By Nancy Walsh
In a recent issue of the New Yorker, long-time staff writer Michael Specter explored the nature of the
placebo effect in medicine, primarily by describing the work of Ted Kaptchuk,
who directs Harvard University’s Program in Placebo Studies and the Therapeutic
Encounter (PiPS). The program’s mission is “to examine the placebo response and
the implications of medical ritual, the patient-provider relationship, cultural
context, and the power of imagination and hope in the healing process. Through
endeavors in the clinical, basic, and social sciences, bioethics, the history
of science and philosophy, PiPS seeks to elucidate, quantify, optimize and
reaffirm the humanistic and more intangible dimensions of health care.”
Kaptchuk, who studied Chinese medicine in Macau and
practiced acupuncture for many years, is arguing for a shift in contemporary
medicine away from high-tech and pure science to a greater emphasis on healing.
Having recently received funding from the National Institutes of Health, he and
his colleagues are undertaking neuroimaging and molecular studies to understand
the biological underpinnings of the placebo response.
In one study, he and his group acknowledged that a problem
in directly exploring the placebo effect in a clinical setting was the use of
deception — not letting patients and providers know of they are receiving an
active drug or not. So they designed a randomized study in which patients with
irritable bowel syndrome were given pills they were told were “an inert
substance, like sugar pills” or no treatment. After 21 days, patients given the
placebo had significantly different changes on global improvement scores (5
versus 3.9, P=0.002) and symptom
severity (P=0.03).
In another study, patients with asthma were randomized to
treatment with an albuterol inhaler, a placebo inhaler, sham acupuncture, or no
treatment. The albuterol group experienced 20% improvement in forced expiratory
volume in one second (FEV1) measured on spirometry, and the other
three groups all improved by 7%. However, when patients were asked if they felt
better, 50% on albuterol reported improvements, as did 45% of those using the
placebo inhaler, and 46% of those who had sham acupuncture, compared with only
21% of those who had no treatment (P<0.001).
The researchers concluded that, while objective measures such as FEV1 are important in asthma care, “other
outcomes such as emergency room visits and quality-of-life metrics may be more
clinically relevant to patients and physicians.”
Specter concludes his article with a personal anecdote. He
had been experiencing chest pain and was worried, being an overstressed
middle-aged man, so went to his doctor, who conducted a careful examination.
The physician told him he was fine, but needed to relax — and the pain simply disappeared.
This was an example of “exactly the type of ritual that, according to Kaptchuk,
will have to play a critical role in the future of American health care.
So what do you think should be the role of placebo — if any — in
tomorrow’s medicine?