Modern medicine prides itself on its evidence-based approach, whereby doctors and hospitals choose treatments based not on faith or hearsay but on hard science.
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.
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 that it’s 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.
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?
According to Mr. Howick, the past 20 years of research in particular have 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.”
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 that they often aren’t 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.
While this opinion has its merits, it also has its critics, who say that testing a drug against another drug can create uncertainty if there are concerns about the original drug’s clinical trial. In other words, if the original drug isn’t all that effective, as in the case of some antidepressants, then testing against it doesn’t necessarily provide a clear picture of a new drug’s effectiveness. Testing against a placebo at least isolates a drug’s effectiveness from the influence of the patient’s thoughts.
It’s typically considered unethical for a doctor to prescribe placebos because they’re generally understood as a kind of deception. Even if a patient might improve from a placebo, it isn’t right to lie.
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 that 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.
Placebos Through the Ages
It isn’t clear how long doctors have understood the placebo concept, but Mr. Howick believes that ancient doctors may have relied on bedside manner to exert an effect on their patients.The word placebo is Latin and 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 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.
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.
How They Work
So what force was behind the phenomenon that Beecher witnessed? One journal article from the 1990s that was critical of 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 past 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,” he said. “Your body also has its own pharmacy to create serotonin, melatonin, dopamine, [and] endorphins. Communication can help induce those positive things.”
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 affect the immune system, Mr. Howick says these expressions of empathy may actually boost our immunity.
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 healing potential, 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 that 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 that the outcome of the effect is a negative one. Because the Hippocratic oath requires that doctors “do no harm,” few researchers have 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 hardwired 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.
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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