Let's Write about medical use of "Placeboes"- some interesting research
As a Registered Nurse, the concept of "placebo" is very real to us because we have cared for people cured without regard for how they were treated and patients have even delayed their death until they achieved a particular milestone.
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| Placeboes a book by Kathryn T. Hall published by MIT press, reviewed by Dr. Gavin Francis* and The Power of Placeboes: How the Science of Placeboes Nocebos Can Improve Health Care by Jeremy Howick published by Johns Hopkins University Press |
Echo essay "What Do You Expect?", about placeboes by Gavin Francis*, published in The New York Review of Books:
One of my patients with chronic depression and anxiety told me recently that he’d had a breakthrough. After years of psychotherapy to explore the traumas he’d endured in childhood, and decades of trying various antidepressants, the answer had come in a small bottle from a private clinic in London. The bottle contained herbal extract pills, he said, from Morocco or perhaps Mexico, and it was strong stuff. “The label said I was to take 1.25 milligrams, which isn’t much, but I took just half of that and I feel better already,” he told me. “I’ve been able to go outside for the first time in weeks.”
I hesitated, concerned about what kind of unregulated, potentially toxic substance he’d been ingesting. As if anticipating my question, he went on: “It’s all aboveboard, Doctor—it came with pages and pages of the science behind it. And the box it came in looks like something from the space age.” I hope the effect will last.
Perhaps the herbal extract was a placebo, or perhaps it did contain psychoactive substances, but either way its manufacturers knew something that is familiar to pharmaceutical companies: the way a medication is marketed, packaged, named, and delivered has immense consequences for the way it’s perceived, and thus its actual success in making the patient feel better. Effective clinicians try to capitalize on their patients’ expectations and beliefs, even as they deliver more conventional therapies. A good bedside manner involves more than politeness; it accelerates healing and reduces pain. In his book The Power of Placebos, the epidemiologist Jeremy Howick recounts a story from a London hospital in the 1980s about the way a senior consulting physician he calls Osler managed a patient with chronic abdominal pain who hadn’t benefited from any standard treatments:
[Osler] disappeared into the office, to reappear a few minutes later, walking slowly down the ward and holding in front of him a pair of tweezers which grasped a large, white tablet, the size of [a] half dollar. As he came nearer, it became clear (to me, at least) that the tablet was none other than effervescent vitamin C. He dropped the tablet into a glass of water which, of course, bubbled and fizzed, and told the patient to sip the water carefully when the fizzing had subsided. It worked—the new medicine completely abolished her pain!… [Osler] felt that the single most important aspect was holding the tablet with tweezers, thereby giving the impression that it was somehow too powerful to be touched with bare hands!
That beliefs can cure the sick is an ancient idea, somewhat neglected in modern medical education. Plato’s Charmides describes a comparable conjuring trick in a discussion of how to relieve headaches. All that’s required, says Socrates in the dialogue, is a particular leaf applied to the skin, but it must be applied while one sings a little song: “There was a charm to go with the remedy,” he says, “and if one uttered the charm at the moment of its application, the remedy made one perfectly well; but without the charm there was no efficacy in the leaf.” Even if Socrates was having fun at the expense of his fellow Greeks, the passage implies he accepted that beliefs and expectations influence healing.
Kathryn Hall’s Placebos is a slim summary volume more focused on the ways the designers of drug trials might exclude “placebo responders” from their cohorts. Placebo responders are people who tend to feel better with placebos; to exclude them increases the likelihood that any benefit seen in a drug trial is owed to the effect of the new drug rather than any placebo effect. It takes almost $1 billion to bring a new drug to market, writes Hall. And in recent years many studies have concluded that new, expensive drugs perform little better than fakes. The book’s emphasis shows just how much Big Pharma would benefit from eliminating placebo responders from their trials—an ethically dubious proposal, given that no clinician gets to exclude placebo responders from their clinic.
Placebo means “I will please” in Latin, and it entered English thanks to Chaucer, who borrowed it from Jerome’s translation of the Psalms. (“Flatterers are the Devil’s chaplains, always singing Placebo,” says Chaucer’s Parson.) Howick traces its first medical usage to the Scottish physician and obstetrician William Smellie, who wrote in 1752: “It will be convenient to prescribe some innocent Placemus, that she may take between whiles, to beguile the time and please her imagination.” Before the pharmaceutical revolution of the later twentieth century, it was a commonplace of medical practice to prescribe placebos. In 1807 Thomas Jefferson wrote:
One of the most successful physicians…assured me that he used more bread pills, drops of coloured water, & powders of hiccory ashes, than of all other medecines put together. It was certainly a pious fraud.
This was a pragmatic, utilitarian view of medicine—few effective drugs were available to doctors, and those that were available were toxic. In 1860 Dr. Oliver Wendell Holmes, in an address to the Massachusetts Medical Society, famously announced: “I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.” To use a placebo was ethical because it both harnessed the formidable power of belief and avoided poisoning the patient.
The idea that the mind has no power over the body is absurd: from the simplest stress headache or nervous bladder to situations in which the dying seem able to hold off the moment of death until a family member arrives, the power of belief and expectation over the progression or regression of illness is inescapable.
In my clinic every day I attempt to gauge what kind of doctor the patient before me wants or expects—is it a collaborative, arm-around-the-shoulder kind of doctor, a guide through the landscapes of illness? Or an old-school, paternalistic doctor who will simply lay down the medical law? Or perhaps an interpreter of science, able to make sense of the dizzying diversity and contradictions of the latest research papers? Judging which kind of doctor that patient needs me to be goes a long way toward being more effective, whether they’re suffering from a low mood or an infected ear. The old Cartesian idea of a split between an ethereal mind and a mechanistic body is increasingly (and thankfully) going the way of bleeding with leeches. The mind influences both how ill health is experienced and how that illness evolves. Though the relationship is poorly understood, it is real.
Take low mood: as the science writer Shankar Vedantam reported in The Washington Post more than twenty years ago,
After thousands of studies, hundreds of millions of prescriptions and tens of billions of dollars in sales, two things are certain about pills that treat depression: Antidepressants like Prozac, Paxil and Zoloft work. And so do sugar pills.
Later meta-analyses confirm this observation: the effect of all our common antidepressant drugs is at best marginally better than that of placebos. Freud’s paper “On Psychotherapy” (1905) put it well: he observed of “primitive and ancient medicine” that most remedies engaged the power of the mind, invoking a state of “credulous expectation,” and that “even after the doctors found other remedial agents psychotherapeutic endeavors never disappeared from this or that branch of medicine.” Freud went on: “It is no modern talk but a dictum of old physicians that these diseases are not cured by the drug, but by the doctor, to wit, by the personality of the physician in so far as it exerts a psychic influence.”
And just as our beliefs can have a positive effect on our well-being irrespective of biochemistry, they can have a negative effect too. Hall writes:
Expectations are shaped by learning from past experience, informed by contextual verbal and nonverbal cues, and can be either positive or negative. Thus through placebo mechanisms, expectations can enhance or minimize the effects of a treatment.
She and Howick both describe the case of a twenty-nine-year-old builder brought to Leicester Royal Infirmary in 1995 with a six-inch nail through his boot. Any attempt to remove the nail caused him to scream in agony. A clinical team heavily sedated him, pulled out the nail, and removed the boot—only to find that the nail had passed harmlessly between his toes. His foot might have been unharmed, but there was no doubt among the team that he had been experiencing real pain. Another man, part of a drug trial for antidepressant pills, took an overdose of his medication. His blood pressure crashed and he had to be carried to the ER, only to later learn that he’d been taking the placebo.
Hall and Howick each show, in different ways, just how vulnerable to both placebo and nocebo effects erectile function can be—it’s the placebo-responsive condition par excellence. Howick:
Men with healthy sexual functions who were given a placebo to enhance their performance developed sexual problems. This is probably because it caused the men to pay attention to responses that had previously come naturally, which probably increased their anxiety…. However, when placebos were given to men with sexual function problems, their performance improved.
Hall describes ninety-six men participating in a study of a beta-blocker called atenolol, which has the potential to cause impotence. Of the men given no information about this side effect, only 3.1 percent developed impotence, and among those given only the name of the drug, 15.6 percent developed it. But of those who were told both the name of the drug and that it might cause impotence, 31.2 percent developed erectile dysfunction. All of those complaining of impotence were then randomized to receive either a placebo or sildenafil (Viagra) to treat the problem; the former was just as successful at restoring erections as the latter. Similarly, of men given finasteride for prostate problems, 43 percent who were told it might cause impotence experienced the problem, against 15 percent who were not warned of side effects.
Modern medicine is good at breaking things down into parts and figuring out which parts “cause” different effects, but it is increasingly evident that when it comes to living beings the parts are less important than the relationships between them, which are themselves in flux. For decades modern neuroscience has been dominated by reductionists, and it is in sore need of some integration. Howick distills a wealth of modern neuroscientific research on placebos and nocebos, only to reveal how little we understand. He lists a few of the biomarkers observed to change in response to such treatments—oxytocin, endorphins, dopamine, cannabinoids, cholecystokinins—and describes changes within the DNA of what some researchers have gone so far as to call the “placebome”: genes that help us respond to placebos.
Hall takes a more neuroanatomical approach, writing of studies that imply that the vmPFC (ventromedial prefrontal cortex) is pivotal in placebo responses, because changes there “have been observed in multiple conditions known to have a high placebo response in clinical trials, including depression, attention deficit hyperactivity, substance misuse or addiction, schizophrenia, and dementia”—a range of conditions so wide that it’s difficult to see how her focus on the vmPFC adds clarity. More activity in a brain region doesn’t necessarily imply its involvement, in any case; it may simply represent excitatory or inhibitory responses to some primary action elsewhere in the brain. Connections, relationships, and networks are what’s important in the brain, not crude levels of activity.
Hall also quotes studies that show parts of the brain—namely the rostral anterior cingulate cortex and the periaqueductal gray—responding similarly both to taking a real opiate for pain and to taking a placebo. “Placebo effects could lead to the interception of incoming pain signals and exert ‘top-down’ control over the pain,” she speculates. In other words, your brain might have the power to stop pain signals from entering it via the spinal cord, simply because after a person takes a placebo the brain doesn’t expect them. We know that expensive placebos work better than cheap ones, capsules work better than tablets, and colored capsules work better than white ones. Blues and greens work better as sedatives, while pinks and reds work better as stimulants and painkillers. (Unless you’re an Italian man: Howick notes that blue is stimulating for Italian men, perhaps because the Italian soccer team wears blue.) Medium-size placebos are the least effective; it seems that we trust either tiny pills or big ones—the latter because they’re more impressive, and the former presumably because tiny capsules must contain powerful drugs.
If I develop cancer, I want access to the best chemotherapy; if I get meningococcal sepsis, give me the penicillin.
Placebos work best for conditions in which subjective interpretation of symptoms plays a large part in the illness, though placebos and nocebos affect more than just your perception—they have objective effects on the body’s reaction to different stimuli. Rats that received powerful immunosuppressants with harmless saccharin later suffered a collapse of their immune systems when given saccharin alone. Other rats, given immune boosters along with saccharin, later experienced a beneficial effect when given saccharin alone.
Hall describes a study in which an irritant allergen was introduced into study participants’ skin with a pinprick. The skin was then rubbed with an inert cream, and the participants were told either that the cream would “reduce the reaction and itching” (positive framing) or that the cream would “increase the reaction and itching” (negative framing). Those two groups were then further divided into some who were told this information by a clinician in a manner that exuded warmth and competence, and others who had a clinician who exhibited little of those qualities. “The size of the wheals among the participants who were randomized to the positive framing was significantly smaller than among those given the negative framing,” Hall writes. “Surprisingly, regardless of expectation, the participants randomized to the high warmth, high competence clinician interaction had the smallest wheal size.” So skin reactions to allergens are smaller if you expect them to be and if your doctor strikes you as kind, able, and caring.
Opiates administered during labor can have dangerous sedative effects on the newborn, and recent studies have shown that giving the laboring mother injections of sterile water under the skin instead can reduce pain by 30 to 50 percent for up to ninety minutes, with no deleterious effects for the baby. But when British national guidelines suggested including water injections as an option for laboring women, there was an outcry from some commentators who felt that women’s experience of pain was being ignored or diminished. (The guidelines were careful to introduce water as an option, not as a substitute.) Dummy injections for pain have a pedigree: Howick tells the story of Henry Knowles Beecher, an American anesthesiologist posted to southern Italy during World War II whose morphine supplies ran out. He found that normal saline worked almost as well for his injured soldiers. Howick also describes a personal communication from an Italian doctor who gave a wealthy woman with a backache an injection of distilled water, which cured her pain: “She was so satisfied that seven days later she called me for the same reason and demanded the same solution, ‘which had done me so much good.’” As he was filling his syringe with water, the woman called out, “Doctor, is it a placebo that you are giving me?” He told her it was, and she replied, “Thank goodness. It helped so much last week.”
Jefferson’s doctor believed he had to deceive his patients with his bread pills and colored water, but modern medical standards forbid lying to your patients. Drug companies put a leaflet into every box of medication, detailing every potential side effect, but print them in tiny fonts because it’s also true that the more you read, the more likely you are to have the side effect listed. (Statins—with common side effects of muscle and joint pain—are the classic case study for this, which both Hall and Howick explore in some detail.) In Italian these leaflets are known colloquially as bugiardini (“little liars”), as if to acknowledge that one shouldn’t believe everything they say. The power of labeling was revealed in a 1990 study that asked participants to randomly affix labels to two bottles of sugar, one marked “sucrose, table sugar” and the other “not sodium cyanide, not poison.” The latter label also pictured a red skull and crossbones preceded by the word “not.” Although the participants applied the labels themselves, they were more hesitant to drink a cup of Kool-Aid sweetened from the second bottle, suggesting that the mere mention of harm is enough to change expectations.
The line between what counts as a placebo and what counts as a treatment that gives identifiable health benefits at a biochemical level is blurred. Antibiotics are placebos with respect to viral infections but not bacterial ones; sugar pills are placebos for pain but not for hypoglycemia. Placebos seem to work on the basis of expectation, and one of the most curious aspects of their function is that they continue to have benefits even when you know that what you’re taking is a dud. These “open-label” placebos are nevertheless commercially valuable: some I looked up recently retail at more than one hundred dollars a bottle, though the label reads, “No active ingredients whatsoever.”
Hall and Howick both insist that doctors must get better at recommending placebos, because they are so much less harmful than conventional medicines and because they are reliably effective for so many conditions. For Hall, they
Take low mood: as the science writer Shankar Vedantam reported in The Washington Post more than twenty years ago,
After thousands of studies, hundreds of millions of prescriptions and tens of billions of dollars in sales, two things are certain about pills that treat depression: Antidepressants like Prozac, Paxil and Zoloft work. And so do sugar pills.
Later meta-analyses confirm this observation: the effect of all our common antidepressant drugs is at best marginally better than that of placebos. Freud’s paper “On Psychotherapy” (1905) put it well: he observed of “primitive and ancient medicine” that most remedies engaged the power of the mind, invoking a state of “credulous expectation,” and that “even after the doctors found other remedial agents psychotherapeutic endeavors never disappeared from this or that branch of medicine.” Freud went on: “It is no modern talk but a dictum of old physicians that these diseases are not cured by the drug, but by the doctor, to wit, by the personality of the physician in so far as it exerts a psychic influence.”
And just as our beliefs can have a positive effect on our well-being irrespective of biochemistry, they can have a negative effect too. Hall writes:
Expectations are shaped by learning from past experience, informed by contextual verbal and nonverbal cues, and can be either positive or negative. Thus through placebo mechanisms, expectations can enhance or minimize the effects of a treatment.
She and Howick both describe the case of a twenty-nine-year-old builder brought to Leicester Royal Infirmary in 1995 with a six-inch nail through his boot. Any attempt to remove the nail caused him to scream in agony. A clinical team heavily sedated him, pulled out the nail, and removed the boot—only to find that the nail had passed harmlessly between his toes. His foot might have been unharmed, but there was no doubt among the team that he had been experiencing real pain. Another man, part of a drug trial for antidepressant pills, took an overdose of his medication. His blood pressure crashed and he had to be carried to the ER, only to later learn that he’d been taking the placebo.
Hall and Howick each show, in different ways, just how vulnerable to both placebo and nocebo effects erectile function can be—it’s the placebo-responsive condition par excellence. Howick:
Men with healthy sexual functions who were given a placebo to enhance their performance developed sexual problems. This is probably because it caused the men to pay attention to responses that had previously come naturally, which probably increased their anxiety…. However, when placebos were given to men with sexual function problems, their performance improved.
Hall describes ninety-six men participating in a study of a beta-blocker called atenolol, which has the potential to cause impotence. Of the men given no information about this side effect, only 3.1 percent developed impotence, and among those given only the name of the drug, 15.6 percent developed it. But of those who were told both the name of the drug and that it might cause impotence, 31.2 percent developed erectile dysfunction. All of those complaining of impotence were then randomized to receive either a placebo or sildenafil (Viagra) to treat the problem; the former was just as successful at restoring erections as the latter. Similarly, of men given finasteride for prostate problems, 43 percent who were told it might cause impotence experienced the problem, against 15 percent who were not warned of side effects.
Modern medicine is good at breaking things down into parts and figuring out which parts “cause” different effects, but it is increasingly evident that when it comes to living beings the parts are less important than the relationships between them, which are themselves in flux. For decades modern neuroscience has been dominated by reductionists, and it is in sore need of some integration. Howick distills a wealth of modern neuroscientific research on placebos and nocebos, only to reveal how little we understand. He lists a few of the biomarkers observed to change in response to such treatments—oxytocin, endorphins, dopamine, cannabinoids, cholecystokinins—and describes changes within the DNA of what some researchers have gone so far as to call the “placebome”: genes that help us respond to placebos.
Hall takes a more neuroanatomical approach, writing of studies that imply that the vmPFC (ventromedial prefrontal cortex) is pivotal in placebo responses, because changes there “have been observed in multiple conditions known to have a high placebo response in clinical trials, including depression, attention deficit hyperactivity, substance misuse or addiction, schizophrenia, and dementia”—a range of conditions so wide that it’s difficult to see how her focus on the vmPFC adds clarity. More activity in a brain region doesn’t necessarily imply its involvement, in any case; it may simply represent excitatory or inhibitory responses to some primary action elsewhere in the brain. Connections, relationships, and networks are what’s important in the brain, not crude levels of activity.
Hall also quotes studies that show parts of the brain—namely the rostral anterior cingulate cortex and the periaqueductal gray—responding similarly both to taking a real opiate for pain and to taking a placebo. “Placebo effects could lead to the interception of incoming pain signals and exert ‘top-down’ control over the pain,” she speculates. In other words, your brain might have the power to stop pain signals from entering it via the spinal cord, simply because after a person takes a placebo the brain doesn’t expect them. We know that expensive placebos work better than cheap ones, capsules work better than tablets, and colored capsules work better than white ones. Blues and greens work better as sedatives, while pinks and reds work better as stimulants and painkillers. (Unless you’re an Italian man: Howick notes that blue is stimulating for Italian men, perhaps because the Italian soccer team wears blue.) Medium-size placebos are the least effective; it seems that we trust either tiny pills or big ones—the latter because they’re more impressive, and the former presumably because tiny capsules must contain powerful drugs.
If I develop cancer, I want access to the best chemotherapy; if I get meningococcal sepsis, give me the penicillin.
Placebos work best for conditions in which subjective interpretation of symptoms plays a large part in the illness, though placebos and nocebos affect more than just your perception—they have objective effects on the body’s reaction to different stimuli. Rats that received powerful immunosuppressants with harmless saccharin later suffered a collapse of their immune systems when given saccharin alone. Other rats, given immune boosters along with saccharin, later experienced a beneficial effect when given saccharin alone.
Hall describes a study in which an irritant allergen was introduced into study participants’ skin with a pinprick. The skin was then rubbed with an inert cream, and the participants were told either that the cream would “reduce the reaction and itching” (positive framing) or that the cream would “increase the reaction and itching” (negative framing). Those two groups were then further divided into some who were told this information by a clinician in a manner that exuded warmth and competence, and others who had a clinician who exhibited little of those qualities. “The size of the wheals among the participants who were randomized to the positive framing was significantly smaller than among those given the negative framing,” Hall writes. “Surprisingly, regardless of expectation, the participants randomized to the high warmth, high competence clinician interaction had the smallest wheal size.” So skin reactions to allergens are smaller if you expect them to be and if your doctor strikes you as kind, able, and caring.
Opiates administered during labor can have dangerous sedative effects on the newborn, and recent studies have shown that giving the laboring mother injections of sterile water under the skin instead can reduce pain by 30 to 50 percent for up to ninety minutes, with no deleterious effects for the baby. But when British national guidelines suggested including water injections as an option for laboring women, there was an outcry from some commentators who felt that women’s experience of pain was being ignored or diminished. (The guidelines were careful to introduce water as an option, not as a substitute.) Dummy injections for pain have a pedigree: Howick tells the story of Henry Knowles Beecher, an American anesthesiologist posted to southern Italy during World War II whose morphine supplies ran out. He found that normal saline worked almost as well for his injured soldiers. Howick also describes a personal communication from an Italian doctor who gave a wealthy woman with a backache an injection of distilled water, which cured her pain: “She was so satisfied that seven days later she called me for the same reason and demanded the same solution, ‘which had done me so much good.’” As he was filling his syringe with water, the woman called out, “Doctor, is it a placebo that you are giving me?” He told her it was, and she replied, “Thank goodness. It helped so much last week.”
Jefferson’s doctor believed he had to deceive his patients with his bread pills and colored water, but modern medical standards forbid lying to your patients. Drug companies put a leaflet into every box of medication, detailing every potential side effect, but print them in tiny fonts because it’s also true that the more you read, the more likely you are to have the side effect listed. (Statins—with common side effects of muscle and joint pain—are the classic case study for this, which both Hall and Howick explore in some detail.) In Italian these leaflets are known colloquially as bugiardini (“little liars”), as if to acknowledge that one shouldn’t believe everything they say. The power of labeling was revealed in a 1990 study that asked participants to randomly affix labels to two bottles of sugar, one marked “sucrose, table sugar” and the other “not sodium cyanide, not poison.” The latter label also pictured a red skull and crossbones preceded by the word “not.” Although the participants applied the labels themselves, they were more hesitant to drink a cup of Kool-Aid sweetened from the second bottle, suggesting that the mere mention of harm is enough to change expectations.
The line between what counts as a placebo and what counts as a treatment that gives identifiable health benefits at a biochemical level is blurred. Antibiotics are placebos with respect to viral infections but not bacterial ones; sugar pills are placebos for pain but not for hypoglycemia. Placebos seem to work on the basis of expectation, and one of the most curious aspects of their function is that they continue to have benefits even when you know that what you’re taking is a dud. These “open-label” placebos are nevertheless commercially valuable: some I looked up recently retail at more than one hundred dollars a bottle, though the label reads, “No active ingredients whatsoever.”
Hall and Howick both insist that doctors must get better at recommending placebos, because they are so much less harmful than conventional medicines and because they are reliably effective for so many conditions. For Hall, they
work best when administered with the clinician sharing the plausible rationale of how placebos work and an overview of the positive effects of placebos in previous clinical trials…. The key instruction to patients is that they must adhere to the treatment.
Howick quotes the phrasing used in a Harvard study that encouraged prospective patients to see placebos in a positive light: they were offered “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in…symptoms through mind-body self-healing processes.” To be offered placebos in a supportive and trusted environment sends a powerful message to the patient, he adds, a message of care, safety, and hope. “Having received this message,” he adds, “the inner governor switches the inner healing powers on, and our body responds by deploying its full immune response, natural killer cells and all.”
Modern technomedicine is big business, now dedicated to wringing tiny benefits at enormous costs, generating new drugs that barely beat placebos. In 2021 a biologic drug called Aducanumab was approved by the FDA even though it didn’t beat a placebo except in the very highest doses. Huge multicenter international trials are often needed to demonstrate only the most marginal of improvements over older, cheaper drugs. And we still pour money into procedures that are no better than placebos: Howick says that annually around £67 million in the UK and $5 billion in the US are spent on knee washout arthroscopies for osteoarthritis, yet it has been shown that simply anesthetizing the patient and giving them a scar on the knee so that it looks as if they’ve had surgery is just as good at reducing subsequent pain. “When considered in light of these arguments, placebo treatments are not just ethical; they are ethically required,” writes Howick.
The World Medical Association is silent on the use of placebos, and the American Medical Association allows the use of open-label placebos with “the patient’s cooperation,” while the German Medical Association states that placebos can be prescribed, Hall writes, “for patients with a minor condition, when there is no other effective treatment available, and when treatment with a placebo is likely to succeed.” I teach at Edinburgh Medical School, where I try to encourage among my students the kind of emotional curiosity Howick insists is essential for eliciting a strong placebo effect, exploring what kind of approach might work best for each patient. “Most people appreciate a bit of extra time with the doctor,” writes Howick, “but some might think that if the doctor can’t make up their mind quickly, they don’t know what they are doing.” There’s no one-size-fits-all in medicine; every consultation is unique and deserves a dynamic, responsive approach. “A confident, authoritative doctor makes many people feel like they are in safe hands,” Howick goes on, “but skeptics may have a negative reaction to authority.”
A revolution is long overdue: as the costs of conventional medicines spiral ever upward and the returns on those costs diminish, doctors owe it to their patients to make room for a different approach, with more humility, curiosity, and compassion. It’s extraordinary that our culture has become so medicalized and reductionist that warm and empathetic care, with its immense proven benefits for the way that a patient feels and heals, has been deprioritized to an optional extra rather than a core element of medicine. A rebalancing is in order: doctors need more time with their patients and, yes, more use of honest placebos—because they work.
Howick quotes the phrasing used in a Harvard study that encouraged prospective patients to see placebos in a positive light: they were offered “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in…symptoms through mind-body self-healing processes.” To be offered placebos in a supportive and trusted environment sends a powerful message to the patient, he adds, a message of care, safety, and hope. “Having received this message,” he adds, “the inner governor switches the inner healing powers on, and our body responds by deploying its full immune response, natural killer cells and all.”
Modern technomedicine is big business, now dedicated to wringing tiny benefits at enormous costs, generating new drugs that barely beat placebos. In 2021 a biologic drug called Aducanumab was approved by the FDA even though it didn’t beat a placebo except in the very highest doses. Huge multicenter international trials are often needed to demonstrate only the most marginal of improvements over older, cheaper drugs. And we still pour money into procedures that are no better than placebos: Howick says that annually around £67 million in the UK and $5 billion in the US are spent on knee washout arthroscopies for osteoarthritis, yet it has been shown that simply anesthetizing the patient and giving them a scar on the knee so that it looks as if they’ve had surgery is just as good at reducing subsequent pain. “When considered in light of these arguments, placebo treatments are not just ethical; they are ethically required,” writes Howick.
The World Medical Association is silent on the use of placebos, and the American Medical Association allows the use of open-label placebos with “the patient’s cooperation,” while the German Medical Association states that placebos can be prescribed, Hall writes, “for patients with a minor condition, when there is no other effective treatment available, and when treatment with a placebo is likely to succeed.” I teach at Edinburgh Medical School, where I try to encourage among my students the kind of emotional curiosity Howick insists is essential for eliciting a strong placebo effect, exploring what kind of approach might work best for each patient. “Most people appreciate a bit of extra time with the doctor,” writes Howick, “but some might think that if the doctor can’t make up their mind quickly, they don’t know what they are doing.” There’s no one-size-fits-all in medicine; every consultation is unique and deserves a dynamic, responsive approach. “A confident, authoritative doctor makes many people feel like they are in safe hands,” Howick goes on, “but skeptics may have a negative reaction to authority.”
A revolution is long overdue: as the costs of conventional medicines spiral ever upward and the returns on those costs diminish, doctors owe it to their patients to make room for a different approach, with more humility, curiosity, and compassion. It’s extraordinary that our culture has become so medicalized and reductionist that warm and empathetic care, with its immense proven benefits for the way that a patient feels and heals, has been deprioritized to an optional extra rather than a core element of medicine. A rebalancing is in order: doctors need more time with their patients and, yes, more use of honest placebos—because they work.
*GavinFrancis: A Scottish physician and a writer on travel and medical matters.
Labels: Gavin Francis, Jeremy Howick, Johns Hopkins University Press, Kathryn Hall, MIT Press, New York Review of Books
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