Placebos Can Relieve Medical Problems, Why Not Use Them

 Gavin Francis is a primary care physician who was asked to review two books addressing the role of placebos in medical care: Placebos by Kathryn T. Hall, and The Power of Placebos: How the Science of Placebos and Nocebos Can Improve Health Care by Jeremy Howick.  His effort appeared in the New York Review of Books as the article What Do You Expect?.

A placebo is most commonly an inert substance given in clinical studies of medicines to compare results obtained for patients receiving the medication with those who only received the placebo.  There are also placebo usages designed to deceive a patient into believing a procedure has been performed when it has not.  These are used to test the efficacy of an operation for example. 

One can describe a sugar pill as a placebo and claim it is physiologically inert, but it need not be psychologically inert, and psychological effects have long been known to affect health outcomes.  Based on his own experience, Francis issues this statement.

“The idea that the mind has no power over the body is absurd: from the simplest stress headache or nervous bladder to situations in which the dying seem able to hold off the moment of death until a family member arrives, the power of belief and expectation over the progression or regression of illness is inescapable. In my clinic every day I attempt to gauge what kind of doctor the patient before me wants or expects—is it a collaborative, arm-around-the-shoulder kind of doctor, a guide through the landscapes of illness? Or an old-school, paternalistic doctor who will simply lay down the medical law? Or perhaps an interpreter of science, able to make sense of the dizzying diversity and contradictions of the latest research papers? Judging which kind of doctor that patient needs me to be goes a long way toward being more effective, whether they’re suffering from a low mood or an infected ear. The old Cartesian idea of a split between an ethereal mind and a mechanistic body is increasingly (and thankfully) going the way of bleeding with leeches. The mind influences both how ill health is experienced and how that illness evolves. Though the relationship is poorly understood, it is real.” 

One is easily convinced that the mind plays a role in how illness is perceived, but the role it plays in the evolution of an illness is a little harder to grasp.  Francis points to the value of the physician in recognizing the mood of the patient and accommodating it or modifying it.  A simple Google search for the effect of mood on immune response provided a document provided by the NIH (National Institutes of Health): Mood configurations and their relationship to immune system responses: Exploring the relationship betweenmoods, immune system responses, thyroid hormones, and social support.  The following conclusion was determined.

“In the field of psychoimmunology or affective immunology, researchers have shown that immune system responses and moods are related. However, findings are not always consistent.”

So, mood can make a difference in health outcomes.  Francis seems to be on to something here.

He provides a short tour through recent history to point out that until the era of modern medicine, less than a century ago, placebos were regularly prescribed and were responsible for most cures obtained.

“To use a placebo was ethical because it both harnessed the formidable power of belief and avoided poisoning the patient.”

It is easy to understand the effect of a placebo when the malady is purely psychological.  It was recognized long ago that if you give people suffering from depression a pill and tell them this pill can alleviate their depression they will hope for and expect to experience some relief.  And they often do.  In clinical studies of antidepressant medications, the patients do not know if they have received medication or a placebo, but they seem to have the same expectations.  People receiving the placebo have about the same probability of relief as those receiving the medication.

“Later meta-analyses confirm this observation: the effect of all our common antidepressant drugs is at best marginally better than that of placebos.”

Psychiatrists who are aware of this result might argue that it would be unethical to charge a patient for medication and deliver a placebo.  But where are the ethics in prescribing an expensive drug with known serious side effects when one recognizes that a sugar pill might work just as well.

Negative expectations can lead to nocebo effects on health.

“Another man, part of a drug trial for antidepressant pills, took an overdose of his medication. His blood pressure crashed and he had to be carried to the ER, only to later learn that he’d been taking the placebo.”

“She [Hall] and Howick both describe the case of a twenty-nine-year-old builder brought to Leicester Royal Infirmary in 1995 with a six-inch nail through his boot. Any attempt to remove the nail caused him to scream in agony. A clinical team heavily sedated him, pulled out the nail, and removed the boot—only to find that the nail had passed harmlessly between his toes. His foot might have been unharmed, but there was no doubt among the team that he had been experiencing real pain.”

These expectation-driven placebo results also can show up in medical procedures.

“…we still pour money into procedures that are no better than placebos: Howick says that annually around £67 million in the UK and $5 billion in the US are spent on knee washout arthroscopies for osteoarthritis, yet it has been shown that simply anesthetizing the patient and giving them a scar on the knee so that it looks as if they’ve had surgery is just as good at reducing subsequent pain. ‘When considered in light of these arguments, placebo treatments are not just ethical; they are ethically required,’ writes Howick.”

Can one consider a placebo as a continuing treatment?  What happens when the patient realizes that the medication is inert?  Apparently, there is good news for placebos.

“Placebos seem to work on the basis of expectation, and one of the most curious aspects of their function is that they continue to have benefits even when you know that what you’re taking is a dud. These ‘open-label’ placebos are nevertheless commercially valuable: some I looked up recently retail at more than one hundred dollars a bottle, though the label reads, ‘No active ingredients whatsoever’.”

If one is inclined to using a placebo on a patient, Hall provides some useful advice.

“We know that expensive placebos work better than cheap ones, capsules work better than tablets, and colored capsules work better than white ones. Blues and greens work better as sedatives, while pinks and reds work better as stimulants and painkillers. (Unless you’re an Italian man: Howick notes that blue is stimulating for Italian men, perhaps because the Italian soccer team wears blue.) Medium-size placebos are the least effective; it seems that we trust either tiny pills or big ones—the latter because they’re more impressive, and the former presumably because tiny capsules must contain powerful drugs.”

The three authors, Francis, Hall, and Howick, agree that physicians should not use deception in getting patients to try placebos.  The appropriate approach is to educate the patient about the data available suggesting the efficacy of their use and convince the patient that the mind and its expectations can affect bodily functions.  This approach is not consistent with a single 15 to 20 minute session, but it can be consistent with lower cost health care and better health outcomes. 

Francis finishes with this statement.

“A revolution is long overdue: as the costs of conventional medicines spiral ever upward and the returns on those costs diminish, doctors owe it to their patients to make room for a different approach, with more humility, curiosity, and compassion. It’s extraordinary that our culture has become so medicalized and reductionist that warm and empathetic care, with its immense proven benefits for the way that a patient feels and heals, has been deprioritized to an optional extra rather than a core element of medicine. A rebalancing is in order: doctors need more time with their patients and, yes, more use of honest placebos—because they work.”

 

You can learn a little about a lot of things or you can learn a lot about a very few things. Guess which is the most fun.

Source: http://letstalkbooksandpolitics.blogspot.com/2025/08/placebos-can-relieve-medical-problems.html