Placebo Surgery?

A pal of mine, medical journalist Kent Steinriede of Outpatient Surgery Magazine, recently tipped me off to the strange phenomenon of sham or placebo surgery, in which medical researchers perform what essentially are fake operations on a portion of the patients in a clinical trial, in order to test the efficacy of a particular surgical procedure.

Here’s an example of how sham surgery works. A few years back, researchers from the U.S. Department of Veterans Affairs and Baylor College of Medicine wanted to find out whether arthroscopic surgery, then a common treatment for osteoarthritis of the knee, really did patients any good. A Baylor press release explains how they went about answering the question:

In the study, 180 patients with knee pain were randomized into three groups. One group received debridement, in which worn, torn, or loose cartilage is cut away and removed with the aid of a pencil-thin viewing tube called an arthroscope. The second group underwent arthroscopic lavage, in which the bad cartilage is flushed out. The third group underwent simulated arthroscopic surgery; small incisions were made, but no instruments were inserted and no cartilage removed.

It should be mentioned that when potential subjects for the study were informed beforehand that they might be receiving sham surgery that would have no effect on their condition instead of an actual arthroscopy, 56 percent — more than half — still agreed to participate. But the results were even more startling:

During two years of follow-up, patients in all three groups reported moderate improvements in pain and ability to function. However, neither of the intervention groups reported less pain or better function than the placebo group. Indeed, the placebo patients reported better outcomes than the debridement patients at certain points during follow-up. Throughout the two years, the patients were unaware of whether they had received real or placebo surgery.

This was particularly significant, because previous studies conducted without a sham group had reported that the majority of arthroscopy patients got relief from knee pain. The V.A.-Baylor study showed that it may not have been the surgery that caused their improvement, but rather the Subject Expectancy Effect  — i.e., if a patient thinks that a treatment will work, he or she has a better outcome than a patient who doesn’t really believe it will help.

The effect was even more startingly apparent in a University of Denver study published in 2004 on the effectiveness of transplantation of human embryonic dopamine neurons into the brains of persons with advanced Parkinson's disease. Half the patients were given the transplants, while the others received a phony operation in which small holes were drilled into their skulls for realism. Those who got the real operation experienced measurable improvements in movement, while those who got the sham surgery didn’t. Nevertheless, a year later, patients who believed that they had received a transplant reported a better quality of life than those who believed that they hadn’t gotten one, regardless of whether or not they actually had. Moreover, doctors treating the patients — who didn’t know which of them had the real transplants — reported more improvement in those who believed they’d received the treatment. As Science Daily reported:

One patient, for example, reported that she had not been physically active for several years before surgery, but in the year following surgery she resumed hiking and ice skating. When the double blind was lifted, she was surprised to find that she had received the sham surgery.

You may ask: How could that possibly be? How could patients experience results from a fake operation that doesn’t actually do anything? Are they simply being fooled into thinking that they feel better? Perhaps not. University of Michigan researchers have found that after patients were told that a fake medicine would alleviate their jaw discomfort,  it apparently caused their bodies to produce endorphins, a chemical that reduces pain. As this BBC News story details:

Their brain scans also showed that they had more endorphin activity after simply being told they were about to get the "medicine."

The most pronounced effects were seen in four parts of the brain known to be involved in processing and responding to pain, namely the left dorsolateral prefrontal cortex, the pregenual rostral right anterior cingulate, the right anterior insular cortex and the left nucleus accumbens.

Furthermore, activity in the dorsolateral prefrontal cortex was associated with the expectation of pain relief.

Activation of the other brain areas was associated with relief of the intensity of pain, how unpleasant it was and how the individuals felt emotionally during the pain.

This leads me to an extremely bizarre — but nevertheless intriguing — thought: If fake surgery actually helps study subjects, what about using it to treat ordinary patients, particularly ones for whom no other effective treatment seems to be available? To medical ethicists — some of whom object to the use of sham treatments even in clinical trials — this would be total heresy.  On the other hand, as I was surprised to learn, many doctors already occasionally engage in therapeutic deception. According to the American Medical Association AMedNews.com, a recent survey of 231 physicians revealed that nearly half had treated their patients with placebos, and 8 percent had used such fakery more than 10 times in the past year. (Only 4 percent of the doctors had bothered to inform patients that they might be receiving the proverbial sugar pill, despite a 2006 AMA report that condemned the use of placebos without patient consent as a breach of trust.)

So, what do you think? Should doctors use fake operations to tap into the placebo effect and try to help consenting patients who might not see improvement through conventional treatment? Or would sham surgery for therapeutic purposes be utterly wrong? Express your opinion below.