Is “Amazing Grace” Mediated Through The Placebo Neurobiologic Effect?

Posted on | July 5, 2015 | 2 Comments

Source: Chronicle Augusta.com

Mike Magee

This week, Ted Kaptchuk and Franklin Miller published a seminal article in the New England Journal of Medicine titled, “Placebo Effects in Medicine”. I believe it will be remembered for many years, not for its scientific insights, which are considerable, but for its’ theologic, sociologic, and historical revelations, buried deep in its straight forward prose.

You see, the authors’ insights happened to be published within days of President Obama’s Eulogy for Reverend Clementa Pinckney in Charleston, South Carolina, a speech reflecting on the subject of grace – Amazing Grace. And in many ways, I believe Kaptchuk and Miller were covering the same ground as our President. I say this because health, the capacity to reach full human potential, requires a bias toward success, and a commitment to equal justice. And as our President said, “.. justice grows out of recognition of ourselves in each other; that my liberty depends on you being free, too… the path of grace involves an open mind. But more importantly, an open heart.”

In the battle for health, we expect and require that our physicians take on all comers, without bias; that they care for others as they would their own; that they touch and empathize, as they advise and council. Kaptchuk and Miller say, “..medicine’s goal is to heal, which can include cure, control of disease, and symptom relief or provision of comfort. When no cure is available — an inevitable occurrence at some points — medicine’s ultimate mission is to relieve unnecessary suffering. Supportive and attentive health care (preferably with effective medications, but even without) legitimately creates a ‘therapeutic bias’ in patients toward hope and an experience of relief and reprieve.”

The authors say we have minimized and undervalued the human physiology that underlies the placebo effect. They define it as the “improvements in patients’ symptoms that are attributable to their participation in the therapeutic encounter, with its rituals, symbols, and interactions… This diverse collection of signs and behaviors includes identifiable health care paraphernalia and settings, emotional and cognitive engagement with clinicians, empathic and intimate witnessing, and the laying on of hands.”

They also say that, “Placebo effects rely on complex neurobiologic mechanisms involving neurotransmitters (e.g., endorphins, cannabinoids, and dopamine) and activation of specific, quantifiable, and relevant areas of the brain…”

They ask us to remember three things about the neurobiologic workings we label the “placebo effect”.

1. “ Placebos may provide relief, they rarely cure.”

2. “Placebo effects are not just about dummy pills: the effects of symbols and clinician interactions can dramatically enhance the effectiveness of pharmaceuticals.”

3. “The psychosocial factors that promote therapeutic placebo effects also have the potential to cause adverse consequences, known as nocebo effects. Not infrequently, patients perceive side effects of medications that are actually caused by anticipation of negative effects or heightened attentiveness to normal background discomforts of daily life in the context of a new therapeutic regimen.”

What if you had a doctor who you could say, “… lived by faith, a man who believed in things not seen, a man who believed there were better days ahead off in the distance, a man of service, who persevered knowing full-well he would not receive all those things he was promised, because he believed his efforts would deliver a better life for those who followed…”

What if you were cared for by a health professional of whom was said, “… his graciousness, his smile, his reassuring baritone, his deceptive sense of humor, all qualities that helped him wear so effortlessly a heavy burden of expectation.. wise beyond his years in his speech, in his conduct, in his love, faith and purity.. he never gave up. He stayed true to his convictions. He would not grow discouraged.”

What if you were cared for by a nurse of whom was said, “She conducted himself quietly and kindly and diligently. She encouraged progress not by pushing her ideas alone but by seeking out your ideas, partnering with you to make things happen. She was full of empathy and fellow feeling, able to walk in somebody else’s shoes and see through their eyes.” Suppose that person believed that “Our calling, is not just within the walls of the congregation but the life and community in which our congregation resides.”

What is the placebo effect really, but a bias toward success, toward trust, toward health, toward hope. What if it is grace – the kind of “Amazing Grace” our President highlighted – in action? What if the “nocebo effect” is the expression of an opposite physiologic effect, one fueled by hatred, fear, prejudice, hopelessness?

What should we do with this grace, this placebo effect? The President says that God has “given us the chance where we’ve been lost to find out best selves. We may not have earned this grace with our rancor and complacency and short-sightedness and fear of each other, but we got it all the same. He gave it to us anyway. He’s once more given us grace. But it is up to us now to make the most of it, to receive it with gratitude and to prove ourselves worthy of this gift.”

The medical authors this week emphasized that symbols can ignite both the “placebo effect” and the “nocebo effect”. On this issue, our President was clear.

“For too long, we were blind to the pain that the Confederate Flag stirred into many of our citizens. It’s true a flag did not cause these murders. But as people from all walks of life, Republicans and Democrats, now acknowledge, including Governor Haley, whose recent eloquence on the subject is worthy of praise as we all have to acknowledge, the flag has always represented more than just ancestral pride. For many, black and white, that flag was a reminder of systemic oppression and racial subjugation.”

“We see that now. Removing the flag from this state’s capital would not be an act of political correctness. It would not be an insult to the valor of Confederate soldiers. It would simply be acknowledgement that the cause for which they fought, the cause of slavery, was wrong. The imposition of Jim Crow after the Civil War, the resistance to civil rights for all people was wrong.”

“It would be one step in an honest accounting of America’s history, a modest but meaningful balm for so many unhealed wounds. It would be an expression of the amazing changes that have transformed this state and this country for the better because of the work of so many people of goodwill, people of all races, striving to form a more perfect union. By taking down that flag, we express God’s grace.”

This week’s medical authors say, “…placebo effects can help explain mechanistically how clinicians can be therapeutic agents in the ways they relate to their patients in connection with, and separate from, providing effective treatment interventions.”

But isn’t that the job of all of us? Shouldn’t each of us try to exercise our internal placebo workings, our “Amazing Grace”, by, as the President said, “recognizing our common humanity, by treating every child as important, regardless of the color of their skin or the station into which they were born and to do what’s necessary to make opportunity real for every American. By doing that, we express God’s grace.”

For Health Commentary, I’m Mike Magee.