“THE doctor who fails to have a placebo effect on his patients should become a pathologist”, wrote English neurologist Dr J N Blau back in 1985.
The mechanisms of the effect may remain largely mysterious, but placebos have been a central component of the healing arts since prehistoric times.
Sugar pills were a normal part of the doctor’s armoury up until World War II and, although most clinicians these days would probably decry that practice as unethical, many admit to having occasionally prescribed vitamins or other “harmless” substances to a patient reluctant to leave the surgery empty-handed.
In fact, a commentary in last week’s Journal of Medical Ethics argues placebos are still routinely used in contemporary medicine, although doctors are often reluctant to acknowledge this.
The Canadian authors delve into the grey area of “impure placebos” — treatments prescribed at a sub-therapeutic dose or for conditions in which they are not effective — citing low-dose antidepressants and inappropriate use of antibiotics as possible examples.
Although impure placebos are more common these days than clearly inert treatments such as sugar pills and saline injections, these authors argue that they have been subjected to far less research and ethical debate.
“With conceptual inconsistencies leaving many physicians unaware of the fact that they prescribe impure placebos, educating medical students about the science of placebos — a topic rarely taught — is a fundamental step towards clarifying misconceptions, aligning terminologies and making ethical and judicious use of placebos in clinical practice”, they write.
And that perhaps is the key issue: how can today’s doctors harness the undoubted healing powers of the placebo effect without engaging in active deception of patients or falling back on the more paternalistic practices of the past?
It’s not just the treatments themselves that come into play here, but the way they are delivered.
Grant Thompson, emeritus professor of medicine at the University of Ottawa, in his book The placebo effect and health: combining science and compassionate care, states one thing we do know is that the effects of both genuine and bogus interventions can be enhanced by extraneous factors such as the appearance and nature of the consultation.
Placebos given by doctors are more effective than those given by nurses. Injections work better than pills. So do capsules. Big pills work better than little pills, though really tiny ones have more impact than regular-sized ones. And so on.
Perhaps most importantly, according to this book the more time and attention a patient receives from a clinician, the more effective a placebo appears to be.
Part of the appeal of many alternative therapies may be that their practitioners are singularly good at all the extra stuff that can help to make a treatment more effective. Sitting with patients, listening to their troubles, providing words of comfort and healing, are all practices that we know enhance the placebo effect. And a dose of showmanship or ritualistic magic doesn’t hurt either.
Of course, that kind of practise takes time and, for most busy doctors, there’s no easy answer.
But it does seem that these latest authors have a point in calling for more research and education into both the science and ethics of placebo use.
The placebo effect may not alter underlying disease processes, but we do know it can have a measurable impact on symptoms in a wide range of conditions, from pain, to gastrointestinal problems, to depression and anxiety.
In some cases, it’s been suggested the beneficial effects could be greater than those of commonly used drugs. Not to mention the lower risk of side effects.
Can medical research really afford not to investigate something that offers such potential benefits to patients, especially when other practitioners — often with questionable ethics — have shown themselves to be exceptionally good at exploiting the phenomenon?
Jane McCredie is a Sydney-based science and medicine writer.
Note: Most of the background information on the placebo effect is taken from Dr W Grant Thompson’s book, The placebo effect and health: combining science and compassionate care (Prometheus Books, 2005).
Posted 4 June 2012