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A placebo is a substance or procedure a patient accepts as medicine or therapy, but which has no verifiable therapeutic activity. The placebo effect (or placebo response) is a therapeutic effect following administration of a placebo, or more generally: is the psychosocial effect of medical treatment. Effective on 30% of humans and only for some conditions, it is also known as the non-specific effect or subject-expectancy effect. A 2008 study showed the placebo response may be genetically determined. In a placebo controlled trial some participants take a placebo as a control while others take the therapy being investigated. Most well-designed studies include a placebo where practical and ethical.
Placebos
Etymology
The word placebo is Latin for I will please. It is in Latin text in the Bible (Psalm 114:1–9, Vulgate version), and was known via the Office of the Dead church service. From that, a singer of placebo became associated with someone who falsely claimed a connection to the deceased to get a share of the funeral meal, and hence a flatterer.
The word obecalp , "placebo" spelled backwards was coined by an Australian doctor in 1998 when he recognised the need for a freely available placebo. The word is sometimes used to make the use or prescription of fake medicine less obvious to the patient.
Inertness
When a placebo is administered to mimic a previously administered drug, it may also incur the same side effects as the authentic drug (see Pavlov). Most of these effects are thought to be a psychological triggering of a physical response. Not all forms of placebo administration are equally effective, and some disease states are entirely resistant to the placebo effect. A placebo that involves ingestion, injection, or incision is often more powerful than a non-invasive technique. Placebos administered by authority figures such as shamans, general practitioners and other trusted figures may also be more powerful than when the psychological or spiritual authority figure is absent.
Doctor-patient relationship
A study of Danish general practitioners found that 48% had prescribed a placebo at least 10 times in the past year. The most frequently prescribed placebos were antibiotics for viral infections, and vitamins for fatigue. Specialists and hospital-based physicians reported much lower rates of placebo use. (Hróbjartsson & Norup 2003) A 2004 study in the British Medical Journal of physicians in Israel found that 60% used placebos in their medical practice, most commonly to "fend off" requests for unjustified medications or to calm a patient. An accompanying editorial suggested the study by Hróbjartsson and Gøtzsche (see below under Objective and subjective effects) was flawed and argued that their results show that placebos can't cure everything, but don't prove that the placebo effect cures nothing. The editorial concluded, "We cannot afford to dispense with any treatment that works, even if we are not certain how it does." (Spiegel 2004)
The editorial prompted responses on both sides of the issue.
- Critics of the practice responded that it is unethical to prescribe treatments that don't work, and that telling a patient that a placebo is a real medication is deceptive and harms the doctor-patient relationship in the long run. Critics also argued that using placebos can delay the proper diagnosis and treatment of serious medical conditions.
- Defenders of the use of placebos suggested that placebos do not work in clinical trials because the subjects know they might be getting a placebo, but do work in medical practice where the patient believes he or she is getting an active drug. Other writers pointed to the empirical data showing that placebos can have measurable biological effects, especially in pain relief (see above), or argued that the use of a placebo to "please the patient" fosters real healing as part of a caring doctor-patient relationship. (Barfod 2005, Di Blasi 2005)
BMJ posted a series of responses to Spiegel's editorial online in their rapid response section. Selected responses were published in later issues of the Journal .
In addition, there are the impracticalities of placebos:
- Roughly only 30% of the population seems susceptible to placebo effects, and it is not possible to determine ahead of time whether a placebo will work or not.
- All placebo effects eventually wear off, thus making the placebo effect impractical for long term or chronic medical matters.
- Patients rightfully want immediate relief or improvement from their illness or symptoms. A non-placebo can often provide that, while a placebo might not.
- Legitimate doctors and pharmacists could open themselves up to charges of fraud since sugar pills would cost pennies or cents for a bottle, but the price for a "real" medication would have to be charged to avoid making the patient suspicious.
- Unscrupulous medical practitioners could swindle patients with fake surgeries and sugar pills, then later claim that they only meant to help their patients by using "placebos".
About 25% of physicians in both the Danish and Israeli studies used placebos as a diagnostic tool to determine if a patient's symptoms were real, or if the patient was malingering. Both the critics and defenders of the medical use of placebos agreed that this was unethical. The British Medical Journal editorial said, "That a patient gets pain relief from a placebo does not imply that the pain is not real or organic in origin...the use of the placebo for 'diagnosis' of whether or not pain is real is misguided."
The placebo administration may prove to be a useful treatment in some specific cases where recommended drugs can not be used. For example, burn patients who are experiencing respiratory problems cannot often be prescribed opioid (morphine) or opioid derivatives (pethidine), as these can cause further respiratory depression. In such cases placebo injections (normal saline, etc.) are of use in providing real pain relief to burn patients if those not in delirium are told they are being given a powerful dose of painkiller.
There is general agreement that placebo control groups are an important tool for controlling several types of possible bias, including the placebo effect, in double blind clinical trials.
The placebo effect is an active area of research and discussion and it is possible that a clear consensus regarding the use of placebos in medical practice will emerge in the future.
Use as morale-boosters
Hooper’s (1811) Quincy’s Lexicon-Medicum defines placebo as " an epithet given to any medicine adapted more to please than benefit the patient ".
In the practice of medicine it had been long understood that, 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 ").
According to Jewson, eighteenth century English medicine was gradually moving away from the patient having a considerable interaction with the physician—and, through this consultative relationship, having an equal influence on the construction of the physician’s therapeutic approach—and it was gradually moving towards that of the patient being the recipient of a far more standard form of intervention that was determined by the prevailing opinions of the medical profession of the day. (Jewson 1974; Jewson 1976)
Jewson characterizes this as parallel to the changes that were taking place in the manner in which medical knowledge was being produced; namely, a transition all the way from "bedside medicine", through "hospital medicine", to "laboratory medicine" (Jewson 1976, p.227)(for more on the effect of the development of various types of medical technology see Medical sign#Increased reliance on signs).
From this point of view, the last vestiges of the "consoling" approach to treatment are to be found in the administration – often without any sort of adequate history being taken or any sort of appropriate physical examination being made (Carter 1953, p.823) – of the morale-boosting and pleasing remedies, such as the "sugar pill", electuary or pharmaceutical syrup; all of which had no known pharmacodynamic action.
Those doctors who provided their patients with these sorts of morale-boosting therapies (which, whilst having no pharmacologically active ingredients, provided reassurance and comfort) did so either to reassure their patients whilst the Vis medicatrix naturae (i.e., " the healing power of nature ") performed its normalizing task of restoring them to health, or to gratify their patients’ need for an active treatment.
Some statements about placebos in scientific articles are:
- Cooper (1823, p.259): " the compound decoction of the sarsaparilla … irritable ulcer, … some think it placebo; others have a very high opinion of its efficacy … after the use of mercury, it diminishes the irritability of the constitution, and soon soothes the system into peace ".
- Shapiro (1968, p.656): " positioning … Introduction of the word placebo to describe a class of treatments not previously specified was an important development in the history of methodology and medicine. "
- Handfield-Jones (1953): " some patients are so unintelligent, neurotic, or inadequate as to be incurable, and life is made easier for them