Placebos offer real therapeutic value: Although they cannot cure an illness, they can make patients feel better. So why not incorporate them into medical practice? In a provocative essay published today (July 1) in The New England Journal of Medicine, Harvard Medical School professor Ted Kaptchuk proposes that placebos should be considered valuable components of medical care and important tools in relieving patients' symptoms — and not simply an inconvenient baseline that "real medicines" are compared to within medical studies. A placebo — the word comes from the Latin phrase meaning "I shall please" — is a fake pill or procedure that can provide a psychological benefit because the patient thinks he or she is getting real treatment. The placebo effect is an improvement in symptoms that can be attributed to fake medicines, or even standard symbols of healing, such as a medical doctor's white coat and diploma, or a witch doctor's menacing mask. "A significant body of research has resulted in a shift from thinking of placebos as just 'dummy' treatments to recognizing that placebo effects encompass numerous aspects of the health care experience and are central to medicine and patient care," Kaptchuk said. And Kaptchuk would know. As director of a research program at Harvard that studies placebos, he has led much of this research. In recent years, Kaptchuk and his colleagues have demonstrated that patients' symptoms may be relieved even if they know they are taking a placebo pill; that sometimes a placebo can cause negative side effects, such as nausea; and that some placebos work better than others. In 2012, Kaptchuk even took placebos to the genetic level and found that patients with a certain variation of a gene associated with the brain chemical dopamine were more likely to respond positively to fake acupuncture for the treatment of irritable bowel syndrome. Such insights may help scientists design better drugs for certain people by ruling out certain side effects or elements of symptom relief that are psychological, rather than biochemical, in origin. But exactly how to capitalize on the placebo effect in the doctor's office, ethically, is an open-ended question that Kaptchuk is posing to the clinicians who read The New England Journal of Medicine. "Medicine comprises two things: the moral care of a patient … and effective therapy," Kaptchuk told Live Science. "You can't lie to patients." Doctors need to think of clinical interventions designed to elicit placebo effects without deceptions, Kaptchuk said. This could include research into how a doctor's touch, gaze or capacity for listening can have positive effects on a patient, or how stern warnings about drug side effects could actually induce those side effects in the patient. Or, a placebo could be ethical in situations when no cure or relief is otherwise available, Kaptchuk added. For centuries, physicians have debated the proper role of placebos in patient care. Some have considered placebos completely harmless, while others have claimed they're damaging tools of charlatans and quacks. A steady flow of medical advances in the early 20th century relegated the placebo effect to the backwoods of clinical care. A 1955 paper by Henry Beecher of Harvard Medical School titled "The Powerful Placebo" changed that by introducing the concept that placebos have therapeutic value that can be exploited. But then, the tide turned, again, with a study published in The New England Journal of Medicine in 2001 by Dutch researchers, who found that most placebo studies were methodologically flawed. With a rub to Beecher, their paper was playfully titled "Is the Placebo Powerless?" Kaptchuk has claimed in previous interviews to have learned much from the Dutch study and has since collaborated with one of the Dutch authors. Nevertheless, there are many critics of using placebos in medical care. In a 2011 article in The Atlantic, in reaction to a study that Kaptchuk conducted on asthma, retired family physician Harriet Hall said, "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." But critics argue that placebo effects tend to be small, temporary and inconsistent, and that they have little proven positive effect on disease outcome, which should be the ultimate goal. Kaptchuk conceded that placebo effects are modest in comparison to lifesaving surgery and powerful medications. But he noted that a placebo can enhance the effectiveness of these methods — a central point he hopes his fellow clinicians will consider. "The New England Journal of Medicine rarely entertains studies on placebos," Kaptchuk said. "I am happy they are considering this." Source
