Take Two Placebo Pills and Call Me in the Morning

What if placebos and their effects are not as "inert" as we once thought, that they might really provide therapeutic benefit? This raises a new ethical question: Are we harming patients by withholding treatments like placebo therapy that might actually help them?
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Jane has suffered from debilitating headaches for the past year. After a number of referrals, and no medical explanation for her headaches, she meets Dr. Smith, who prescribes her 100mg of Vitamin X. Dr. Smith tells her that, "This has helped others with your condition."

Finally experiencing relief from her headaches, Jane says, "This is the best I've felt in years. Vitamin X is a miracle cure." When Dr. Smith is asked by his colleague about the prescription for Vitamin X and Jane's recovery, Dr. Smith says, "I don't know why it worked. Vitamin X doesn't cure headaches, but I thought she might get better if I just prescribed her something, and I didn't think it would hurt for her to have some extra Vitamin X in her diet."

Jane's "miracle cure" is widely referred to as the "placebo effect." Placebos are generally inert substances, like sugar pills, thought to relieve patient symptoms through an expectation of getting better. It seems that, in some reported cases, simply the act of taking medicine or believing that medicine might work can impact patient outcomes. Because of this, placebo effects have historically been discounted as effects that aren't medically "real."

But what if placebos and their effects were not as "inert" as we once thought, that they might really provide therapeutic benefit? This raises a new ethical question: Are we harming patients by withholding treatments like placebo therapy that might actually help them?

Some patients and physicians frown upon placebo use primarily because placebo effects are thought to require deception, that an "unreal" treatment will give "real" relief, and therefore their use betrays patient-physician trust through deceit.

However, in 2008 two independent studies documented that 50 percent of physicians utilize placebo in practice, contrary to what they document in their medical records. Of note is that 96 percent of those physicians felt that patients were truly deriving a very real physiological benefit from placebos.

Indeed, while placebos are generally defined as having no inherent effectiveness in physically curing illnesses, a growing body of neuroscientific evidence challenges this assumption. Accumulating data suggest that placebos have measurable effects on the brain as well as objective (physicians can measure improvement in patients) and subjective (patients report feeling better) benefits for patients.

Some have called placebo effects "the endogenous (or your body's own) healthcare system." For each ailment, placebos seem to produce physiological improvements specific to that particular ailment, whether it be a neurodegenerative movement disorder like Parkinson's disease, migraines, or depression. Moreover, one study suggests that deception is not necessary for placebos to benefit patients, at least for those suffering from Irritable Bowel Syndrome (IBS).

To be clear, it's hardly advisable for placebo therapy to serve as a substitute for chemotherapy, surgery for a broken arm, or vaccination. While it's true that placebos may be a valuable adjunct to any therapy -- indeed, placebo effects have been found to enhance the effects of some medications -- placebos are perhaps most compelling and promising for conditions that currently have no successful standard therapies, such as some psychogenic disorders: "medically unexplained" conditions characterized by debilitating pain, paralysis, blindness, tremors, and seizures, which make up 20-30 percent of primary care patients at an estimated cost of $100 billion per year.

Placebos could provide a cost-effective solution here, and many of us are already comfortable with and in the habit of using a variety of placebos; local grocery stores and health food stores contain many shelves of non-FDA regulated solutions to a variety of ailments including the common cold.

But, if we are to move forward with placebo treatment, we will have to apply a systematic means of implementing it. Because placebo treatment is so intensely context-dependent -- seemingly unimportant factors like color, or mode of delivery, or what is stated at the time of administration can significantly bear on their efficacy -- many potentially influential factors must first be analyzed. Some patients, more than others, may be strongly susceptible to placebos and it will be important to determine which sub-populations would benefit or be harmed by such treatments. Therefore, the first step will require standardizing placebo treatments for specific patients by collecting in-depth data on how and for whom physicians are using placebos now.

It's a step we should take. Placebos are widely used and prescribed today, and have significant benefits to those seeking treatment. We must move beyond asking whether we approve of placebo use and instead reinvigorate research on how and under what conditions we should use them. This research will not only have an impact on a host of medically unexplained illnesses, but could also make headway in addressing a wider range of illnesses such as the common cold and pain.

This story originally appeared in our weekly iPad magazine, Huffington, in the iTunes App store.

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