I recently came across a medical study that caught my eye because it investigated a controversial subject. In a survey of doctors from 21 countries, researchers posed this question: How often do you prescribe treatments that are “essentially placebos”?
As a reader of the Wellness Letter, you’re no doubt familiar with the concept of the placebo—inert substances, like sugar pills or saline solutions, that are routinely used in clinical trials to test the effects of a new medical treatment. If the treatment works better than the placebo at, say, easing pain or lowering high blood pressure, then we know it’s having distinct effects on those conditions. Just as important, we get an idea of the treatment’s side effects, compared to the placebo.
While placebos are a crucial part of medical research, doctors don’t prescribe them to patients in everyday practice. Usually.
The study, published in the journal JAMA Network Open, found that of the 818 primary care doctors who responded, 84 percent admitted that they had prescribed a treatment that was essentially a placebo to at least one patient. They didn’t do it often—on average, at one out of every 150 appointments. But the point is, most physicians had done some placebo prescribing.
To be clear, this doesn’t mean doctors are sending patients to the pharmacy to pick up a bottle of sugar pills. The study asked physicians how often they had recommended “essentially placebo” treatments—vitamins, supplements, or medications that had active ingredients but none that they expected would ease patients’ symptoms.
Why would a doctor do that? The study authors didn’t ask. But previous research has found that doctors sometimes do it to avoid conflicts with patients who are pushing for a remedy. In many cases, though, they prescribe placebos when they cannot determine the cause of a patient’s symptoms but believe that there’s a psychological component; they reason that giving the patient something will create a positive expectation and, hopefully, help them feel better. They are, in other words, trying to take advantage of the “placebo effect.”
The phenomenon of the placebo effect has been recognized since antiquity, and it’s still seen all the time in modern clinical studies. In every so-called randomized clinical trial, some number of patients in the placebo group show an improvement in their health condition even though they’re not receiving a treatment with an active ingredient. This is most evident in clinical trials that involve patients with symptoms such as pain, depression, nausea, or stress-related insomnia—where a person’s subjective experience of the problem is particularly important. If you have painful arthritis, a placebo might not change anything about your arthritic joints, but if you believe that the pill you’re taking every day will help you, it might alter your perception of the pain.
Again, placebos are vital to conducting clinical trials of new treatments. It’s also ethical to use placebos in that context: Before patients enroll in a trial, they are informed that they might end up in the placebo group and not receive the treatment under study.
Routine medical care is another story. Before the 1960s, it was actually common for doctors to prescribe inert substances, including sugar pills or “bread pills,” in order to promote the placebo effect in their patients. But as scientific research began yielding effective treatments for all types of ailments—and the principle of patients’ informed consent took shape—placebo prescribing came to be seen as unethical.
While bread pills might be a thing of the past, doctors are still, apparently, prescribing “essentially placebo” treatments. And that brings up some concerns. In the new JAMA study, those treatments were usually benign—vitamins or other dietary supplements with a low risk of causing side effects (though patients can take a hit in the wallet). But in a small number of cases, doctors did prescribe antibiotics, sedatives, or other medications that can do real harm if taken inappropriately.
And even when a placebo is unlikely to cause any significant side effects, we’re still left with a major issue: deception. In my own practice, I never prescribed placebos to patients because I believed that would be a breach of trust—the foundation of the doctor-patient relationship.
I do, however, think it’s vital for us to deepen our understanding of the placebo effect. Some fascinating research has been done in recent years, showing how the placebo effect operates. It’s more than just positive thinking. When people experience a placebo effect, research shows, their brains may bump up the production of chemicals that affect mood, sleep, pain perception, and other critical functions. So even though a placebo may have no active ingredient, for some people it may still have a real impact on the brain.
Can we capitalize on that knowledge in everyday healthcare? Many researchers and doctors think there are ways to ethically use what we’ve learned about the placebo effect. Doctors could, for example, take more time to discuss the potential benefits of a medical treatment (without overselling it), to help patients have positive expectations. Relatedly, doctors could also talk about the true likelihood of having any scary-sounding side effects that a patient may have come across online or in a TV commercial. That could help address the “nocebo effect,” where negative expectations raise the odds of suffering treatment side effects.
Finally, I’ll circle back to what I said about trust. The placebo effect depends on more than patients’ expectations of the treatment, per se. It also depends on the “ritual” of receiving treatment from a medical professional who demonstrates care. Studies show that when patients feel their doctor is empathetic and communicates openly and honestly, they are more likely to believe that any recommended therapies will help them. I think this is where doctors can really harness the power of positive expectations—not by prescribing supplements we don’t really believe in, but by building trusting relationships with our patients.
