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Over the last 200 years, the placebo effect has cast a large and persuasive shadow over the medical field. In that time it has been by turn; harmless charade, charlatan's ruse, therapeutic device, methodological tool, ethical dilemma, research theme and source of controversy. Despite popular recognition, pervasive problems underlie conceptualisation of placebos and placebo effects. With medicine now firmly entrenched in the age of evidence-based practice, there is a question as to whether it is time to leave the old placebo behind us. The idea of a magical black box from which unexplained therapeutic effects spring up is archaic and also unhelpful from a scientific point of view. If there really is an effect, surely we are best served by directly investigating what is responsible for it. This knowledge can be used in the clinic to improve treatment effectiveness and in research to inform study design.
The view and role of placebos have developed over time. Modern medical understanding of placebos dates back to the late 1700s1, and since then, placebo interventions appear to have been used fairly commonly in medical practice alongside other treatments.2 Up until midway through the 20th century, the prevailing opinion appears to have been that placebo interventions had no effect on pathophysiology. Placebos were used only to bring comfort to the patient, ‘a camouflage behind which to watch nature takes its course’1 (p. 512).
From the 1950s onwards, there was a shift towards regarding placebos as having genuine effects of their own. Beecher's well-known article ‘The Powerful Placebo’3 apparently confirmed the claims of widespread and important therapeutic effectiveness of placebo interventions. This period also saw the start of rapid growth in the use of placebos as a control intervention for testing the efficacy of other treatments. Thus, as research generally, and …
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