Institute For The Future

Telling Stories About Chemicals

The Boston Globe this week ran a great feature noting that as the ability to pinpoint causes of the placebo effect, as well as medical concerns that seem to respond well to placebos increases, doctors face an increasingly difficult practical and ethical question: Should they use placebos as part of their regular medical practice? Or, as Rebecca Tuhus-Dubrow frames the question, "if the placebo effect can help patients, shouldn’t we start putting it to work?"

 

At the beginning of her piece, Tuhus-Dubrow frames the debate as a sort of either-or--use placebos as medicine or don't:

 

But any attempt to harness the placebo effect immediately runs into thorny ethical and practical dilemmas. To present a dummy pill as real medicine would be, by most standards, to lie. To prescribe one openly, however, would risk undermining the effect. And even if these issues were resolved, the whole idea still might sound a little shady--offering bogus pills or procedures could seem, from the patient’s perspective, hard to distinguish from skimping on care....

 

There are limits to even the strongest placebo effect. No simulation could set a broken arm, of course, or clear a blocked artery. As a rule, placebos appear to affect symptoms rather than underlying diseases--although sometimes, as in the case of depression or irritable bowel syndrome, there’s no meaningful distinction between the two. Moreover, placebos have often received undue credit for recovery that might have occurred anyway. Indeed, the effect is famously difficult to identify, measure, and even coherently define. There is debate about the magnitude of the response, with some calling it modest at best, and opposing the idea of using placebos clinically.

 

But according to advocates, there’s enough data for doctors to start thinking of the placebo effect not as the opposite of medicine, but as a tool they can use in an evidence-based, conscientious manner. Broadly speaking, it seems sensible to make every effort to enlist the body’s own ability to heal itself--which is what, at bottom, placebos seem to do. And as researchers examine it more closely, the placebo is having another effect as well: it is revealing a great deal about the subtle and unexpected influences that medical care, as opposed to the medicine itself, has on patients.

 

 

This notion of an either-or debate, however, seems somewhat misguided. A few months ago, Wired Magazine ran a great feature looking at the variety of placebo effects and the different social and cultural factors that impact those effects. Among those factors? Not surprisingly, the illness being treated was key, as were things like the cost of the placebo, its size, even its color. My favorite example from that article pointed out that blue placebos make great tranquilizers--"except among Italian men, for whom the color blue is associated with their national soccer team—Forza Azzurri!"

 

I like the Italian soccer example because it's funny, but also because it's instructive. The impact of blue on Italian men compared with just about everyone else doesn't stem from any sort of chemical interaction--the placebo effect, as an academic might describe it, is culturally constructed. As a result, this suggests that doctors could make some fairly substantial improvements just by better understanding their patients emotionally, and doing a better job communicating.

 

Toward the end of the Globe piece, someone is quoted making roughly the same point.

 

“Medicine is intensely meaningful,” says Daniel Moerman, a professor emeritus of anthropology at the University of Michigan at Dearborn who coined the phrase “meaning response.” “It’s this highly stylized, highly ritualized thing.” He urges us to “forget about the stupid placebo and start looking at the system of meaning involved.”

 

 

This is a useful insight, to a point. But a lot of what creates the meaning, and hence the placebo effect, has to do with living in a context where medical sciences, and sciences in general, make constant improvements. And so we have an expectation that pills will do powerful stuff. Even if it were possible to harness all of the ritual value of taking a pill through better communication--and I'm skeptical about that possibility--I can't imagine that it would be nearly as efficient.

 

Which brings us back to a difficult ethical dilemma for the coming decade about how we can harness the power of storytelling about the chemicals we put in our bodies, without engaging in what amounts to lying. It's a very tricky, but I also think important challenge.