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Placebo 5 - Placebo treatments and the moral debate

Until the modern era, most medical treatments lacked any scientific basis and any impression of their effectiveness stemmed from a combination of the placebo effect and natural recovery (or natural fluctuations in the disease)

Antique medicine bottles from Britain. From Wikipedia
Antique medicine bottles from Britain. From Wikipedia

as we have seen in the previous post, the placebo effect apparently Is not Heals diseases on a physical level, but one thing is hard to argue with - He can make patients feel much better, at least in some situations. This can manifest itself in symptomatic improvements, pain reduction and more. If the patients' suffering can be alleviated, Why not give them placebo treatments?

The use of placebo in ancient medicine
Until the modern era, most medical treatments lacked any scientific basis and any impression of their effectiveness stemmed from a combination of the placebo effect and natural recovery (or natural fluctuations in the disease).

Exotic treatments, any connection between them and healing is purely coincidental, have been given to patients throughout history, and included for example a toad's eye, a bat's wing, dried fox lungs, electric currents, and mummy powder (which was believed to cure epilepsy, purulent wounds, rashes, fractures, paralysis, migraines, ulcers and more). For those whose mummy powder sounds like exaggeration or a wild exaggeration, we will tell you that in 1908 It was still possible to order "A real Egyptian mummy" from the Merck company.
In the 17th century there was a recipe for a medicine that cures "everything". Please open the notebook and make a note for yourself for a good day, who knows, sometimes these grandmother's remedies really work:
You take a fresh corpse of a 24-year-old ginger (preferably one that died by hanging, breaking on a wheel or impaled on a stake), and after a day in the sunlight and moonlight, cut strips from it and sprinkle some spices to soften the taste...
(The examples from chapter 10 in the book "Irrational and not coincidental").
But beyond the ridiculous treatments, the treatment of different "healers" throughout history To the sick, to the person suffering, or rather to the disease at the physiological level It is perhaps the main point that should be considered.
Think for a moment about the town doctor who arrived in a carriage with his famous suitcase containing not much more than a stethoscope. He would sit all night next to the feverish patient holding his hand, placing wet towels on his forehead and muttering words of encouragement (at least that's what I remember from "Little House on the Prairie"). Although such a "doctor" knew almost nothing about the disease from a scientific angle, and the procedures he used did not have any physiological effect in themselves on the course of the disease, it is very possible that his visit relieved the patient.

The Doctor - Luke Fildes - 1891 - Wikipedia
The Doctor - Luke Fildes - 1891 - Wikipedia

Placebo in today's medicine
With the development of medical science, man acquired understanding and knowledge on topics such as vaccines, hygiene and disinfection, bacteria, viruses, genetics and more. Recently, advanced medical technologies have been developed that allow rapid diagnoses, different types of imaging, advanced surgical techniques, transplants and effective drug treatments.
In the Western world familiar to us, a ray of "Bluetooth technology the medicine", while "The art of medicine” – that benevolent therapeutic envelope – has been pushed to the margins, some would say, too much. The enthusiasm for identifying substances and procedures that are highly effective in themselves has turned the spotlight away from the therapist-patient relationship, and has turned any additional benefit they provide to the patient into a "research bias" that needs to be cleaned up.
Treatments that are no more effective than sham treatments gone Approved for use, or deprecated (such as the artery ligation surgery we mentioned In the first part).
but Doctors don't always have an answer to the patients' complaints.
Every day dozens of people visit the doctor's office who suffer from headaches, stomach cramps, fatigue or those who have caught some virus, looking for some kind of relief. Many times the doctor has nothing to offer them except rest for a few days until the body subdues the virus, stress reduction, etc. But the patients expect real help. Click to get something. Why would the doctor not give them a sham treatment, if it could make them feel better?
It turns out that many doctors do!
A survey done in the USA found that although only a small percentage of doctors give dummy pills or injections, About half Of which they give prescriptions that they believe cannot directly help the patient's condition (like vitamins for example), but are only used as a placebo. Many more studies It is confirmed that the use of placebo is a very common phenomenon. The problematic point is that in quite a few cases doctors prescribe antibiotic treatment to treat viruses, a treatment that is not only ineffective, but has harmful effects on the entire population (in that it encourages the bacteria to grow stronger by natural selection). About half of the doctors who answered A survey done in Israel Admit that they are Placebos are used on a regular basis.

Placebo in alternative medicine

Placebo is the whole story

The success and wide spread of exotic treatments, any connection between them and healing is purely coincidental, are not the preserve of history alone. Hundreds of different types of placebo treatments They continue to thrive even today: crystals, magicians, spells, magnets, simple water (homeopathy), acupuncture, pressures, waving hands (healing, reiki), technological toys lacking any relevant activity - all these have been proven to be as effective as a placebo, at best.
Here and there you can find studies whose results showed some advantage of this or that treatment over placebo, but from a bird's eye view, as far as the research controlled Better yet, inclusive Many subjects יותר And up to date More, the results are getting closer to the results of the sham treatment given to a control group.
It is not my intention and ability to prove my sweeping claim in this record. This will require many records in the future. I previously touched on the subject The crystals, auras, prayers וA positive thought, and very soon I will briefly review homeopathy. In the meantime, I will argue that The vast majority of treatments that are defined as "alternative" or "complementary" are creative placebo treatments and nothing more. (The curious reader is welcome to start in the book "Healing or seduction” which refers to hundreds of studies in the field, in addition, you can check what is written In this document Regarding your favorite alternative method - it is recommended to save it for a closed day).
But does this mean that these treatments have no effect on the patient? The answer is of course negative. As we have seen, there are sometimes considerable differences between the condition of patients who received no treatment at all and those who received sham treatment.
Here are some tidbits from the field of Chinese acupuncture, which will sharpen the interest.

Real acupuncture vs. sham acupuncture - find the differences

A series of studies carried out in Germany compared three groups of subjects: one group received treatment in classical acupuncture, a second group received Sham acupuncture (superficial acupuncture on points that are not acupuncture points), and a third group or who did not receive treatment at all or received standard treatment (depends on the study). It is important to note that the participants were not told that "they may receive sham acupuncture", but that "they will receive either classical acupuncture or another type of acupuncture, which has shown effectiveness in clinical trials in the past" (which is true), and this is so as not to damage the element of expectation of improvement (as we have seen happen if tested know that they may receive a placebo). The conditions studied were Migraines, Chronic lower back pain, knee rheumatism, and more.
No A significant difference was found between the two acupuncture groups (real and simulated) but Yes There was a significant difference between them and those who did not receive treatment or who received standard treatment.
for example, in research which included over 1100 low back pain sufferers, the subjects received a series of 10 acupuncture treatments of 30 minutes each over 5 weeks. About 48% of the real acupuncture recipients reported an improvement, So are 44% of the sham acupuncture recipients, compared to only 27% who performed physical therapy and received painkillers as needed.
These findings, which indicate that Chinese acupuncture has no specific effect As for the conditions for which the treatment is given, they have been reinforced in many other studies, for example in this review of 13 additional studies that included over 3000 subjects. The real acupuncture showed a small and insignificant advantage over the sham acupuncture, and the researchers claim that it can easily be due to biases of one kind or another.
in this study and also in this study, acupuncture dummy Get results Even better than real acupuncture...
Thoroughness check More than a few of the studies mentioned above showed that it was A significant correlation between the level of expectations of the subjects that the treatment will help them, and its usefulness in practice in alleviating their condition (regardless of whether it was real or fake acupuncture).
On the one hand, these results can be seen as a triumphant blow to the supporters of the Chinese acupuncture method, since it does not seem that the thousands of years old Chinese Torah differs in its effectiveness from sham treatment.
On the other hand, these placebo treatments benefited the patient יותר than the standard treatments that medicine had to offer in these cases.
In any case, the placebo researchers won a wonderful gift - a powerful placebo to use in their studies! (At least until the validity of Chinese acupuncture decreases, and with it the strength of the placebo response).

Changing marketing tactics

As the serious studies that examined different fields of alternative medicine multiplied, the clear picture emerged - These are placebo treatments that lack specific medical effectiveness (The situation regarding Homeopathy for example, the same). For many years, the believers in alternative medicine struggled with the facts, and cited anecdotal studies that showed that their method has an advantage over placebo.
In recent years, the attitude seems to be changing, and a spin is being put on the placebo effect. "OK", they say, "our methods No Better than placebo, but the placebo effect is amazing! The placebo cures everything! This is a revolution in medicine! Placebo treatments work just as well as drugs! They work even when you know you are taking a placebo! Consciousness heals the body! With the power of thought you can overcome any disease!" And so on.
But these claims are not based on evidence. The studies that have been carried out to date (and we examined some of them closely) indicate that the patient's belief that he is receiving effective treatment maid to his feeling Because his condition is better, and in the best case it reduces the external symptoms of the disease, but Does not affect the causes of the disease and the course of its development.
The situation is somewhat ironic. Supporters of alternative treatment methods boast that, unlike modern medicine, which only treats symptoms, they, according to them, treat the root of the disease. In fact the situation is the opposite. If one of the parties is accused of superficial and symptomatic treatment only, then the finger is pointed at all those placebo treatments.

The dangers

Beyond the lack of medical benefit of the treatments, the symptomatic improvement provided by the placebo effect may harm the person, If he doesn't get real treatment at the same time. In the end, pain can be seen as the body's way of signaling to us that there is some problem that requires attention. As soon as the pain is alleviated without treating the root of the problem, the situation will worsen without our knowledge.
Let's go back to the experiment with asthma patients that we reviewed earlier. The placebo treatment did give the patients the The feeling Because their condition improved, while the objective measurements of the lung functions showed that That is not the case. Treatment at the initial diagnosis stage of asthma may stop the worsening of the condition. Furthermore, if the situation is already severe, an asthma attack may lead to death - About 250,000 people die each year from that around the world. A patient who takes a placebo treatment (=alternative, in this context) and feels that his condition has improved, instead of receiving medical treatment that improves the condition objectively, may end his life prematurely.

About tasty food versus nutritious food, and about the winning combination

A simple analogy can clarify the way I see things.
At one end (the right) are the effective medical procedures that are given without any empathy. Cold, alienated, pressed for time, and without any interest in the patient. The patient feels like a malfunctioning device in a repair lab (I exaggerate and exaggerate on purpose to sharpen the distinctions). This is like sitting in a cold, dark basement and drinking a thick greenish drink with a repulsive taste that contains all the nutrients that a person needs for their health.
At the other end (left) we find (again, at best) a supporting treatment envelope based on medical procedures that are ineffective in themselves. This is likened to a dish of artificial food to which flavor, smell, color and texture components have been added, but in fact it lacks any nutritional value (in the photo - one of the plastic dishes in the shop window of a typical Japanese restaurant).
In the middle is the winning combination. The ultimate goal of medicine (as I see it at least): An effective and safe medical procedure, which is given in a supportive, strengthening and caring therapeutic envelope. This is like a gourmet meal Delicious and nutritious. The good elements of both worlds are combined for them.

Now people will jump up and say - "But this is exactly what is meant when talking about medicine Complementary! A combination of conventional and alternative treatments!"
And I ask, why combine a disgusting health drink with a delicious fake food? Why not make a nutritious gourmet dish?
Isn't it more correct to strive for one therapeutic framework in which the same therapist will provide both a supportive, empathetic and encouraging attitude as well as safe and medically effective treatment?
As a dessert dish (with macabre humor sauce) here are some more creative alternative treatments in action (don't miss the last 3 minutes):

Perhaps the analogy of delicious and beautifully served food is not the first association that remains after watching the video...

The moral dilemma

We will return to the question with which we opened this record and push it to the end. Obviously, it would not be a wise idea to settle for a symptomatic placebo treatment if a treatment with objective physiological efficacy exists. But what about cases in which there is no effective treatment available? If the patients' suffering can be alleviated through placebo treatment, why not give it to them?
On the one hand, apparently there is no special reason to avoid such treatment - at least it will ease the suffering. But on the other hand, placebo treatment is mandatory Patient fraud by definition and stands in contradiction to the principle of transparency of information given to the patient about his condition. Clearly, two basic principles are at odds here: the duty to help the patient, versus the duty of transparency.
* Should a doctor deceive the patient in the hope that he will be among those people whose condition will be improved by the sham treatment?

* Should the doctor lie bigger lies and make bigger promises to enhance the effect?

* Should pharmaceutical companies produce dummy drugs and sell them for money? Should a higher price be charged for them to increase the effect? (Although the cost of the drug will be zero?)

* Should the drug's marketing include fictitious superlatives to increase its effectiveness?

* Should a doctor avoid giving a too negative (and true) diagnosis to the patient in order not to intensify the side effects by the nocibo effect (the opposite effect to the placebo, in which following negative expectations we experience symptoms of worsening of the condition)?

* Could the success of a placebo treatment undermine the patient when he learns the truth, and make him think that this proves that "it was all in his head"?

* What about a violation of trust between the patient and the therapist when he finds out one day that he received a placebo? And trust in the medical system as a whole?

* If we allow the commercial use of placebos, will we not create a situation where no one will know what is a real drug and what is not? (After all, if it is written on the drug page that it does not contain any active substance, its effectiveness as a placebo will probably disappear).

Can you offer guiding principles regarding when, how much and in what way to give placebo treatment, if at all?

* * *
Thanks again to Dr. Karen Landsman, a specialist in epidemiology and public health, who read the material and made helpful comments. You are welcome to visit her blog - The end of the world - a view from the stands (On reality and other diseases). Also thanks to Itzik Shohat - an intern, who also reviewed the material and made his comments.
Sources and extensions

5 תגובות

  1. what's the story? Doctors still think they are fighting some kind of holy war against disease and death.
    Do yourself a favor and just let the patient feel good, as almost half of the doctors in America have already understood

  2. What is the problem? As in evolution, they will be subjected to enormous and immediate trauma and the patients will evolve

  3. 1. Regarding the questions at the end of the article: for the first five my answer is no. Which does not prevent their existence already in the present. My answer to the last three is yes. Which does not prevent their existence already in the present.

    2. Have other ways of creating a dummy effect been tested? Long term distractions for example?
    What I mean is that instead of a placebo, accompanying the patient by the therapist or positive reinforcement, the patient went for a walk, played a game or was given an interesting and challenging activity during the treatment that would distract him from his condition?
    If so, will we measure these results in relation to placebo, real treatment and no treatment?

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