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The importance of placebo in medicine |
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People are self-healing.
As a living being people have a natural ability to change, grow, adapt
and the capacity to self-heal. All living creatures have this ability
though and some are more capable of this than others. For instance
some animals have the capacity to regenerate limbs and even within
people we find there is great variation in the capacity to heal
different tissues within the body. The liver has significant capacity
to regenerate while the brain has almost none. We also find that this
ability to self-heal can be affected by many factors. It can be
influenced by diet, exercise, genetic makeup, environment and even our
mental attitude.
The variation in different peoples ability to heal is a significant
factor in the development of the concept of placebo in medicine.
Placebo is from Latin meaning "I shall please" in its original use it
was a term of religious origin. By the 14th century it had moved beyond
its religious context and was used to refer to a flatterer or sycophant
-- a meaning that probably reflected disdain for professional mourners
of the time. Placebo's first usage in common medical terminology
appears to have occurred in the latter half of the 18th century. It
maintained its pejorative connotation and was used to disparage
treatments that were understood to derive not from sound medical
principles but were rather dispensed in order to please the patient
and thereby curry both favour and income. In modern times placebo is
understood to have no pharmacologic activity. It does however, have an
effect.
The placebo effect.
During the late 19th and early 20th century the medical profession was
striving to become more objective and scientific. Their aim was to
develop methods to "objectively" determine the "truth" about
therapeutic intervention. By this time it had become apparent that the
attitude of the patient and of the practitioner might have an influence
on the results of any treatment under trial. Research then determined
that a treatment made with an inactive substance such as sugar,
distilled water or saline solution would often prove to be effective.
This process, where a person's illness would improve with only the
expectation of an improvement is called the placebo effect. By the
mid-20th-century it had become common to study the effects of
medication by comparing it to a placebo. In these studies patients
taking the placebo would often improve but it was believed those taking
a truly effective medication would show a significant improvement
beyond that of the placebo. The commonly referred to blind trial is
when the patient involved in the study does not know if they are
receiving a drug or placebo. Double blind is when patient and
therapist do not know.
There is currently much debate as to whether it is ethical to use a
placebo in a medical trial. It is generally preferred in modern
research to test the drug against a known benchmark or accepted
treatment instead of against the placebo. This may however have its own
problems. There have been studies that indicate that people can
experience the adverse effects of a drug just because they have been
told about them. Other studies show people get less effect from pain
medication when administered secretly compared to openly. These
problems and others can change considerations and assumptions in study
design but the main issue with placebo is that it is not ethical to
knowingly leave a patient untreated for a medical condition when a
treatment is available.
Alternative therapies and placebo.
In today's society it is not uncommon to describe any benefit obtained
by alternative therapies as simply the result of the placebo effect.
When people state this they are usually referring to their belief that
there are no blind trials to support the use of this treatment. The
assumption seems to be that only blind trials can determine the "truth"
about the effectiveness of the treatment. Yet the effective use of
blind trials is often difficult and is easiest to achieve when dealing
with drugs. Blind trials are not common in surgical treatments or
psychological treatments, and are not well suited to most alternative
therapy treatments. So while blind trials have certainly been of
benefit in improving some aspects of medicine - much of human knowledge
and much of what we do is not amenable to such a ridged and limited
method of study. I have yet to see a blind study that proves the
existence of love but most of us seem to seek it out anyway.
One reason the blind studies are difficult with alternative therapies
is that many of the alternative therapies take an holistic approach.
That is to say that they look at the whole persons state of health and
individualise treatment to the specific persons presentation. As an
example, modern western medicine considers ulcers to be caused by
bacterial infection. Modern treatment involves the use of antibiotics
to kill the bacteria. In essence they have only one treatment for
ulcer and this treatment would not be expected to deal with any other
health problems that this person may be suffering. If this treatment
proves ineffective they are left with the assumption that this ulcer
cannot be cured.
However, most traditional medicines would ask the question why the
bacterium has become a problem in one person but not necessarily in
another. In Chinese medicine, for instance, the practitioner would
look at the complete set of symptoms experienced by the patient to
determine which imbalance they believe leads to the susceptibility to
ulcers. Treatment would then focus on making adjustments to restore
balance to the person, to clear the ulcer and prevent its recurrence.
Traditional Chinese medicine recognises approximately 11 or 12
different categories of imbalance that can lead to ulcers. Each would
require a different treatment strategy. The interesting thing is that
this treatment strategy would automatically take into account and deal
with other health problems and symptoms at the same time. This is one
of the reasons that many people upon trying alternative therapies
continue to use them. They find improvements in their health beyond
the problem they sought help for.
This need for individualised treatment makes blind studies much more
difficult. Much larger numbers of people are needed for the study and
it is difficult to insulate from the effects of attitude with this
individualised approach.
Experienced practitioners of alternative therapies recognise that
placebo plays a role within their treatment. They also realise this is
true of any medical practice. It should also be noted that the
community in general tends to have greater faith in the established
medical profession and tends to visit them first. It should then be
expected that if placebo were going to be effective it would prove most
effective for the established medical practice.
In clinic many practitioners often experience an early subjective
improvement in patients. However on examination they realise that
other less objective changes are not obvious. It seems, if these
changes are related to expectation, they often are short lived.
However, genuine therapeutic intervention will produce lasting results
and this is what modern alternative therapies base their assessments on.
Since placebo, is based upon expectations one area of support for
natural therapies being more than a placebo effect is that they are
effective in the treatment of animals. And there is significant growth
in the number of veterinarians who are using alternative therapies in
their practices. There are also studies supporting the effectiveness
of natural remedies in animal populations. Since an animal has no
knowledge that a medication is supposed to be good for him, he can have
no placebo effect.
Deliberate use of placebo.
Science tends to treat the placebo effect as a nuisance, as it makes
establishing the truth about medicine much more difficult. However,
clinical practice of both alternative and modern western medicine will
often make use of the placebo effect, either deliberately or
unconsciously. While some may consider this unethical it does tend to
be unavoidable. As I mentioned at the beginning of this article a
person's ability to heal is influenced by many factors, a caring
practitioner will automatically attempt to swing these factors into the
persons favour.
A medical practitioner facing a viral infection knows that antibiotics
that will have no benefit. Instead of recommending no treatment, they
may suggest an over the counter medication for symptom relief and
reassure the patient that all will be well. Noting that they should
contact them if they show no improvement. This type of caring approach
will be more likely to be of benefit to the patients health than an
alternative response such as telling them there is nothing to be done
but the condition should pass, if however it doesnt, come back and see
me. After all the implication is - we can do nothing, even if you do
come back.
A common way for doctors to satisfy a patients desire for treatment is
to give an antibiotic for a viral infection on the flimsy excuse that
its to prevent secondary infections. Perhaps we should all take
antibiotics in case I get an infection the reality is its a quick
and simple way to please the patient which is the original meaning of
placebo.
To please a patient is, in itself, not wrong. As I said before pleasing
a patient and keeping their attitude positive is a useful process.
Studies have found that being upset or depressed can have a significant
effect on the bodies immune responses. In a parallel to this it is not
wise to make a big deal of potential adverse effects of a medication.
This is due to what has become known as the nocebo effect. Nocebo is
the phenomena of people in medical trials experiencing the adverse
effects of a drug whilst on a placebo. To quote DeAnna McDonald
New Yorker; August 11, 2003; Annals of Medicine--"Sick With Worry" by
Jerome Groopman
"nocebo effect: even though these patients were in the group randomly
assigned to take a chemically inert placebo, they reported suffering
from side effects associated with taking Prozac...[they] had likely
read their informed-consent forms, which detailed all the possible
symptoms from taking [the non-placebo] a bit too carefully."
Of course, this is not to suggest that significant risks not be
discussed with a patient before they commence a treatment.
Alternative medicine is not just placebo.
Whilst it is likely that the placebo effect has some effect it is
frequently over exaggerated. Those that would like to use it to
discredit others often do this exaggeration. As I mentioned before most
results of suggestion appear to be short lived. In modern therapeutic
situations a viable ongoing clinic could not survive if all they
offered was placebo. This is supported by a Danish study from 2001 in
which, Asbjorn Hrobjartsson, M.D., and Peter C. Gotzsche, M.D
concluded We found little evidence in general that placebos had
powerful clinical effects. Although placebos had no significant effects
on objective or binary outcomes, they had possible small benefits in
studies with continuous subjective outcomes and for the treatment of
pain. Outside the setting of clinical trials, there is no justification
for the use of placebos.
Daniel E. Moerman from the University of Michigan has even suggested
that the term placebo response should be dropped that instead we
should be using meaning response as he explains in Placebo Versus
Meaning : The Case for a Change in Our Use of Language
In situations where inert medical treatments are given, whatever else
we may say, insofar as a particular treatment is truly inert, a
placebo wont have any effects; that is what we mean by inert.
Hence, there is simply no such thing as a placebo effect. In a
control group, several things can influence change in a patients
condition, primarily regression to the mean, natural history, physician
or patient bias, and, sometimes, a residual increment of improvement,
which Ernst has called the true placebo effect (Ernst & Resch,
1995) and which I have called the meaning response (Moerman &
Jonas, 2002).
If one were to change the emotive language and substitute meaning
instead of placebo , perhaps we could make more headway in
understanding some of the processes that impact on our ability to
recover from illness. However, as it stands at the moment the idea that
the placebo effect can be used to explain all of the benefits of
alternative medicine, is untrue. Alternative medicine often works for
animals, it has long-term results and those results can usually be
measured by objective changes in the patients health. All of which
point to placebo not being a significant factor in their success.
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Disclaimer: The entire contents of this website are based upon the opinions of the respective author, who retains copyright. The information on this website is not intended to replace a consultation with a qualified health care professional and is not intended as medical advice. It is intended as a sharing of knowledge and information from the research and experience of the authors. Healing Traditions encourages you to make your own health care decisions based upon your research and in partnership with a qualified health care professional. |
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