Pekka Louhiala, D.Med.Sci., PhD
Hjelt Institute, University of Helsinki, Finland 

Raimo Puustinen, MD, PhD, FT
School of Medicine, University of Tampere, Finland

It is common knowledge that patients may exhibit improvement following an encounter in which no specific drugs or effective medications were prescribed. Indeed, even fictional doctors have often been depicted as knowing that their patients may require no active drugs and that their mere presence, their advice and encouragement, will often lead to improvement of their symptoms or even recovery from their illness. This is exemplified by four extracts from the literary world which illustrate that the complex interactions between human beings represent phenomena related not merely to healthcare but to human communication in general.

Tolstoy: War and Peace

Natasha Rostova, a central character in War and Peace¹ by Leo Tolstoy (1828–1910), fell seriously ill after her engagement was broken:

She could not eat or sleep, grew visibly thinner, coughed and, as the doctors made them feel, was in danger. They could not think of anything but how to help her. Doctors came to see her singly and in consultation, talked much in French, German, and Latin, blamed one another, and prescribed a great variety of medicines for all the diseases known to them, but the simple idea never occurred to any of them that they could not know the disease Natasha was suffering from, as no disease suffered by a live man can be known, for every living person has his own peculiarities and always has his own peculiar, personal, novel, complicated disease, unknown to medicine – not a disease of the lungs, liver, skin, heart, nerves, and so on mentioned in medical books, but a disease consisting of one of the innumerable combinations of the maladies of those organs” (517–518).

The doctors made “the patient swallow substances for the most part harmful (the harm was scarcely perceptible, as they were given in small doses).” (518)

They assured Natasha

that it would soon pass if only the coachman went to the chemist’s in the Arbat and got a powder and some pills in a pretty box for a ruble and seventy kopeks, and if she took those powders in boiled water at intervals of precisely two hours, neither more nor less. (518)

The usefulness of the physicians did not, however, depend on these medicines. They were useful and necessary, because

they satisfied a mental need of the invalid and of those who loved her. … They satisfied that eternal human need for hope of relief, for sympathy, and that something should be done, which is felt by those who are suffering. They satisfied the need seen in its most elementary form in a child, when it wants to have a place rubbed that has been hurt. (518)

Chekhov: A Case History

Anton Chekhov’s (1860–1904) short story A Case History² depicts a house call by a young physician, Dr. Koryolov, to a wealthy family living in the countryside. The patient was

a girl of twenty – Liza, Mrs. Lyalikov’s only daughter and heiress – who was ill. She had been unwell for some time, she had been under various doctors, and during the entire previous night she had suffered heart palpitations so acute that no one in the house had slept – they had feared for her life. (180)

Dr. Koryolov performed a physical examination and found no organic problems. The treatment was reassurance and advice to get some sleep, but then something happened to change the situation:

Then a lamp was brought into the bedroom. The sick girl squinted in the light, suddenly clutched her head in her hands—and burst out sobbing. … He saw a gentle, suffering look so wise, so moving that she seemed all feminine grace and charm – he wanted to soothe her, now, with a few simple kind words: not with medicines or advice. (181)

As Koryolov was leaving the house, Mrs. Lyalikov asked him to, instead, stay until the following day, and he agreed. When he came back to the house he heard the patient weeping. He entered her room and asked how she was.

‘All right, thank you.’ He felt her pulse, pushed back the hair which had fallen on her forehead.

‘You can’t sleep,’ he said. ‘There’s wonderful weather outside – spring, nightingale song – but you sit brooding in the darkness.’ She listened, gazed into his face. Her eyes looked sad and wise, she obviously wanted to tell him something. (186)

With these small gestures, Koryolov formed a connection with his patient. A little later he interpreted her problem as a struggle with the questions of right and wrong. The short story has an open ending: the doctor leaves the house and the patient is seen standing on the porch, smiling sadly, as if hiding her innermost secrets.

Waltari: The Egyptian

The Egyptian³ is the first and most famous of the historical novels by Mika Waltari (1908–1979), a Finnish author known for the accuracy of the historical facts in his works.⁴ The book depicts the life of Sinuhe, a fictional physician working in ancient Egypt. He tells his story in exile after Pharaoh Akhenaten’s fall and death in the 14^th century B.C.

Sinuhe’s father was Senmut, a poor but widely respected physician in his community. As a boy, Sinuhe used to help his father in his office. One day the wife of a spice dealer “wearing jewelry and a collar sparkling with precious stones” came for examination. She “sighed and moaned and lamented over her many afflictions” while Senmut listened carefully. Sinuhe describes the event:

He wrote a line in ancient characters copied from a worn papyrus roll, then poured oil and wine into a mixing bowl and soaked the paper in it until the ink had been dissolved by the wine. Then he poured the liquid into the earthenware jar and gave it to the spice dealer’s wife as a medicine, telling her to take some of it whenever head or stomach began to pain her. When the woman had gone, I looked at my father who seemed embarrassed. He coughed once or twice and said, ‘Many diseases can be cured with ink that has been used for powerful invocation.’

He said no more aloud, but muttered to himself after a time, ‘At least it can do the patient no harm.’ (10)

Canetti: The Tongue Set Free

Elias Canetti (1905–1994), the Nobel laureate for literature in 1981, was a cosmopolitan “with one native land, the German language.”⁵ He wrote in several genres but his most widely read work is his memoirs in three volumes, The Tongue Set Free (1977), The Torch in the Ear (1980), and The Play of the Eyes (1985).

In The Tongue Set Free⁶, Canetti describes an episode from his childhood, when he was playing with his friend Laurica. The children were running inside the house, Laurica caught Elias close to a caldron of hot water and he fell into it. He suffered from severe burns, and the family feared for his life. Elias’ father was in England at the time, and his absence was even worse for the boy than the pain of the burns. He missed his father desperately and kept asking, “When is he coming?”

The father left for home immediately when he heard of the accident, but, at that time, it took several days to travel across Europe. Canetti describes his father’s arrival:

Then I heard his voice, he came to me from behind, I was lying on my belly, he softly called my name, he walked around the bed, I saw him, he lightly put his hand on my hair, it was father, and I had no pains.

Everything that happened from then on I know only from what I was told. The wound became a wonder, the recovery began, he promised not to go away anymore and he stayed during the next few weeks. The doctor was positive I would have died if my father hadn’t come and remained. The doctor had already given me up but insisted on my father’s return, his only, not very sure hope. (Canetti, 31–32)

Discussion

All of these stories describe effects that are real and meaningful for the patients involved. Yet in today’s medical terminology these effects would easily be labeled placebo effects, suggesting that the patients did not receive real or specific treatment. They accordingly illustrate why the term is unhelpful and misleading in the context of clinical reality. Moreover, while the term placebo refers to inert drugs or treatments, no such inert substances or fake treatments were used in two of the four preceding stories. Dr. Koryolov, in A Case History, did not provide drugs, but only his words and his presence, and, in The Tongue Set Free, the key person provoking the healing effect was not a physician, but instead the little boy’s father. According to today’s standards, the powder and pills given to Natasha in a pretty box in War and Peace were probably more harmful than helpful as such, and the ink dissolved in wine in The Egyptian was by no means biologically inert, although Waltari hints that Senmut did not actually believe the solution as such would be helpful.

Even a brief look at the medical and scientific literature on placebos and placebo effects shows that there are many understandings of the terms and that they are often used in vague ways. We agree with Daniel Moerman, according to whom placebo effect “is an unfortunate term, used carelessly for such a broad range of phenomena that we should probably abandon it; or, if we must keep it, we should use it only to refer to the changes observed in the subjects in a control group in an experiment.”⁷

There have been several attempts to replace the term placebo effect by something that would better describe what happens and would not have the negative connotations (“inert,” “sham,” “noise,” “bias”) that so easily accompany the word placebo. Di Blasi and Kleijnen⁸ have suggested the term context effects “to overcome some of the negative connotations associated with the term placebo and to highlight the therapeutic nature of the health care context.” Moerman and Jonas⁹ have proposed that much of what is called the placebo effect is a special case of the meaning response, which is defined as the physiological or psychological effects of meaning in the treatment of illness. We have suggested the term care effect,¹⁰ which refers to the phenomena that take place within clinical consultations and lead to beneficial therapeutic outcomes in cases when the medical treatment given cannot fully explain the outcomes.

None of these terms have, however, gained wider acceptance. Finniss et al.,¹¹ for example, have noted that “the placebo terminology, despite its defects, is too ingrained in the scientific literature to replace it at this time, especially in the absence of a satisfactory alternative.” The authors mention some alternatives but do not comment on why they are not satisfactory. We argue that the present placebo terminology is not only unsatisfactory, but even harmful. It transfers the negative connotations related to the term placebo to the concept of placebo effects and prevents both the scientific community and lay people from seeing that what is now referred to as placebo effects represent complex phenomena that at the present state of knowledge remain incompletely understood.

Notes

1. Tolstoy, Leo. War and peace (transl. Louise and Aylmer Maude). London: Wordsworth Classics, 2001.
2. Chekhov, Anton. The princess and other stories. (transl. Ronald Hingley). Aylesbury: Oxford University Press, 1990. 179-88.
3. Waltari, Mika. The Egyptian. Porvoo: Werner Söderström Osakeyhtiö, 1983.
4. Saloheimo, P.,”Medical Classics: The Egyptian” Br Med J 345 (2012):e4712.
5. “The Nobel Prize in Literature 1981: Elias Canetti.” http://www.nobelprize.org/nobel_prizes/literature/laureates/1981/press.html
6. Canetti, Elias. The Tongue Set Free. Croydon: Granta Books, 2011.
7. Moerman, Daniel. Meaning, Medicine and the ’Placebo Effect’ . Cambridge: Cambridge University Press, 2002. 4.
8. Di Blasi, Z., Kleijnen, J., “Context effects. Powerful therapies or methodological bias? Eval Health Prof. 26(2003): 166–79.
9. Moerman, D.E., Jonas, W.B., “Deconstructing the placebo effect and finding the meaning response” Ann Intern Med 136 (2002):471–476.
10. Louhiala, P., Puustinen, R., “Rethinking the placebo effect” Medical Humanities 34 (2008):107–109.
11. Finnis, D., Kaptchuk, T.J., Benedetti, F., “Biological, clinical, and ethical advances of placebo effects” Lancet 375(2010):686–95.

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PEKKA LOUHIALA, D.Med.Sci., PhD, is a lecturer in medical ethics at the University of Helsinki, Finland. He has degrees in both medicine and philosophy, and he also works as a part-time pediatrician in private practice. He has published on various topics in medical ethics, philosophy of medicine and epidemiology. His current academic interests include conceptual and philosophical issues in medicine, such as evidence-based medicine and placebo effects.

RAIMO PUUSTINEN, MD, PhD, FT, is acting Professor of General Practice at the University of Tampere, Finland. He has published articles and books on general practice, medical ethics and philosophy of medicine.