Today, I found I
had lost my voice and was confined to a corner unable to verbalise anything and
feeling rather left out, when on the radio, I heard a talk on ‘Placebos’. It worked
like a tonic on me!
We heard the word
in our training in connection with clinical trials to establish the truth about
the efficacy of a ‘real’ drug against a ‘placebo,’ the latter being a sugar
pill or some inactive inert material made to look like the real thing. The Wikipedia
defines a placebo as
a substance or treatment of no intended therapeutic value. Common placebos
include inert tablets (like sugar pills), inert injections (like saline), sham-surgery, and
various other procedures.
In the talk I
listened to, a woman spoke about her episodes of irritable bowel syndrome (IBS)
which made life impossible. She heard about a practitioner who would treat her.
He gave her a placebo to start with and extolled its virtues as the ideal
treatment for her condition, she took it and was completely healed. She never
suffered from IBS again. She was unaware it was a ‘placebo’ that healed her. So,
what happened here? She believed it was a drug which was magical as much as the
reputation of this practitioner. She had faith; she ‘knew’ it would work. So,
it was a reaction in the whole body associated with this faith.
Later in these
trials, patients were told they were receiving a placebo but that it has been
known to work. And it did! Why? Because the patient’s ‘faith’ made certain
changes in the working of her body, which enabled getting rid of the unwanted
condition.
So, it now
appears that a placebo effect and the placebo itself are quite powerful and
patients while being completely aware that they are receiving a placebo yet get
benefit. It finally appears that what works is the faith in the doctor, his
personality, his well-wishing toward the patient, his touch, his kindness, all
of which militates against the very basics of our medical training which were
based on basic sciences, pharmacology, pathology and therapeutics to name a
few.
So why is this
‘placebo’ and the ‘p-effect’ gaining currency now?Should trained medical
practitioners ‘pooh pooh’ these ideas and stick to what they were taught? Or
should doctors be aware of and appreciate and even use other treatment
modalities such as placebo effects, acupuncture, faith healing, religious
healing, and such methods which were not part of our curriculum except to
mention such subjects in an almost derogatory way?
I for one, have
the policy of ‘live and let live’. I don’t claim to know everything. I respect
and accept my training and it has been my life. But there are things in the art
of healing which I do not understand. And this is because, I think, that our
minds are powerful complex structures and anatomy, physiology and pathology
cannot truly claim to know all that is going on.
Further reading: https://en.wikipedia.org/wiki/Placebo_studies
PMCID: PMC2653635
Placebo
Response of Non-Pharmacological and Pharmacological Trials in Major Depression:
A Systematic Review and Meta-Analysis
Zita, Thank you for bringing up this interesting topic which is currently being enthusiastically researched.
ReplyDeleteIt is easy to see that faith and medical placebo act in the same ways.
The neuroscientific evidence points to multiple mechanisms by which they have their effect- including social cognition, level of learning, patient expectation and experiences,as well as release of neurochemical mediators such as Dopamine and Opioids.
One of the best and simplest articles I read on this was a few years ago in a Time magazine, but many are available in journals of neuroscience www.jneurosci.org
Medical research relies on the use of placebo in their trials - but in day to day practice, there is the ethical issue where proven drugs are available, unless a situation is reached where one has run out of options for one reason or another.
A combination of placebo and effective medication could work well as has been found in patients recovering from major cardiac surgery. I cannot off-hand quote chapter and verse, but it has been documented that those patients who prayed during cardiac rehabilitation did better than those who did not. I shall have to look deeper into this in time. Enjoyed your article.cheers
Rohini, you have brought up some relevant points on this subject. What concerns medical practitioners, as you point out, is the ethical issue where proven drugs are available. Adding a placebo to please the patient sounds quite an 'OK' thing to do. I agree that a lot of reading on this subject is necessary. However much we read, our position as medical practitioners doesn't change. But it is good to know the place of placebo as we have to acknowledge the place of 'mind' in healing. Zita
DeleteP.S. The cardiologists in our batch would be able to expand on the above.
ReplyDelete2. The best effective placebo yet might be the doctor’s attitude towards the patient, the manner in which he/she is greeted and treated, the confidence and clarity with which the malady and the treatment are explained and the empathy excercised etc.
There is also ‘the healing touch’ talked about in SL as ‘ath waasiya’. I do sometimes, without thinking , touch patients to reassure and console, but in this day and age one needs to be cautious ! Zita , I see you have already touched on this. Thank you.
Thanks for your comments Rohini. This subject is indeed fascinating Before discussing the placebo effect itself, Zita alluded to a interesting aspect of how we arrive at conclusions. She said " But there are things in the art of healing which I do not understand. And this is because, I think, that our minds are powerful complex structures and anatomy, physiology and pathology cannot truly claim to know all that is going on". My amendment for that would be to add that ...anatomy etc cannot YET truly claim to know.... etc. I say that because I believe in the scientific method of solving mysteries through research. There is in my view, no need to postulate that there are mechanisms "beyond the understanding of Science" to explain phenomena. Over centuries, "mysterious occurrences" such as the Plague were found to be caused by microorganisms and not by the wrath of Supernatural beings. As Science observes, understands, forms a hypothesis,test it and accept or reject it, more and more "strange" occurrences are explained. Mental illness for example was "possession by the Devil".The placebo effect was at one time thought to be due to "faith", stronger the faith the better the effect and often, religious practices were invoked. People truly subscribing to Science would not disclaim some of the miracle cures merely because they are not able to explain them. The proper approach is to investigate them and firstly ensure that the facts are correct. For example, if a person with a "stroke" in a wheelchair stood up and walked unaided after a prayer session, the first duty is to establish whether the person in fact had a well documented and well investigated illness.
ReplyDeleteThe scientific approach to the placebo effect was precisely that. It was first established that the improvement was genuine. Then further analysis at first pointed to the possibility that a placebo works only if the patient believes it to be the real drug. The patient was affected psychologically into believing that he/she was on an effective drug. Then to their surprise they found that even if the patient knew that it was a blank pill, they could still improve if the drug was given with reinforcement that it would do you good and the patient subsequently had faith in it. What appears to be paramount is the mindset of the patient who by whatever means strongly believed and wanted the drug or procedure to work.
The point was then reached where actual demonstrable changes for example in the immune system, brain neurochemicals and even structural changes in the brain were shown to occur . There is no longer a mystery about the placebo effect apart from how exactly the strong belief in the patient leads to the observed changes. What matters is the strong and intense desire on the part of the patient for the treatment to work and if practices such as "Thovil", prayers, "sacrifices" induce that strong faith, the chances of success are increased.The personality of the Doctor plays a part in this as Zita commented. This is why we hear of so many magical "cures" in a wide range of religious and other non-traditional practices.
I have no doubt at all that in the years to come, Scientists will be able to provide a physical explanation and plot the pathways through which the placebo effect operates. Anatomy Physiology, Neurochemistry, are all part of how we our "minds" operate. We are still learning but we know a heck of a lot more than we knew before.
One investigator of the Placebo effect commented thus:-"This study raises the possibility that we could all use the placebo effect to convince ourselves that sucking on a sweet or downing a glass of water, for example, will banish a headache, clear up a skin condition or boost the effectiveness of any drugs that we take
Finally, we must refer to the "nocebo" effect which is the opposite where if you merely believe that you will get side effects, you will get them.
Mahendra, you have brought out some 'pearls' on this subject of placebos. The point you make about the part made by the mind in healing, is crucial to this argument. Yes, it is possible that in healing after effective drugs given for a condition is accentuated by the thought process in the patient's mind that this is it! So why can't it happen if the patient thinks 'this is it' in the use of placebo? The danger of course occurs when the condition is caused by a known virulent organism to which medical science has an effective treatment and one allows the use of placebo which delays the use of the effective medication. The 'nocebo' effect that you mention is very interesting. I wonder whether anyone has experience of this? Zita
DeleteZita
ReplyDeleteThank you for this wonderful post raising important and interesting issues. Remember the old adage "Faith can move mountains". With our finite minds we shouldn't disregard some of the faith healing that goes on as "rubbish". I have not been at the cutting edge of patient treatment having been in diagnostic imaging most of my life. It was the multidisciplinary clinical meetings that brought me closer to patient care. Nevertheless it is interesting to follow the discussion and contributions by yourself, Rohini and Mahen. The effect on the immune system and the neuro-chemicals seem a plausible pathway for its action. I remain willing to be educated more on this important topic.
Hey, Nihal, you have a lot to offer to this placebo argument particularly because you have been at the 'cutting edge' of diagnosis by imaging most of your working life! How about the instances where imaging revealed fractures, tumours, fluid entrapment, enlargement of vital organs and all the myriads of ways by which diagnostic imaging helps! How would placebos help here! So you see, placebos will have a limited effect in certain cases but by far the most effective are good diagnostic methods, good basic knowledge of disease processes and treatment aimed at the cause. But we do accept the limited place of placebos and the effect of the mind on the success of a treatment in certain cases. It would be nice to hear from anyone who has seen action of the mind alone despite the presence of a treatable serious cause and the patient not accepting direct treatment but it was healed by only a placebo. Zita
ReplyDeleteTo me the fascination with the placebo effect is to find out how it works. The first step as I said is to show that it does work and having established that, we need to provide a scientific explanation. I am an unashamed rationalist and is of the opinion that more and more mystical "miracles" are susceptible to rational explanations. We have come a long way in unraveling these mysteries but we still have some way to go. One thing that struck me is that the "placebo effect of prayers" work only if the person to whom it is addressed believes it will work and secondly, if the exercise is done without his/her knowledge, it doesn't work, as far as I can ascertain although I may be wrong in thinking so. The mind (whatever that is!) seem to have a powerful effect on our systems,not just psychological but physical systems but it cannot be influenced over the ether and in the case of prayer or ritual requires a sensory connection between the sender and the recipient. The sender has to be trusted implicitly and the recipient has to be aware that a trusted sender is sending these signals and have confidence that it will work, the higher the confidence, the greater the chance of success. These ingredients have been in place with widely varying belief systems; Muslims, Christians, Buddhists, Hindus all have records of success and the common ingredient is what I referred to, i,e., the conenction between sender and recipient.
ReplyDeleteWhat is fascinating to me is how this actually happens. How does a strong belief or faith cause these changes? Personally, I don't need to invoke any Supernatural causes, just an acknowledgement that with our current state of knowledge, we cannot fully explain it, just as long ago we didn't understand eclipses, the rising and setting of the sun, and numerous other phenomena which were explained on a reductionist basis as all caused by a Deity of some sort. Science for me has been the way we have understood phenomena in our Universe and will remain so. Science is humble in that it readily admits where we are ignorant and is always ready to change currently established views with the discovery of new evidence against them. Science never did and does not claim to know everything. And Science promotes questioning and a spirit of inquiry and challenges blind acceptance.
After this deviation for which I hope I will be forgiven, I can see the immense possibilities of harnessing the Placebo effect for our benefit once we gain a greater understanding of how it works.
I rest my case!
The other interesting aspect of the placebo effect is the changing relationship between the Phsyician and the patient. In the days when "cures" were limited the interaction between the two was of great importance. The empathy, ability to impart confidence for example mattered a lot. This became less important as for example in infections, the antibiotic was foremost and the physician's manner very much secondary. The Placebo effect contributes in some degree to the importance of psychological aspects as more and more diseases (mainly degenerative) for which there is no "cure" surface. It is good to see aspects of doctor-patient relationship being given more prominence in the medical curriculum. As Ambroise Paré (1510–1590) had expressed it, the physician's duty was to "cure occasionally, relieve often, console always" ("Guérir quelquefois, soulager souvent, consoler toujours").
ReplyDeleteHi everyone, I'm getting in late into the discussion. I think when the placebo effect works, it is because we don't always understand how our brains and minds work. (What is the 'mind' anyway? that could set off another great discussion!) And we should also question if the original diagnosis is accurate. In Zita's original story, the patient was though to have IBS. But was it really IBS? There are so many types of colitis and they look different under the microscope. (I have to add my pathological opinion, here!) Some are self limited and clear up in about 4 weeks. Rohini referred to neurochemical mediators. May I add stress hormones to the mix, causing physical symptoms and signs. One example that I think of is takotsubo cardiomyopathy (aka 'broken-heart syndrome') where a surge of adrenaline causes the apex of the left ventricle to dilate, clinically mimicking a heart attack. It is temporary. Rohini, do not be afraid to touch your patients. I think everyone should watch Abraham Verghese on Ted Talks where he talks about "A Doctor's touch." You can find it on YouTube. You'll learn some interesting medical history as well.
ReplyDeleteHi everybody A late entry to the discussion I firmly believe in the Healing Touch of a doctor who can comfort and show effective compassion as well as the positive effects of music and a pleasant view through a window in an I C U. in reducing the need for analgesics. Both topics were dealt with in two of my orations "Learning again to Care" delivered in 1996 and Stress the Oger in I C U delivered in 2006. I feel the basic message still holds true even after 2 decades. Suri
ReplyDeleteSuri, so nice to see you and hear your opinion on these important issues.
DeleteI would be very interested in reading the contents of your two orations if you’d be happy to share them. Do continue to be in touch and enrich the blog. Cheers
Hi Speedy Thanks for your comments on the subject .I was delighted to read your reference to the quote " to cure sometimes, relieve often and comfort always" a message I have tried to impress on my students both under and postgraduate. . for over 4 decades. However I don't agree that for prayers to be effective the person who is being prayed for must be aware of the prayers on his/her behalf though I do agree that even without a cure the knowledge that you are being supported by prayers has a beneficial effect . Suri
ReplyDeleteHi Suri, Thanks for your own observations. Regarding "However I don't agree that for prayers to be effective the person who is being prayed for must be aware of the prayers on his/her behalf", I would certainly expect a devout Christian like you who believes in God to say so, entirely justified from your perspective. The fascinating thing for me is that from a purely material point of view, how prayers can work could be explained in the way I put it but if prayers can work without the person who is being prayed for being aware, then no plausible material or physical explanation could be given as to how it works. However, the lack of an explanation does not rule out the possibility of one being found in the future as scientific knowledge is advancing all the time. By the same token, it would be wrong to conclude that if it can be proven beyond reasonable doubt that prayers have worked without the knowledge that the person being prayed for, the only explanation is a supernatural one. One cannot deny the possibility that there is a supernatural explanation but one cannot conclude that this is the ONLY explanation.
ReplyDeleteMahen, I believe that there is much in this world that we cannot explain or understand. Perhaps there will be scientific explanations for some of these mysteries in the future. The spiritual world is mysterious and I am personally OK with not knowing the answers to every question! I enjoy the search though!
ReplyDeleteHi Srianee. Mankind has made progressed only through questioning and inquiry. Imagine a world where diseases were thought to be the work of the Devil, psychiatric disorders were because people were "possessed" and the placebo effect was thought to be "magical" without a scientific explanation.A World where the Earth was the Centre of the Universe and the sun went around us, rising and setting. I am not saying that spirituality (however you define it) has no place. It has given comfort and solace to billions and will continue to do so but if we stop asking questions and stop trying to explain phenomena we observed, we will be so much the poorer. Can you give me just one instance where the illnesses we are subject to have been dramatically eliminated by spiritual practice? Which Doctor is better, a "Witch Doctor" or a properly trained Medical practitioner? One last and not the least -Science admits ignorance and Science is always willing to change on the face of new evidence. Science is honest and Science is dynamic!
ReplyDeleteHi Mahen, You may have misunderstand my last comment. I have not stopped asking questions, but I don't beat myself up if I don't always find the answer. I agree with everything you say in your comment, and yes, Science has found logical explanations for some of the phenomena that people believed to be supernatural in the past. I most emphatically agree that we need to continue asking questions, carry out investigations and try to find the answers to mysterious phenomena and illnesses. In answer to your question whether I can give you an example of an illness that has been "dramatically eliminated by spiritual practice?" my straightforward and simple answer is "No, I cannot!"
ReplyDeleteBut, I do believe that Science alone cannot explain all facets of the "human organism." I believe there is spiritual component of our being, that affects our physical condition. Perhaps we have simply not yet found the answers. I checked the Merriam-Webster Dictionary for definitions of 'Spirituality' and there are many. My own (mish-mash) definition of Spirituality is "Having a strong connection to one's religious beliefs and values, but yet a tolerance for the beliefs of others; as well as a connection to the universe, humanity and all living things." As for medical practitioners, I think the best ones are those who respect their patients' beliefs and values during their interaction with the patients. By the way, an interesting aside (which you may already know) is that Sir Arthur Conan Doyle was a believer in the supernatural. He declared himself a "Spiritualist" in 1916, believed in the afterlife, and participated in seances. He joined various organizations of similar thinkers/believers before he died at age 71. Interesting isn't it?
Srianee, I cannot find fault with anything you have stated. Of course human beings have limitations and I don't think anybody is in a position to deny the possibility that there is a spiritual component which Science cannot yet explain. All we can say is whether we are able to accept or reject such a belief. There is a well known logical argument that states that it is not necessary to provide proof to discredit a belief.The classic statement is that I cannot prove beyond any reasonable doubt that there is a hamburger circling Venus but most people will accept that proof is unnecessary in that situation because it is so manifestly ridiculous. What is ideally required is proof to support a belief and such proofs will always be open to debate. I fully agree with you about tolerance for the beliefs of others. But I would make it conditional. They should not impinge on the rights and liberties of others. I can never for example, condone female genital mutilation and display "tolerance" for people who hold that belief. At the same time, it would be arrogant of me to dismiss strongly held religious beliefs on such profound matters as the origin of the Universe and whether there is a Creator or not. I feel I am perfectly entitled to say I don't agree with some views but I am open to changing my mind if acceptable evidence is provided. The question of "mind", "consciousness","soul" are very complex and opinions have and will continue to differ but my personal belief is that Science is the only available method by which we can gain insight to these metaphysical questions. Thanks for this interesting exchange of ideas!
ReplyDeleteYes, it is very interesting to exchange ideas this way, and we could go on and on! When you mentioned FMG (Female Genital Mutilation) I decided to check it out. In the information published by the WHO, which along with other organizations are trying their best to abolish this practice, it is stated that "No religious scripts prescribe the practice, but practitioners often believe the practice has religious support." It is practiced in Africa, Middle East and Asia, and migrants from those countries practice it in other places too. It is a socio-cultural custom "aiming to ensure pre- marital virginity and marital fidelity." In my opinion, these customs were designed to keep women subservient to men. People tend to continue these customs because it is a "cultural tradition." They want to be accepted by the rest of the community. I will continue my thoughts in a private email to you!
ReplyDeleteIt's awesome to visit this site and reading the views of all friends about this piece of writing. By: The Academic Papers UK
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