The seemingly widespread use of sugar pills and other inactive treatments identified by the survey highlights a mounting debate over the issue, with some experts arguing that placebos should be accepted as a legitimate — and side-effect-free — alternative to drugs.
Others say giving patients harmless but chemically inert treatments — especially when disguised as something else — cannot be justified until there is better-quality research proving they actually help.
Many in the profession already seem convinced. Most of the 600 MDs across Canada surveyed by Amir Raz, a McGill University psychiatry professor, and colleagues indicated that they thought placebos do, in fact, have some therapeutic advantage, a paper just published in the Canadian Journal of Psychiatry indicates.
"Physicians really know and have known for a very long time that placebos can be clinically effective," said Prof. Raz in an interview. "But at the same time most physicians realize that giving placebos is sort of professional bad form.... At medical schools, they teach absolutely nothing about this."
They should get more attention because health care relies too much now on pharmaceutical products that often do harm as well as good, argues Dr. Ted Kaptchuk, a Harvard University medical professor who has studied the topic extensively. Yet suggesting that inactive substances can make people feel better still rankles some in the medical profession, he said.
"Doctors went to medical school to give out pills, to do procedures, to do surgeries," said Dr. Kaptchuk. "Telling them to actually show their colours -- to admit that a lot of what they do is actually what a shaman does -- is very disconcerting."
Placebos emerged as a major issue in modern medicine in the 1940s with drug trials that tested medicines by comparing their effects to those of similar-looking fake pills or injections.
Such testing is still the norm and drugs with no more impact than a placebo are generally considered worthless, fuelling a negative perception of the inactive treatments, notes Franklin Miller of the U.S. National Institutes of Health in a recent report.
In 2006, the influential American Medical Association issued an ethics policy that specifically barred doctors from giving patients placebos while deceiving them about the true nature of the treatment.
McGill's Prof. Raz and his team conducted a survey of specialists throughout Canada, receiving responses from 606 doctors, 257 of them psychiatrists.
About 20% of both psychiatrists and non-psychiatrists said they had used placebos in treating patients. The specific treatments they confirmed using included actual placebo tablets, sugar pills and saline injections. Some -- including 35% of psychiatrists -- said they also used "sub-therapeutic" doses of real drugs, amounts too small to have any chemical effect on the patient.
Of those who said they might give patients a placebo, just 17% said they would reveal the true nature of the therapy, the others indicating they would use some kind of deception, the researchers wrote.
Even some experts who urge caution in the area acknowledge there is evidence placebos work. Administering them without telling patients they are placebos is unethical, however, and there need to be rigorous, randomized trials -- the gold standard in medical research -- proving their worth before the practice becomes routine, Dr. Miller of the NIH Bioethics Clinical Center in the States concluded in a 2009 paper.
Prof. Raz argues, however, that the evidence is all but incontrovertible that placebos do make some patients better, and it is too late to bar the practice or turn blind eye to it.
In an intriguing display of the dummy-pill effect, he issues medical students in one of his classes either blue or red tablets, and tells them they are placebos. Students then examine each other. Those taking the red pills tend to have higher blood pressure and heart rates, those taking the blue, an opposite, calming effect.
Dr. Kaptchuk says there is evidence that placebos actually trigger chemical changes in the brain, and are especially useful in treating conditions, from back pain to depression and anxiety, that involve patients' subjective feelings.
The practice harnesses the intangible "ritual of medicine -- the white coat, the stethoscope, the diploma," he said.
And contrary to widespread belief, it is not necessary to convince patients they are actually taking a real drug for placebos to work, he said. A trial he and colleagues published a few months ago found that irritable-bowel syndrome patients who took a placebo, and were told what it was and the effect placebos can have, improved significantly compared to those getting no treatment.
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