Placebos: Can we use them? Should we use them?
September 29, 2016
Amy Givler, MD
Don’t we all want to please? That is what “placebo” means, after all—“I shall please.” Yes, if it is possible to provide good healthcare while making patients happy, then by all means let us make them happy. Let’s be warm and caring in our attitudes, for starters.
But what if our patient has an illness for which there is no effective treatment? Can we give a placebo, saying it is the latest, greatest cure for what ails them?
In a word, no.
As Christians, we should not lie.
But can we give something that won’t hurt them, but hasn’t been shown to help, either—something along the lines of a multivitamin—and give it with enthusiasm, saying, “I think this will help you.”
To answer this, let’s explore the placebo effect.
The word “placebo” actually comes from a mis-translation of the Bible. Psalm 116:9 in the Latin Vulgate roughly states, “I shall please the dead in the land of the living.” Later translations better reflected the original Hebrew with, “I will walk before the Lord in the land of the living,” (KJV) but in the Middle Ages, the Latin Vulgate was the only Bible most people knew. This line was chanted by professional “mourners” at funerals, and because they were hired, their sorrow was faked. Such a person was called by the first word of the chant: “placebo.”
A famous article on the placebo effect published in the Journal of the American Medical Association in 1955 reviewed 15 studies of 1,082 patients who took placebos for varying amounts of pain. On average, placebos relieved pain 35 percent of the time. Never again would medicine discount the power of the placebo. Since then, thousands of studies have been published on various aspects of the placebo effect. As a 2011 The New Yorker article put it:
“Slowly, over the past decade, researchers have begun to tease out the strands of the placebo response… In most cases, the larger the pill, the stronger the placebo effect. Two pills are better than one, and brand-name pills trump generics. Capsules are generally more effective than pills, and injections produce a more pronounced effect than either. There is even evidence to suggest that the color of medicine influences the way one responds to it: colored pills are more likely to relieve pain than white pills; blue pills help people sleep better than red pills; and green capsules are the best bet when it comes to anxiety medication.”
Placebos are effective, but how do they work? A landmark 1978 study of patients who were in pain after a tooth extraction found, first of all, that some people responded to a saline injection with pain relief. These “placebo responders” were then given naloxone, an opioid receptor antagonist, or another saline injection. Those who received the saline continued to have pain relief. Those who received naloxone, however, experienced a sharp increase in pain. Clearly, these patients, after receiving the placebo injection, had produced something—something tangible that could be blocked by naloxone. This was later confirmed to be opioid-like endorphins, natural pain relievers.
That study changed the minds of many clinicians. The placebo effect was doing something detectable in the brain; that is, it wasn’t just an interesting psychological phenomenon. Thus it became legitimate.
Dozens of further studies have shown biological effects that go beyond endogenous endorphins. A study of Parkinson’s patients receiving placebos showed a boost in dopamine production, and a study published this summer showed that mice whose reward circuits in their brains had been activated (mimicking a placebo) had improved immune systems. For patients with depression, studies using PET scans and fMRI scans show that depressed patients given placebos have enhancements in metabolic and electrical activity in serotonin-rich areas of the brain.
But is that all there is to generating the placebo effect—take a pill and get a response? No, there also needs to be an expectation of benefit. The person taking the placebo needs to believe it will help. Patients with advanced Alzheimer’s, for example, get minimal relief from any pain pill, whether it is a placebo or an opioid. The effectiveness of every medicine available owes some of its benefit to the placebo effect. On the flip side, it’s also possible to believe that an inert pill will cause harm and then develop an unpleasant side effect. This is called the “nocebo effect.”
So now we are back to the initial question: can we give patients a multivitamin to treat a condition not related to vitamin deficiency, saying we think it will help them?
The doctor-patient relationship is built on trust. If I violate that trust, it will take a long time—and perhaps forever—to build it back. But is suggesting an unsubstantiated treatment a violation of trust? The key is the context in which the suggestion is given. When the healthcare professional has cared for the patient over time, the relationship itself is therapeutic. Patients come to the clinic expecting to be treated well and receive benefit. If I cannot point to an evidence-based treatment for their particular illness, and especially if there seems to be a psychological component to their distress and they expect me to recommend some sort of treatment, then I can turn to something in pill form that won’t hurt them.
Do I lie? No, I don’t lie. I tell them that studies haven’t been done that show a benefit, yet taking it has helped other people and I think it could help them as well. I want to relieve my patients’ suffering.
But I don’t forget that the encounter itself is therapeutic.
Not everyone responds to placebos—pills, that is. But everyone responds to a friendly greeting, a caring touch and a warm smile. The more I have learned about the value and effectiveness of the doctor-patient relationship itself, the more I want to master it.
Everyone who treats patients knows that some of them are harder to care for than others. I’ve heard the toughest patients described as “difficult” because they are sometimes irrational, often irritable and always full of physical complaints. To avoid exhaustion, the temptation of the clinician is to hastily suggest a medication and cut the visit short, and that is what I used to do when I first became a physician. But 30 years have passed, and I’ve learned these are the people who most need the “therapy” of the encounter itself. As a follower of Christ, I have emotional resources that can be replenished, so I ask God to fill me with His love and grace before I enter the exam room.
And it is in that context that a relatively benign medication could be a real help to the patient. Is it a placebo? In a sense, perhaps. But in another sense it is an extension of the therapeutic relationship I have built with that patient. It’s a tangible way for patients—when they are home between clinic visits, daily taking their pill—to harness the power they have within themselves, the power that helps the body heal itself