Issue 26 / 15 July 2013

DARK matter — the stuff that fills the universe among the planets and stars — is of immense interest to contemporary astronomers.

Geneticists are turning their attention to the genetic material beyond the orderly confines of the genome. Public health practitioners are seeing how much of health is determined beyond infective organisms and environmental toxins in the extraordinarily complex world of community and culture. Microbiologists have defined a new body organ — the immense biome that dwells in our intestines.

Colleagues, we live in the midst of deep mystery, whether we stare skyward, consider our genes, contemplate where illness comes from or why our guts are rumbling.

No less mysterious is our response to therapies. The first editor of the MJA perished from a streptococcal infection. He would presumably not have met this fate today with antibiotics at hand. But in other settings the outlines are more softly drawn.

Perhaps the most mysterious element in medicine is the placebo effect. When an encounter between a doctor and a patient is secured with a script or a proposal for surgery, in some cases the placebo effect can occur. Yet we still don’t know why.

Kerr White, a towering public health physician from Canada and the US, was attracted to medicine while working in industry because of the mystery of the Hawthorne effect — an improvement in surveyed workers’ performance attributable to nothing more than being surveyed.

Kerr subsequently wrote about the placebo effect, arguing that from the evidence it probably accounted for about 10% of many therapeutic outcomes.

Things may have changed: Cochrane reviews are critical of the effect.

However, a recent study in the UK showed that GPs regularly prescribe knowing that the drug in question will not improve things — antibiotics for viral infections, for example. Less frequently they may prescribe sugar pills.

Is this ethical?  Should the patient be told or passively deceived? Opinion is divided, which for me raises the interesting question as to whether patients visit a doctor to be told everything or to be helped through an illness without necessarily being fully informed?

Two years ago Michael Specter wrote an article about placebos entitled “The power of nothing” in The New Yorker. Harvard, he said, had established a program in placebo studies and the therapeutic encounter, based at the Beth Israel Deaconess Medical Center.

Ted Kaptchuk, who directs the program, told The Atlantic: “It’s weird. There are reasons why I thought placebos might work.” Not all have panned out.

“We should examine what are the ingredients in a doctor-patient relationship that can be modified or altered”, he told The Atlantic. “By adding a supportive, warm, and empathic relationship to a dummy injection, we got much greater effects. That tells you something about medicine.”

Interesting, when you consider that the word “placebo” shares a root with “placate” and is found in 12th century Latin prayers for the dead as meaning “I shall please”.

However, Dr Harriet Hall, a retired family physician in the US, takes a harder line in The Atlantic article. “It involves deception. Lying is wrong, and if doctors start lying to patients, it destroys the trust. And that’s a bad thing”, she is quoted as saying.

She admits that “placebos can make people feel better”. “But the effect is small, temporary, and inconsistent, and doesn't have any objective effect on the disease process. Rather than giving a placebo, doctors should aim to enhance effective treatments with placebo effects [her term] by giving the patient more time, attention, and confidence.”

Wise advice — but the residual mystery around the placebo effect remains.

Professor Stephen Leeder is the editor-in-chief of the MJA and professor of public health and community medicine at the University of Sydney.

Jane McCredie is on leave.

8 thoughts on “Stephen Leeder: Mysterious placebos

  1. Richard J D'Souza says:

    Placebo treatments can be effective for hypochondriacs. It is up to the consultant to diagnose who is one and can then treat their psycho-somatic conditions.

  2. Sue Ieraci says:

    The side-effect profile of placebo is also known as ”nocebo”. There is quite a lot written about the phenomenon – including this: In homeopathy practice, it’s also ”expect to get worse before you get better, it’s just the remedy doing its job”.

  3. Anthony Morton says:

    The Hawthorne effect is almost certainly a Complex Adaptive System effect. Such systems involve interacting agents and they display self-organisation and emergent behaviour that is typically non-linear. It seems highly likely that the Placebo effect is similar. Previous comments show how.

  4. Romney Newman says:

    I have always been intrigued by the high side effects as well as the response to placebo in the migraine drug trials. Could there be a relationship between the physical condition and the response to placebo?

  5. michael pitney says:

    You are all confusing placebos with waking hypnosis. In an appropriate drug trial the patient should not only be blinded but should have no expectation that the agent will have any effect.If an agent is given to a patient with an expectation of effect  in the patients mind,this is no longer a placebo, but uses the power of suggestion,in fact what is known as waking hypnosis…I use this successfully all the time…see Dave Helman… “hypnotherapy”…. 1964……. mycosis

  6. Sue Ieraci says:

    Thanks for the article. I am fascinated by the differences in the expectations of our general community from doctors compared with ”alternative” providers. In the past, there was an image and expectation for doctors to be paternalistic and to give advice from a position of authority, including the use of placebo. COmmunity expectations – from both inside and outside the profession – have shifted. It is now expected that the doctor-patient relationship be a cooperative and mutually respectful one, and the deceptive use of placebo is not ethically acceptable. Doctors should communicate information and choices, and enable second opinions. At the same time, expenditure on “CAM” therapists is higher than ever before. It seems to me that some innate part of human nature craves a simple answer and a paternalistic approach which takes decision-making out of our hands – except that it is no longer acceptable to relate to a doctor in this way. The CAM providers – the New Paternalists – give you simple, directed answers disguised as choice, and sell you remedies as well as their time and reassurance. In the CAM world, placebos are not only accepted, but virtually compulsory.

  7. Dieter Luske says:

    Indeed mysterious, and warranting much more research on how to harvest this mysterious power.
    I have been asking for a while …

    Have Practitioners lost their placebo effect…?  Do we still trust our Practitioners ?

    One of the greatest underlying healing powers a doctor  can have, is their own …

    … “personal Placebo effect”, their trust factor.

    It has long been recognised that the placebo effect is much more, than simply believing in something.

    A placebo effect, be it from a pill or the trusted presence of a practitioner will set a chemical reaction into motion.

    It is this chemical reaction which makes the placebo effect real, and sadly this is undermined by a general distrust in practitioners as a whole.

    If you are taking a placebo pill with the anticipation that it is going to help, the chemical cascade released from your brain is real and has a real effect, there is no doubt about it.

    The trick however is how to make this placebo effect happen and stay within your integrety as a practiitoner?


  8. Bruni Brewin says:

    Dr Harriet Hall is incorrect when she says that the effect is small and temprary.  It has been shown that a control of two people going through a sham operation on the knee when nothing more that tiny incisions in the skin around the knee had occured, but a video showing the knee operation and the doctor talking as though he was actually performing the same occurred – 5 years later, both controls still had no further pain in their knees.  The same occurs in other such things as depression etc.  

    If the placebo effect is around 10%, then it would be of more interest to research how that can be increased rather than dismissed.  And if the reason were that the 10% (as shown in hypnosis) are those able to access deep hypnosis where things become real by pure suggestion, then could we teach patients who are not the normal natural deep access people to become that through repetition learning?

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