Placebos

Sometimes, it is easy to recognise a good idea. Oral rehydration solution, a simple sugar and salt formula, costs about 10 cents per packet. Since its development in the 1970s, it has saved millions of people, mainly in the developing world, from dying of diarrhoea. It could well have saved those in Zimbabwe who, in the past few weeks, are reported to have died from dehydration following cholera.

Western healthcare, meanwhile, is expensive, and our contribution to humanitarian aid remains inadequate. When we fret about whether a test for genetic biomarkers will help us to avoid assault by nefarious disease, we seem to be missing the point. We could be concentrating our efforts on saving other people’s lives with simple remedies instead of worrying about how complicated tests could buy us a few more years.

Indeed, the more advanced the medicine, the more equivocal the benefits. A thought provoking piece in the British Medical Journal last year questioned whether the rise in statin prescriptions for elderly people might decrease the number of sudden deaths due to heart disease, only to increase the incidence of cancer.

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When I was at medical school, hormone replacement therapy was not just the treatment of choice for the flushes and sweats of menopause. It was also thought to reduce the risk of heart attacks, strokes, dementia, colon cancer, bone and even teeth loss.

Yet over the past few years new research has made many doctors reluctant to prescribe HRT in the longer term. Their concern stems mainly from a study conducted during the US Women’s Health Initiative (WHI), a government-funded project to investigate the health of postmenopausal women.

The large, randomised, placebo-controlled trial was stopped early, in 2002, when researchers became concerned by the increased rate of heart attacks and strokes in the HRT group, compared with those taking the placebo. HRT did seem to reduce the rate of bone fractures and colon cancer, but the investigators decided that the adverse effects outweighed the beneficial ones. In the UK, research projects such as the Million Women Study have also found HRT to prompt side-effects such as breast and ovarian cancers.

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There is an interesting study this week in the BMJ. The study was a mailed survey to US internists and rheumatologists about their use of placebo treatments. The response rate wasn’t great (57%) but about half said they regularly prescribed placebo treatments. Most also said they thought it was ethically permissible.

Placebos do work and the placebo response is usually a clinically useful one. The question is how to use it practically without deceiving the patient. (I am not aware of any research that explores how the placebo effect varies according to what the patient is told about what the treatment contains; do let me know if you do know of any.)

Ethically, doctors should not deceive by lying or exaggerating what is being given. Some ethicists have postulated that by giving a placebo treatment and saying something like ‘we don’t really know how the treatment we are going to give you will work, but I believe it will, and it will not cause any side effects’ is okay. My  problem is that I am not quite sure this is a good enough explanation; I find the explicit omission uncomfortable.

However, the ‘placebo effect’ can be very usefully and ethically harnessed by way of ‘placebo-like’ effects,  the effect more generally of an ongoing relationship between patient and doctor. For example, continuous care from the same doctor, longer appointment times and empathy, all result in better outcomes for patients . The political direction that primary care has been sent in, though, hardly allows for the importance of these things to flourish.

Margaret McCartney’s Blog

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A forum on healthcare policy and professional issues, by Glasgow-based GP and FT Weekend columnist Margaret McCartney.

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