Exploiting expectations

The scope of treatment options being researched or offered by doctors in 2017 is baffling. While in vitro fertilization procedures shook the consciences of many when they were introduced in the late 1970s, the extent to which these procedures intervene with natural human systems seems innocuous compared to today’s nascent medical controversies — gene editing and the use of technology to compensate for failing organs, to name a couple.

Given the apparent omnipotence of modern health care professionals, it would be easy to write off less tangible treatments, especially those that are not well understood.

The ‘placebo effect’ may be one of those elusive treatments.

In medicine, a placebo may be used in place of a drug or procedure. It has no direct therapeutic effect on an illness but can still cause a patient to feel better. People expect doctors to prescribe treatment that will cure them and their expectations alone result in the feeling of being cured — this is known as the placebo effect.

The placebo effect demonstrates how our expectations can literally change how we experience the world. The placebo effect exploits this belief to allow us to subconsciously change our physical and mental interior worlds using our faith in medicine and healthcare providers.

Mind over matter?

The power of our minds is immense. Studies on the placebo effect show how we enable sugar pills, sham surgeries, and homeopathic medicine to ‘cure’ us.

Acupuncture, for example, may rely entirely on the placebo effect, as the majority of research on the topic has shown that acupuncture has no specific restorative ability. By comparing results from participants who went through acupuncture and those who went through simulated acupuncture, researchers have concluded that the physical relief acquired from acupuncture is based on the belief the participants had in its ability.

This, of course, does not invalidate the fact that patients felt better after treatment — simulated or real — and many continue to seek out acupuncture to treat a wide variety of ailments. Perhaps, then, the placebo effect is strong enough to sustain entire industries.

Though this may be true, Ted Kaptchuk, a leader in placebo effect research and Director of Harvard’s Program in Placebo Studies and the Therapeutic Encounter, has cautioned that you can’t just “think yourself better.”

Instead, Kaptchuk’s research shows that the placebo effect is real in a biological sense, and it can also be considered a treatment of its own.

The neurological basis for the placebo effect is still being tested. Current research shows that the placebo effect can measurably change neurotransmitters and other biological conditions, such as heart rate and blood pressure, though only so much as medication is capable of impacting these factors.

One study by Kaptchuk gave participants either a placebo marked as a drug or a medically active drug marked as a placebo. The placebo did significantly better than the active drug in mitigating the symptoms of a migraine according to patient reports.

Another study was conducted by Dr. Michael E. Wechsler, Kaptchuk, and other scientists on asthma medication and placebos. Two placebo trials showed equal benefits in self-reported outcomes as the medicinally-active drug, and all three trials showed more improvement with the use of the placebo compared to no treatment. Though the two placebos caused no improvement in the presence of the chemical cue, the placebo patients felt equally improved, which is an incredible reaction.

The most important factor in these studies is that the patients were primed beforehand into thinking the placebos were effective.

The priming effect occurs when people are exposed to positive or negative stimuli before experiencing an unrelated situation. The formerly presented stimuli change the way the latter situation is perceived, even if the two are unrelated.

Many studies on this topic have come to the same conclusion: people’s reaction to the world can be changed completely to match the tone of the original stimuli. Our mind creates the world we inhabit based on the sensations and memories it has available.

Ethical controversies

Placebos have been used both in experimental trials and clinical practice. While their use in experimental science is unquestionable, the ethics of their use in clinical practice is dubious. Physicians swear to cure and provide medicine for illness and disease. Placebos do not ‘work’ insofar as they do not actually cure.

Patients feeling better but not biologically recovering is a major point of contention when it comes to placebo as a medicinal tool. Dr. Harriet Hall, a retired physician, commented on the asthma research by Wechsler and Kaptchuk for The Atlantic: “Asthma can be fatal. If the patient’s lung function is getting worse but a placebo makes them feel better, they might delay treatment until it is too late.”

Results of studies considering the neurological and biological components of the placebo effect show that changes in actual symptoms and physiological causes of the illness are very minor or the variations seen are to be expected from the sickness. This means that, even if patients feel better, they might not actually be getting better. The purpose of medicine is to heal and cure, and many believe that prescribing ‘medicine’ which doesn’t do so is unethical.

A major problem in the practical use of placebos has to do with the types of patients that are more likely to be prescribed placebos. Studies have shown that physicians tend to underestimate the level of pain and intensity of symptoms in women and people of colour; doctors are more likely to under-treat these populations. Therefore, should the placebo effect be accepted in mainstream medical practice, it may only further jeopardize already vulnerable members of society.

Doctor-patient relationships

Placebos are also controversial for the way they necessitate deception in the patient-doctor relationship. Dr. David Gorski is a surgical oncologist at the Barbara Ann Karmanos Cancer Institute and a faculty member at Wayne State University who doesn’t believe in using placebos.

In an essay for Science Based Medicine, Gorski critiques the ethics and healing capabilities of the placebo: “Basically, in medicine it is very unethical to lie to patients, and inducing placebo effects requires lying to patients.”

The doctor-patient relationship is a cornerstone of medicine; trust and understanding needs to be present on both sides for the patient to get appropriate treatment. When a doctor lies, they reduce trust in them and in the entire institution of medicine.

What is more, science has shown a positive correlation between the amount of information a patient has of the treatment and their level of recovery. A patient who has all the information about their condition and treatment may be in a much better situation to recover.

The modern version of the Hippocratic Oath includes the following line: “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.” In other words, it is part of a doctor’s job to provide warmth and demonstrate empathy to the patient. Showing empathy leads to reassurance and creating a state where the patient believes that they can get better, which is where the placebo effect can be most useful.

Placebos are used to pacify — to treat mild or psychosomatic symptoms. Medical conditions such as broken bones, heart disease, and cancer will not heal themselves, no matter what we believe. Yet our minds still play a role — it has been shown that even the medications for these sicknesses work better when the patient has a better understanding or trust in the treatment and the physician administering it.

Placebo in practice

Some nations and medical associations have guidelines that consider placebos unethical. The Canadian Medical Association, however, does not provide guidelines for the use of placebos in clinical practice. The lack of regulation allows them to be used by physicians.

Regardless of the ethical concerns, some reports have indicated that around 20 per cent of Canadian doctors in some disciplines prescribe placebos. Between 17–80 per cent of doctors from other nations use them. These statistics show that, whatever moral concerns about placebos there are, at least some medical professionals consider the practice useful.

Kaptchuk conducted a study on patients with irritable bowel syndrome, with three treatment groups. Group One had no treatment, Group Two had treatment with a distant, quiet acupuncture practitioner, and Group Three had treatment with a warm and friendly practitioner. The most important factor in patient relief turned out to be the interaction between the patients and practitioners. Group Three had significantly higher improvement rates at 62 per cent, compared to 28 per cent and 44 per cent for Group One and Group Two, respectively.

While the methodology of placebo studies is tricky, Kaptchuk’s study emphasizes that when it comes to the power of the placebo effect, its greatest strength lies in the relationship between doctor and patient, not necessarily in the patient and treatment. As Hall put it, “It’s not just about curing; it’s about caring and comforting when we can’t cure.”