One Scholar's Take On The Power of The Placebo
IRA FLATOW, HOST:
This is SCIENCE FRIDAY. I'm Ira Flatow. It's a story we've heard before: A doctor prescribes a fake pill to a patient after other medications have failed. The patient begins to feel better after taking what she thinks is a real drug, but is only a placebo.
The story is not fictitious. It's rooted in real data. One study estimates 50 percent of U.S. physicians who believe in the benefits of placebos and the placebo effect secretly give dummy pills to unsuspecting patients. The ethical-questionable practice led researchers at Harvard University to explore whether the power of placebos can be harnessed honestly, and what they found was the placebos work even when patients are in on the secret that it is a sham treatment. They know that they're taking a placebo, and it still works.
Ted Kaptchuk is an associate professor of medicine at Harvard Med School, director of the Program in Placebo Studies and the Therapeutic Encounter at Beth Israel Deaconess Medical Center in Boston. The program was created last summer and is wholly dedicated to the study of placebos. He joins us from Cambridge, Mass. Welcome to SCIENCE FRIDAY.
TED KAPTCHUK: Ira, thanks for inviting me.
FLATOW: How do you define a placebo?
KAPTCHUK: Well, a placebo is a sugar pill or inert substance that's used to hide the genuine treatment in a clinical trial. A placebo effect is the effect of a sugar pill. The problem with that common definition is that it's an oxymoron: An inert pill can't have an effect. So what our team says is that the placebo is also hiding a very important phenomena: the clinical encounter. We think the placebo effect is the - a surrogate marker, or a way of measuring the effect of just caring for a person, the act of caring for a person.
We think that it's - the placebo is about the words, the gestures, eye contact, warmth, empathy, compassion that a physician exchanges with a patient, a doctor-patient relationship. We think the placebo is about medical symbols, white coats, diplomas, prescription pads.
We think the placebo is about medical rituals, the ritual procedures in medicine: waiting, talking, disrobing, being examined and being treated by pills or surgery. Ultimately, we think the placebo is about the power of the imagination, trust and hope in the medical encounter.
FLATOW: Can you quantify any of this, then?
KAPTCHUK: Well, that's what my work is, and that's what our program at the Beth Israel Deaconess and Harvard Medical School is trying to do, is that this is usually considered the art of medicine. It's in the background. People are mostly concerned about drugs, procedures and surgery, and our job is to quantify what's been hidden in the background and move it to the foreground, to make the human aspects of health care more prominent and optimalize them once we understand what they can do and how they work.
FLATOW: Because we hear that the placebo effect works about 30 percent of the time, correct?
KAPTCHUK: No, that's more of a medical myth. Sometimes - sugar pills will not shrink a tumor, will not lower cholesterol, don't lower hypertension. Placebo effects work in some conditions much better than others. Placebo treatments will work in things like pain, insomnia, depression, anxiety, functional bowel disorders, functional urinary disorders. So that 30 percent is really a myth that was created a long time ago.
FLATOW: And you've discovered - let me see if this is correct - that even when the patients know they're taking a placebo, it still works?
KAPTCHUK: Well, discovery is a big word. We - what we did was we randomized patients with irritable bowel syndrome, half of whom went - we gave them placebos. We told them it was placebos. The bottle said they were placebos. We told them that the study was about placebos. This is an inert pill they were taking. And half of them we randomized to no-treatment control wait-list to make sure that if they changed and got better, it wasn't the normal, natural waxing and waning of diseases or spontaneous remission.
And we found, after three weeks, that people who were taking placebos did much better than those in the comparison group. Our study was small. It needs to be replicated. It's more proof of principle. But it certainly changes the conventional wisdom, which was if you know you're taking a placebo, you're not going to get better.
And what we - I think many other teams have to replicate this in other diseases, and we hope that that will happen down the line.
FLATOW: But you're saying, if I heard you correctly, just to go back on your original statement, is that the placebo basically masks, or it's really the encounter with the doctor and all the trappings of the office and being taken care of that - is the action that is actually helping the patient and making the patient feel better.
KAPTCHUK: I think that's what I meant to say. I'm glad you said it that way. Yeah, a sugar pill doesn't do anything. What does something is the context of healing. It's the rituals healing. It's being in a healing relationship. And that's what we study.
But the placebo pill is a wonderful tool, or a saline injection is a wonderful tool to isolate what is usually in the background, take it away from the medications and procedures that medicine does, and actually study just the act of caring. That's, I think, what we're measuring when we study placebo effects.
FLATOW: And how did you get involved in this, in Harvard opening up this center?
KAPTCHUK: I was originally hired at the Beth Israel Deaconess Medical Center and Harvard Medical School in 1990 to help do research in Asian medicine. And when I got there - my original training was in Asia - they talked about we have to find out whether this intervention, be it acupuncture, herbs or other kinds of alternative therapies, is more than placebo.
And I would ask: So what does it mean that it's more than placebo? And they say: Well, it's more than placebo. And I have a background in civil rights when I was a young person. And I said, boy, they're treating this placebo effect like it's really some kind of disgusting phenomena. And what is it exactly? So I would ask, and I realized there wasn't a lot known. And I thought this would be a better way of doing my career.
Luckily, at that time, the NIH created a National Center for Complementary and Alternative Medicine, which has a deep interest in investigating the placebo effect. And I've been able to receive funding for many, many experiments, which hopefully have contributed to understanding this phenomenon better.
FLATOW: One criticism of giving patients placebos is that it's unethical, it involves deception.
KAPTCHUK: Anytime one deceives a patient, in my opinion, it is unethical. The clear standard of ethics is transparency, respect for person and informed consent. The only time you're able to do deception is if a patient agrees in a randomized control trial that things will be concealed.
So my job is to think of ethical ways of optimizing the different aspects of the therapeutic encounter so that we can use placebo effects ethically. The second way, my job is, to try to figure out: Is there a way of using sugar pills in situations where we really don't have good therapies, where the sugar pill may be valuable?
A third aspect of my job is to figure out ways of lowering placebo effects, because one of the problems for drug development is that sometimes the drug may be effective, but it competes with the placebo effect, and it's very hard to detect the difference. So those are my three jobs that I think I'm doing.
FLATOW: You had some interesting findings of an asthma study that you did.
KAPTCHUK: Yeah, our asthma study was published in the New England Journal this summer. It was funded by NCCAM at the NIH, and it was - it actually came out different than we expected. We gave - we bought time from asthma patients, 40 patients. And we brought them in, and we took them off their medication 12 different times.
And we brought them in every few days at one session, and at different times, we gave them an active bronchial dilator, albuterol, which is an effective drug for relieving asthma. Three times we gave them fake inhalator. Three times we gave them fake acupuncture, and three times we gave them no treatment, just sitting and doing nothing, because sometimes people get better by just sitting and doing nothing. We want to make sure that it's this - the placebo that's doing something, not just sitting and waiting.
And we had a very interesting finding that actually we didn't expect. We found that when we looked at objective measures, the amount of air that's pushed out of the lungs in one second, we found that the real medication was - showed a great improvement. The two placebos - the placebo inhalator, the placebo acupuncture - had a little bit of improvement, and the sitting there and doing nothing had a little bit of improvement.
There actually was no placebo effect at all on an objective measure on the pathophysiology of asthma. But then my asthma colleagues said, oh, my God. This whole experiment didn't work. And I said, someone get the statistician to get the subjective outcomes. How did people feel?
And when they crunched the numbers while we were waiting, it turned out that the - when you asked the patient how much they feel relief from their asthma, their subjective experience, their own personal sensation, the real medication was very effective. The fake inhalator was very effective, and the fake acupuncture was very effective. And just sitting there for two-and-a-half hours was - is very, very little.
And what we found was that on subjective, person-centered, how one feels, there was no drug effect, because the drug was no different than the two placebos. And it - we inferred to this, at least in this situation, that the placebo effect is mainly about how we experience things: symptoms, complaints, how we react to the underlying pathology.
Whether this applies across the board I think is too early to say, but I think it can say - at least in this experiment - it looks like the placebo is about the experiences that patients have, not necessarily about the underlying pathology. But obviously, more research.
FLATOW: Yeah. You didn't prevent the underlying pathology from working, but the patients didn't mind as much that something...
KAPTCHUK: Well, they felt as good as taking the drug, yeah.
FLATOW: Yeah, they felt as good as taking the drug.
KAPTCHUK: Right, absolutely.
FLATOW: Yeah. Is there any message here for doctors? We've got about a minute left. Any message here...?
KAPTCHUK: Well, I think the bottom message is the drugs are real important, but also just taking care of people and the act of compassion, taking care, the act of trust is really critical. And that - and with lots of experiments - show that that potentiates the effects of very powerful drugs.
The bottom line is low-tech placebo may have something to contribute to high-tech procedures, surgery and medicine.
FLATOW: And be much cheaper.
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FLATOW: Of course, you have to spend time with the patient, too, which is another story in itself, isn't it?
KAPTCHUK: Yeah, yeah. But, you know, a skilled physician, if you know - if you know how to ask: How is the person - how's your aunt doing? That's a major, major thing that takes a minute. Or how's the things - how's that problem at work going? Besides asking about the urination or where the pain is.
FLATOW: Interesting. Thank you, Ted.
KAPTCHUK: Thank you so much for inviting me.
FLATOW: Ted Kaptchuk is an associate professor of medicine at Harvard Med School and director of the Program in Placebo Studies and the Therapeutic Encounter at Beth Israel Deaconess Medical Center in Boston. We're going to take a break. We're going to come back and look at the debate over publishing two bird flu studies and the questions of balancing science and security. Should the studies be published as they were done, or should some data be withheld? All coming up after the break. Stay with us.
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FLATOW: I'm Ira Flatow. This is SCIENCE FRIDAY from NPR.
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