Saturday, January 12, 2008

The Placebo

...a world of kindred spirits
The persisting question of whether a placebo or a placebo “effect” somehow has the power to effectively change the state of a disease- even today- continues to challenge and confront practicing clinicians of all stripes. For example, this recent article in Reuters discusses a questioner done at three Chicago academic medical centers and illustrates just how ingrained placebo use and its associated problems may be among health professionals.

Although a simple and superficial survey, it does shed some light on how medical practitioners view the concept of the placebo beyond a research setting. According to the authors 45 percent of 231 internists admitted to using a placebo during clinical practice. A positive aspect to this is it suggests these practitioners are aware of the body’s natural healing potential. On the other hand according to the survey, some level of deception was used on patients when implementing placebo use. The survey also supports the familiar mantra that the placebo effects- at least in clinical settings- require "belief" on the part of the patient in order to work.

The authors correctly note that this opens the doors to serious ethical dilemmas regarding the all important doctor/patient relationship. Interestingly, a possible solution mentioned by them is to develop consent forms, thus obviating any ethical issues.

On the surface, placebo consent forms sound comical- basically asking for permission to lie to your patient. They could open the doors all kinds of other unanticipated issues and problems. Consider, for example the fact that there exist “nocebo” effects- the anti-placebo if you will- and one can only imagine the hopelessly tangled web of legal and regulatory hell just waiting to really complicate things. Even an imaginary effect from a sugar pill might conceivably require professional advice and a warning label before ingesting!

At any rate, this does bring us to an age old problem concerning placebos, their study, and their use in a clinical setting. Thomas Jefferson in 1807 described the placebo in terms of being a “pious fraud” noting “one of the most successful physicians I have ever known has assured me that he has used more bread pills, drops of colored water, and powders of hickory ashes, than all of the other medicines put together”.*

Many today support this sentiment- that it is legitimate to deceptively use a clinical placebo- as did this fine 19th century doctor. The implication might be, at best, that this deception gives the body time to spontaneously heal while occupying the patients mind on something besides their suffering. However, though there is some merit to the essence of this concept, this is not the 19th century. The placebo effect should no longer be confused and connected with mythical mind/body powers or other mysterious magical influences.

In and of itself, the placebo might occasionally have mild physiological effects but it does not significantly impact the natural history of an organic disease. Its influence lies in the fog of the mind- human and, to a degree, otherwise. A plethora of socio-cultural and psychological conditions- not to mention the often naturally waxing and waning nature of disease- can now be teased away from the placebo phenomenon and focused on much more effectively. These complex interactions between doctors, patients, disease, and emotions to name but a few describe the ever so nuanced “human condition”. In this context, it seems we can do better than just giving a clinical placebo. Maybe the perceived need for deception -for a "white lie"- can be better turned towards more honest and open client/doctor interactions.

On a related note, there has recently appeared an intriguing and rather refreshing site on the web that claims to sell homeopathic products. They openly admit to selling items that have no therapeutic effects beyond the placebo, recommend medical care at the drop of a hat if one is actually sick, and note that belief is required for the placebo to have any effect. Spoof or not, this site certainly illustrates a possible solution to these difficult issues.

It wouldn’t surprise me that part of a solution to much of alternative medicine- heavily laden with placebo- might not be to follow this lead and create a whole new genre. An open and honest approach that moves away from deceptive therapeutic claims offering instead differing versions of belief based services that may make you feel better- if you want them to.

Imagine that.

* De Craen AJ, Kaphthuk. TJ, et al Placebos and placebo effects in medicine: historical overview. JR Soc Med. 1999 Oct, 92 (10): 511-515

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