Is surgery a placebo?

April 10, 2007

From Martin Hutchison in BBC News:

In the early days of medicine, physicians might diagnose patients using bumps on their head, or dispense a couple of leeches to draw off “ill humours”.
Yet a medieval doctor might give a more confident response than his modern equivalent if a patient asked for the evidence to support their treatment.
These days, it seems many of our “tried and tested” approaches to disease are nothing of the kind.

Researchers writing recently in the British Journal of Surgery concluded the practice of daubing patients with a disinfectant skin gel prior to operations made little or no difference to the rate of infections they suffered afterwards. Simple soap and water was just as effective.

However, despite this, it’s more than likely that, in future, waking up after your operation in many British hospitals, you’ll have that tell-tale orange stain around your wound. You’ll have been given a treatment that doesn’t work.

Read more here. The article goes on to describe a study by Andrew Booth at the School of Health and Related Research in Sheffield that found that 15-20% of health care facilities in Britain used treatments that “did not have a shred of worthwhile evidence to support their use.” There are of course, many unfortunate consequences of this. The first is that patients often aren’t getting the treatment that they need. Second some of the ill-informed treatments are actually harmful. One example mentioned by the piece is the test for prostate specific antigen (PSA) which is done as a screening test for prostate cancer despite the fact that those who have the test performed are just as likely to die from prostate cancer as though who don’t. Moreover the use of the test may end causing someone to have an unnecessary surgery performed.

This last issue, unnecessary surgery, made me wonder. Just how scientific are surgeries in general? After all it’s not so easy to give someone the sugar-pill equivalent of a surgery to really “subtract out” the placebo effect in the standard double-blind fashion. To really test the efficacy of a given surgical procedure you’d have to give some group of people a scar and tell them you’ve actually performed the surgery, and since this enters an ethically gray area (to say the least), it hasn’t to my knowledge, been done. Furthermore if the placebo effect really does have something to do with “the power of suggestion” then one would expect the placebo effect to be extremely high in the case of surgeries since one is literally removing a tumor or repairing a malfunctioning organ, in a very dramatic and immediate fashion. In fact, saline injections are very useful in burn victims when they are told that they’re being given a very strong painkiller. So the invaseiveness of a procedure seems to increase the placebo effect. Another important factor is the niceness of the doctor prescribing the treatment, which also increases the effect of the placebo.

So sometimes placebos are useful. But not all of the time of course. A Danish study of placebos found that 48% of general practitioners had prescribed a placebo in the last year. The placebo prescriptions range from vitamins for fatigue, to antibiotics for viral infections (even though antibiotics only kill bacteria, not viruses) which is certainly not a good thing since natural selection will give rise to ever nastier antibiotic resistant super-bacteria! So I’m more or less on the pro-placebo side of the debate, but only if those Danish doctors switch to a more inert placebo for viral infections. So Danes, if you’re reading, here are some suggestions for harmless placebos: vitamins(!), eat more vegetables, vote for Bill Richardson for President, comment on ..dotted and undotted dotterings.., and of course more ice cream from Scoops!


3 Responses to “Is surgery a placebo?”

  1. vera said

    Strangely enough, vitamins are not always harmless…even the ones that have been proven to have a specific chemical action, such as folic acid. In one study, people with heart problems were given folic acid supplementation in order to reduce levels of homocysteine, a substance associated with inflammation. Others were not. The folic acid did reduce homocysteine, which is the soundbite that sells floic acid, but those people died of heart attacks in significantly larger numbers than those that were not given folic acid.
    On a slightly different note, perhaps the placebo effect has something more to do with the intent of the people who administer the meds. Maybe placebos actually say more about the incomplete nature of western biomedicine, that something is missing. Maybe this something is the part of human physiology that has to do with subtler states, such as emotions, or dare I say spirit. Then again, maybe ‘placebo’ is just another word for ‘spirit.’ Many of the actually tried and true methods that are part of ancient healing systems such as TCM and Ayurveda have been proven to have quantitative as well as qualitative physical effects that have been traditionally explained in a metaphor that does not exclude the ‘spiritual’ aspects of the issue. Of course, many of the same substances have also caused illness and death when used in improper context, without a balanced idea of the whole person.

  2. pieceful said

    So when I suggested vitamins as a more or less safe placebo I should have been more explicit about which vitamins. I didn’t know the folic acid example, but that’s a good example to be aware of. Another more obvious example is iron which is actually lethal in large doses.

    With regard to the placebo-spirit issue, I think your description is pretty accurate. It’d be interesting to hear from a medical anthropologist on the issue. Of course, saying that some traditional practices have an element of placebo to them doesn’t imply that they’re “wrong.” It’s certainly a possibility that certain cultures learned over time how to achieve a strong placebogenic response in their patients. In fact I wouldn’t be surprised if the placebo effect that some traditional healers use could account for their success in treating certain diseases that western medicine doesn’t know how to treat. In particular I’m thinking of acupuncture’s success in treating chronic fatigue syndrome and chronic pain.

  3. Surgical placebos certainly have been done. Although not nearly as often as they should be!

    The most prominent example in recent times is a fascinating study done by the Veteran’s Administration in the US. They did a real knee cartilage debridement procedure on about 150 people, and a sham surgery on another 150 — that’s right, fake surgery.

    This is not an ethical problem. That’s what waivers are for. You explain to the study subjects that they may receive a sham surgery, or they may receive a sham surgery, and that this is essential for understanding whether or not the procedure really works. People are amazingly generous about this … with a noncritical procedure anyway. 😉

    Anyway, the amazing result was that everyone recovered from the surgery equally well, regardless of whether they had real surgery or not. Incredible, no? This is why surgical studies need to be controlled.

    The study:

    An article that addresses some related issues:

    “Getting back surgery sooner is better than getting it later: But is either one better than a placebo? Or nothing?”

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