have donated their time and blood for these studies that they have certain genetic disease risks, right?