“Placebo” is derived from Latin, “I shall please.” It generally refers to an inert or innocuous substance used as a comparator in controlled clinical trials; indeed, such trials generally require use of placebo controls to meet the gold standard for human subject research. “Placebo” can also refer to a pharmacologically inactive substance prescribed for its impact upon the psyche of the patient.
The effects of placebos are thought to be “a consequence not of the treatment itself, but exclusively of the patient’s expectations and beliefs about a more or less beneficial treatment outcome in terms of efficacy, safety, usability or side effects.” Benedetti, F., Placebo Effects. Understanding the Mechanisms in Health and Disease, 2d edition. Oxford: Oxford University Press (2015). The effect is generally more marked in children than in adults because, it is thought, kids are more suggestible than older people. Rheims, S., Cucherat, M., Arzimanoglou, A., Ryvlin, P., “Greater Response to Placebo in Children Than in Adults: A Systematic Review and Meta-Analysis in Drug-Resistant Partial Epilepsy,” 5(8) PLoS Med. e166 (2008), http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0050166.
The efficacy of the placebo has been recognized since at least Henry K. Beecher’s classic 1955 paper on “The Powerful Placebo,” 159 JAMA 1602-6. Beecher recounted how severely wounded soldiers would decline morphine, speculating that they were so relieved to have survived combat that their perception of pain had diminished. In a famous study, a placebo given to asthmatics had no effect on the maximum volume of air the patients could exhale in one second, a commonly used objective measurement of the severity of the disease, yet those so treated reported feeling better. Wechsler, M.E., Kelley, J.M., Boyd, I.O.E., et al., “Active albuterol or placebo, sham acupuncture, or no intervention in asthma,” 365 N. Engl. J. Med. 119-26 (2011). Patients given identical medications sometimes report better results when they believe they are getting costlier preparations than they do when they think they are getting something cheaper. See, e.g., Ariely, et al., “Commercial Features of Placebo and Therapeutic Efficacy,” 299(9) JAMA 1016-1017 (2008)(letter).
Some argue that placebos can provide patients such symptomatic improvement that they have earned a legitimate place in clinical practice. Lichtenberg, P., Heresco-Levy, U., Nitzan, U., “The ethics of the placebo in clinical practice,” 30 J. Med. Ethics 551-554 (2004), http://jme.bmj.com/content/30/6/551. A recent paper actually laid out a four-part test to determine whether, to ascertain whether a new, “real” operation was useful, sham surgery was ethically permissible. Tambone, V., Sacchini, D., Spagnolo, A.G., et al., “A proposed road map for the ethical evaluation of sham (placebo) surgery,” 265 Ann. Surg. 658–661 (2017). The authors argue, “The use of a placebo and of double-blind control groups in surgery CTs [controlled trials] would improve the quality of results, providing that an accurate ethical assessment procedure is in place, firstly to ensure patient safety and secondly to prevent abuses/procedural biases.”
The placebo effect may account for at least some of the apparent effect and popularity of so-called “complementary and alternative medicine” (“CAM”) treatments. Such treatments are in surprisingly widespread use. Recent stories report that, even at some of the nation’s premier teaching hospitals and research institutions, “alternative” medicine is on offer. Casey Ross, Max Blau, Kate Sheridan, “Medicine with a side of mysticism: Top hospitals promote unproven therapies,” STAT (7 March 2017), https://www.statnews.com/2017/03/07/alternative-medicine-hospitals-promote/; David Gorski, “In the tradition of Chairman Mao, traditional Chinese medicine gets a new boost by the Chinese government,” Science Based Medicine (2 January 2017), https://sciencebasedmedicine.org/traditional-chinese-medicine-gets-a-boost/. Serious publishing houses put out periodicals that discuss all manner of treatments devoid of scientific rationale or empiric evidence of efficacy. Steven Salzberg, “Fake Medical Journals Are Spreading, And They Are Filled With Bad Science,” Forbes (3 Jan. 2017), https://www.forbes.com/sites/stevensalzberg/2017/01/03/fake-medical-journals-are-spreading-and-they-are-filled-with-bad-science/#6abc1f9f30c9 (The author lists The Journal of Acupuncture and Meridian Studies, published by Elsevier; Acupuncture in Medicine, published by BMJ; Chinese Medicine, published by BioMed Central (owned by Springer).) The Association of American Medical Colleges provides “Resources for Developing and Integrating Innovative Curricula in Complementary and Alternative/Integrative Medicine,” (30 Nov. 2009), https://www.mededportal.org/publication/1738; it reports that in 130 of the nation’s approximately 140 medical schools, a course on “complementary and alternative healthcare” is actually required. See, Number of Medical Schools Including Topic in Required Courses and Elective Courses, available at https://www.aamc.org/44826/search.html,s=rel,q=complementary+and+alternative+medicine,p=4,fc=102.
Comment
Critics claim that the real reason why prestigious medical centers offer “alternative” medicine is financial. See, e.g., Ross, et al., supra. In part because of promotion by ignorant celebrities, a certain fraction of the American population believes that naturopathy, homeopathy, and the like are scientifically legitimate therapies. Such belief gives rise to demand, and, the reasoning goes, academic centers are not above profiting from satisfying that demand.
An explanation less damning could lie in the desire to alleviate symptoms–unquestionably a legitimate goal of all health care professionals–by allowing patients access to placebos. Most of the so-called “alternative” therapies seem to do relatively little harm, except when they delay real therapy for those needing it. If after undergoing some science-free therapy the patient reports suffering less from his illness, that could easily be explained in some cases by its natural history, in others by chance, and in others, quite possibly, because he devoutly believes that whatever potion he took or treatment he underwent was effective. Whatever the explanation, surely no one can disparage the value of symptom amelioration as such. Admittedly, such a defense fails when the disease in question is life-threatening, and/or time is short. One hopes that legitimate medical schools that teach these subjects distinguish between cases where the risks are acceptable and those where they are not. If so, at least until the public can be properly educated about scientific medicine, perhaps a placebo here or there is not unacceptable.