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:
- placebo effects are not usually powerful,
- they are not normally long-lasting,
- they are not reliable,
- they are merely symptomatic,
- they are not always risk-free,
- they usually require deceiving patients, and that is not ethical,
- pretending that a bogus treatment is alright can undermine rationality in general,
- happily using bogus treatments because they generate placebo effects is a disincentive to find effective treatments,
- 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.