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the alternative fix

the placebo effect
the clash

Critics of alternative medicine often dismiss reports of successful treatments by attributing the success to the "placebo effect": if the patient feels better, it's because he believes the therapy will work, not because of any actual physiological effect. Does it really matter? Medical historian James Whorton, alternative practioner Andrew Weil, and Harvard University's Marcia Angell and Tom Delbanco discuss the controversy.

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James Whorton

Professor of Medical History, University of Washington

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How do alternative practioners understand the "placebo effect" as compared to allopathic doctors?

One of the really interesting elements of the debate historically, but which I think is really coming to a head today, is over the significance and the importance of the placebo. Historically alternative medicine has been dismissed as nothing more than placebo effect. It gives the patient attention, the patient's given something that he hopes will be effective and the placebo response follows. Allopathic doctors have tended to see the placebo as something that is useless in their practice, and believe, in fact, that is unethical to give because it's a kind of deception. You shouldn't give a patient something that's not a drug without telling him it's not a drug--but then of course you won't get the placebo effect.

Alternative practitioners argue that the placebo should be regarded as just as valuable as a drug. It is in a sense a drug. It's a therapy. It produces an indirect effect, perhaps, rather than the direct effect of a drug, but still it does provide benefits for patients and so it should be incorporated into therapy and utilized rather than disdained.

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marcia Angell, M.D.

Senior Lecturer, Harvard Medical School

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You should not use a placebo except in a research setting. When you do a clinical trial and you use a placebo, what you're saying to the people who enter the trial is, "Some of you may be getting a dummy pill, or a placebo, is that okay with you?" And then people say, "Yes, it's okay." But when you're giving it in the context of treatment, they don't say, "Would you like therapeutic touch, it's a placebo?" so it's deceptive in that sense. It implies that it works. And I think it's wrong to give a placebo if you're not honest about it. … I think placebos are unethical, except in a research setting. …

It's been said by some complementary and alternative medicine proponents that it doesn't matter whether their treatments work or not, that even if it is a placebo treatment that's fine. If it works, it's fine. And so it ought to be offered as a placebo, if nothing else. I have a lot of problems with that because I think that any use of a placebo without saying it's a placebo is deceptive. It's patronizing and I wouldn't think that consumers who've in some sense turned to alternative medicine because they see it as empowering, would want to sign on to something so infantilizing and patronizing as the idea that people can just give them placebos and tell them it works. I don't think that that's right.

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Andrew Weil, M.D.

Founder and Director, University of Arizona's Program in Integrative Medicine

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How do you respond to critics who say that the anecdotal results you see from some alternative therapies are simply the "placebo effect?"

Well, I think when they say it's placebo, what they're saying is that it has no intrinsic effect, so it's a way of dismissing. I think they're contemptuous of placebo effects, also, but it's a way of saying the therapy is worthless, just people believe in it. And it's odd that at the same time that they say that, they're maintaining the mind has no great influence on the body.

… My vision of this is that you've got an intrinsic effect and then you've got a halo of placebo effect and that the placebo effect is very important. In fact to me the best medicine is getting the maximum placebo response with the minimum intervention. Placebo responses are pure healing responses from within that are elicited by belief. The best medicine is getting the maximum healing response with the least intervention. So we should be finding ways of giving people gentler and gentler treatments or at least the gentlest treatments demanded by the situation and getting the maximum placebo response.

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tom delbanco, M.D.

Beth Israel Deaconess Hospital Boston; Professor, Harvard Medical School

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I believe very strongly in placebos. I personally think we should give people placebos, tell them what they are and know that they'll help. My wife will swallow a pill when she has a headache and she'll be the first to say she feels better after she's swallowed it, knowing that it hasn't dissolved yet. That's the placebo effect. It works. I do the same thing.

Placebos help people enormously. They're cheap, they're certainly safe. I have no trouble with the notion that in the future we should say, here, take this, we have no idea why it works, it's sugar in a pill, it shouldn't cost you too much. If you pay more for it, you'll probably think it works better; swallow it, you'll feel better. That's the placebo effect. I think it's terrific. It works in many circumstances, no matter about recent papers that say it doesn't work, that's nonsense. It does work and we should be honest about it.

How does it work?

Placebo effect is very complicated. Number one I say, try this. It's the doctor, an authority figure, saying it. Number two I say, you've got to pay five dollars for this glossy pill that surrounds a piece of sugar. You've already put some of your own money into it. Number three, I say with my authority, this is something that's just sugar, covered by a surface. I have no idea in the world why it should make you feel better, but a lot of patients do feel better. I'm combining my authority, your five dollars, this shiny looking pill, and I'm giving it all to you.

That's a lot of a dose of placebo. It's a large placebo dose, if you will...There's a psychiatrist, Walter Brown, who studies depression and was fascinated by the placebo. He said, let me be honest with patients about placebos. I'm going to give depressed patients a sugar pill covered by a surface, tell them that it's a placebo, that I don't know why it works but it probably does in depression, take it, I'm going study it and compare it to the medicines we think are psychopharmacologically active [and to] psychotherapy, and see what happens. He found that at least for mild to moderate depression, they were no different.

How does what you're describing apply to alternative medicine?

If you have a warm, caring, not-time-limited setting which is patient-centered, which focuses on the music that patient may want to hear, which has the magazines that patient may want to read in the waiting room, and also has a high price tag attached to it that comes out of pocket (not covered by insurance), boy you are motivated then to get something out of that experience. That calls every bit of the placebo effect in my view into full throttle. You are ready to go.

In fact, one of the things about human beings is, they like to justify what they did. When their friend says to them, hey, did it work? You say to yourself, at some kind of unconscious level, I spent money, I took time, I went somewhere, [it] must have been a rational decision, therefore I'd better say it worked. And it gets around.

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posted november 4, 2003

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