A Placebo is more than just a Sugar Pill

Andi Leff (’18) majored in Biological Chemistry at Grinnell College and will be attending medical school at the Uniformed Services University of the Health Sciences in the fall of 2018. Her favorite color is orange, she believes wholeheartedly that WAWA is the greatest gas station ever, and she advocates daily the east coast is the best coast. Her inspiration for this article arose from her shadowing experience with a family physician this past summer. This experience allowed her to recognize that medicine is about much more than the symptoms, it’s about the patient.

What if I told you your doctor should be tricking you?

In the medical field, there is a phenomenon called the placebo effect; the idea a treatment can relieve symptoms just by the belief that it will. In order for pharmaceuticals to be considered legitimate, their research must prove they are more effective than placebos. Placebos are mostly studied in response to pain treatments and unfortunately even when they do “work”, they do not result in permanent cures [1].

But, what if there was such a thing as a placebo effect for any treatment? If you look closely at the origins of medicine, you will see the placebo effect is much more prevalent in all aspects of medicine than just pain management. A person’s belief about their medical treatment has a bigger influence on the success of it than you’d think. Mainstream medicine makes it difficult to study this phenomenon because feedback of medical treatments is not the standard, or even recorded, in most cases. There are also several influences that factor into the success of a treatment, making it very difficult to determine how influential a patient’s trust in their treatment is on its success.

The greatest discrepancy that occurs in the biomedical world that can most easily be attributed to treatment success is the cultural variation in the definitions of disease and illness. Originally, most medical practices originated from religious beliefs. Native Americans often turned to ancestors and spirits to guide their medical decisions, and African Americans had a very cultural and community based sense of healing. Due to these various views of medicine, there was tension between the various communities as to the proper medical approach. Mainstream White Society often dominated in terms of prevalence, however, their treatments were not always the most effective for every patient.

Modern medicine has relied heavily on pharmaceuticals and focused more greatly on the biological components relative to alternative forms of medicine [2]. Modern medicine is said to be very disease-centered; it focuses on symptoms and treatments that will best resolve those symptoms. Over time, society has accepted the resolution of symptoms as the main goal of medicine and in the process neglected the necessity of understanding the realistic component to treatments. Medicine in any form is ethnocentric because it is reflective of society’s ideals, and thus is inherently flawed in being able to accommodate a population of patients unlike its culture. The issue arises when the patients utilizing a form of medicine do not partake in the mainstream culture, causing the values of the practice to not align with the beliefs of the patient, resulting in unsuccessful treatments.

In a study conducted by the Department of Gynecologic Oncology at the University of Texas M. D. Anderson Cancer Center in Houston, Texas, the researchers focused on the social factors that can influence the success of a person’s treatment such as socioeconomic status, accessibility, and health literacy [3]. This case study not only highlighted the negative effects of not having access to resources (one of the flaws of our society’s healthcare system) but it also emphasized the lack of trust held by many non-privileged individuals for the medical system. In this case, due to lack of trust, the patient (a lower-class, African-American woman), even after she obtained access to proper medical care, was unable to recover from her diagnosis. While this paper places more emphasis on social factors rather than patient beliefs, it’s important to recognize there are systematic flaws that induce patients’ mistrust in the medical system. Often, poor outcomes do not arise from rumors and myths, but from stories and occurrences of real people.

Cultural competence plays an important role in determining a patient’s trust in their doctor. About 50% of the patients physicians will encounter will be minorities of varying cultures and beliefs; each of which will hold those beliefs precedent to their medical treatment. In order to have the most successful treatment, it is crucial that their religious and cultural values be accounted for. A study from 2007 analyzed the difference in treatment outcome between African Americans and Caucasians, finding not only were Caucasians given preferential treatment, but they also have higher success rates in all forms of treatment [4]. According to Giger, African Americans often associate health with luck or success, and in order to become well again, it is critical their community believes in them and physically is there to support them. This cultural aspect of suffering health due to poor decisions made in life is not a connection made by physicians who practice modern medicine. As a result, when the physicians are unwilling to incorporate the patient’s beliefs into their treatment plans, the tension and conflict prevents the patient from getting better regardless of the “hard science” available to prove the treatment effective.

In Eiser’s study, he found African American patients when able and encouraged to continue practicing their spiritual beliefs tended to have lower blood pressure and had more successful medical visits, as opposed to their counterparts who were restricted to the mainstream white-centric form of medicine [5]. Eiser also introduced a new concern by noting the incorporation of spiritual beliefs increased medical success, but too much religious reliance had adverse effects because patients refused treatment and relied completely on divinity to cure their health issues, which did not result in patient survival a majority of the time.

Taking a look at the case of Desbah, a 99 year old Native American woman, we can see the cultural disparity between the definitions of disease and illness play out [6]. In the Native American community, wellness is much more spiritual and health is promoted by living in harmony with the earth. She still visits a modern physician for wellness visits. However, she uses modern medicine in conjunction with the herbal and spiritual practices of her Native community. Unfortunately, these spiritual beliefs have tapered off through the generations, and unlike their ancestors, modern Native Americans who have integrated into modern society more have had increased incidence of many medical conditions, the most prevalent being diabetes. It can be speculated by integrating into mainstream society, the younger generations of Natives lessened their belief in Native culture. Because of this, the Native spiritual practices had less of a positive influence on their health.

While making this assumption alone would make great strides in the medical field of understanding the influence of the placebo effect with treatments, neglecting other cultural influences such as eating habits and exercise, would be ignorant. Also, we must account for the growing influence modern medicine has on mainstream culture. With its recent boom in advancements, medicine has gained much more social capitol and has become a trusted institution in society. As a result, younger Native Americans may be experiencing stronger influences from modern medicine, which are less flexible and inclusive of religious and spiritual ideas, making it more difficult for the younger generations to incorporate their cultural practices into their healthcare. This conflict of modern medicine, suggested by family physicians and mainstream society, and cultural medicine, learned from ancestors and encouraged by family, creates tension within the patient’s healthcare and leads them to be unsure of which practice they believe in. Not to mention, spiritual and biomedical treatments often conflict heavily, causing patient’s to reconsider their core values when determining medical treatment.

A similar study looked at protocol differences between the UK and America for Hodgkin’s Lymphoma treatments to better understand the cultural differences that could play into treatment success [7]. Overall, there were not many protocol differences found between the two countries. The only distinct difference was in how physicians categorized the severity of the patient’s condition. Based on age, gender, etc., different cultures defined the same disease in different ways highlighting the complexity in pinpointing the factors responsible for treatment success. The inability to separate out the factors responsible for successful treatments make it easy for modern physicians to hide psychosocial influences under the rug and ignore their negligence towards their patients and their specific circumstances; if it’s not biologically relevant, it does not have to be accounted for.

In order to try and account for all the variables mentioned, it is helpful to analyze patient beliefs in a small homogenous population that are recovering from a less severe condition. In a study performed on U.S. Marines recovering from Musculoskeletal injuries, those who had high recovery expectations were five times as likely to have a successful recovery by their follow up visit than those who had low recovery expectations [8]. By controlling for many of the demographic and psychosocial factors that influence the success of a patient’s treatment, a correlation between optimism and recovery was able to be made.

This study also opens gateways by looking at medicine through a non-religious lens. While the importance of incorporating patient’s beliefs and values into their treatment has been seen to have a huge effect on the patient’s trust and success of their treatment, by relying on religion to dictate medical outcomes, the population of patients able to utilize this information narrows, which is something the medical field is striving to improve on. Looking strictly at whether or not the patient had an optimistic outlook on their recovery/treatment regardless of spiritual/religious belief is a huge stride in understanding the power in the placebo effect as more than just a pain reliever.

This study, just like the others, also unfortunately highlights the complexity of determining treatment success. While they were able to determine a correlation between belief and success, they were still unable to account for influential factors such as mental health, pain severity and sensitivity, and job influence. Using this information we could argue that positive and optimistic mindsets can greatly improve the success of treatment, however, they cannot be the end all be all; A positive outlook on the treatment is necessary in addition to proper medication and healthy habits in order to have the most success. There are many factors that influence a patient in any stage of disease/illness, and the power of the mind should not be taken for granted when determining the best course of treatment. These studies suggest that, within reason, some biomedical sacrifices could be made as long as they are supplemented with a great attitude and optimistic outlook on the future of the treatment.


End Notes

[1] Scott, R. (2010). Belief, Hope, and Healing. In Miracle Cures: Saints, Pilgrimage, and the Healing Powers of Belief (pp. 128-148). Berkeley; Los Angeles; London: University of California Press. Retrieved from http://www.jstor.org/stable/10.1525/j.ctt1ppj66.12

[2] Putsch RW III, Joyce M. (1990) Dealing with Patients from Other Cultures. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths. Chapter 229. Available from: https://www.ncbi.nlm.nih.gov/books/NBK340/

[3] Westin, Shannon N.; Bustillos, Dan; Gano, Jacalyn B.; Fields, Margaret M.; Coker, Ann L.; Sun, Charlotte C.; and Ramondetta, Lois M., “Social Factors Affecting Treatment of Cervical Cancer: Ethical Issues and Policy Implications” (2008). CRVAW Faculty Journal Articles. 139. http://uknowledge.uky.edu/crvaw_facpub/139

[4] Giger, J.N., Davidhizar, R.E., Turner G. (1992). Black american folk medicine health care beliefs: implication for nursing plans of care. ABNF J. Vol 3(2); 42-46.

[5]  Eiser, A.R., and Ellis, G. (2007). Cultural Competence and the African American Experience with Health Care: The case for specific content in cross-cultural education. Academic Medicine, Vol. 82 (2); 176-183.

[6] Koithan, M., & Farrell, C. (2010). Indigenous Native American Healing Traditions. The Journal for Nurse Practitioners : JNP, 6(6), 477–478. http://doi.org/10.1016/j.nurpra.2010.03.016

[7] FitzGerald, T. J., & Bishop-Jodoin, M. (2018). Hodgkin Lymphoma: Differences in Treatment Between Europe and the United States/North America: Evolving Trends in Protocol Therapy. Clinical Medicine Insights. Oncology, 12, 1179554918754885. http://doi.org/10.1177/1179554918754885

[8] Booth-Kewley, S, Schmied, E., Highfill-McRoy, R., Sander, T., Blivin, S., Garland, C. J (2014) Occup Rehabil. 24, 287-296.


Further Reading

  1. Ernst, E., & Resch, K. (1995). Concept Of True And Perceived Placebo Effects. BMJ: British Medical Journal,311(7004), 551-553.
  2. Bock, G. (2008). Medically Valid Religious Beliefs. Journal of Medical Ethics,34(6), 437-440.
  3. Blease, C. (2012). The principle of parity: The ‘placebo effect’ and physician communication. Journal of Medical Ethics,38(4), 199-203.