People are self-healing.
As a living being people have a natural ability to change, grow, adapt and the capacity to self-heal. All living creatures have this ability though and some are more capable of this than others. For instance some animals have the capacity to regenerate limbs and even within people we find there is great variation in the capacity to heal different tissues within the body. The liver has significant capacity to regenerate while the brain has almost none. We also find that this ability to self-heal can be affected by many factors. It can be influenced by diet, exercise, genetic makeup, environment and even our mental attitude.
The variation in different peoples ability to heal is a significant factor in the development of the concept of placebo in medicine. Placebo is from Latin meaning "I shall please" in its original use it was a term of religious origin. By the 14th century it had moved beyond its religious context and was used to refer to a flatterer or sycophant -- a meaning that probably reflected disdain for professional mourners of the time. Placebo's first usage in common medical terminology appears to have occurred in the latter half of the 18th century. It maintained its pejorative connotation and was used to disparage treatments that were understood to derive not from sound medical principles but were rather dispensed in order to please the patient and thereby curry both favour and income. In modern times placebo is understood to have no pharmacologic activity. It does however, have an effect.
The placebo effect.
During the late 19th and early 20th century the medical profession was striving to become more objective and scientific. Their aim was to develop methods to "objectively" determine the "truth" about therapeutic intervention. By this time it had become apparent that the attitude of the patient and of the practitioner might have an influence on the results of any treatment under trial. Research then determined that a treatment made with an inactive substance such as sugar, distilled water or saline solution would often prove to be effective. This process, where a person's illness would improve with only the expectation of an improvement is called the placebo effect. By the mid-20th-century it had become common to study the effects of medication by comparing it to a placebo. In these studies patients taking the placebo would often improve but it was believed those taking a truly effective medication would show a significant improvement beyond that of the placebo. The commonly referred to blind trial is when the patient involved in the study does not know if they are receiving a drug or placebo. Double blind i when patient and therapist do not know.
There is currently much debate as to whether it is ethical to use a placebo in a medical trial. It is generally preferred in modern research to test the drug against a known benchmark or accepted treatment instead of against the placebo. This may however have its own problems. There have been studies that indicate that people can experience the adverse effects of a drug just because they have been told about them. Other studies show people get less effect from pain medication when administered secretly compared to openly. These problems and others can change considerations and assumptions in study design but the main issue with placebo is that it is not ethical to knowingly leave a patient untreated for a medical condition when a treatment is available.
Alternative therapies and placebo.
In today's society it is not uncommon to describe any benefit obtained by alternative therapies as simply the result of the placebo effect. When people state this they are usually referring to their belief that there are no blind trials to support the use of this treatment. The assumption seems to be that only blind trials can determine the "truth" about the effectiveness of the treatment. Yet the effective use of blind trials is often difficult and is easiest to achieve when dealing with drugs. Blind trials are not common in surgical treatments or psychological treatments, and are not well suited to most alternative therapy treatments. So while blind trials have certainly been of benefit in improving some aspects of medicine - much of human knowledge and much of what we do is not amenable to such a ridged and limited method of study. I have yet to see a blind study that proves the existence of love but most of us seem to seek it out anyway.
One reason the blind studies are difficult with alternative therapies is that many of the alternative therapies take an holistic approach. That is to say that they look at the whole persons state of health and individualise treatment to the specific persons presentation. As an example, modern western medicine considers ulcers to be caused by bacterial infection. Modern treatment involves the use of antibiotics to kill the bacteria. In essence they have only one treatment for ulcer and this treatment would not be expected to deal with any other health problems that this person may be suffering. If this treatment proves ineffective they are left with the assumption that this ulcer cannot be cured.
However, most traditional medicines would ask the question why the bacterium has become a problem in one person but not necessarily in another. In Chinese medicine, for instance, the practitioner would look at the complete set of symptoms experienced by the patient to determine which imbalance they believe leads to the susceptibility to ulcers. Treatment would then focus on making adjustments to restore balance to the person, to clear the ulcer and prevent its recurrence. Traditional Chinese medicine recognises approximately 11 or 12 different categories of imbalance that can lead to ulcers. Each would require a different treatment strategy. The interesting thing is that this treatment strategy would automatically take into account and deal with other health problems and symptoms at the same time. This is one of the reasons that many people upon trying alternative therapies continue to use them. They find improvements in their health beyond the problem they sought help for.
This need for individualised treatment makes blind studies much more difficult. Much larger numbers of people are needed for the study and it is difficult to insulate from the effects of attitude with this individualised approach.
Experienced practitioners of alternative therapies recognise that placebo plays a role within their treatment. They also realise this is true of any medical practice. It should also be noted that the community in general tends to have greater faith in the established medical profession and tends to visit them first. It should then be expected that if placebo were going to be effective it would prove most effective for the established medical practice.
In clinic many practitioners often experience an early subjective improvement in patients. However on examination they realise that other less objective changes are not obvious. It seems, if these changes are related to expectation, they often are short lived. However, genuine therapeutic intervention will produce lasting results and this is what modern alternative therapies base their assessments on.
Since placebo, is based upon expectations one area of support for natural therapies being more than a placebo effect is that they are effective in the treatment of animals. And there is significant growth in the number of veterinarians who are using alternative therapies in their practices. There are also studies supporting the effectiveness of natural remedies in animal populations. Since an animal has no knowledge that a medication is supposed to be good for him, he can have no placebo effect.
Deliberate use of placebo.
Science tends to treat the placebo effect as a nuisance, as it makes establishing the truth about medicine much more difficult. However, clinical practice of both alternative and modern western medicine will often make use of the placebo effect, either deliberately or unconsciously. While some may consider this unethical it does tend to be unavoidable. As I mentioned at the beginning of this article a person's ability to heal is influenced by many factors, a caring practitioner will automatically attempt to swing these factors into the persons favour.
A medical practitioner facing a viral infection knows that antibiotics that will have no benefit. Instead of recommending no treatment, they may suggest an over the counter medication for symptom relief and reassure the patient that all will be well. Noting that they should contact them if they show no improvement. This type of caring approach will be more likely to be of benefit to the patients health than an alternative response such as telling them there is nothing to be done but the condition should pass, if however it doesnt, come back and see me. After all the implication is - we can do nothing, even if you do come back.
A common way for doctors to satisfy a patients desire for treatment is to give an antibiotic for a viral infection on the flimsy excuse that its to prevent secondary infections. Perhaps we should all take antibiotics in case I get an infection the reality is its a quick and simple way to please the patient which is the original meaning of placebo.
To please a patient is, in itself, not wrong. As I said before pleasing a patient and keeping their attitude positive is a useful process. Studies have found that being upset or depressed can have a significant effect on the bodies immune responses. In a parallel to this it is not wise to make a big deal of potential adverse effects of a medication. This is due to what has become known as the nocebo effect. Nocebo is the phenomena of people in medical trials experiencing the adverse effects of a drug whilst on a placebo. To quote DeAnna McDonald
New Yorker; August 11, 2003; Annals of Medicine--"Sick With Worry" by Jerome Groopman
"nocebo effect: even though these patients were in the group randomly assigned to take a chemically inert placebo, they reported suffering from side effects associated with taking Prozac...[they] had likely read their informed-consent forms, which detailed all the possible symptoms from taking [the non-placebo] a bit too carefully."
Of course, this is not to suggest that significant risks not be discussed with a patient before they commence a treatment.
Alternative medicine is not just placebo.
Whilst it is likely that the placebo effect has some effect it is frequently over exaggerated. Those that would like to use it to discredit others often do this exaggeration. As I mentioned before most results of suggestion appear to be short lived. In modern therapeutic situations a viable ongoing clinic could not survive if all they offered was placebo. This is supported by a Danish study from 2001 in which, Asbjorn Hrobjartsson, M.D., and Peter C. Gotzsche, M.D concluded We found little evidence in general that placebos had powerful clinical effects. Although placebos had no significant effects on objective or binary outcomes, they had possible small benefits in studies with continuous subjective outcomes and for the treatment of pain. Outside the setting of clinical trials, there is no justification for the use of placebos.
Daniel E. Moerman from the University of Michigan has even suggested that the term placebo response should be dropped that instead we should be using meaning response as he explains in Placebo Versus Meaning: The Case for a Change in Our Use of Language
In situations where inert medical treatments are given, whatever else we may say, insofar as a particular treatment is truly inert, a placebo wont have any effects; that is what we mean by inert. Hence, there is simply no such thing as a placebo effect. In a control group, several things can influence change in a patients condition, primarily regression to the mean, natural history, physician or patient bias, and, sometimes, a residual increment of improvement, which Ernst has called the true placebo effect (Ernst & Resch, 1995) and which I have called the meaning response (Moerman & Jonas, 2002).
If one were to change the emotive language and substitute meaning instead of placebo, perhaps we could make more headway in understanding some of the processes that impact on our ability to recover from illness. However, as it stands at the moment the idea that the placebo effect can be used to explain all of the benefits of alternative medicine, is untrue. Alternative medicine often works for animals, it has long-term results and those results can usually be measured by objective changes in the patients health. All of which point to placebo not being a significant factor in their success.
