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Rapid Responses: Rapid Responses published:
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The "placebo effect"
- Thomas Szasz (4 May 2008)
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A perfection of means, and confusion of aims, seems to be our main problem.
- BM Hegde (5 May 2008)
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Haiku Voodoo
- Hugh Mann (5 May 2008)
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Honestly!
- Margret M. Westwater-Hobbs (7 May 2008)
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Studying Placebo Effects Advance the Neuropsychiatric Understanding of Medical Interventions
- Stefan P. Kruszewski M.D. (7 May 2008)
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A Pedant's Lament
- Hugh de Glanville (9 May 2008)
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Re: Another Pedant's Lament in Rhyme.
- Roger K.A. Allen (12 May 2008)
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Thomas Szasz, Professor of psychiatry emeritus State University of New York, Upstate Medical University, 750 East Adams Street, Syracuse, New York
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The mystery of the “placebo effect” is dispelled by calling the placebo by its rightful name -- a lie. As Mark Twain explained, “The history of our race, and each individual's experience, are sewn thick with evidences that a truth is not hard to kill, and that a lie well told is immortal” ("Advice to Youth," 15 April 1882). Placebos have no place in intensive care units, and have “effects” only when given to conscious patients. That is the open secret of the placebo effect. Competing interests: None declared |
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BM Hegde, Retd. Vice Chancellor Mangalore-575 004, India
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“In every work of genius we recognize our own rejected thoughts; they come back to us with a certain alienated majesty.” Ralph Waldo Emerson. Interesting editorial indeed! The “so called” placebo effect has been the most vital part of medical care system ever since the dawn of modern medicine, nay any system of medical care. It shall remain the sheet anchor of the healing process for all times to come. Medical consultation, so called by Sir James Spence in the last century, is the summit of all medical care. It consists of two human beings coming together-one who is ill or imagines being ill and, the other in whom the former has confidence. This will remain so for all times to come. Man’s greatest enemy is pain which was so in the past and will remain so in the future as well. Any ill person needs another human being, the physician, to help him get well. (1) "The Austrian physicist, Ernst Mach, was the first advocate of positivism in physics. Positivism is a philosophy that accepts only those facts that are verifiable by our senses and experiments. This idea was first mooted by the French philosopher August Comte and his contemporary d’Alembert in the 18th Century. Positivism rejects all thoughts that can not be tested by the senses and experiments. Placebo effect, therefore, did not have a place in positivism. Mach was a great influence on Albert Einstein during his early years in Zurich. Einstein became a very staunch positivist. This is one of the reasons why he refused to understand quantum physics and its laws almost to the end. Mach’s dictum was that “theoretical physicists should never use any idea in physics which cannot be given a precise, direct meaning through experimental operations.” (2) This is the bane of science even to this day. "John A Wheeler, a student of Bohr, gives the story of Bohr having an evening dialogue with his mentor and teacher Herald Hoffding, at the famous House of Honour about the uncertainty principle of Heisenberg. Hoffding is said to have put his finger on the diagram between the double entrance slit and the photographic plate asking": “Where can the electron be-said to be?” Bohr’s famous reply was: “To be? To be? To be? What does it mean “to be”? (2) The shadow of this kind of experimental science fell on modern medical science to the detriment of the suffering humanity. Modern technological medicine does not understand the suffering human being’s mind. The latter can not be fathomed by the conventional sciences but, most, if not all, diseases get born in human mind and even get healed there. We have been missing the bus in this area. Direct extrapolation of reductionist science to medicine has created technology which we use indiscriminately without understanding the patient that is suffering. This had brought the medical technological profession to be one of the leading causes of human misery! (3) This was exactly what was to be avoided if one goes by the daily prayers of a leading physician, Hutchinson, where he lamented-“let not my intervention become worse than his disease, let me leave the “well” alone…….” The last well person needs to keep away from the modern medical claptrap! Recent scientific research has thrown up a new concept that explains the placebo effect very scientifically, if ever that was needed. Expectation Effect (EE) is the latest mantra in science circles. It is this effect that stimulates the immune system that ultimately results in healing. The drugs and interventions are only tools in that process. Expectation effect depends on that confidence, mentioned earlier, in the context of medical consultation. Even from the scientific point of view bedside medicine takes the cake. “If you listen to your patient long enough, s/he will tell you what is wrong with her/him” was the strong belief of Lord Platt, who wrote those words way back in 1949 when he was at the University College Hospital. That was shown to be true in a randomized prospective controlled study done using even the PET scanner in the diagnosis of medical outpatients in London, published in your journal decades ago. (4) Hans-Peter Duerr, emeritus President of the Max Planck Institute in Munich, was the one who first showed that even hard sciences like physics are not totally objective. He calls them “subjective-objectivity” as the observer’s consciousness impinges on that of the observed even if the latter is inanimate. (5) That is precisely the reason why no body has been able to see an electron! Electron is what it is depending on who looks at it and at what time? When we do not look at it we do not know what it does! Galileo, Isaac Newton and Laplace could evolve the laws of deterministic predictability but they don’t seem to fit the rules of this universe. Whereas there are four types of forces described in physics there seem to be a host of other occult forces that shape the destiny of this world. What about human beings, that too sick ones, with all their emotions roused to the maximum during the medical consultation? The best evidence in favour of the placebo effect is here. In June 2005, Harvard Medical School associate professor of medicine Dr. Roger J. Laham reported on follow-up results of a randomized trial looking at laser surgery to improve blood flow. “Patients who got the surgery had significantly less pain and improved heart function. But so did patients who had a sham operation -- the equivalent of a placebo. After 30 months the placebo effect was still there. Scans and other tests showed physiological gains in blood flow among only those who thought they had been operated on”. A similar large placebo effect might explain "most of the benefits that we've seen so far with balloon angioplasty and bypass surgery," Laham said. (6)The title of this response, a quote from Einstein, tells it all. Yours ever, bmhegde References: 1) Hegde BM. What doctors don’t get to study in medical school? 2006. Anshan Publishers, Kent, UK. 2) Swami Jitatmananda. Modern Physics and Vedanta. 2004. Bharatiya Vidya Bhavan, Bombay, India. 3) Starfield B. Is US medicine the best in the world? JAMA 2000; 284: 483- 485. 4) Hampton R, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. BMJ. 1975; 2: 486–9. 5) Han-Peter Duerr. 2007. Personal communications. 6) Carey J and Barrett A. Is heart surgery worth it? 2005 July 7th, Business Week. Competing interests: In search of truth in modern medicine |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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Placebos assuage Competing interests: None declared |
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Margret M. Westwater-Hobbs, Student Counsellor/PhD student Wellington School of Medicine
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I read your current editorial with a feeling of despondency: should doctors lie to their patients or not? Why are we still debating whether doctors need to be honest? Whether the placebo effect relies on omission or commission, it is a form of lying. Deciding what a patient needs and proceeding to intervene on that basis is not only deceit-full but a clear abuse of power. Healthy relationships are always undermined by deceit. What makes for a good enough fiduciary relationship is one based on competent practice, genuineness and open interested concern in the person to whom attention is owed. Competing interests: None declared |
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Stefan P. Kruszewski M.D., Neuropsychiatrist Harrisburg, Pennsylvania 17110 USA
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I hope that the editorial by Fiona Godlee (1), the work of Kaptchuk, et al.(2) and the comments by Pittrof and Rubenstein (3) continue the process of exploring the potential of the Placebo Effect. Since it is not a null effect and has a good safety profile, it deserves more than the dismissive response offered by Dr. Szasz in his 04 May 2008 commentary. (4) Furthermore, Dr. Szasz’ comments are not entirely accurate. His suggestion that placebo treatments only have ‘effect’ when provided to conscious patients assumes that he can demonstrate that there is no effect to patients with altered levels of consciousness, including unconsciousness. However, that work has not been adequately performed and, therefore, his commentary is, at best, premature. Medicine has never been concrete or absolute. That is, perhaps, truer for psychiatry, where clinical practitioner results and the risk- benefit ratios of medicines and medical devices are more difficult to quantitate and, therefore, more difficult to predict. Psychiatry, like medicine, has always been an art [some aspects of which were highlighted in BM Hegde’s Rapid Response of 05 May 2008 (5)], which, at its best, provides hope and encouragement to live a life that is free from torment, to be personally fulfilling and interpersonally satisfying. The Placebo Effect is not a lie because it has a neurobiological mechanism of action. That that mechanism has not been fully elaborated is of little consequence(not unlike obesity, HIV/AIDS or schizophrenia). To assume that it does NOT have a neurochemical basis would require enlisting spiritual or completely random or unknown forces to explain its effect on patients’ immune, nervous and endocrinological systems that give rise to positive-or negative- responses. That argument is unlikely because it bypasses the scientific understanding of human neuropsychiatric reactions. Since we know that human cortical reactivity changes when individuals are confronted with subtle verbal interventions, facial grimaces or body movements, and those changes in cortical reactivity produce changes in feeling states, cognition, emotional tone and behaviors, we already have verifiable scientific proof that placebo therapies, in whatever form they are provided, unquestionably produce neurobehavioral consequences. When the consequences of Placebo Effects are able to provide relief from pain or other suffering, we should endeavor to explore how to use them wisely, carefully and gracefully. Stefan P. Kruszewski, M.D. (1)Godlee F, editor. Reclaiming the placebo effect [Online]. BMJ 2008 May 3 [cited 2008 May 7]; 336. Available from: URL:http://www.bmj.com/cgi/content/full/336/7651/0. (2)Kaptchuk TJ, Kelley JM, Conboy LA, Davis RB, Kerr CE, Jacobson EE, et al. Components of placebo effect: randomized controlled trial in patients with irritable bowel syndrome [Online]. BMJ 2008 May 3 [cited 2008 May 7]; 336:999-1003. Available from: URL:http://www.bmj.com/cgi/content/full/336/7651/999?ijkey=45db1e7332413b3ce10342ab04fe640b6c8c5450. (3)Pittrof R, Rubenstein I. The thinking doctor’s guide to placebos [Online]. BMJ 2008 May 3 [cited 2008 May 7]; 336:1020. Available from: URL:http://www.bmj.com/cgi/content/full/336/7651/1020. (4)Szasz T. The “placebo effect” [Online]. BMJ Rapid Response 2008 May 4 [cited 2008 May 7]. Available from: URL:http://www.bmj.com/cgi/eletters/336/7651/0#194707. (5)Hegde BM. A perfection of means, and confusion of aims, seems to be our main problem [Online]. BMJ Rapid Response 2008 May 5 [cited 2008 May 7]. Available from: URL:http://www.bmj.com/cgi/eletters/336/7651/0#194632 Competing interests: None declared |
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Hugh de Glanville, Retired Weybridge KT13 9EQ
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That I should live to see
Passed by proofers unobservant,
Competing interests: A 'soi-disant wordsmith' and former temporary BMJ proofreader |
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Roger K.A. Allen, Senior Consultant Thoracic and Sleep Physician Wesley Medical Centre, Auchenflower, Brisbane, Australia
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Our editors once walked on water
But now they drown in words abundant
Off the radar, gerund, hyphen and the colon,
What the poop's a preposition?
Let infinitives be cleaved asunder!
Competing interests: None declared |
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