Richard L. Kradin, MD
Researchers at several American institutions recently
reported that half of 679 American doctors who had been surveyed
said they regularly prescribed placebos to their patients. This
news came as a shock to many people -- and raised serious ethical
questions.
Everyone knows what placebos are -- “sugar pills” or “dummy pills”
that masquerade as medication. But is it that simple?
There’s a lot more to the question than meets the eye, according to
Richard L. Kradin, MD, one of the country’s foremost experts on the
use of placebo treatments. To learn more,
Bottom
Line/Health recently spoke with him...
What exactly is a placebo? It’s any type of
therapeutic intervention -- for example, a fake or unproven
medication, a sham surgical procedure or a talk with the doctor --
that, in and of itself, is judged to have no therapeutic capacity.
When it works, the success is attributed to an activation of what’s
called the “placebo response.”
How is the placebo response believed to work? Before
there were any scientific medical treatments, people got sick and
got well. In species such as ours, some of these responses involve
the body’s ability to soothe itself and to restore states of
physical and mental well-being. This self-soothing process is key
to the placebo response.
Certain memories are probably involved. For example, children are
usually soothed by their parents. Their mothers kiss minor hurts to
make them better. They are given pills and told the medicine will
make them well. When adults are sick and receive care from someone
who’s supposed to help them, the situation can reawaken this
capacity to be soothed. After a visit to the doctor, some people
report that they feel better right away.
Can a person who has a serious illness be healed by the placebo
response? There are people who appear to have been
cured of cancer by what might be termed the placebo response. In
one case, an experimental chemotherapy drug -- later shown to be
inactive -- was highly effective in a patient as long as he
believed it was capable of curing his cancer. But that scenario is
quite rare.
Placebos seem best able to restore well-being when problems are
minor, such as a headache or stomachache. It’s important to
remember that the placebo response isn’t necessarily separate from
real therapeutic responses brought about by effective treatment,
but part of them. If you take a drug that works, the placebo
response may make it work better. Many of the factors involved in
the placebo response have been scientifically confirmed in a number
of studies on the topic.
Do placebos do more for some people than for
others? In most clinical trials, one-third of
patients who receive a sugar pill feel better. But it’s hard to
predict which people will respond positively to placebo
treatment.
Trust and expectation increase the chance of a positive response.
If you believe that a drug or treatment is likely to help you, the
odds are that it will work as a placebo.
If the doctor or other caregiver conveys a sense of competence and
authority, and the visit to the doctor’s office promotes relaxation
and trust, these factors also seem to elicit the placebo response.
The doctor’s ability to listen and make patients feel that they’re
understood is important. If the doctor doesn’t convey his/her own
belief that the intervention will work, the chances are good that
it won’t work.
Can a placebo have harmful effects? Negative, or
so-called nocebo, responses are quite common. For example, about
25% of participants in clinical trials report side effects after
receiving a harmless pill. Similarly, a certain proportion of
adverse reactions to prescribed medications are no doubt due to the
nocebo response.
Here, too, expectation plays a role. Nocebo effects commonly occur
after a patient reads the drug package insert that lists, often in
alarming detail, a medication’s potential side effects. The
health-care provider can elicit the nocebo response, too. People
sometimes leave the office of a brusque, uncaring doctor feeling
much worse, and getting little benefit from the medication the
doctor prescribed. If a caregiver expresses too many doubts about
the treatment, patients detect that as well.
Is it ethical for a doctor to prescribe a drug as a placebo without
the patient’s consent? In many situations, with many
types of people, conveying the entire truth, including doubts
surrounding the treatment, may not be in the patient’s best
interest in terms of therapeutic outcome. On the other hand, if a
doctor is caught prescribing a placebo, he risks losing his
credibility. Most placebos are prescribed unwittingly by doctors
who prescribe a medication “off-label” -- for an unapproved use --
in the belief that it will help.
By the same token, when I talk in detail with a patient about a
particular drug’s potential side effects, as mandated by law, I can
see fear well up in his face. Is that the role of a healer? I’m not
so sure.
Can medical consumers harness the power of their own placebo
responses? Yes. In choosing a health professional,
you should try to find someone you can trust and have confidence
in. Don’t go to anyone who doesn’t evoke this trust. It’s possible
for a doctor to be brusque and still convey the confidence that a
patient needs. Some people respond well to that kind of
personality.
Know yourself. If you leave a treatment situation feeling doubtful
and not reassured, you’re probably in the wrong place.
How can you minimize nocebo effects? I suggest to my
patients that they read the medication package insert only if they
experience a side effect, to check whether it is a common one. I
believe it’s better to stay modestly informed -- and to recognize
and respect the expertise of the doctor or other health
professional.Important: Any side effect that is not
short-lived should be reported to your physician so that
potentially serious adverse reactions are not missed.
You should be a working partner in your treatment and have some
idea of what’s going on. But when people start involving themselves
in the fine details, it tends to have a disturbing effect on
mind-body processes -- either resulting in a nocebo response or
limiting the advantages of the placebo response.