Department of Medical HistoryPowerful placebo: the dark side of the randomised controlled trial
Section snippets
Pre-RCT placebo
When pre-World War II paternalistic ethics prevailed, informed consent was not a standard of care.1 Physicians were generally comfortable with benevolent deception and a “polychromatic assortment of sugar pills” was routinely swallowed by patients.2, 3 In 1903, Richard Cabot (1868–1939), the eminent professor at Harvard Medical School, described the placebo's persuasiveness. He was “brought up, as I suppose every physician is, to use placebo, bread pills, water subcutaneously, and other
RCT placebo effect
In 1955, the modern biomedical concept of the placebo makes its first definitive appearance with the publication of Henry Beecher's (1904–1976), “The Powerful Placebo” in the Journal of the American Medical Association (JAMA)11 Beecher, a distinguished medical researcher at Harvard Medical School, summarised and mathematically presented a perspective that had been developing in a few elite biomedical research centres since 1946.12 Beecher used a proto-meta-analytic method to aggregate the
RCT and creation of the modern placebo
World War II has been called the great divide in medical research and certainly, for the placebo, this is true. In fact, the “powerful placebo” was born in the vortex of one of medicine's most momentous transitions. Before World War II the evaluation of new therapeutics was made by recognised leaders of the medical profession whose judgments were based on clinical impressions, and on rare occasions, poorly controlled evidence.21 In an effort to impose an objective and scientific discipline onto
Powerful placebo and acceptance of RCT
Medical proponents of the RCT were under pressure to convince their colleagues of the RCT's value.23 Few physicians wanted randomly to assign treatment to patients, forgo the individualisation of therapy, and withhold promising new therapies. Austin Bradford Hill (1897–1991), the designer of the first randomised trial, many years later confessed that he “deliberately left out the words ‘randomisation’ and ‘random sampling numbers’ at the time because… I might have scared them [collaborating
RCT and placebo: the light and dark of a partnership
Elite medical reformers created a symbiosis between the RCT and the powerful placebo effect. A new gold standard was constructed to fit the new technical procedures. Until the RCT, medical therapy became legitimate because of beneficial outcomes; after the RCT, a medical intervention was only scientifically acceptable if it was superior to placebo.34 No longer was it sufficient for a therapy to work: it had to be better than placebo. For the first time in history (outside of religious healing
RCT and powerful placebo at 50 years
The powerful placebo is a modern entity constructed in the shadow of the RCT. In the current RCT era, a legitimate therapy must demonstrate an effect greater than a decoy disguised as a real intervention. Yet, under the rhetorical label of powerful placebo lies many rich contributions to health care. These include: nature taking its course; regression to the mean; routine medical and nursing care; regimens such as rest, diet, exercise, and relaxation; easing of anxiety by diagnosis and
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