THE online discussion between proponents of conventional medical science and those who see the scientific method as too “closed-minded” can become frustratingly repetitious. When evidence is shown of a therapy being ineffective beyond placebo, this question is frequently posed: “If it makes the person feel better, where’s the harm?” Having had this discussion many times myself, I’ll share with you what I think the answer is.
There are multiple harms. The harms are both direct and indirect, and both physical and ethical.
First, medicine has spent decades adapting to the societal call to drop the paternalistic role, where The Expert was not to be questioned. Instead, we are encouraged to be skilled advisors, using our knowledge and experience to assist patients in medical decision making. Our expertise lies in understanding how the body works in health and disease, how to identify what is going wrong, and how to approach fixing it. Our more subtle skills include gaining an understanding of what the patient needs from us and how this is most effectively communicated and delivered. What is needed can be as simple as an explanation or reassurance, or as complex as an intensive care unit admission on inotropes and a ventilator, or major invasive surgery. If the treatment we offer is a sham “therapy” for its placebo effect, we are not honouring our professional training or our patients’ rights to evidence-based care.
Next, if the patient does feel some symptomatic relief from a placebo, they may be falsely reassured about the original condition, and not seek a review of diagnosis. This is particularly dangerous if the placebo is delivered by a provider other than a medical practitioner, who has not made a competent diagnostic evaluation first. We know that the placebo effect can only improve a sense of wellbeing, but not bring about healing of tissue (although spontaneous healing of self-limited conditions may occur).
Third, the provision of a “remedy” for every symptom encourages patients to have a dependence on the health care provider, rather than to take responsibility for their own health and wellbeing. If we are always recommending “medicine”, we are teaching patients that every symptom reflects a “disease”, or that their body is somehow “damaged”. On the other hand, we know that watchful waiting can safely monitor self-limited conditions. The ability to do this, however, requires a long term doctor–patient relationship, with the ability to recheck and review symptoms and progress. The current tendency of many emergency department staff to do a “full work-up” on patients presenting with likely benign conditions works against the ability to educate patients about review and reassessment, and, frequently, the tests become the placebo.
In moving away from authority figures towards the role of consultants in health assessment and disease management, we can regain wonder and pride in our mastery of medical science. We understand metabolic pathways and cell membrane structures in intimate detail. We can distinguish dietary ketosis from diabetic keto-acidosis, glucose metabolism from fructose, understand the risks of thromboembolism and of its prevention and treatment. We can explain about acid-base balance and why “alkaline water” isn’t therapeutic. We can keep in touch with newer areas of physiology and therapeutics through reading, journal clubs and clinical meetings, and use what we learn to educate and benefit our patients.
When patients ask us about the advice they got from their naturopath, the product they bought from the homeopath or the supplements they are taking, we can explain how the placebo effect works and refer them to the evidence. The time taken in explanation and reassurance provides a placebo effect in itself – without any deception.
Dr Sue Ieraci is a specialist emergency physician with 35 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She is an executive member of Friends of Science in Medicine.
To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.