HUMAN BEHAVIOUR ESSAY 1993.

Topic 10: Discuss the concept of the Placebo Effect and how it pertains to the real-life practice of Pharmacy and Medicine.

"The Power of Thought - the Magic of the Mind!" (Lord George Byron. Cited by K.L. Roberts, 1940). How true, the human mind is undoubtedly quite magical. It's complexities stretch beyond our own horizons of comprehension and reach out into the mystic of the unknown. The mind possesses powers unrivalled by anything else - powers which extend to the self-healing of the human body with no aid other than faith - alias `the power of thought!' The use of the Placebo in medicine and pharmacy harnesses this incredible power and instigates the phenomenal self-healing process. The `Placebo Effect' has been used extensively throughout the history of medicine. Physicians have discovered the power of the human mind in healing and have tried to utilise this to it's full potential in all applicable aspects of therapeutic intervention. This report aims to discuss the Placebo Effect, it's power and history in relation to other forms of therapy, Case studies, the Ethical issues involved and whether they should be used or not. The `Placebo Effect' was defined by Wolf as "any effect attributable to a pill, potion or procedure but not to it's pharmacodynamic or specific properties" (Wolf, 1959. Cited by H.Brody, 1980). To date, the placebo has played a dynamic role throughout the history and development of medicine. Substances with no perceivable pharmacological benefit such as spiders, crocodile dung and human excrement have been prescribed up until the beginning of modern scientific medicine to treat various maladies. Obviously each of these substances induced a `Placebo Effect' in order to achieve the desired result as the treatment itself had no real medical value. However, as the medical sciences developed further, the incredible power of the placebo effect was anything but discredited - the power of the human mind in it's self-healing was deemed by clinicians as `voluminous'. It is quite profound, for instance, how a patient will commonly react much better when they are administered with a placebogenic injection as opposed to a lesser response from a tablet or capsule. This infers that the reaction received will vary in proportion to how potent the patient feels their treatment really is; obviously with the injection seeming to be the most potent agent. It is in conjunction with these hypotheses that the therapeutic sciences such as psychotherapy are formulated. It is also through the application of various forms of these `insight therapies' (communication therapy) that the use of the placebo effect becomes evident in real-life medicine and pharmacy. Psychotherapy (a form of insight therapy) relies heavily upon good communication. The interaction between the therapist and patient builds an environment in which the patient is helped to come to terms with his/her feelings and inner conflicts. The use of the placebo effect in therapy is quite relevant to present-day pharmacy and medicine. Pharmacists and medical professionals constantly have to use such therapy tactics when dealing with their clientele. This therapy may be in a directive or a non-directive manner. Many clinicians believe that psychotherapy is nothing more than the use of the placebo effect as it is the desire and expectation of the patient to be healed which is, or will become the therapeutic factor involved. This goes also for other forms of therapy such as psychoanalysis, psychosurgery, somatotherapy and behaviour therapy. The placebo effect is the one factor common to all areas of therapeutic intervention. Therefore it can be seen that it is not necessary to use a placebo pill, capsule or other agent for the placebo effect to be useful. What is required for any improvement is the patient's commitment to a therapeutic relationship, whether that be with a doctor, pharmacist or any other allied health professional, rather than a particular strategy employed by the therapist. Thus, for all practical purposes the therapist takes on the role as the placebo. The other side to this story is that no matter what skill or tactic is utilised by the therapist, if the patient comes into therapy with a negative attitude, then that patient will not experience any benefit from the therapy whatsoever. For instance, if the patient does not believe there is a problem or believes that the therapy is without any real merit. In short, therapies which utilise the placebo effect can only owe their success to the faith held in it by the patient as distinct from the therapeutic strategies employed. One of the most common explanations as to the placebo effect itself focuses upon the `self-fulfilling prophecy'. According to this, "people are motivated to interpret events to support their expectancies" (Worchel & Shebilske, 1983). For instance, in the following case study:
Case Study One: Bob and Mary are in group therapy to overcome shyness. Mary strongly believes that the therapy will be effective while Bob does not. After two sessions they meet a stranger on the bus and strike up a conversation. Mary sees this as a sign that the therapy is working. Her new confidence in the therapy motivates her to talk to other people. Bob on the other hand, focuses on how uncomfortable he felt talking to the stranger. This reinforces his doubts in the therapy. These doubts lead to his trust in the treatment diminishing until he fails to see any point in continuing and drops out. This case study shows how people's expectations not only influence the way people interpret their behaviour but also how these expectations have future consequences upon their efforts in therapy. The feelings of control describe a second reason for the placebo effect. A large portion of those who enter therapy do so as they believe that they have no control over what they feel or how they behave. It was suggested by Gatchel in 1980 that "the expectancy that therapy will be effective gives people a feeling of control over their lives" (Cited by Worchel & Shebilske, 1983). And it is this new found confidence and `control' which makes the therapy successful. A third explanation focuses upon a principle called `effort justification'. This entails people feeling compelled to justify to themselves anything they put effort into. The more effort, the greater the need to justify it. A method used for this justification process is to modify one's attitudes so that one will believe that the effort was worth it, seeing it as a positive and beneficial experience. The medical physician has held a position of great respect and trust in near all communities for most of time. Their position in society may impress people to the extent where people believe most all of what the doctor says. This faith instigates a placebo response which would explain the curation of many diseases and conditions through the administration of a pharmacologically inert agent such as `crocodile dung'. Thus, it is not solely the placebogenic agents prescribed as it is the faith that the patient has in his/her physician and the course of the treatment they are advising. Therefore, it is obvious that for the placebo effect to be instigated in therapy, it is imperative that the treatment be presented to the patient by the therapist in a positive and trusting manner. If not, the patient will not believe in the treatment as they do not feel that the therapist holds it in any high regard. Take the following case study as an example.
Case Study Two: A patient suffers from pain due to periodic bouts of rheumatoid arthritis. During one of these episodes he is administered sugar capsules being told that they are a new analgesic drug by an enthusiastic doctor. The patient reported drastic relief. This case is a straightforward example of the placebo effect in action. The patient believed in the treatment and became well without any real medical intervention. It is also very interesting to note how the placebo effect can be brought about through the colour of the placebogenic agent. This is demonstrated by the ability of placebos to heal certain kinds of tissue damage. The placebo treatment for warts, for instance. The warts are painted with a brightly coloured but inert dye. The patient is told that the wart will be gone once the colour wears off. This is as effective as any other treatment. Apparently the emotional reaction to a placebo can change the physiology of the skin so that the wart virus can no longer thrive (Barber, 1961. Cited by J.D. Frank). The true strength of the mind in conjunction with the placebo effect can be seen in the following:
Case Study Three: "A patient in acceptable physical condition who is scheduled to undergo open heart surgery becomes very depressed and insists, despite support and reassurance from the medical staff, that he is sure that he is going to die during surgery. The operation is begun and all is going well until, for no apparent reason, there is a sudden drop in blood pressure. All attempts to correct this fail and the patient dies." (H.Brody, 1980). This ability of one to `think' themselves into death is a good example of identifying placebo effects as either positive or negative. This death being attributable to a negative placebo effect. This is one of the many instances which support the suggestion that "Psychological states influence bodily processes or perceptions of bodily processes (Frank, 1974. Cited by H.Brody, 1980). The above case studies show how the resultant placebo effect may be beneficial or detrimental. And so, there are many ethical issues as to whether placebo use in medicine and pharmacy is justified. "They (placebos) weaken the confidence of the patient in the physician, because every placebo is a lie, and in the long run the lie is found out". "Placebo giving is quackery. It also fosters the nostrum evil." (R.Cabot, 1906. Cited by M.Strauss, 1968). This quote, taken from the Journal of the American Medical Association unfurls the concern of the medical profession over the moral reasoning of the placebo. Is this deception of patients ethically wrong? Placebos do deceive the patients but can this form of deception be justified? Physicians "cannot always tell the plain facts to the patient without injuring him" (Editorial in `Medical Record', 1885. Cited by H. Brody, 1980). A counter-argument to this deception issue is based on pragmatism. If a placebo can produce improvement isn't it then ethically wrong not to use it? How can it be better to prescribe a pharmacologically active substance, risking it's side effects when a totally inert substance will do the same work? There are obviously many advantages to the placebo and the placebo effect. The avoidance of active drugs and their side effects has already been mentioned. However, this does not take into account the "deleterious side effects that placebos can produce on their own" (Bok, 1974. Cited by H. Brody, 1980). It is true that placebos have an important beneficial capacity. However, it is predominantly the issue of deception which opposes their use. The Ethics debate remains unsolved. However, with doctors and pharmacists working in a therapeutic capacity, they must uphold some ethical doctorine. "The therapist must, inter alia, preserve patient's confidences, respect patients, not exploit them in any way and ensure that his methods are safe" (S. Bloch, 1982). Medical authors have suggested specific circumstances concerning placebo use. It is in these instances only that their limited use may be justified in keeping with medical ethics. These include:
* "Diseases for which no pharmacologically active treatment exists" (Frank, 1974. Cited by H. Brody, 1980);
* "Instances of necessarily prolonged diagnostic testing, during which the patient, if not placated by `treatment', might become dissatisfied and not return for needed therapy" (Leslie, 1954. Cited by H. Brody, 1980);
* "Illnesses for which no drug or other treatment is indicated, but for which the patient demands treatment" (Bourne, 1971. Cited by H. Brody, 1980);
* "Temporary situations in which placebos are used initially to placate the patient until a doctor-patient relationship can be established for more direct use of psychotherapy or emotional support" (Wolf, 1959; Frank, 1974. Cited by H. Brody, 1980). The relationship between the doctor/pharmacist and the patient is a critical part of the therapeutic treatment. The placebo effect is an integral part of any such therapy. Thus the success of the doctor/pharmacist in inducing a positive placebo effect depends in part on congruence between the expectations a patient has and what treatment they receive. The placebo and the placebo effect have a staggering amount of power. A power, which when properly studied and developed can, in the words of Howard Brody, 1980, "do much to highlight the centrality of the whole person both to the philosophy of medicine and to medical practice".

References.

Bloch,S. What is Psychotherapy? London : Oxford University Press, 1982.

Brody, H. Placebos and the philosophy of medicine. United States of America : University of Chicago Press, 1980.

Frank, J.D. Persuasion and Healing. New York: Scocken Books, 1975.

Roberts, K.L. Hoyt's New Cyclopedia of Practical Quotations. New York: Grosset & Dunlap, 1940.

Strauss, M. Familiar Medical Quotations. Boston: Little & Brown, 1968.

Worchel,W & Shebilske,W. Psychology: Principles and Applications. Englewood Cliffs : Prentice Hall Inc. 1983.