The Placebo Prescription

A sugar pill for the mildly depressed. Sham surgery for a bum knee. A hand to hold for the flu-stricken. Placebos aren't real medicine, but they can often help patients heal. So why not exploit their power? By MARGARET TALBOT
n the summer of 1994, a surgeon named J. Bruce Moseley found himself engaged in an elaborate form of make-believe. Moseley had 10 patients scheduled for an operation intended to relieve the arthritis pain in their knees. The patients were men -- most of them middle-aged, all former military guys -- and they weren't ready to consign themselves to the rocking chair yet. So they had decided to take a risk and volunteer for a study that must have sounded, when Moseley first told them about it, rather peculiar. All 10 would be wheeled into an operating room at the Houston Veterans Affairs Medical Center, draped, examined and anesthetized. All 10 would be dispatched to the recovery room and sent home from the hospital by the next morning equipped with crutches and a painkiller. But there the similarities ended. For while two of the men would undergo the standard arthroscopic surgery for their condition -- the scraping and rinsing of the knee joint -- and three would have the rinsing alone, five would have no recognized surgical procedure at all. Their surgery would be a placebo, an exercise in just pretend.
Moseley would stab the placebo patients' knees three times with a scalpel -- to make it feel and look real, there had to be incisions and later, scars -- but that was it. And he couldn't break character. If he knew in advance which kind of surgery he was to perform, he might somehow give it away, so it wasn't until he entered the gleaming O.R., scrubbed and in his greens, that he opened an envelope telling him whether he was doing a real procedure or a fake one that time. Only the anesthetist and the nurse assisting him were in on the secret.
In some ways, Bruce Moseley was an unlikely actor for such a role. As a surgeon and a team physician for the Houston Rockets, he wasn't the kind of doctor given to woolly introspection about the Mind-Body Problem. He was simply skeptical about the specific benefit of arthroscopic surgery for arthritis of the knee and wanted to test its efficacy. Then Moseley started talking with a doctor named Nelda Wray who had been put in charge of health care research at the Houston V.A., and she asked him a startling question: How did he know that whatever benefit came from this surgery wasn't a product of the placebo effect -- that is, that those who improved did so not because the operation actually healed the knee joint but because they expected it would?
"I said: 'It can't be,'" Moseley recalls. "'This is surgery we're talking about.' And she said: 'You're all wrong. The bigger and more dramatic the patient perceives the intervention to be, the bigger the placebo effect. Big pills have more than small pills, injections have more than pills and surgery has the most of all.'"

The Placebo Prescription