In the last decade, the study of placebo has moved from the backwaters of medical research to nearer the mainstream. There is now a Program in Placebo Studies at Harvard. NIH and nonprofits like the Robert Wood Johnson Foundation fund placebo work. Journals publish papers. What used to be dismissed is now taken increasingly seriously.
It's fair to say this shift wouldn't have happened without Ted Kaptchuk, who heads Harvard's placebo program. Over 35 years, he's been investigating placebos, which are medical interventions without active drug ingredients, in various contexts and expanding the scope of the field—including, for a time, to his own acupuncture practice.
To Kaptchuk, the placebo effect is brought about by much more than sugar pills and saline injections. It's about the whole "drama" or "theater" of medicine—essentially the context of the encounter between patient and physician—as much as treatment itself. "The placebo effect is the effect of everything surrounding the fake pill, or the real pill," he says. "It's the compassion, trust, and care. It's the ritual and symbols. It's the doctor-patient interaction."
Kaptchuk has published several papers that have gotten wider attention beyond the world of academic journals and conferences. For example, he got a big response for a study with irritable bowel syndrome patients, where he showed that placebo could be effective even when patients knew the treatment was fake. (The drug bottle had a big "placebo" label on it.) Though the study only included 80 volunteers, the results seemed to indicate something profound: When patients want to get better, and believe that doctors are there to help them, good things happen.
Kaptchuk credits the growing respectability of studying placebos down to the wider availability of neuro-imaging techniques. By demonstrating physiological impact in the brain when a patient takes a placebo treatment, researchers can move beyond conjecture about how the effect works. "The discovery of neurobiology has made physicians in the medical community more comfortable that something is going on that they have to pay attention to," he says. "Before it was just the imagination. Now, the imagination has a real neurobiology."
Researchers can begin to see inside the brain, helping to gauge what works and when. Neuro-imaging has allowed researchers to look at whether there's a genetic basis for why some people seem more susceptible to placebo treatments than others.
The recent research findings do beg a serious question, though. Are we going to see actual treatments based on pills that are no more than sugar as alternatives to active drugs? How might medicine incorporate the work that Kaptchuk and other placebo researchers are bringing to the world?
In some ways, it's already happening. A survey from the U.K., recently showed that many doctors are already prescribing placebos on a regular basis. Out of 783 doctors, 12% said they had used "pure" placebo (sugar pills, saline injections) while 97% had used "impure placebos" (prescribing drugs without scientific basis, like antibiotics for viruses). More than three-quarters said they did so at least once a week, and many didn't have an ethical problem with deceiving patients if treatments were effective.
Kaptchuk is not in favor of deception. Nor does he think sugar pills cure cancer. He does believe placebo research can help with conditions where self-appraisal is important. "You can change a person's sense of the symptoms. The only thing we know for sure is that the ritual of medicine changes subjective outcomes and that there's a biological substrate to that," he says. "The placebo is going to be for things like headache and back pain, muscular skeletal pain, and digestive and urinary problems."
Kaptchuk says small changes in how drugs are delivered can improve a patient's well-being. For example, if you inject someone with morphine, and tell them what they're getting, it has double the effect of putting an IV in their arm and telling them nothing. That puts more responsibility on the medical community to provide care, rather than just relying on drugs to do the work.
"Placebo is about how we improve care independent of medication. It really puts the onus on the physician, because it says, 'if you're not doing this, it's actually bad care.' In the pharmaco-centric world that medicine is, it's about finding the right drug. Placebo research begins to shift that whole concept."