Illustration by CR SasikumarWhile we have been swept off our feet by the incredible developments in medical care, from genetic engineering of embryos to robotic cardiac surgery, perhaps the most astonishing advance of all has gone relatively unnoticed. This medical miracle has been recognised since antiquity and practised by all healing traditions. However, until recently, it was not considered to be an authentic medical intervention because it lacked a robust biological explanation and was considered to be no more than plain luck. Perhaps the real reason this marvel has gone unnoticed, particularly by allopathy, is because the active ingredient needs no prescription, is not shrouded by scientific jargon, is not patented by corporations, and does not enrich its practitioners.
Hope is that miracle. It resides in each of us, costs absolutely nothing, and all it needs to be pumped into action is a state of mind, which can be invoked by simply believing in the possibility of recovery. Yet, physicians like myself who were groomed in a rigorous scientific temper, have been taught that this pervasive human quality is the biggest threat to the discovery of medical interventions.
The allopathic tradition of medicine has historically distinguished itself from all other forms of healing by rejecting hope as a scientifically-sound basis for recovery, for there was no discernible way it could restore biological systems disrupted by disease. This is precisely the reason that allopathy dismissed other traditions of medicine, from homeopathy to spiritual healing. According to our dogma, you were fooled by ritual into be feeling better but, in actual fact, you were just lucky.
This is why all new allopathic medications must be compared with a dummy pill, the placebo, to test whether there is a “real” benefit, one which outwitted the magical effects of hope. This is especially true for medications targeting complaints which are subjective, such as aches and pains, allergies and all mental health conditions. In all these conditions, clinical trials have repeatedly shown that the effects of hope on relieving distress were large, often larger than the specific benefits of any medication. But in the past year, we have now been confronted by the finding that such placebo effects are even observed in the case of surgical procedures, previously thought to be immune to the confounding effects of hope.
In part due to the absence of any plausible “placebo” control for surgical procedures, and the belief that because surgical procedures corrected pathological anatomic disruptions they did not need to be tested in the same way as medications, surgical procedures such as coronary angioplasty to relieve the chest pain, or shoulder surgeries to relieve arthritic pain, have grown at an industrial scale.
Recently, some courageous researchers, practitioners, patients, ethics committees and funders have begun to interrogate the placebo response to common surgical procedures. Two such experiments, funded by the United Kingdom’s national research agency whose goal is to determine whether specific medical procedures are worthy of public financing, published their findings in the Lancet this past year. Both have upended the widely-cherished beliefs about the effectiveness of two of the most commonly used, and lucrative, surgeries in modern times, neither of which had been compared with a placebo before.
One experiment evaluated coronary angioplasty in patients with angina who had severe blockage of a single coronary artery; this procedure is believed to relieve chest pain by opening up a passage to allow blood to flow through the blocked artery. The second experiment evaluated decompression of the shoulder joint. The anatomic rationale for this surgery is that the shoulder pain is caused by physical contact during arm movement between the shoulder joint tendons and a bony spur and the surgery is intended to reduce the contact between these parts of the joint.
A key aspect of the placebo condition is that the patient must believe they have had the procedure to trigger the hope response. Incredibly, this means that the placebo group of patients had to go through all the procedures which the group receiving the actual intervention did, from being admitted to hospital, having all the diagnostic tests, being prepared for surgery, being anaesthetised and getting a skin incision; everything except the actual procedure itself. Apart from the astounding fact that the researchers received ethical approval for these experiments, and that patients (more than 200 hundred for the angioplasty study) consented to participate knowing they might receive a sham procedure, what was even more astonishing was the finding that both groups showed exactly the same degree of improvement in their symptoms following the procedures.
The discovery of the placebo response to these common surgical procedures adds to the mountain of evidence that hope is a major driver of recovery in response to many medical procedures. Hope is not, as it were, all in our minds. Thanks to novel neuro-imaging technologies, we now know that hope is a powerful stimulant of a brain pathways triggering a series of complex, if yet to be fully deciphered, biological processes which not only relieve distress but even lead to physiological remission in a diseased organ. Amazingly, it seems that all the accessories of surgery, the rituals of being scrubbed, prodded by a gowned figure, anaesthetised, waking up experiencing the pain of an incision and so on, are no different from those which might explain the miracles of recovery from homeopathy and faith-healing, also replete with rituals and experiences out of the ordinary.
Many allopathic practitioners will reject these findings, claiming they do not conform with their clinical experience. They will be joined by hospitals and device manufacturers who will fortify themselves with jargon and promote expensive treatments for conditions which may just as often be treated by something we all possess and costs nothing. Of course, some medical procedures are needed for some afflictions, but hope is needed for all. The implications of this medical miracle for my fellow physicians is patently obvious: Before we whip out your prescription pads or polish our scalpels, we should be spending more time listening to our patients, building a therapeutic relationship and giving hope. This may well be a better investment than anything else we do, particularly if we count our returns in terms of patient satisfaction and recovery.
Patel is the Pershing Square Professor of Global Health at Harvard Medical School and is affiliated with the Public Health Foundation of India and Sangath
