Is placebo a dirty word?
Is placebo unethical?
I have heard it described as both and I want to challenge this a little further.
In 1955, Henry Beechers published ‘The powerful Placebo’ in the Journal of American Medical Association and he outlined the difference between placebo and a ‘dummy’. He described a ‘dummy’ as the prescription of a medicine/procedure/therapy which is intended to have no effect. He quotes the Oxford dictionary’s description of placebo quite literally as a medicine given to please more than to benefit.
These may seem to be the same thing when perceived from a physical perspective, but his article is enlightening when we delve further into the research surrounding this phenomenon. A sugar lump that is given with the intention of pleasing rather than benefit may seem unethical. But what if it’s as effective as the a real drug or therapy intended for that purpose?
Raul de la Fuente-Fernandez et al published a paper in 2002 from The University of British Columbia (1). This was a Randomised controlled trial involving patients with Parkinson’s disease (PD). Half the patients were offered an injection with an active ingredient and the other half, a ‘control’ injection of saline. This was repeated twice, the first time the patients were not told which they received and as the second injection was administered the subjects were told which they were given. Positron emission tomography (PET) was used to study the brain during and after the injections to measure the amount of dopamine released by the brains.
Humanity’s need to explain all of the therapies down to a physical source has forgotten that pain goes beyond the physical realm of understanding.
People with PD have an impaired ability to produce dopamine, so according to the Oxford dictionary definition of placebo there should be no dopamine release with saline injections. Intriguingly, patients who received placebo injections exhibited significant dopamine releases. The authors conclude that dopamine release “is linked to expectation of a reward in this case, the anticipation of therapeutic benefit.” In other words, the expectation of the reward is as powerful as the reward itself.
Could you imagine the potential of creating healing without the need for nasty side effects? Which would be more ethical?
This brings into question whether it is unethical to refuse a treatment when there is anecdotal benefit despite a lack of evidence (perceived non-benefit) There is well established evidence to show no correlation between tissue damage and pain or even biomechanics and pain, so what do we think is actually happening when we deliver rehab, exercise or a procedure in line with current guidelines? Are we naïve enough to reduce an explanation down to simply a physical reasoning? Is there placebo in everything we do?
This also opens a question of control groups used within research. It has long been believed that the administration of a procedure with no benefit can be compared to an active treatment to measure effect. If the above mentioned research shows that control/placebo therapy might actually have a similar healing effect as the active treatment, we ought not to compare treatments to a control/sham treatment and instead rely more of the anecdotal evidence.
the expectation of the reward is as powerful as the reward itself
Perhaps this is also why the Cochrane reviews reveal such a lack of high quality evidence with rehab and medicine for healing. The research does not always capture the behaviour seen clinically.
If we consider the history of medicine, rehab and sport, we may all remember the frequent use and anecdotal success of ultrasound machine, ankle strapping and the magic sponge. Despite the ultrasound machine not being turned on, the tape being ineffective after 10 minutes and a sponge not seeming to do anything on a scientific level, they all had some success in helping people to overcome pain. Humanity’s need to explain all of the therapies down to a physical source has forgotten that pain goes beyond the physical realm of understanding.
Within the science of chronic pain, the understanding of Corticol remapping shows us that the pain experience may reside within the brain and not within structural deformity.
Given this, I wonder whether placebo treatment might have interesting effects on the brain that we saw within the British Columbia study for people with musculoskeletal or chronic pain?
Surely there is placebo in everything we do?
Perhaps expanding on the British Columbia paper allows us an insight into the potential we all have for healing when we look beyond the physical. Perhaps our success in creating a healing environment has a lot to do with the confidence, compassion and kindness we take into the exchanges we have with clients and patients. A research article from The Pain Clinic in 2000 revealed stereotypes held by medical professionals towards patients experiencing a painful medical procedure(2).
It revealed that the majority of medical professionals perceived older and less attractive patients to experience less pain than those who were younger and more attractive. What sort of compassion and kindness might a medical or exercise professional display towards patients that they perceive as older or less attractive? If we consider the 2002British Columbia paper, which teaches that the expectation of the reward is equally powerful as the reward itself, it may be worth investing in the meta aspects of healing rather than purely the physical.
1. Fuente-Ferna´ndez R.D.L, Phillips A.G, Zamburlini M, Calne D.B„ Ruth T.J, Stoessl A.J. (2002). Dopamine release in human ventral striatum and expectation of reward. Behavioural Brain Research 136: 359⁄363
2. Thomas Hadjistavropoulos, Diane LaChapelle, Carla Hale & Farley K. MacLeod (2000). Age- and appearance-related stereotypes about patients undergoing a painful medical procedure. The Pain clinic: 12(1).
David is a Physiotherapist who has been involved in Professional Sport, battlefield trauma, chronic pain and the NHS. He continues to work clinically alongside his development role in Rehab Guru. David is passionate about Health tech to transform outcomes for patient