MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Placebo effects are important and often misunderstood. This is perhaps nowhere more true than in the realm of alternative medicine. Here they are often used to justify bogus treatments with the argument ‘I DON’T CARE HOW IT WORKS AS LONG AS IT DOES HELP PATIENTS, EVEN IF THIS SHOULD BE VIA A PLACEBO EFFECT’.

A recent article published in the prestigious NEJM sheds some light on these issues – all the more so, as one of its authors has a background as an advocate of alternative medicine. Here are a few passages from this paper which I think are particularly relevant:

… placebo effects are improvements in patients’ symptoms that are attributable to their participation in the therapeutic encounter, with its rituals, symbols, and interactions. These effects are distinct from those of discrete therapies and are precipitated by the contextual or environmental cues that surround medical interventions, both those that are fake and lacking in inherent therapeutic power and those with demonstrated efficacy…

So what have we learned about placebo effects to date, and what does our current understanding say about medicine?

First, though placebos may provide relief, they rarely cure. Although research has revealed objective neurobiologic pathways and correlates of placebo responses, the evidence to date suggests that the therapeutic benefits associated with placebo effects do not alter the pathophysiology of diseases beyond their symptomatic manifestations; they primarily address subjective and self-appraised symptoms…

Second, placebo effects are not just about dummy pills: the effects of symbols and clinician interactions can dramatically enhance the effectiveness of pharmaceuticals…

Third, the psychosocial factors that promote therapeutic placebo effects also have the potential to cause adverse consequences, known as nocebo effects. Not infrequently, patients perceive side effects of medications that are actually caused by anticipation of negative effects or heightened attentiveness to normal background discomforts of daily life in the context of a new therapeutic regimen…

… research on placebo effects can help explain mechanistically how clinicians can be therapeutic agents in the ways they relate to their patients in connection with, and separate from, providing effective treatment interventions. Of course, placebo effects are modest as compared with the impressive results achieved by lifesaving surgery and powerful, well-targeted medications. Yet we believe such effects are at the core of what makes medicine a healing profession.

So what about the claim that it is fine to use homeopathy, for instance, because it might help via a placebo effect? There are several reasons why this is not a good idea some of which are hinted at in the above article:

  1. placebo effects are not usually powerful,
  2. they are not normally long-lasting,
  3. they are not reliable,
  4. they are merely symptomatic,
  5. they are not always risk-free,
  6. they usually require deceiving patients, and that is not ethical,
  7. pretending that a bogus treatment is alright can undermine rationality in general,
  8. happily using bogus treatments because they generate placebo effects is a disincentive to find effective treatments,
  9. we do not need a placebo to generate placebo effects because any empathetic therapeutic encounter will do that too.

My conclusion is deliberately flippant and provocative: PLACEBO EFFECTS ARE TOO IMPORTANT TO LEAVE THEM TO QUACKS AND CHARLATANS.

13 Responses to Placebo effects: at the core of all health care

  • Edzard, I do not share your concern that placebo effects might be ‘merely symptomatic’ (point 4).
    If I have symptoms and something seems to me to help me with my symptoms, that’s a benefit for me.
    I’m OK with that, even though the effects are within my own cerebrum and may not apply to anyone else.

    Kaptcuk and Miller point out the work of Kam-Hansen S, Jakubowski M, Kelley JM, et al. (Altered placebo and drug labeling changes the outcome of episodic migraine attacks. Sci Transl Med 2014;6:218ra5-218ra5), which has shown folks get some placebo effect even when they are told they are being given placebos (your point 9).

    Type I effects of a therapeutic encounter should be distinguised from type II effects resulting from’discrete therapies’. Style from substance. Therapist from therapy. Practitioner from practice. Camists conflate the two to avoid facing the fact their therapies have no type II effects.

    I am most concerned that camists (those who practice camistry, the domain of CAM) seem rarely to tell patients that their preternatural powers, pushing, prodding, pricking and pills work through placebo mechanisms – and they are therfore treating patients who have not given fully informed consent. Your point number 7 does need consideration.

    I certainly agree that quacks and charlatans who fail to address the elephants in their consulting rooms (the ones with big labels stating ‘Integrity and Honesty’) must be made accountable.

    In my book, placebos simply work through the same mechanism as hypnotism. Patients who expect to get a response from camistry will, in many cases, do so. At least a few Universities are now establishing departments for ‘Placebo Studies’ no doubt stimulated by your own at Exeter, so progress can be expected, albeit, slow.

    • I agree with your arguments regarding placebos adressing only symptoms, but I do not read Prof. Ernst’s words as expressing concern over that aspect, but merely stating it as a fact.

      The problem occurs when patients are not properly informed over the scope of the relevant intervention. People usually know that while pain medication will help aleviate the pain, they are not suited to address the origin of the pain, e.g. a brain tumor does not vanish just because the headaches caused by it are gone.

      Unfortunately, the effects of placebo seem to be greatly overestimated by a large portion of the population, and the fact that they most probably are only symptomatic is not well known. This is the weakness that sCAMmers use for business.

  • My experience with alternative practitioners is that most are convinced that they are actually treating their patients. In a way this makes them ethical practitioners since they are convinced that they are not deceiving their patients (No 6). I thus agree with your conclusion that generation of placebo effects should be kept out of the hands of the deluded. Unfortunately those who make the rules are not inclined to do anything. Propaganda works. ( Sorry, for the quackspeak wording).

    • Back in the day when I undertook a counselling course the mini-dissertation I did looked at Carl Rogers’ “Core Conditions” and their efficacy or otherwise: much of the research in counselling and psychotherapy that I read strongly suggested that what was most effective was how the client/patient perceived the therapist’s belief in the efficacy of what they were doing, alongside factors to do with quality or perceived quality of the working relationship, rather than any effects which could be ascribed to a particular form of counselling or psychotherapy.

  • Placebos are designed to confuse the client into thinking that they are receiving the real.
    It suites the pharmaceutical system to claim that everything that is to be tested on a clinical trial has to have a placebo, something that is not, and their claims are based on the placebo system.
    That is the main aim that Scepicts use to lay claim that something does not work.
    Not every thing has a Placebo, are left or right, a yes or no.

    • @len
      It’s seriously important to distinguish the placebo effect, the topic of this blog, from ‘a placebo’. The latter is an inert substance that, in a double-blind trial, is made to look, feel and smell indistinguishable from the test substance.
       
      You are (as usual) mistaken when you state that “everything that is to be tested on a clinical trial has to have a placebo”. The accurate statement would be that every experimental/test (system) has to have a control (system). This applies to all experimental science: without this basic constraint anyone can prove anything they like. Many clinical trials are done with the control group receiving an existing medication, not a placebo. In such circumstances patients all sometimes receive two medications, when the two under test look and feel very different. They get medication A plus a placebo version of B and vice versa. This keeps the blinding blind.
       
      “Not everything has a placebo”: certainly, in medicine some things create difficulties for placebo design: for example, chiropractic. But a bit of ingenuity usually finds a way to overcome the difficulty and apply science to the test. If a placebo is truly impossible to come up with there are other ways to test therapies, albeit less robust and convincing than the prospective, double-blind, placebo-controlled trial. Your repeated insistence that there are effective therapies that can never be tested scientifically is bunk. Even the placebo EFFECT can be tested scientifically, and has been many times!

  • To me, one of the major differences between what we’ll call placebos introduced clinically and placebos introduced through “alternative medicine” lies in the difference in the requirements put upon the patient.

    While clinically-introduced placebos may sometimes involve lying to the patient about the nature of the nostrum being given (“It’s a new type of non-addictive cocaine for pain relief”), the lie always conforms to the natural laws (“This new neuro blocker will block neuros 20% better than previous neuro blockers.”) In other words, patient may be required to swallow a small untruth, but in no way is required to shift his or her fundamental understanding of the physical world.

    Such is not the case with alternative medicines. In fact, one of the defining features of alternative medicines would seem to be their need to essentially “convert” the patient to a radically different cosmology — a cosmology that contains such laws as “like cures like,” “chi,” and “positive energies.” And of course, usually it is necessary for the patient to fully embrace this new cosmology before the techniques being employed can work effectively, “because negative and skeptical energies can interfere with the healing power of the amythyst.”

  • I think the assumption that obtaining a placebo effect always requires the patient to be deceived is not the whole truth. While agreeing that it is the case when a practitioner is deliberately aiming for such an effect (even if it is referred to as a cure), perhaps we are overlooking the many occasions when a sympathetic doctor or other practitioner gets better results simply by being sympathetic. It used to be called a good bedside manner; I’m not sure what it is called, if anything, now. It is represented by when patients at large practices prefer to see one doctor rather than another – she makes them feel better. This does not mean that other doctors are not trying to cure their patients, just that the personality – or whatever – of others somehow helps them to get the job done better, or perhaps a little more quickly.

  • But what can the justification be for homeopathic teething treatments for babies?

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