Adventures in Ethics and Science

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.

Comments

  1. #1 Matt
    October 24, 2008

    Doesn’t the knowledge that a treatment is a placebo nullify its effects?

  2. #2 DrPal
    October 24, 2008

    Another question is for medically unsophisticated patients (most patients) is *everything* the ethical equivalent of a placebo. Most of my patients can’t understand the literature about ACE-inhibitors, but take them and benefit from them. I’d argue that placebo is really just background noise, and that, for instance, listening to and examining someone with a bad cold is as effective as prescribing them a non-science-based treatment.

  3. #3 Kamel
    October 24, 2008

    What about the issue of charging money for a placebo? In your example above, even a non-astute patient can probably figure out that they’re being given a placebo when a full course of treatment costs as much as a pack of Tic-Tacs. And as Matt points out, doesn’t this negate the placebo effect? (And this is further complicated by the recent study that showed that expensive placebos work better than inexpensive ones)

  4. #4 katy
    October 24, 2008

    What if the patient didn’t figure out as a placebo? It would affect their perceived choices in other medications. They might not be able to get a treatment or drug they need because they THINK they’re on something that is on its list of “do not mix” interactions.

  5. #5 Maria
    October 24, 2008

    I’m terrified that Orac or someone will post some screed demolishing the idea that chamomile tea is a weak antibiotic and beneficial all-purpose tonic, and then I’ll be deprived of my favorite placebo.

    I don’t know if I’m fooling myself well enough to be getting the full effectiveness of the placebo treatment, but I think there’s a line to walk where you know it’s a bit silly but believe it anyway.

  6. #6 Abel Pharmboy
    October 25, 2008

    Ping-o-rama!

    Maria, drink up and enjoy! This review by a group at Tufts supports some uses of chamomile but mostly from animal studies. Be sure to take some chamomile tea bags while hiking; they have wound-healing activity in rats. Of course, read the review with a critical eye since it was funded in part by BigHerba (Hain Celestial). The only caution is for people who are on antithrombotic therapies like Coumadin or Plavix since chamomile contains coumarins.

    Another note: The biostatistician R. Barker Bausell, author of Snake Oil Science noted in his superb book that if you really want to maximize a placebo effect, you have to jump in with full enthusiasm, even if you know the treatment is a placebo.

  7. #7 Michael Pyshnov
    October 25, 2008

    “…chamomile contains coumarins”?
    coumarin is a carcinogen. It used to be added to tobacco for aroma. They stopped adding it, apparently, in early ’60s. The data on lung cancer and smoking include the period when people smoked coumarin. I worked with it long time ago to get chromosomes stretched and reveal heterochromatin bands for chromosome identification.
    Here are your natural remedies.

  8. #8 SteveWH
    October 26, 2008

    We just talked about the ethics of physicians and nurses deceiving patients in my medical ethics class this week. I think the class needs links to these blog posts.

    Thanks!

  9. #9 David Harmon
    October 27, 2008

    Maria:

    I’m terrified that Orac or someone will post some screed demolishing the idea that chamomile tea is a weak antibiotic and beneficial all-purpose tonic,

    Well, it’s certainly still a mild tranquilizer, so… have some, and you won’t be as anxious about it! ;-)

  10. #10 prosaica
    October 29, 2008

    I have an additional approach to ethical usage of placebos (sugar pills, not antibiotics). Many people I know always want a medication when they, or their kids, are sick. If a doctor won’t give them what they want, they’ll go doctor shopping until they’ll find one who does. Educating is not easy, and sometimes not realistically feasible (dctors can’t devote so much time to any one patient). Plus, they would have a hard time reversing the effects of a consistently science-averse education and media.

    In this situation, I think placebos are a reasonable choice.

The site is undergoing maintenance presently. Commenting has been disabled. Please check back later!