A Placebo’s Role in Modern Health Care 

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Perceived ethics can stand in the way of the positive effects of the use of placebos for healing patients.

Modern medicine prides itself on its evidence-based approach, where doctors and hospitals choose treatments based not on faith or hearsay, but hard science.

What if our faith in medicine can be scientifically shown to have a significant therapeutic effect?

Enter the Placebo

Generally understood as the illusion of treatment, a placebo often takes the form of a sugar pill masquerading as a genuine drug.

A placebo has no discernible pharmacological value, and yet research has shown that when patients take placebos, their symptoms improve.

This effect works so well that drug trials are often built around it. When evaluating new pharmaceuticals, researchers routinely compare one group of people who receive the actual drug, with another group who receives a placebo. It’s only when new drugs and procedures can outperform this placebo effect that they can be deemed legitimately effective.

To many, the idea that patients can find relief through the power of suggestion smacks of quackery—but the evidence of this phenomenon is undeniable. Just consider is supported by the vast number of drug studies that use placebo controls in their trials. In this way, placebos are the most thoroughly tested medical interventions ever.

It’s not just fake pills—placebo surgeries have also shown a surprising amount of success.

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Despite all this evidence, most doctors or hospitals would never even consider using placebos on their patients. However, since researchers already use placebos to test the effectiveness of new medicines, why don’t we harness this mysterious (and no-cost) effect for direct healing?

That’s the aim of a new book, “The Power of Placebos,” by Jeremy Howick, a professor of empathic health care at the University of Leicester.

According to Mr. Howick, the last 20 years of research in particular has shown that placebos at least deserve a supporting role in modern medicine. His book offers practical ideas on how doctors can use them in practice to improve health outcomes.

“The placebo effect can boost the effect of whatever else we’re doing, and in some cases, it has the best benefit-to-harm ratio,” Mr. Howick said. “But all that knowledge is being stuck in the walls of academia. It’s got to break out from those walls to help patients.”

In one recent study published in The Lancet journal, researchers from the University of Sydney compared an opioid (morphine) with a placebo in two groups of patients suffering acute low back or neck pain.

After six weeks, the group given actual opioids showed about the same level of pain relief as those in the placebo group. However, the opioid group saw a far greater risk of drug misuse, which can include addiction and intoxication.

An Honest Placebo

Many studies show placebos can be effective, but the predominant notion is that playing a trick on patients by administering a fake drug is unethical. That’s why placebos are still largely relegated to drug trials.

But according to Mr. Howick, this prevailing wisdom has it all backward.

“Not only are they ethical in routine practice, but placebo effects, which don’t always require a pill, are an ethical requirement in clinical practice, and the opposite is true for clinical trials,” he said.

Placebo-controlled trials are the gold standard for drug testing, but Mr. Howick believes they’re often not the best choice. Consider this example: Since the 1990s, doctors have known that steroids can prevent death in about 20 percent of people with alcoholic liver disease. But in the early 2000s, when a new drug was created to treat alcoholic liver disease, this medicine was measured against a placebo, not steroids.

According to Mr. Howick, building a study around such a comparison puts subjects in the placebo group at a greater risk of death, and that doesn’t make sense either.

“When you buy a new car, you’re looking at a side-by-side comparison—Toyota versus Ford. Why the difference in drug trials? We should test the best thing against all the known alternatives, not how it compares against a placebo,” he said.

It’s typically considered unethical for a doctor to use placebos in the clinic because they are generally understood as a kind of deception. Even if a patient might improve from a placebo, it isn’t right to lie.

However, lying isn’t necessary to get the placebo effect to work. In 2016, Ted Kaptchuk, director of the program for placebo studies at Beth Israel Deaconess Medical Center and professor of medicine at Harvard Medical School, conducted a study where participants were given a medicine bottle labeled “placebo pills” with directions to take two capsules twice daily.

Because they knew they were receiving placebos in the study, subjects expressed suspicion about the phony treatment. But these “honest” or “open” placebos performed so well that many subjects believed they must have been given a real drug. Several participants asked for a placebo prescription after the study was over.

According to Mr. Howick, as long as doctors use honest placebos, the ethical issue vanishes.

“I think it’s crazy not to use placebos,” he said. “In fact, if the outcome is better, it’s unethical to not do that.”

Placebos Through the Ages

It’s not clear how long doctors have understood the placebo concept, but Mr. Howick believes that ancient doctors may have been more in touch with this phenomenon than modern doctors.

“Before the advent of modern medicine, doctors did not have powerful drugs,” he said. “All they had was what they called bedside manner, which is kind of a fancy term for the placebo effect.”

The word placebo didn’t find its way into medical jargon until the late 1700s and the meaning was a bit different than it is today. Back then, placebos weren’t used for drug trials but referred to any kind of dummy pill that could be used to satisfy a patient’s demand for a prescription even if a doctor had nothing to offer.

This is why the word placebo comes from a Latin root which means “I shall please.”

Over time, our understanding of placebos went from a fake pill used to placate patients, to a mysterious technique that could relieve symptoms using the power of suggestion. This modern understanding of placebos comes primarily from Dr. Henry K. Beecher, a Harvard Medical School graduate who became chief of anesthesia at Massachusetts General Hospital in 1936, and the world’s first chair of anesthesia at Harvard University in 1941.

Dr. Beecher’s interest in placebos is said to come from his time serving in World War II. The story goes that Dr. Beecher ran out of morphine, so he was forced to turn to placebos. Despite the switch, his patients still experienced pain relief.

Beecher’s seminal article, “The Powerful Placebo,” published in the December 1955 edition of the Journal of the American Medical Association looked at 15 different trials examining a variety of diseases. According to Dr. Beecher, 35 percent of 1,082 patients experienced relief from their ailment just from taking a placebo.

How They Work

So what force was behind the phenomenon that Dr. Beecher witnessed? One journal article from the 1990s critical of Dr. Beecher’s findings offered numerous explanations for the placebo effect: “Spontaneous improvement, fluctuation of symptoms, regression to the mean, additional treatment, conditional switching of placebo treatment, scaling bias, irrelevant response variables, answers of politeness, experimental subordination, conditioned answers, neurotic or psychotic misjudgment, psychosomatic phenomena, misquotation, etc.,” but certainly not some medicinal power of suggestion.

Mr. Howick says the science of the last 20 years has given us a better idea of how the placebo effect may work. The human body already contains within it the power to heal itself. Placebos just offer a little positive push to help the process.

“If you get a cut, your body heals itself,” Mr. Howick said. “Your body also has its own pharmacy to create serotonin, melatonin, dopamine, endorphins. Communication can help induce those positive things,” he said.

Consider just one aspect of our physiology: the stress response. Research has repeatedly shown that chronic stress is hard on our bodies and a major contributor to chronic disease.

However, if a doctor is talking to you with empathy, care, and understanding, even before he writes a prescription, your stress response may begin to subside. Since stress can impact the immune system, Mr. Howick says these expressions of empathy may actually boost our immunity.

”That being said, the effect is small, on average. But to put it into context, the average effect of most drugs is also small,” he said.

Limits and Dangers of the Placebo Effect

Although Mr. Howick strongly supports doctors employing honest placebos with their patients, he doesn’t recommend replacing every facet of modern medicine.

“If you get in a car accident you want the latest technology. If someone is having an anaphylactic shock, you give them an adrenaline shot,” he said. “Those situations, however, are thankfully the exception rather than the rule. Placebos can boost the effectiveness for some things, including moderate pain, depression, and anxiety.”

Once modern medicine is sold on the idea of placebos, a big part of using them effectively will come from understanding how this power of suggestion can work. While placebos show potential for healing, they can also harm.

Strange as it may sound, placebos can produce unwanted side effects. Researchers who issue informed consent forms as part of the drug trial process may include a number of symptoms patients can experience with the genuine drug. However such informed consent may even cause a placebo group to report adverse events.

This dark side of placebos is known as the nocebo effect, which comes from the Latin verb “I shall harm,” meaning the outcome of the effect is a negative one. Because the Hippocratic oath requires doctors “do no harm,” little study has examined the effects of nocebos.

However, available evidence suggests that the nocebo effect is even stronger than the placebo effect. According to Mr. Howick, this is part of our survival mechanism.

“We’re hard-wired to avoid things that are dangerous more than we are to seek pleasure. If you avoid danger, you stay alive,” he said.

The nocebo effect can destroy a patient’s confidence in health care professionals and the treatments they provide. This means that even if doctors never use placebos in their practice, they should at least strive to avoid triggering a nocebo effect.

This is harder than you might expect. A review of nocebo studies published in 2016 reports that “The verbal and nonverbal communications of physicians contain numerous unintentional negative suggestions that may trigger a nocebo response.”

Mr. Howick says what’s most important is that doctors understand how much their bedside manner can influence their patients’ health. While this may require a bit more time spent with each patient, it may mean more successful treatments and better health outcomes.

“I think there should be a major shift in the health care system,” he said. “We need more in-depth communication with patients. We need to shift towards a system where doctors are reimbursed for how much value they provide, not how many tests and treatments they give.”

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