If placebos work, should doctors use them?

Others aren't so sure. If "we look at the first rule of a medical practitioner of 'first, do no harm' there could be an argument made for saying that using a placebo, if it does no harm and if it does help, could be quite a reasonable solution to problems," says Rory Coughlan, a health psychology professor at Trent University in Peterborough, Ontario.

A fuller understanding of the placebo effect would embrace the entire doctor-patient relationship, says Anne Harrington, a professor of the history of science at Harvard University and author of the book "The Placebo Effect." A better way to think about the placebo effect would be as "the sum total of effects," she adds. Part of that experience might be going into a waiting room where the patient sees lots of certificates on the wall, and where a confident doctor walks in with a white coat that designates him as a professional expert. "All of these things produce the placebo effect," she says. "There's a placebo effect probably that's involved in every treatment, not just treatments using sugar pills."

"In a sense, placebo is the clinician's best friend," Mr. Coughlan says. "But in the scientific view of medicine, it's the enemy because we're always trying to prove that something is better than placebo."

Even those who study placebos acknowledge that the jury is still out.

The 2001 NEJM study "still has not been refuted," points out Ted Kaptchuk, a professor of medicine at Harvard University who has been involved in a number of clinical trials studying the placebo effect.

That study - titled "Is the Placebo Powerless?" - reviewed 130 clinical trials. While inert pills "had possible small benefits" for the treatment of pain, the study concluded, "outside the setting of clinical trials, there is no justification for the use of placebos."

"There's still a need for rigorous research in terms of the power - or the lack of power - of the placebo in conditions that have to do with real illnesses over time," Professor Kaptchuk says.

To be effective, these studies need to be three-tiered, comparing placebos not only to active drugs but also to doing nothing - no treatment at all, researchers say.

Despite the 2001 NEJM report, "there has been a change in the last couple of years" in recognizing the importance of the placebo effect, argues Daniel Moerman, a medical anthropologist at the University of Michigan at Dearborn, who's studied the placebo effect for nearly three decades.

He and others in the field also urge more research into why placebos work.

"That's a big, tough, wide-open question," says Professor Moerman, author of the book "Meaning, Medicine and the 'Placebo Effect.' " "My own feeling is that there's a lot of different things going on, and if you think it's just one thing, you get lost," he says. "The one thing we can know about 'placebo effect' is that it isn't caused by placebo [pills], because they're inert."

Can placebos play a significant role in healing? "I don't know," Kaptchuk says. "I think so. But I don't think the clear evidence is out there.

"I think that the way medicine has constructed itself or parsed itself, there's no place for placebo," he adds. "Placebo is really about the patient-doctor relationship; it's about how people respond to symbols; it's about the intangible parts of medicine," such as the inherent capacity of human beings for self-healing.

Most of the drugs that people take probably are not doing much more than placebos or "natural history" - people getting better without treatment, Kaptchuk says. "And that's important to know. We have a society that's taking lots of drugs."

Perhaps 50 percent of the effect of seeing a physician is "based on the doctor-patient relationship, the art of medicine, and it's not acknowledged," he adds. "And I think that's what people want more of. We want high-tech, and we want sophisticated interventions. But we also want the art."

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