Placebo

The placebo effect can be produced by inert tablets, by sham surgery, and by false information, such as when electrical stimulation is turned "off" in those with Parkinson's disease implanted brain electrodes.

A placebo is a sham medical intervention that produces a placebo effect. In medical research, placebos depend on the use of controlled and measured deception. Common placebos are inert tablets, sham surgery, and other procedures based on false information. In one common placebo procedure, a patient is given an inert pill, told that it may improve his/her condition, but not told that it is in fact inert. Such an intervention may cause the patient to believe the treatment will change his/her condition; and this belief may produce a subjective perception of a therapeutic effect, causing the patient to feel their condition has improved. This phenomenon is known as the placebo effect.

Placebos are widely used in medical research and medicine, and the placebo effect is a pervasive phenomenon; in fact, it is part of the response to any active medical intervention. When used as treatment in clinical medicine (as opposed to laboratory research), the deception involved in the use of placebos creates tension between the Hippocratic Oath and the honesty of the doctor-patient relationship. The House of Commons of the United Kingdom Science and Technology Committee states that: "...prescribing placebos... usually relies on some degree of patient deception" and "prescribing pure placebos is bad medicine. Their effect is unreliable and unpredictable and cannot form the sole basis of any treatment on the NHS."

Since the publication of Henry K. Beecher's “The Powerful Placebo” in 1955 the phenomenon has been considered to have clinically important effects. This view was notably challenged when in 2001 a systematic review of clinical trials concluded that there was no evidence of clinically important effects, except perhaps in the treatment of pain and continuous subjective outcomes. The article received a flurry of criticism, but the authors later published a Cochrane review with similar conclusions. Most studies have attributed the difference from baseline till the end of the trial to a placebo effect, but the reviewers examined studies which had both placebo and untreated groups in order to distinguish the placebo effect from the natural progression of the disease.

Definitions, effects, and ethics

A placebo has been defined as "a substance or procedure ... that is objectively without specific activity for the condition being treated". Under this definition, a wide variety of things can be placebos and exhibit a placebo effect. Pharmacological substances administered through any means can act as placebos, including pills, creams, inhalants, and injections. Medical devices such as ultrasound can act as placebos. Sham surgery, sham electrodes implanted in the brain, and sham acupuncture, either with sham needles or on fake acupuncture points, have all exhibited placebo effects. Bedding not treated to reduce allergies has been used as a placebo to control for treated bedding. The physician has even been called a placebo; a study found that patient recovery can be increased by words that suggest the patient "would be better in a few days", and if the patient is given treatment, that "the treatment would certainly make him better" rather than negative words such as "I am not sure that the treatment I am going to give you will have an effect". The placebo effect may be a component of pharmacological therapies: pain killing and anxiety reducing drugs that are infused secretly without an individual's knowledge are less effective than when a patient knows they are receiving them. Likewise, the effects of stimulation from implanted electrodes in the brains of those with advanced Parkinson's disease are greater when they are aware they are receiving this stimulation. Sometimes administering or prescribing a placebo merges into fake medicine.

The placebo effect has sometimes been defined as a physiological effect caused by the placebo, but Moerman and Jonas have pointed out that this seems illogical, as a placebo is an inert substance which does not directly cause anything. Instead they introduced the word "meaning response" for the meaning the brain associates with the placebo, which causes a physiological placebo effect. They propose that the placebo, which may be unethical, could be avoided entirely if doctors comfort and encourage their patients' health. Ernst and Resch also attempted to distinguish between the "true" and "perceived" placebo effect, as they argued that some of the effects attributed to the placebo effect could be due to other factors.

The placebo effect has been controversial throughout history. Notable medical organizations have endorsed it, but in 1903 Richard Cabot concluded that it should be avoided because it is deceptive. Newman points out the "placebo paradox", - it may be unethical to use a placebo, but also unethical "not to use something that heals". He suggests to solve this dilemma by appropriating the meaning response in medicine, that is make use of the placebo effect, as long as the "one administering ... is honest, open, and believes in its potential healing power."