Placebo Effects Analyzed

The subject of placebo effects frequently appears when discussing alternative medicine/CAM.  Following is from what I consider a good article on the subject by Steven Novella, MD of the Science-Based Medicine blog and The Skeptics Guide to the Universe podcast:

• Understanding placebo effects is critical to making sense of medical research and ever-expanding health claims within an increasingly unregulated market.
• Placebo effects (plural) are varied and complex. For the most part they are not a biological response to the expectation of benefit, which is what most people assume.
• If a trial is rigorously designed, placebo effects should include everything other than a physiological response to a biologically active treatment. Therefore, we can subtract placebo-effect findings from the treatment group, who will display treatment effects plus placebo effects, and we are left with a measurement of the treatment effect alone.
• Placebo effects fall into several categories: illusions of observation, bias, nonspecific effects, and physiological effects. Much of what is measured as a placebo effect is, in fact, simply an illusion of the process of observation.
• ---when you look at any objective or clinically important outcome--the kinds of things that would indicate a real biological effect--there is no discernible placebo effect. That is, there is no "mind over matter" self-healing that can be attributed to the placebo effect.
• --- significant placebo effects were found only for subjectively reported symptoms.
• Increasingly, placebo effects are being used to justify the use of ineffective and even inert treatments, with the assumption that "the" placebo effect is a true healing effect. What the research indicates, however, is that there are many placebo effects, and they are mostly bias and illusion--not real effects.
• There are also nonspecific effects that are likely valuable, but these effects can mostly be categorized as stress reduction and improvement in mood through attention and encouragement.
• On close inspection, placebo effects are not a justification for substituting hocus-pocus for real medicine.

http://www.csicop.org/si/show/the_poor_misunderstood_placebo

Given that there are positive effects from placebo, even if only significant regarding subjective symptoms, is it ethical for physicians to use a placebo in management of his/her patients?  Following is from a recent article on the website Discover that attempts to justify such:

• --- prescribing drugs like antibiotics or supplements like vitamins as placebos is now a widespread practice. This is happening without any public guidelines or regulations for placebos’ use, which raises an important question: How, exactly, should physicians be using the placebo effect to help patients?
• Physicians today generally agree that placebos can actually have a positive effect on the patient’s body, and that mind-body medicine “works.” That’s important, and has not been sufficiently noted.**  (** My Comment:  Research does not support the claim of significant objective clinical improvement from placebos.  Virtually all studies that report objective clinical improvement have design flaws)
• There are at least two reasons to be very wary of prescribing impure placebos. First, you don’t want to sow false ideas: Will patients understand that this drug is indeed intended solely for its mind-body effect? Or will patients continue to be miseducated that antibiotics are good for colds (they are not) and that everyone should take vitamins for extra energy (they should not)? Patients should be able to trust their physicians as sources of up-to-date, valid medical information.
• False ideas about what works in medicine lead to the second problem. There are real risks—several of the categories of impure placebos favored in some of the recent surveys, namely antibiotics, sedatives, and analgesics, can cause serious adverse reactions.
• ---what a physician would have to do, to maximize the chances that either a pure or an impure placebo would work for the patient’s benefit:  listen carefully to the patient and be sure to explain the patient’s medical problem in easily understandable terms;  demonstrate care and concern;   help the patient feel more hopeful about and in charge of the bothersome symptoms;  create positive expectations about the effects of the treatment.** (**My Comment:  In other words, interact with the patient as a physician should)
• So my question is—why not do all that anyway and avoid giving out phony pills at all?**  (** My Comment:  Exactly!!!)

http://blogs.discovermagazine.com/crux/2012/06/26/how-doctors-can-ethically-harness-the-placebo-effect/#.U5GuyXYvCM0

Dr. Novella sums up the dangers of placing placebo effects in a more respectful position then they deserve:

• The integrity of science-based medicine is critical to the health of the public, the legitimacy of modern medicine, and also the economic health of modern society (as is being forcefully argued recently). We need to have one scientific standard that is fair, rational, and scientifically sound. The creation of a double standard for proponents of modalities that do not meet the very reasonable standards of scientific medicine is eroding the standard of care and the integrity of modern medicine.
• The public, the media, politicians, and regulators should not fall for the deceptive language that is being used to disguise the truth of these efforts to undermine science-based medicine. This is a brass attempt at changing the rules of science to meet their perceived needs. When you change the rules of science you no longer have science – you have pseudoscience or something even more nefarious.

http://www.sciencebasedmedicine.org/the-rise-of-placebo-medicine/

So, anyone reading the above who is still in favor of using the placebo effect clinically, what say you?  Should alternative medicine (virtually ALL placebo) be part of the USA health care system?  If so, should it be paid for by tax funds and insurance?  Or, should it be limited to simply encouraging health care providers to enter into a empathetic and instructive relationship with their patients?  I will take door number two, Monty.