History, ethics and the placebo effect

Beecher acquired BA and MA degrees from the University of Kansas, before going on to enrol at Harvard Medical School in 1928. He graduated cum laude four years later and went on to work in the laboratory of the Danish physiologist and Nobel Laureate August Krogh. Ultimately Beecher became anaesthetist-in-chief at Massachusetts General Hospital (1936) and professor of anaesthesia research at Harvard Medical School (1941). 

In 1966, Beecher published an influential article in the New England Journal of Medicine entitled ‘Ethics in clinical research’ and, in doing so, drew attention to 22 examples of unethical practice in research that endangered the lives of patients.¹ Although the paper was not without its critics (for unreasonable over-generalisation, for example), it was instrumental in the establishment of US federal rules on research and informed consent. Indeed, Beecher’s stance on medical ethics is well recognised and the prestigious Beecher Prize is awarded annually at Harvard Medical School to a student who excels in the field of medical ethics. 

So, what about Beecher’s work on the placebo effect? As we know, a placebo is something designed to simulate a medical intervention without actually exerting any biological effect on the disease being treated. The term is derived from the Latin meaning ‘I shall please’. Placebos were popular with the Catholic Church in the 16th century as a means of discrediting charlatans who sold exorcisms, and were used more widely by the medical community by the 18th century. It has been asserted by researchers such as Dr Cristina Guijarro that the history of medicine itself is essentially the history of placebo, in view of how so many conventional treatments predating the modern era were ultimately shown to be of little benefit.² But the concept of ‘the placebo effect’ only received true recognition as clinical trials were regulated in the aftermath of World War II. 

Beecher did not coin the term ‘placebo effect’; this credit goes to TC Graves in The Lancet in 1920. However, Beecher famously published a paper in 1955 entitled ‘The Powerful Placebo’ in which he was the first to assert the necessity for double-blind, placebo-control clinical trials as standard.³ The first such trial had already been conducted in 1931 – a study by Amberson et al involving sanocrysin for the treatment of tuberculosis. Nothing less than a randomised control trial is acceptable in 21st century pharmaceutical research, but it was a pioneering concept in the early 20th century. Beecher asserted that the placebo effect occurred in around one-third of people, but his paper was revisited some 40 years later and not inconsiderable doubt was cast on the existence of placebo in any of the studies that he cited. 

Ethical debate persists today over the prescription of substances without active ingredients. So-called ‘alternative’ treatments remain popular and yet some 90% are thought to be based on the placebo effect. So, perhaps guidelines on the use of placebo in alternative and conventional medicine alike are needed to control for their impact. Were he alive today, Henry Knowles Beecher would undoubtedly agree. 

References

1. Beecher HK. Ethics and Clinical Research. New Engl J Med 1966; 274(24):1354-60

2. Guijarro C. A history of the placebo. Neurosciences and History 2015; 3(2):68-80

3. Beecher HK. The Powerful Placebo. JAMA (1955); 159(17):1602-6