Invoking the Placebo Effect
In addressing the mechanisms by which spiritual experiences and spiritual practices affect pain, it becomes apparent that these events engage pathways that can both modulate pain and initiate a variety of physiological, and salutogenic processes.2 This supports the concept that particular external events—whether environmental, ritual, or interpersonal—engage one or more sensory systems, activate the peripheral and central nervous system, evoke cognitive substrates involved in different types of memory and emotion, and generate a change in the somatic state.3 This instigates both directed actions/behaviors and the phenomenon of the bodily response and external provocation, that are perceived as a ‘mind state.’ This is what Damasio has called the ‘feeling of what happens’ and is intrinsic to sentient experience.4
We possess a pain modulating system that is non-linear, adaptive, responsive to internal and external environments, and which can be environmentally and circumstantially conditioned.5 While such responses are common, if not universal (not only to humans, but perhaps many mammalian species), the extent to which these systems are responsive, and the fortitude and pattern of responses all appear to be individually variant. Individual responses are determined by genetic predisposition and epigenetic-phenotypic interactions with various environmental factors throughout one’s lifespan. Hence, we possess both the substrates for pain (as sensation, perception, and conscious event), as well as mechanisms by which pain (in all its dimensions) may be modulated or suppressed. The adaptability of these mechanisms allows not only reduction of pain, but also reduction of many of the correlated physiologic processes (e.g., inflammation, immunologic changes, etc.) that perpetuate potentially maladaptive cognitive responses and may impede repair and recovery.
Recent work by Wachholtz and Pargament has shown that spiritual experiences and practices increase pain tolerance, decrease anxiety, and reduce negative, cognitive and behavioral features associated with pain and distress.6 If we accept the philosopher Leon Kass’ definition of health as an integrated “wholeness,”7 then a role of spiritual experience and practices may be to facilitate salutogenic effects in the strictest sense: by preserving or enhancing the sense and, perhaps, the functional basis of “integration” that is “health,” and by decreasing the dis-integration incurred by pain—particularly chronic pain as illness.
Our growing recognition that such experiences and the effects they generate are relevant to the clinical encounter should not be wholly surprising, as the use of ritual to enhance susceptibility and promote readiness to healing experiences has been characteristic of shamanic practices throughout history.8 Creating a sense of expectation that a healing would occur thereby established the reciprocity of the encounter. In the Aesclepian tradition, it was believed that the attendance of the graces (notably Hygieia and Panacea) established and maintained the durable healing power of the Aesclepian ‘cure.’9 To be sure, the notion of a ritual evoked by the physician’s demeanor and actions was critical to Hippocratic medicine.10
The focus of the clinical encounter is the good of the patient, for it is the patient who seeks the physician’s professed skills to effect a healing. The satisfactory outcome of the clinical encounter may not entail cure, but must involve care. To paraphrase Hippocrates, the regard for the patient is the art, and such positive regard is therefore instrumental to the ends of medicine to render a right and good healing.11,12 Is it not rational to assume that the supposedly “mystical” nature of shamanic healing—when interpreted in light of our contemporary understanding of neural mechanisms of expectation and belief—may, in fact, still be an important element of the modern clinical encounter. Simply, if the patient seeks the physician with some expectation (i.e., “hope”) of healing that is based upon the physician’s profession (i.e., literal declaration of knowledge intent and skills), then it is clear that the moral obligation of the physician is to prudently act within reason to attempt to realize that which has been professed by maximizing the good for, and of, the patient.13 In this sense, the tenor of the clinical encounter should “please” the patient by meeting the expectation for a positive interaction with the physician and that, at very least, does not harm.
It is in this light that I offer a re-examination of the concept of placebo. Literally translated from the Latin, “placebo” means “I shall please.” Given the aforementioned premises of the clinical encounter, is that not essential to the act of medicine, at least in the context of care, hope and expectation arising from, and within, the physician-patient interaction? The notion of placebo as an ‘inert agent’—while relatively viable in the research literature to refer to a sham treatment—should be reconsidered, both in terms of the apparently non-specific effects that such ‘inert’ treatments produce, and the relevance of such ‘placebo effects’ to clinical practice. Taken in accordance with the literal definition of placebo ‘to please,’ it is important not to misregard placebo as a mere placation. This is etymologically incorrect, conceptually inaccurate, and ethically unacceptable. Rather, placebo effects are those processes—or events that engage resultant processes—that are facilitative to healing.13 In this way, placebo effects might be better considered as patient-specific biopsychosocial effects. Unfortunately, however, the ambiguous terms placebo and placebo effect—retaining a considerable burden of ‘folk’ meaning and reflecting a connotation of sham treatment—still persist. It is this folk interpretation that has led to definitional ambiguity and ethical consternation regarding the use of placebo effect in medical practice. Not unlike the notion of ‘spirituality’ (as confused with religion or religiosity), such definitional ambiguity can sustain both philosophical and pragmatic problems.14 Also, like spirituality, a mechanistic understanding may be critical to increasing the relevance and resonance of such processes to medicine.