Jake has a great post up today about the frequency with which American internists and rheumatologists prescribe placebos and the ethical questions this raises. Jake writes:
For my part, I don’t think I would be comfortable deceiving my patient under any circumstances. I see my role as a future physician partly as a healer but also as an educator. Patients — particularly patients with intractable chronic illnesses — want to understand what is happening to them. I almost feel like in deceiving them, I would be denying them that small measure of control — that small measure of dignity — that is vital to feeling like a complete person, even in the face of a life destroying illness. The ability to make decisions for yourself is an empowering feeling. You only take that away if you are absolutely convinced — as in the case of dementia or severe mental illness — that someone is completely incapable.
The whole post is well worth reading. But I’m wondering whether there couldn’t be some conditions under which use of a placebo wouldn’t violate a patient’s dignity.
First, let’s specify that we’re talking about a therapeutic context rather than a research context. In clinical trials, giving placebos to your control group is not always unethical (although in some cases it may be ethically required to provide the control group with the current standard of care).
Second, let’s stipulate that using substances like antibiotics as placebos is really, really stupid. Antibiotic-resistant bacteria are a significant public health problem, while sugar-pill-resistant bugs are not.
The main ethical problem with therapeutic placebo use is the deception involved — the doctor tells the patient that the substance being administered will have some useful therapeutic action even though there is no good reason to expect it to do so.
But to the extent that there is evidence for a placebo effect, there is reason to expect that placebo treatment will be better than no treatment.
What if a physician were to present the patient with the following information:
I am going to offer you a treatment that might do nothing, but that might help relieve your symptoms. We have no reason to believe that this treatment will make your symptoms worse, nor that it will cause other harm to you. Treatments of this sort have helped other patients, but we still aren’t clear on the mechanism behind it. I am leaving the choice of whether to try this treatment up to you, and I’m happy to talk with you about the research we have now about the efficacy of this kind of treatment. If you feel you would like to try it, I am happy to provide it. If not, I will do my best to alleviate your symptoms and treat your condition with the other tools available to us.
To the extent that there is evidence for a placebo effect, using placebos is not a departure from the principles of evidence-based medicine. And while, as Jake points out, it is preferable that there be well-understood mechanisms for the treatments modern medicine offers, I’m not sure that all of the treatments we know (through clinical trials, for example) to be reliable are also ones whose mechanisms have been pinned down. (Aspirin and IUDs are two medical interventions that were safely used for years without fully elucidated mechanisms of action.)
I don’t think the hypothetical physician statement here depends on deceiving the patient. Indeed, I think an astute patient presented with this statement could figure out that she was being offered a placebo.
If I were the patient, I think I might even accept the placebo — because I believe in the placebo effect.
I suppose, ultimately, we might need research to determine whether a sugar pill retains its therapeutic efficacy when coupled with this kind of physician instruction to the patient. If someone wants to propose the research, I’d be pleased to get an acknowledgment.