[Stitcher]

NOVEMBER 14, 2008, 5:19 A.M. ET

It's All in Your Head

By SALLY SATEL
http://online.wsj.com/article/SB122662161651026511.html

About one in two American doctors say they prescribe placebos to their patients, and more than two-thirds believe it permissible to do so, according to a new study from the National Institutes of Health. Surveys of physicians in other countries, including Israel, Denmark and the U.K., have found similar results. These revelations, published last month in the prestigious BMJ, formerly known as the British Medical Journal, seem disquieting, even unethical. After all, when doctors prescribe a medication, we trust them to dispense the real thing.
[David Gothard] David Gothard

In their coverage of the new study, the media portrayed placebo use as commonplace -- "For Many Doctors, Placebos Are an Answer" said the Washington Post -- and even a guilty indulgence: "Many MDs Admit, Privately, Giving Patients Placebos," as the Star-Ledger put it. It would be no surprise if most people concluded that arrogant, impatient doctors were cheating them or pushing their concerns aside. In this light, the placebo story was simply further evidence that the cherished doctor-patient relationship is becoming a relic of the past.

But before we rush to judgment about placebos and the physicians who use them, let us examine what doctors actually mean when they say they occasionally use placebos and why so many of them find these pseudomedications valuable.

Typically, we think of placebo as a sugar pill or other substance that is not intended to have a direct pharmacological impact on disease. In the BMJ study, however, the researchers defined placebo as "a treatment whose benefits derive from positive patient expectations and not from the physiological mechanism of the treatment itself." In fact, only a handful of the almost 700 physicians who completed the survey claimed to use inert substances such as sugar pills or saline. The vast majority offered innocuous over-the-counter products, sometimes called "impure" placebos, such as vitamins or Tylenol, though 13% used antibiotics and another 13% used sedatives. By offering an actual pharmaceutical, doctors stand on firmer ground in telling patients that what they are prescribing is a medication whereas describing a sugar pill as medication is much harder, perhaps impossible, for most to justify as a matter of conscience.

Notably, too, the researchers targeted internists and rheumatologists. Such doctors commonly treat debilitated patients with chronic illnesses, such as fibromyalgia, that are notoriously refractory to care -- rather than, say, infectious-disease specialists or surgeons whose patients typically respond to conventional therapy and for whom withholding active treatment is clearly dangerous.

The doctors who used placebo within the last year -- about 55% -- did so between one and three times per month. More than two-thirds of those described the treatment to patients as "a medicine not typically used for your condition but [that] might benefit you," but only 9% described it as "a medicine with no known effects for your condition."

According to Jon C. Tilburt, the lead author on the BMJ study, placebo prescribing is a last resort. "With untreatable conditions or chronic conditions when we have run out of treatments," he said, "doctors are willing to try virtually anything -- if they are convinced it is safe -- to make the patient feel better, even if the mechanism is a psychological mechanism."

The "psychological mechanism" Dr. Tilburt mentions goes by the more familiar name of placebo effect. Psychologists call it the subject-expectancy effect, referring to the observation that an individual is more likely to feel better if he believes an intervention will be therapeutic. This belief can be a very powerful force. In research studies, generally 30% of participants receiving a sugar pill derive actual, if short-lived, relief from post-operative pain, wound pain, headache, mild depression, motion sickness and anxiety.

Clearly the placebo pleases -- indeed the word itself means "I shall please" in Latin. The question is how? Scientists posit that the very expectation of effect unleashes a cascade of biochemical events in the brain. Consider pain relief. Brain-imaging reveals placebo and opiate-drugs activate the same regions of the brain. This suggests the existence of a common neurological pathway underlying the placebo-induced pain relief and narcotic-induced analgesia. Conversely, placebo-induced pain relief can be abolished by administering a drug known to reverse narcotic analgesia.

The downside of deceptive placebo administration is obvious. Foremost, it is misleading; the patient risks feeling duped. Losing trust in one's physician or the profession itself would be disastrous. Second, placebo use reinforces a quick-fix approach to minor afflictions and discomforts. This is particularly risky when it comes to children who would probably be better off learning how to tolerate low levels of discomfort or manage them nonmedicinally. And, of course, giving ineffective antibiotics for a cold virus encourages the development of antibiotic-resistant strains, a serious public-health problem.

The American Medical Association says that it is unethical for a physician to use a placebo in the guise of therapy unless the patient "agrees to its use." If the patient knowledgeably consents, however, the association does not require doctors to identify which treatments are placebos and which are active (that is, which ones will have a specific pharmacological effect upon the condition being treated). This raises a key question: If a patient has been warned that he might receive a sham drug, will it still exert its placebo effect?

In an insightful paper called "A Limited Defense of Clinical Placebo Deception," in the Yale Law and Policy Review in 2007, law professor Adam Kolber argues that, in some cases, placebo deception may be justified. With its prohibition against the deceptive use of placebos, the medical association, he says, "makes assumptions about how we ought to trade off such incommensurables as honesty and pain relief, truth and comfort." Yet, as Mr. Kolber duly notes, different patients and physicians will make these trade-offs differently. He hopes research will better illuminate the appropriate uses of placebo in clinical practice.

The power of suggestion has long played an essential role in healing. It can be elicited with placebo -- and also by the rituals of medicine: the white coat, prescription pad and so on. In his essay "Of the Power of Imagination," the Renaissance philosopher Michel de Montaigne wrote that "there have been men with whom the mere sight of a medicine did its work." And a century ago the great American psychologist William James argued that there was much to be said for what were referred to at the time as "mind cures." "It makes no difference whether you consider the patients be deluded victims of their imaginations or not. That they seemed to themselves to have been cured by the experiments tried was enough to make them converts to the system." He even suggests that it would be "pedantic and over-scrupulous" to insist that such patients receive a different kind of care instead.

Physicians who use placebos carefully recognize that the practical value of faith must neither be underestimated nor dismissed. If patients suffer less because a conscientious physician administers an effective, if inauthentic, "medication" out of true caring, maybe they won't think that is so bad. It is worth finding out.

Dr. Satel is a psychiatrist and a resident scholar at the American Enterprise Institute. She is editor of the forthcoming book "When Altruism Isn't Enough -- The Case for Compensating Kidney Donors" (AEI Press).

[lou_lou]

In this week's issue of the journal Science, there's stunning testimony from University of British Columbia researchers about how the mind can heal the body.

Their study suggests that the placebo effect in Parkinson's disease produces the same neurological outcome as active drugs used to treat Parkinson's: an increase in dopamine release by neurons impaired by the disease.

The placebo effect occurs when individuals take an inactive substance, rather than an active drug, and experience beneficial effects only because they believe they're receiving beneficial treatment.

http://articles.mercola.com/sites/ar...ternative.aspx