Dr. Russell Sanders, a pseudonymous New England pediatrician blogging at Blinded Trials, has an interesting take on Micheal Specter’s New Yorker essay on the placebo effect (abstract).
Specter asks whether new discoveries about the power of placebos could change the practice of medicine. Some studies have shown placebos to be as potent as painkilling drugs, and since they’re just dummy pills or false assurances that a drug has been administered, they’re unlikely to be toxic. Specter even asks a senior FDA official whether the agency might one day approve a placebo qua placebo. Short answer: Signs point to no. Hell, no. The FDA is not amused by such foolishness.
Sanders argues that this is a moot point because doctors cannot ethically practice pure trickery, even to relieve suffering. What they may do – and what he sometimes does for his patients – is prescribe mildly beneficial remedies that he might otherwise skip, primarily for the sake of reassuring the patient, or their parents. Interestingly, he tells the parent exactly what he’s doing and gives them permission to skip the treatment if they don’t think it’s worth it. As Specter points out in the essay, placebos can work even when patients are told they’re taking placbos.
Specter’s essay was pretty good, but the whole question about the whether the FDA could ethically license a placebo seemed a bit forced.
Even if known placebos can work in clinical trials, it would be really shortsighted of doctors to start prescribing FDA-certified placebos. Since the dawn of scientific medicine, physicians have been trying to dig themselves out of the PR hole dug for them by faith healers and snakeoil salesmen. Real doctors have spent the last century trying to convince the public that they have something more to offer than showmanship and ritual. Even today, a lot of patients already suspect, rightly or wrongly, that real drugs are just gussied up placebos.
The article didn’t show that you get more placebo effect out of a fake pill than you do out of selling the therapeutic merits of something genuinely but mildly beneficial. In fact, if the placebo effect really is an outgrowth of the therapeutic ritual as Specter strongly implies, it seems like any kind of medical attention could work.
Maybe doctors should do a better job of selling sound self-care advice as real medicine, as opposed to a consolation prize when there’s no drug for what you’ve got. So, instead of just suggesting offhandedly that a patient with non-specific low back pain might feel better after a hot bath, a doctor might try to harness an extra placebo effect by writing out the advice as a “doctor’s order” on an official looking prescription pad and present it with some gravity.
We’d need trials to see if a little extra white coat theater boosts the effectiveness of run-of-the-mill self-care advice, but it seems like it might have all the benefits of a placebo with none of the ethical pitfalls.
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