Heroes Not Zombies

Today’s BMJ carries three articles about the placebo effect.

Firstly, in an Editorial by Spiegel and Harrington, they discuss a paper published by Ted Kaptchuk and colleagues where patients with Irritable Bowel Syndrome were randomised into three groups – those who were simply observed, those who were given sham acupuncture, and those who were given sham acupuncture with an enhanced doctor-patient relationship. 3% of the first group got good improvements, 20% of the procedure alone group an 37% of the “augmented intervention group”. As the authors point out,

the doctor-patient relationship in the sham acupuncture only group sounds like a caricature of procedure based medicine practised under strict time limitations:the practitioners explained that this was “a scientific study” and they had been instructed not to talk about it with patients.

and

Clearly the group with the greatest relief of symptoms was the one that received not only sham acupuncture but 45 minutes of quality contact with a clinician. This contact involved questions about the patient’s symptoms and beliefs about them, a “warm, friendly manner,” empathy, and communication of confidence and positive expectations

This is a powerful argument for practising medicine with care and attention. As the authors say –

Perhaps the ratcheting down of the time that doctors spend with patients and our modern overemphasis on drugs and procedures is “penny wise and pound foolish.” Patients might respond better to real as well as placebo interventions if they were associated with a good doctor-patient relationship. Although the increased time and concern may enhance the effects of the placebo, it also changes the context of associations with the treatment—the doctor may enhance the effect of the sham needle, but the needle also becomes a reminder of the enriched relationship.

Here’s their “take home message”

We treat patients in a social and psychophysiological context that can either improve or, alas, worsen outcome. The meanings and expectations created by the interactions of doctors and patients matter physically, not just subjectively.

Human beings cannot be reduced to mere physical components. We are thinking, feeling, meaning-seeking creatures. Health care should be founded on that understanding.

Then, in a reflective article, Pittrof and Rubenstein, consider the ethics of using placebo. They make the point that randomised clinical trials of drugs vs placebo show real effects in the placebo groups –

Published evidence only applies to patients if they have similar characteristics to patients in the study population. Even if this is the case, their response can rarely be accurately predicted. This is one of the problems with evidence based medicine: often its application to the individual is under less than ideal conditions. However, where the study shows that placebo results in a response, when compared with baseline, then that is precisely what the study shows. It is possible to state with confidence that, were the conditions of treatment to be replicated as in the study, the patient would have a statistical likelihood of responding to the placebo, just as we can say that the patient is statistically likely to respond to the active intervention. There is thus a response whose cause is debatable but the response is genuine. On strictly scientific grounds no deception would be involved in referring to this response as an evidence base.

They also point out that full disclosure of information to patients should include a discussion of potential harms –

For example, when advising a patient about treatment for mild to moderate depression clinicians might explain that use of SSRIs may be associated with a higher risk of suicide attempts and that about 80% of the benefits of SSRIs might be attributable to a placebo effect.

and go on to say

we have seen many risk averse patients who would happily accept reduced benefits for much reduced risks.

In other words, if you were told that a treatment had a chance of helping but hardly any chance of harming you, would you choose it first over a treatment that had a greater chance of doing both – helping and harming?