Placebo Power: It Shouldn’t Work but it Does

“There are two ways to be fooled. One is to believe what isn't true; the other is to refuse to believe what is true.” — Soren Kierkegaard

Patient’s daughter:"I agree with your opinion, doctor, that my father has no real problem. He is a bit of a hypochondriac who won't accept that he is in good shape for his age. Can't you just give him some sort of a dummy pill to keep him quiet?"

Doctor: "You want me to give him a placebo?"

PD: "What's that?"

Dr: "A 'sugar' pill, so to speak. A tablet that contains no formulation: something totally innocuous, but makes the patient feel that he is taking some medicine."

PD: "Yes, something like that."

Dr:"I am not comfortable with prescribing placebos. I feel it is unethical."

What’s the Harm?

PD:"Why? What's the harm? You are not hurting him. You may even be helping him."

Dr: "On the surface, yes, but, I am not being truthful. And that bothers me. I can't knowingly give someone a sham treatment. The Hippocratic Oath binds us to sharing the whole truth with our patients."

Do They Work?

PD:" I respect that, doctor, but tell me, do placebos work?"

Dr: "Quite often, and more effectively than we would like to admit. For a long time, we have known that a large number of conditions will respond to any treatment that looks like one: a placebo effect. For an equally long time, we tended to dismiss this important event as being too quirky and unpredictable to be of any use.

Still, the placebo effect is so persistent that it is a requirement that all new drugs that are being evaluated be first compared against a placebo and be shown to be demonstrably better. In many conditions, a placebo can cure the majority of patients. So, the new drug must be better than the placebo to be stamped as valid.

In recent years, there has been a lot of scientific research on the placebo effect. We are finding out that it is definitely there and cannot be brushed away."

Are Weight-loss Diets Merely Placebos?

There are dozens of weight-loss diets being pushed: Atkins, Mediterranean, Paleo, Keto, Volumetric, Weight Watchers — each one claims to be the best. Each one describes a unique and hitherto unknown principle behind it. The market is, pardon the pun, huge. Books (many on Best-Seller lists), videos, memberships — there's an industry based on diets.

Curiously, there is only one feature in common between all of them.

• For the first few weeks or months after starting on the diet, weight loss is consistent.
• The trend then plateaus and starts rising. At around 2 years, the vast majority of dieters are back where they started.
• Many overshoot and go above the weight they began at. They get frustrated and shift to another diet. This “yo-yo dieting” is known to be harmful.

This diversity of regimens and unanimity in results, raises the question: “Can all diets be mere placebos?”

Likewise, there are many common conditions, often with no permanent cure, where specific interventions seem to work. Once again, the placebo effect at work.

What If the Patient Knows it’s a Placebo?

PD:"What happens then, if a patient finds out or knows that he has been given a placebo?"

Dr:"Another surprise here. The placebo still works!"

PD:"You're telling me that the doctor knows he is giving a dummy and the patient also knows that, yet, there is a benefit? The lie, works?"

Dr: "Some years ago, there was a study published in the very respected medical journal, PLoS One, that seemed to show exactly that. The authors of this paper report their experience with the use of placebos in a condition known as the irritable bowel syndrome (IBS). This common problem can be difficult to treat. A wide range of options are available, none of them guaranteed to work. Patients in this study were randomly assigned to undergo no treatment at all (controls) or to receive a placebo. The important aspect of this study was that patients were clearly informed that the pills had no active compound. Despite knowing that they were taking dummies, 59 percent of the group reported improvement of their symptoms as opposed to 35 percent in the controls; nearly twice as many showed a benefit. The reported improvement rate is almost equal to that seen with the most powerful IBS medications!"

PD:"Doesn't this shake the foundations of pharmacology and therapeutics? You are telling me that significant benefits can be seen even with fakes. Science depends on demonstrable cause and effect, but you are saying that there can be an effect in the absence of cause. Worse still, that spurious drugs may work."

Dr: "Not an absence of cause, merely a misunderstanding of what might be the cause."

Dr: “There is a famous truism: "A doctor cannot just treat, he must be seen to be treating." Meaning that he must go through the motions of a medical transaction, the most iconic part of which is the writing out of a prescription. The bedside manner may be more of a treatment than we realise. A professional look, a calm demeanour, sympathetic and clear conversation: all this may be what is affecting the cure rather than the pill or injection. We never teach any of this in medical school."

Before we go about discarding current textbooks of therapeutics, it is worth pointing out that most of these studies are carried out in conditions that have no demonstrable cause -- as yet -- and often show a natural remission. It would be unwise to extend this finding beyond certain limits. For instance, treatment of conditions like HIV/ AIDS, where we know that drug treatment is effective and failure to take the right medicines can lead to dangerous consequences.

From being dismissed as an unreliable quirk of the human mind, the placebo effect is now the object of serious scientific study. There is something here, something more profound than physical reality -- mind over matter.

Exciting times ahead, so stay tuned to the placebo channel.

Dr Arjun Rajagopalan

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