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The Placebo Effect: The Power of Nothing

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    Message 1 of 1 , May 26, 2001
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      THE POWER OF NOTHING
      Geoff Watts
      New Scientist Magazine
      26 May 2001

      http://www.newscientist.com/newsletter/features.jsp?id=ns22922

      Want to devise a new form of alternative medicine? No problem. Here's the
      recipe.

      Be warm, sympathetic, reassuring and enthusiastic. Your treatment should
      involve physical contact, and each session with your patients should last at
      least half an hour. Encourage your patients to take an active part in their
      treatment and understand how their disorders relate to the rest of their
      lives. Tell them that their own bodies possess the true power to heal. Make
      them pay you out of their own pockets. Describe your treatment in familiar
      words, but embroidered with a hint of mysticism: energy fields, energy
      flows, energy blocks, meridians, forces, auras, rhythms and the like. Refer
      to the knowledge of an earlier age: wisdom carelessly swept aside by the
      rise and rise of blind, mechanistic science.

      Oh, come off it, you're saying. Something invented off the top of your head
      couldn't possibly work, could it? Well yes, it could--and often well enough
      to earn you a living. A good living if you are sufficiently convincing or,
      better still, really believe in your therapy.

      Many illnesses get better on their own, so if you are lucky and administer
      your treatment at just the right time you'll get the credit. But that's only
      part of it. Some of the improvement really would be down to you. Not
      necessarily because you'd recommended ginseng rather than camomile tea or
      used this crystal as opposed to that pressure point. Nothing so specific.
      Your healing power would be the outcome of a paradoxical force that
      conventional medicine recognises but remains oddly ambivalent about: the
      placebo effect.

      Placebos are treatments that have no direct effect on the body, yet still
      work because the patient has faith in their power to heal. Most often the
      term refers to a dummy pill, but it applies just as much to any device or
      procedure, from a sticking plaster to a crystal to an operation. The
      existence of the placebo effect implies that even quackery may confer real
      benefits, which is why any mention of placebo is a touchy subject for many
      practitioners of complementary and alternative medicine (CAM), who are
      likely to regard it as tantamount to a charge of charlatanism. In fact, the
      placebo effect is a powerful part of all medical care, orthodox or
      otherwise, though its role is often neglected and misunderstood.

      One of the great strengths of CAM may be its practioners' skill in deploying
      the placebo effect to accomplish real healing. "Complementary practitioners
      are miles better at producing non-specific effects and good therapeutic
      relationships," says Edzard Ernst, professor of CAM at Exeter University.
      The question is whether CAM could be integrated into conventional medicine,
      as some would like, without losing much of this power.

      At one level, it should come as no surprise that our state of mind can
      influence our physiology: anger opens the superficial blood vessels of the
      face; sadness pumps the tear glands. But exactly how placebos work their
      medical magic is still largely unknown. Most of the scant research to date
      has focused on the control of pain, because it's one of the commonest
      complaints and lends itself to experimental study. Here, attention has
      turned to the endorphins, natural counterparts of morphine that are known to
      help control pain. "Any of the neurochemicals involved in transmitting pain
      impulses or modulating them might also be involved in generating the placebo
      response," says Don Price, an oral surgeon at the University of Florida who
      studies the placebo effect in dental pain. "But endorphins are still out in
      front."

      That case has been strengthened by the recent work of Fabrizio Benedetti of
      the University of Turin, who showed that the placebo effect can be abolished
      by a drug, naloxone, which blocks the effects of endorphins. Benedetti
      induced pain in human volunteers by inflating a blood-pressure cuff on the
      forearm. He did this several times a day for several days, using morphine
      each time to control the pain. On the final day, without saying anything, he
      replaced the morphine with a saline solution. This still relieved the
      subjects' pain: a placebo effect. But when he added naloxone to the saline
      the pain relief disappeared. Here was direct proof that placebo analgesia is
      mediated, at least in part, by these natural opiates.

      Still, no one knows how belief triggers endorphin release, or why most
      people can't achieve placebo pain relief simply by willing it. Several labs
      are now thinking of using brain imaging to study the neurobiology of the
      placebo effect in more detail. "The brain has already been imaged during
      drug-induced analgesia," says Price. "There's going to be a race between
      laboratories to do this experiment first for placebo analgesia."

      Though scientists don't know exactly how placebos work, they have
      accumulated a fair bit of knowledge about how to trigger the effect. A
      London rheumatologist found, for example, that red dummy capsules made more
      effective painkillers than blue, green or yellow ones. Research on American
      students revealed that blue pills make better sedatives than pink, a colour
      more suitable for stimulants. Even branding can make a difference: if Aspro
      or Tylenol are what you like to take for a headache, their chemically
      identical generic equivalents may be less effective.

      Special delivery

      It matters, too, how the treatment is delivered. Decades ago, when the major
      tranquilliser chlorpromazine was being introduced, a doctor in Kansas
      categorised his colleagues according to whether they were keen on it, openly
      sceptical of its benefits, or took a "let's try and see" attitude (American
      Journal of Psychiatry, vol 113, p 52). His conclusion: the more enthusiastic
      the doctor, the better the drug performed. And this year Ernst surveyed
      published studies that compared doctors' bedside manners (The Lancet, vol
      357, p 757). The studies turned up one consistent finding: "Physicians who
      adopt a warm, friendly and reassuring manner," he reported, "are more
      effective than those whose consultations are formal and do not offer
      reassurance."

      Warm, friendly and reassuring are precisely CAM's strong suits, of course.
      Many of the ingredients of that opening recipe -- the physical contact, the
      generous swathes of time, the strong hints of supernormal healing power --
      are just the kind of thing likely to impress patients. It's hardly
      surprising, then, that complementary practitioners are generally best at
      mobilising the placebo effect, says Arthur Kleinman, professor of social
      anthropology at Harvard University.

      "This doesn't go down well in these communities because of the denigrating
      connotations of placebos. It's very threatening to people in those fields,"
      Kleinman says. "The problem is that biomedicine has an extraordinarily
      negative view of placebos. They're treated as a nuisance rather than being
      seen as what they really are." And what they are, according to Kleinman, is
      part of the complex interaction of physiology, psychology and culture which
      underlies the process of turning a sick person into a healthy one.

      This, needless to say, is a world away from the mechanistic approach of most
      conventional medicine, which has little to say about what people's
      experience of illness means to them. As Ernst puts it: "The very popularity
      of complementary medicine is a criticism of mainstream medicine. In the
      mainstream we have sharper and sharper tools. But in terms of empathy, time,
      understanding and touch we are losing out."

      But even if many CAM therapies do get much of their power from the placebo
      effect, it's still important to ask whether there's anything more to them
      than that. To say -- as many a CAM practitioner does -- that a treatment
      "works" begs the question of how well it works. If a mantra-induced placebo
      effect will ease the pain of my bad back, that's good. But might something
      else do it even better? A handful of aspirin, for example? If doctors had
      been content to declare that a treatment works and leave it at that,
      orthodox medicine would not have got far. We want to know not just what
      works, but what works best. In answering that question, there's no
      substitute for clinical trials.

      Yet it's not easy to design those trials in a way that both CAM advocates
      and conventional scientists will agree is fair. To give the clearest
      possible test of the treatments in question, experimentalists want to
      randomly assign patients to receive, say, aspirin or mantra therapy while
      rigorously holding all other conditions constant. But CAM practitioners
      charge that this cookie-cutter regularity is unfair to CAM therapies because
      it removes the individualised care that is such a central feature of most of
      them. "Because I apply orthodox research methods to complementary medicine,
      I've been accused of stripping it of what makes it work," says Ernst. "They
      say I'm throwing out the baby with the bath water. I accept that this could
      be a danger. If a therapy works only as a placebo then maybe one should keep
      science out of it. On the other hand this is how science advances."

      This problem of context extends far beyond the realm of research. It also
      casts a shadow over attempts to integrate alternative therapies, with their
      powerful placebo-invoking techniques, into mainstream medicine. In practice
      this integration would mean, among other things, offering alternative
      medicine on state systems like Britain's National Health Service. To a
      limited but growing extent this already happens: the NHS runs a couple of
      homeopathic hospitals, and increasing numbers of family doctors invite
      aromatherapists, acupuncturists, herbalists and others into their surgeries.
      Some doctors even administer these treatments themselves.

      But for much of CAM--especially techniques in which the placebo effect
      accounts for most or perhaps all the benefit--integration might well be
      counterproductive. After all, the value of CAM depends partly on its
      unorthodoxy. Price talks of a "clash of cultures". Would your free,
      state-registered crystal therapist, pressed for time and perhaps wearing a
      uniform just like other paramedical staff, still be able to mobilise as good
      a placebo response? Ernst, for one, doubts it, and sees this as a powerful
      argument against integration. "Although there is little evidence to support
      the view, one intuitively feels that something exotic has a stronger placebo
      effect than something bog standard. And some complementary therapies are
      very exotic," he says.

      Integration faces other obstacles, too. Doctors would face serious ethical
      problems in recommending what they know to be placebo treatments to their
      patients (see "An ethical dilemma" below). And complementary practitioners
      would likely be disparaged by their conventional counterparts, as they often
      are today. With the growing emphasis on evidence-based medicine, installing
      a roomful of radionics boxes or setting aside a clinic for dispensing Bach
      flower remedies would be hard to justify, however much it might please the
      customers. Integrated medicine "would have about as much validity as a
      hybrid of astronomy and astrology", Neville Goodman, an anaesthetist in
      Bristol, wrote in the April newsletter of HealthWatch.

      Healthcare managers, too, may view such moves with some alarm. The addition
      of a whole raft of new and time-consuming treatments could play havoc with
      already overstretched budgets. In the long term, though, a few CAM
      techniques might achieve integration. A study of low back pain by Britain's
      Medical Research Council, for instance, revealed that chiropractic compares
      favourably with conventional hospital treatment in terms of cost and
      effectiveness (British Medical Journal, vol 300, p 1431). It's likely that
      chiropractic treatment provides specific benefits over and above the placebo
      effect.

      Even CAM techniques that do largely depend on their placebo value could
      achieve the same cost-effectiveness. Indeed, for most of medicine's history,
      compassion, attention and tender loving care -- all big contributors to the
      placebo effect -- were all that doctors had to offer. The advent of science
      changed that, but in adopting their new role of body technician, doctors
      have to a great extent dropped the traditional one of healer: the
      non-specific but still valuable business of caring. Most doctors would now
      be faintly embarrassed by the suggestion that "healing" might be part of
      their job description. It sounds a bit pre-scientific. But that's what most
      CAM practitioners still offer, and they are certainly not embarrassed by the
      idea.

      A professor of surgery with a confident manner, an expensive suit and an
      international reputation who sees you privately and guarantees to solve your
      problem with a costly operation may still be unrivalled as a source of
      placebo power. But most doctors are beaten hands down by countless
      alternative practitioners who might not know a lymphocyte from a lump of
      cheese. What they do know is how to make you feel better. And that's a big
      part of the battle.

      ------------

      AN ETHICAL DILEMMA

      For doctors who take their medical ethics seriously, the placebo effect can
      pose a dilemma. Imagine that a patient turns up asking asking for advice
      about a remedy which is harmless but, in the doctor's view, also useless. If
      there's a proven orthodox cure for the complaint, the correct course of
      action is clear: steer the patient towards that treatment.

      But suppose there is no orthodox treatment, or the patient has tried
      whatever there is and not responded. Should the doctor stay true to science
      and declare that the remedy is a waste of time, thereby undermining any
      beneficial placebo effect it might have? Or should scientific purity be
      sacrificed in favour of an enthusiastic but dishonest endorsement which
      might boost the treatment's placebo action? Could the doctor even argue that
      endorsement would be legitimate because the remedy would in fact have some
      benefit, thanks to the placebo effect?

      In practice, many doctors try to avoid betraying either their allegiance to
      science or their ethical duty to tell the truth. One escape route is to find
      a form of words which wriggles round the problem. Something like, "I've had
      no first-hand experience of this treatment, but I know that some people find
      it rewarding." That's what you call the art of medicine.

      ------------

      Geoff Watts is a medical and science journalist, and author of Pleasing the
      Patient, a book on the placebo effect. He is also vice-chairman of the group
      HealthWatch, which argues the case for reliable information about medicine

      ------------

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