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You’ve Been Tricked by Sham Medicine: The Deception Behind Placebos

By definition, a placebo is “a harmless pill, medicine, or procedure prescribed more for the psychological benefit to the patient than for any psychological effect.” While a placebo is used to create a mental state that does in fact promote well-being and healing, it can be argued whether it is “harmless.” Remedies for physical illness benefit from a positive mental outlook, at the same time a pessimistic outlook can make people feel increasingly sick. Even terminally ill patients can alleviate their suffering if they commit to a belief in their own cure. While no reputable physician would lay hands on a patient and advise him or her to assign a cure to a higher power, providing patients with a placebo has much the same effect in patients whose commitment to the curative power of the therapy is strong enough. The placebo effect effectively deceives patients into believing that they are receiving medication to heal them while leaving the actual work to their psychological systems. In addition to this, the inconsistency of studies regarding what’s called the placebo effect and the ethical issues surrounding the use of “illusionary medicine” by medical professionals create a moral ambiguity surrounding placebos and their uses.

Psychological factors play a key role in a placebo treatment. An individual’s brain decides whether treatments effectively work or not. Even if the placebo effect is deceptive, it still represents an alternative worth trying for patients who don’t respond to the application of more conventional medications and treatments. Placebos work differently between diseases, disorders and syndromes. While diseases and disorders can almost be used interchangeably, they are slightly different. Disease is the physical difficulty the body is facing; a disorder is the reaction the body is having to the disease. A syndrome is a mix of signs that suggest the possible disease associated with an illness. Placebos work most effectively in disorders as they can be mental rather than diseases where the physical body is in jeopardy. A placebo should cause “clinical improvement” according to the Journal of Neuroscience. Typically, this treatment is used for cases that involve the psychological part of the body. People that benefit more from it usually have fundamental trust in the medicine. They expect and believe that whatever is inside the medication, will alleviate their pain. Only when patients are unaware that their medication is a placebo and believe they are taking “real” medicine the placebo effect may have positive outcomes. However, this isn’t the case when patients know the medicine is a placebo. Harvard Medical School Professor and Director of the Harvard-wide Program in Placebo Studies, Dr. Ted J. Kaptchuk did a study on people with irritable bowel syndrome (IBS). This is a condition that causes pain in the abdominal area and diarrhea or constipation. While it is called a syndrome, it is based on a set of disorders in the patient’s body. Half of the study received an “open-label” placebo, while the other received no treatment at all. The results showed that there was a vast improvement with the placebo group’s symptoms even though they knew they were taking a placebo. This group also felt that their symptoms were lessened in severity and that relief was much more prominent, which in turn improved their quality of life. This questions the underlying reason for the deception of placebos. Is it better for the patient to be given an “open-label” placebo or to not take one at all? Is there a more beneficial effect on a patient who receives a placebo deceptively? According to the results of this study particularly, an “open-label” placebo gives patients a better benefit to their symptoms than ones who didn’t take anything at all. Which means they still work even without deception. It should, however, be noted that this was a study for just IBS, which means not all open-label placebo treatments will work the same in other disorders or diseases.

In the next study they analyzed what would occur when a physician gives a placebo to a person with Parkinson’s disease? A disease that involves the central nervous system, motor functions and dopamine production. For this study, patients were given a placebo, but were told that it was an antiparkinsonian drug that would help with their movements. They were injected with a saline solution that had no confirmed effect. Neuronal activity in the subthalamic nucleus was recorded before and after the procedure. The people who felt an effect showed actual bursting activity of neurons in the body, while the non-responsive group, didn’t show anything. This means that the cases in which the placebos worked the brain showed an increase of activity. If placebos are not real medicine and yet patients’ bodies are responding to the medication and they are experiencing psychological changes, would the same psychological treatment without the placebo intermediary have the same healing effect?  In other words, if a placebo is only supposed to be therapeutic, is it possible that a person’s mental abilities are strong enough to cure themselves? Placebos, may in fact, just be dependent on each patient’s mental state.

The Journal of Neuroscience did studies on different mechanisms of the placebo effect treatment. “The study of the placebo effect, at its core, is the study of how the context of beliefs and values shape brain processes related to perception and emotion and, ultimately, mental and physical health.” Fabrizio Benedetti says that if we want to see how a placebo affects a person in a psycho-social context, the placebo must be treated as a real treatment. Medical professionals must prescribe this treatment to trusting patients. Since there is a fundamental trust between medical professionals and patients the patients will most likely believe the treatment the doctor has prescribed. The response that the patient has is dependent on each individual person. Since a placebo isn’t supposed to have any actual psychological outcome, it depends on the mindset of the patient. The patient who has the desire to feel better will have a longer lasting benefit than the one who feels indifferent when both take a placebo. “It has been defined as the ‘positive physiological or psychological changes associated with the use of inert medications, sham procedures, or therapeutic symbols within a healthcare encounter'” according to Franklin G. Miller. There are many mechanisms on how to go about a placebo treatment. The most positive one in patients is the one referred to as “response expectancies.” Brain imaging techniques are being used to reveal the neurophysiological part of these expectations and the different mechanisms underlying placebo effects in many ways that depend on each individual person. A National Institutes of Health requested applications that stated, “understanding how to enhance the therapeutic benefits of placebo effect in clinical practice has the potential to significantly improve healthcare.” Open-mindedness to alternative medical therapies is the distinguishing characteristic shared by patients who report successful outcomes of placebo treatment. According to the Journal of Neuroscience, something as simple as having an expectancy can impact the neurobiological effects of a placebo. “The study of the placebo effect reflects a current neuroscientific thought that has as its central tenet the idea that ‘subjective’ constructs such as expectation and value have identifiable psychological bases, and that these bases are powerful modulators of basic perceptual, motor, and internal homeostatic processes.” This means that a placebo is just the factor that give the patients confidence in their ability to be healthy again.

In a study, conducted by Brian J. Anderson, Gerald A. Woollard, and Nicholas H. Holford, they recorded effects of Acetaminophen analgesia and placebo in children undergoing outpatient tonsillectomy. Acetaminophen is a brand of analgesic used to relieve pain. These children were randomly selected from a group of 9±3.0-year-olds with a weight of 37.9±16.6 kg. They were to respond with a pain score after taking either the drug or placebo after a certain period of time of 4-8 hours. The results showed that even in high dosage, the acetaminophen didn’t have much of an effect than a lower dosage of the same drug, and that it came with side effects such as nausea and vomiting. The placebo had a higher pain reduction than the acetaminophen. Even when combined, the pain reduction was less than the placebo effect by itself. In this study, placebos are counterproductive to the scientific basis of medicine. It even questions the ability of medicine to heal patients when faced against belief based medicine.

Due to the physical and psychological differences, it is more reasonable to believe that minor health conditions are the only treatable cases of placebos; symptoms that can be cured through off-the-counter drugs. They may include pain or depression or other slight side effects of a disorder, but not the actual disease. Placebo effects are outcomes that positively affect the patient even when it is known they are taking a placebo in the form of an inert substance. Providers who are part of a journal company for research in dermatology and venereology investigated the effect of the simplicity of someone’s voice to get rid of itch. 92 randomized volunteers were split up to be put to the test on whether open-label suggestions had a more significant change than a control group that received no suggestions. The results barely showed a difference between the two, but the placebo group had a slightly greater reduction in itch. This revealed that verbal treatments and explanations of the effect of placebos may play a key role in clinical methods. In a controlled trial of an open-label placebo, 46 randomized patients with allergic symptoms received placebos without deception or no pill at all. In the placebo group, positive recommendations about the placebo effect were given along with the treatment. A two week long trial showed that the open-label placebo group’s allergic symptoms had improved. According to the patients, the recommendation had no effects on their improvement. But it did help the overall well-being of the person and the “mental or emotional quality of life.”

In a study involving placebo effects and acupuncture, 12 people were interviewed at the start, middle, and end of a trial for Irritable Bowel Syndrome (IBS). Each person was told to give their thoughts on placebos. The four conceptualizations made were ‘placebos are necessary for research; placebo effects are fake; placebo acupuncture is not real acupuncture; placebos have real effects mediated by psychological mechanisms.” By the end of the trial, the results of the study were nearly half and half. Some believed had “positive conceptualizations” of placebos and others believed that people who had those conceptualizations were “gullible.” According to Franklin G. Miller, “the use of deception is considered necessary to understanding the placebo effect…” It is required to trick patients into thinking their health will improve. This creates an ethical concern for medical professionals. While some argue that placebos don’t require the use of malignant deception. The “major driving force” as Miller recalls is “response expectancy.” A common aspect of research focuses on deception. Some may say it is necessary to deceive patients by manipulating their expectations. The therapeutic outcomes reveal positive results after modifying patients’ assumptions. Both scientific methods and ethical standards are considered when using deception. When there is a balance between the two, the placebo effect does its job. Is “consideration” enough when it involves a patient’s health?

Back in its earliest uses, placebos led to “the evolution of the physician from witch doctor and priest-physician” according the American Journal of Psychotherapy. Galen estimated that 60% of patients had symptoms that were emotionally based, rather than physical. The medical treatments were not trustworthy, in addition they were rarely scientifically proven to work. Patients would ingest anything given to them. Their only concern was to get better, as a result, patients gave into “therapeutic practices” such as puking, leeching, shocking to name a few. Some are still used today like heating in the sauna, freezing in an ice bath or cupping to relax muscles. As bizarre as they sound today, patients still believed that there were lasting effects. Dr. Arthur K. Shapiro, M.D. stated “medicine was closely related to the finest scientific, religious, cultural, and ethical traditions in most periods of history…” This still seems unreasonable how traditions could have an impact on their health but once again it was the psychological reaction of belief. It has been proven by history however, most of these drugs and procedures were helpful only to particular patients. If not for the temporary aid these practices provided, physicians would not be giving such prescriptions today. The only reason for patients to have believe in successful results was the fact that psychological factors forced them to. Depending on the diagnosis at hand, the effect may sometimes lead to failure. Not every disease or disorder may be cured by psychological change. When analyzing the origin of placebos, it further questions the ethics surrounding the prescription of placebos.

Belief is different for everyone and each person has a belief that they feel strongly about. We can apply this to placebos. Whether one believes placebos work or not doesn’t matter. What matters is if the individual feels that it gives effective results. That can only remain true if the individual is susceptible to the idea that it will work. The worst thing for placebo-believers to hear is that placebos are a myth. Even if they do work, there is no real consistent scientific results. The only way for this scam medication to do its intended job is for it to be unknown to the patient. If a sick individual really wants to be healthy, they would do everything they can to get what they want. We can apply this to the placebo effect. Patients most of the time want to feel better, free of unnecessary stress and setbacks caused by the disorder they have. The solution to their ills is all about having the right mind-set. Having an optimistic personality would help as well. Only the patient can decide whether they feel better or not. Without the right attitude, it is very unlikely the patient will discover how to end their suffering. Since placebos are based solely on the psychological reaction based on belief, should doctors be involved in the belief-based system.

As said by Florida Law Review, placebos should have no effect on a patient’s health. The trust in placebos that physicians have nowadays are increasing at a rapid rate. If it’s cheaper and more efficient to use, then why not use them? The use of deception makes the therapeutic placebo seem like a real treatment. Some physicians believe placebos work and make their patients feel better, but they were not so sure how they worked. It makes no logical sense for medical professionals to participate in the prescription of a treatment which they don’t understand. In addition to this, the relationship between the physician and patient is affected by whether a placebo works on the patient or not. Proof of a powerful placebo will cause the medical world to question the practice of medicine. However, there is an inconsistency in determining if placebos do in fact work. If somehow proven that the placebo effect works, physicians may have to reconsider their methods of prescribing them. Not only does this affect the relationship between physician and patient, but also the legal team is involved now too. Lawyers are going to have to reexamine the degree of deception, these doctors will be allowed to use legally. With the proper consent of the patient, physicians may prescribe whatever placebo they think is needed. However, by definition, having actual consent would prove to be detrimental to the effect of the placebos.

The goal of the placebo effect is to be positive, but of course there is going to the negative aspect of it. It’s up to pharmaceutical companies and even the physician to emphasize the side effects, positive or negative, of the drug given to the patient. Without the ultimate use of deception, none of these scenarios would work anyways. Placebos are used mainly to heal a patient that has minor symptoms. They aren’t effective with diseases. Placebos can’t cure cancer or diabetes. They can, at most, help ease pain, but they will not cure these serious conditions. Due to the uncertain nature of placebos, the lack of scientific data, the questionable origin, and the level of deception related to placebos I believe it is unethical to allow physicians to negligently assign the cure of their patients to the placebo effect. By prescribing placebos medical professionals are in effect violating their Hippocratic oath to patients. In careers like medicine, or law, where professionals have an expertise in their fields which the common individual or common knowledge cannot fathom, there is a duty of transparency which is nonexistent in the practice of placebos. Only in cases where placebos are the only alternative available should they be used on patients.

References

Anderson, B. J., Woollard, G. A., & Holford, N. H. (2001, October). “Acetaminophen analgesia in children: Placebo effect and pain resolution after tonsillectomy.”Retrieved from https://link.springer.com/article/10.1007/s002280100367

Benedetti, F., Mayberg, H. S., & Christian S. Stohler, J. Z. (2005, November 09). “Neurobiological Mechanisms of the Placebo Effect.” Retrieved from http://www.jneurosci.org/content/25/45/10390.short

Bishop, F. L., Jacobson, E. E., Shaw, J. R., & Kaptchuk, T. J. (2012, January 18). “Scientific tools, fake treatments, or triggers for psychological healing: How clinical trial participants conceptualise placebos.” Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0277953612000160

Boozang, K. M. (2002). “The therapeutic placebo: The case for patient deception.” Florida Law Review, 54(4), 687-746. Retrieved from https://heinonline-org.ezproxy.rowan.edu/HOL/Page?collection=journals&handle=hein.journals/uflr54&id=716&men_tab=srchresults&t=1556592990

Kaptchuk, T. J., Friedlander, E., Kelley, J. M., Sanchez, M. N., Kokkotou, E., Singer, J. P., Lembo, A. J. (2010, December 22). “Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome.” Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0015591#references

Marshall, M. (2016, June 23). “A placebo can work even when you know it’s a placebo.” (H. LeWine M.D., Ed.). Retrieved from https://www.health.harvard.edu/blog/placebo-can-work-even-know-placebo-201607079926

Meeuwis, S. H., Van Middendorp, H., VeldHuijzen, D. S., Van Laarhoven, A. I. M., De houwer, J., Lavrijsen, A. P. M., & Evers, A. W. M. (2018). “Placebo Effects of Open-label Verbal Suggestions on Itch.” Acta Dermato-Venereologica, 98(2), 268–274. Retrieved from https://doi-org.ezproxy.rowan.edu/10.2340/00015555-2823

Miller, F. G., Wendler, D., & Swartzman, L. C. (2005). “Deception in Research on the Placebo Effect.” PLoS Medicine, 2(9), 853–859. Retrieved from https://doi-org.ezproxy.rowan.edu/10.1371/journal.pmed.0020262

Schaefer, M., Sahin, T., & Berstecher, B. (2018). “Why do open-label placebos work? A randomized controlled trial of an open-label placebo induction with and without extended information about the placebo effect in allergic rhinitis.” PLoS ONE, 13(3), 1–14. Retrieved from https://doi-org.ezproxy.rowan.edu/10.1371/journal.pone.0192758

Shapiro, A. K., M.D. (2018, April 30). “Factors Contributing to the Placebo Effect.” Retrieved from https://psychotherapy.psychiatryonline.org/doi/abs/10.1176/appi.psychotherapy.1964.18.s1.73.73

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