From inert pills to subjunctive medicine: an exploration of the placebo effect in general practice

Abstract

The placebo effect is a complex concept with a long and contentious history. In the context of clinical practice, it pumps the intuition that beneficial treatment effects are not solely reliant on the specific biologically conceived mechanism that characterises a medical treatment. This is considered particularly relevant in general practice. However, despite a substantial body of research, considerable ambiguity exists regarding the conceptual coherence and clinical effectiveness of the placebo effect. In this thesis I explore the placebo effect in general practice, including how clinicians and patients conceive of the concept, and how it might be harnessed to improve patient care. I first conducted a meta-ethnographic systematic review of patients’ and clinicians’ views on the placebo effect in the context of primary care. Through my findings I deconstructed the placebo effect from the predominant notion of the effects of ‘inert’ pills, towards the potential benefits of the therapeutic encounter. This deconstruction informed the second phase of this thesis: an ethnography of a general practice surgery in southern England. My ethnographic findings suggest that clinicians capitalise on the benefits of the therapeutic encounter – in the face of substantial constraints – by adopting good habits, which I broadly conceive in two categories: using expert judgement and taking patients seriously. I further suggest that clinicians do not merely will themselves towards these habits but maintain them by developing a secondary ‘meta’ habit of enaction. This suggests an important feature of the general practice consultation: it is conducted as much in the subjunctive as the indicative mood. Developing this proposition, I propose a more general form of medical practice – subjunctive medicine – grounded in the transitory, shared social situation each unique consultation creates. Synthesising my meta-ethnographic and ethnographic findings, I argue that, in clinical practice, the placebo effect is an untenable concept grounded in an unrefined naturalist account of healing. As such I suggest that the placebo effect cannot be usefully harnessed to improve patient care in general practice. Beyond this conclusion I propose that subjunctive medicine represents an alternative expansive naturalist framework for general practice, which can more usefully accommodate phenomena the placebo effect purports to encompass.

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Identifiers

ORCID for Douglas Iain Hardman: orcid.org/0000-0001-6717-2323

ORCID for Adam Geraghty: orcid.org/0000-0001-7984-8351

ORCID for Mark Lown: orcid.org/0000-0001-8309-568X

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