Views & Reviews Personal View

It’s time to put the placebo out of our misery

BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b1568 (Published 20 April 2009) Cite this as: BMJ 2009;338:b1568
  1. Robin Nunn, lecturer, Institute for the History and Philosophy of Science and Technology, University of Toronto
  1. r.nunn{at}utoronto.ca

    We need to stop thinking in terms of placebo. The construct of the placebo has shifted several times during its history, from the periphery to the mainstream of medicine, from the lie that heals to a confounding factor in experiments, and to powerful medicine.1 I hope we will see another shift as we look back without nostalgia on the placebo, just as we look back on Galenic medicine and its humours, which were once plausible and useful but whose time has passed. It’s facile, however, to cite historical change as evidence that the placebo construct is unstable. All sorts of concepts change over time. So let’s stick with what’s wrong with the current placebo era and what could be right about a post-placebo era.

    Shapiro and Shapiro described placebo as the only treatment common to all societies and cultures.2 Apparently almost anything can be a placebo, and a wide variety of medical conditions respond to it. Bausell claims that all forms of complementary or alternative medicine are placebos, including those with a massive share of the medical marketplace, such as herbal medicine, chiropractic, homoeopathy, hypnosis, and acupuncture.3 Singh and Ernst essentially agree.4 Placebos are not even needed to generate placebo-like effects. Secretly injecting morphine, for instance, seems to be less effective than doing the same thing and telling the patient about it.5 When placebo, or any other construct, can be virtually anything, then it just may turn out to be virtually nothing.

    Nobody who came and saw the placebo has conquered its definition. Shapiro tried repeatedly until the definition became as convoluted with caveats as legislation.2 …

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