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Placebos in Clinical Practice
REINFORCING MIND-BODY LINK
Medical dictionaries define placebo as a non-medication substance, prescribed or given to reinforce the patient's expectation to get well. Research on the effect of placebos is of great significance to healthcare professionals because of their widespread use. That widespread use draws from their effect in the improvement of a symptom or disease without specifically improving the condition under treatment. That effect, called the placebo effect, has been proven powerful and inherent in clinical work. Furthermore, the patient-practitioner relationship is an equally essential part of the psychosocial aspect of treatment. Within that context, the practitioner communicates information on recovery and wellness through words, gestures and behavior. In addition to previous studies on the wide acceptance and use of placebos, a more recent one revealed that 46% of academic physicians in the Chicago area used placebos in their everyday clinical practice. A high 96% of them believed in the therapeutic effect of placebos and the connection between the mind and the body.
No specific protocol governs the clinical use of placebos. The bioethical aspect of their use has also been questioned. Despite these issues, most academic physicians frequently use placebos in clinical practice out of a belief in their therapeutic effect and the mind-body connection.
Placebos were already commonly used before the 19th century until displaced by modern medicine (Raz et al., 2008). Modern knowledge about the neural correlates of placebo mechanisms, however, restored the use of placebos. They soon gained popularity and hounded only by bioethical issues in evidence-based medicine. Nonetheless, some clinicians, mostly academic physicians, favor their relative usefulness and role in the body-mind connection. The worth of placebos may be questioned outside the realm of research but they are popularly used in clinical trials (Raz et al.).
Research itself provides evidence of the usefulness of placebos in clinical settings (Raz et al., 2008). A study of head nurses at a Connecticut health district said that they used placebos at that time or for the past six months at 44%. Another study conducted with house officers and registered nurses. The house officers said that 78% of respondent physicians ordered the use of placebos and 82% of the registered nurses administered them as painkillers. Doctors and nurses at the Victoria General Hospital in Canada said that 80% of the nurses administered placebos while on duty, 91% I the form of saline injections. Another research conducted with 263 respondents found that 68% administered placebos and only 12% within the previous year. A separate study among physicians and nurses in Israel showed that 53 out of the total of 89 respondents prescribed placebos. Of this total, 33 were prescribed to take once a month. And the most recent evidence comes from the study conducted with academic physicians in the Chicago area (Raz et al.).
The Placebo Effect
"Placebo" is a Latin term for "as I please (Jansen, 2005; ACS, 2010)." It was connoted with death during the Middle Ages. Professional mourner-singers during funeral masses were also called "placebos (Thomas, 2002 as qtd in Jansen)." It was only in 1811 when the term was included in the Hooper's Medical Dictionary that it was made to refer to a type of medicine to please him rather than cure or keep healthy. The placebo effect is the response of the patient to the placebo. While the modern scientific community has been aware of the beneficial placebo effect, the prejudice remains that it is not real. Thus, the full recognition of all its potentials is not attained to contribute to healing. There was even a problem agreeing on an acceptable definition. It was not until researchers Walach and the team of Moerman and Jonas came up with one, which now is generally acceptable. Walack (2004 as qtd in Jansen) defines the placebo effect as a therapeutic meaning response, which offers critical information on the mind, the body and culture that will heal the sick. Moerman and Jonas (2000 as qtd in Jansen) defined it as a positive healing effect arising from any healing intervention, assumed to be mediated by the effect and which develops some meaning to the patient. Their definition suggests that the placebo effect can be created by complementary and alternative medicine modes too. These modes include therapeutic touch, hypnosis, acupuncture and biofeedback ( Available evidence supports and explains the valuable mechanism of the placebo effect (Jansen, 2005).
Available evidence supports and explains the valuable mechanism of the placebo effect (Jansen, 2005). In his editorial at the Journal of American Medical Association, David Spiegel wrote that the placebo effect is not merely mind over matter and that the mind clearly matters. The need of the hour is to explore the healing power of the placebo effect that will transform it into an accepted therapeutic mode. This goal may be achieved by three types of belief. The first is the belief and expectation of the patient. The second is that of the physician, clinician or mentor of the patient. And the third is that belief and expectation, which grow out of the positive relationship between the patient and the practitioner. This possibility requires openness to alternative forms of therapy (Benson, 2003 as qtd in Jansen).
Brown (Thomas, 2001 as qtd in Jansen, 2005) suggested a model that can respond to the requirements of informed consent, clinical trials and clinical settings. The clinician should develop a professional and trusting relationship with the patient. He should inform the patient about all treatment options. He should inform the patient if a medication, such a placebo, has no active ingredient but may induce some healing effects in him or her. And he should reveal necessary information in order to comply with legal requirements. These requirements will, however, not eliminate one's reason to believe in the beneficial action of placebos.
Academic Doctors of Chicago
A survey of 231 physicians from the Internal Medicine Department of three medical schools in Chicago said that almost half of them at 45% use placebo in clinical practice.
(Sherman & Hickner, 2008). Their most common reason for the use is to calm the patient and to as a supplemental treatment. The responding physicians did not have a uniform explanation to the mechanism of action. About 96% of them believed in the probable psychological therapeutic effect of placebos on patients. Of this total, about 40% believed that create physiological benefits to cure or alleviate certain health conditions. Only 12% of those surveyed thought that its use in routine medical care should be categorically disallowed (Sherma & Hickner).
Findings of 8 earlier studies on hospital-based physicians and nurses revealed that 10 & and 80% of them, respectively, used placebos in their clinical practice (Sherma & Hickner, 2008). The use in two of the most recent studies showed that more than 50% of them used placebos. They considered the use ethical under certain circumstances. There have been concerns over informed consent and non-deceptive therapeutics in the use of placebos in medical practice. Other practitioners say the placebo effect may be pursued if there are no ethical questions. Scientists put placebos under a broad category of interventions, which affect and induce "psycho-biological functioning." Anthropologist Daniel Moerman perceived the placebo effect as a "meaning response." In his view, it encompassed the physiological and psychological effects of meaning in treatment. Goodwin and associates almost 3 decades ago reported on what the majority of academic physicians thought about placebos. They thought that these could determine the genuineness of a patient's symptoms. Large numbers of physicians believe that placebos have therapeutic effects. They help distinguish between psychogenic and merely organic symptoms. More and more physicians are taking the same position about placebos (Sherma & Hickner).
Nature and Mechanism
A placebo is an inactive substance that mimics regular medicine or treatment (ACS, 2012). It is given or prescribed to a person but he or she does not know it is not medicine. It may be a sugar pill, an injection, a liquid, a procedure or any other form of therapy. It does not directly affect the illness under treatment. It may not have direct biological effect on the illness or condition but, in out of 3 patients, they seem to assert the desired effect. An observed change in symptoms is termed as the placebo effect. This effect often lasts for a short while. In that duration, it seems to relate with the body's inherent capacity to briefly relieve pain or other symptoms. In other cases, however, it creates the opposite undesirable or worse symptoms, "side effects" collectively called nocebo effect. Headaches, nervousness, nausea and constipation are among these (ACS).
Placebo and nocebo effects are referred to together as expectation effects (ACS, 2012). Experts interpret this as the patient's experiencing what he or she expects. If he or she expects to be better, that will happen. But if he or she thinks the placebo is too strong, it may produce the undesired side effects. The placebo, in reality, does not cause these side effects directly. Rather,…[continue]
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