The Ethics of Using Placebos

ResearchBlogging.orgA survey of American internists and rheumatologists has revealed that over 50% of them regularly prescribe placebos. Tilburt et al. surveyed internists and rheumatologists to see whether they were prescribing placebos, and if so how and what kind they were using. The study, published in BMJ, found the following:

679 physicians (57%) responded to the survey. About half of the surveyed internists and rheumatologists reported prescribing placebo treatments on a regular basis (46-58%, depending on how the question was phrased). Most physicians (399, 62%) believed the practice to be ethically permissible. Few reported using saline (18, 3%) or sugar pills (12, 2%) as placebo treatments, while large proportions reported using over the counter analgesics (267, 41%) and vitamins (243, 38%) as placebo treatments within the past year. A small but notable proportion of physicians reported using antibiotics (86, 13%) and sedatives (86, 13%) as placebo treatments during the same period. Furthermore, physicians who use placebo treatments most commonly describe them to patients as a potentially beneficial medicine or treatment not typically used for their condition (241, 68%); only rarely do they explicitly describe them as placebos (18, 5%).

The use of placebos poses a very serious ethical dilemma for physicians. On the one hand, they do work in some cases. Usually they only work when the patient believes that they are going to be effective, but you can get some clinical benefit from them. It doesn't actually surprise me that they surveyed internists and rheumatologists because these physicians are often dealing with patients who have chronic conditions that may be difficult to diagnose and to treat. If you are dealing with a patient in chronic pain that you have been unable to alleviate, and you knew that they would feel better if you gave them a sugar pill in the guise of a "new medicine," would you do it? On the other hand, the use of placebos involves a degree of deception by the physician. Medicine has moved away from the paternalism present even 25 years ago to the idea of patient autonomy: the patient must be informed of the risks and benefits of all their medical procedure and make a decision of what to do based on their values. Further, the whole idea of using a placebo irritates my sense of evidence-based medicine. We are supposed to understand the mechanism for how what we are doing will help the patient. The mechanisms for why placebos work are complex and still not entirely clear. Add to that, what if the patient found out that you had deceived them? Not only would the placebo fail to work, but you would have destroyed that relationship. 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. In my opinion, prescribing a placebo is not only insulting a patient's intelligence, it involves an attack on their dignity. (Further, I have a real problem with physicians who are using placebos that actually have some chemical activity -- like sedatives or antibiotics. That is not acceptable because they might have very serious side-effects.) I am very curious to hear what others have to say about this. Is this lazy medicine? Is this the conditional use of different means when conventional treatment has failed? Is this ethically acceptable deception? Hat-tip: NPR J. C Tilburt, E. J Emanuel, T. J Kaptchuk, F. A Curlin, F. G Miller (2008). Prescribing "placebo treatments": results of national survey of US internists and rheumatologists BMJ, 337 (oct23 2) DOI: 10.1136/bmj.a1938

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"Prescribing 'placebo treatments': results of national survey of US internists and rheumatologists," is the title of a newly-published article in the 23 October issue of BMJ (British Medical Journal). The full text article and PDF are available for free at the time of this posting. In this study…
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This article is cross-posted at Science-Based Medicine. Check it out. --PalMD In a previous post, I argued that placebo is an artifact of certain clinical interactions, rather than a treatment that we can exploit. Apparently, there are a whole lot of doctors out there who don't agree with me.…
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I did a little piece here, but in sum, placebos are unpredictable. They cannot be effectively prescribed in any rational manner. One placebo "effect" is the relationship between doctor and patient---this should always be used anyway.

Prescribing a pill, elixir, etc and giving false information as to it's effectiveness is unethical.

oh please. how many medications do we have where we do not really and truly understand how they work? Just because you have a handful of acute pharmacological effects to report doesn't mean you really understand the critical mechanism. How the hell does Ritalin work? How about Prozac, which takes many weeks for efficacy? Antipsychotic medications...what is the real, clinically specific mechanism of action?

The placebo effect is not different in any way that matters. Parroting "See here, patient, this medication is a SerotoninTransporterInhibitor! (which, oh by the way, only works in some patients and these other pharmacologically near-copies don't work in the same patient but might work in another subset and....)" is not really more of a physician understanding than is "Some studies show that placebo treatments offer benefits, shrug"...

Prescribing a pill, elixir, etc and giving false information as to it's effectiveness is unethical.

Interesting. Is it "false information" to fail to communicate the true state of uncertainty about a treatment practice or drug? Particularly when, as you say, the doctor-patient relationship (i.e., I trust my doctor's advice) may be a very critical part of the therapeutic efficacy?

I think I have a fair appreciation of variability in populations, diseases or conditions and therapies thereof. an understanding of the unknowns in treatment. The usual line that I get from the medical profession on various topics are clearly lies. Lies to children, but still falsehoods. I also understand the apparent reasons for this- because most people do not have the above appreciations and they are comforted by certainties. I am comforted by relatively precise and accurate knowledge that comports with my understanding of the variability in the natural world. I conclude that "truth" can mean different things for different patients.

This makes blanket statements about telling "falsehoods" to patients a very tricky business indeed.

The placebo effect may very well depend on generating a false belief in the patient. If lying works, why is this necessarily unethical? It should be subject to cost/benefit analysis like any other therapy...

DM, there is a difference between not knowing mechanism of action and knowing the anticipated efficacy and utility.

I tell my residents/students regularly that we don't really know how SSRI's work. It can't be explained by putative mechanism alone. But (I would argue, perhaps wrongly) they are effective when used properly.

We don't understand every mechanism as to how statins reduce CV events in diabetics, but we know they do. It's not a placebo.

DrPal, as Jake noted, placebos work in some cases. My argument is gated on the assumption that there is indeed a real, therapeutically beneficial effect of prescribing a placebo. Given that that is true, it is no more "insulting a patient's intelligence" or "giving false information" to prescribe the placebo (unknown mechanism of action) as the SSRI (unknown mechanism of therapeutic action, some hints as to basic pharmacological effect)

Now, you may be defining anything that has statistically reliable tested effects as "not a placebo" but that's sophistry.

By DrugMonkey (not verified) on 24 Oct 2008 #permalink

The problem is that placebos are not "statistically reliable".

I think we are rapidly descending into a semantic debate over what is a "placebo" treatment.

By DrugMonkey (not verified) on 24 Oct 2008 #permalink

I don't think patients give a damn about their dignity, they just want the doctor to DO SOMETHING. "I'm sorry, there is nothing that I can do." gets transmuted as not caring about the patient even to tell them to take a simple aspirin.

Why do people go for prescription Motrin rather than take four Advil. You can educate all you want, and folks will leave and go get what they want. Giving placebos, you're caring and compassionate.

Never underestimate people's desire to be bullshitted.

By William the Coroner (not verified) on 24 Oct 2008 #permalink

For my part, I don't think I would be comfortable deceiving my patient under any circumstances.

Good for you. I agree.

The doctor-patient relationship is one based on trust. As a patient, I don't have the expertise to evaluate my condition and all my treatment options. That's my doctor's job, along with honestly communicating treatment options to me. If I can't trust that my doctor is giving me a real drug or snake oil, why the fuck should I trust him about anything else he says or does?

I don't see it as all that complicated. Either you are honest, or you are not. Prescribing a placebo IS deceiving the patient, as a rule, otherwise, they wouldn't be "tricked" into getting well. The whole premise is based on a lie. It all depends on how a doctor chooses to be in his life and his profession.
As for the obvious lack of efficacy of most psych drugs...well, I guess that's just a lesson that the patient must learn on their own. I just think it's a crime to prescribe such potent drugs to growing children who are not able to make that choice themselves.

By Deborah Hill (not verified) on 27 Oct 2008 #permalink

I heavily weigh the element of trust very heavily in the doctor-patient relationship, but there is one element that is more important than this: treatment. I would much rather have a deceiving devil-doctor that attempts to treat me, than an angel that weighs trust above treatment.

I was with you right up until you said something ridiculous:

"The mechanisms for why placebos work are complex and still not entirely clear."

Placebos don't work, by any objective metric. That patients are more likely to report a positive outcome when given a placebo treatment compared to no treatment just illustrates the unreliability of patient reports.

They don't work, plain and simple. You wouldn't have even suggested otherwise if every usage of the word "placebo" was replaced with "prayer", which is a qualitiatively identical term. There are, after all, "studies" which establish a statistically significant benefit to intercessory prayer, too. A meaningless intervention by any other name...

By yeahsurewhatever (not verified) on 28 Oct 2008 #permalink

Has anyone considered the side effects on a larger scale. The overzealous prescription of antibiotics has contributed to the mutation of some previously treatable maladies. Is it wrong for a doctor to simply hand out antibiotics because of the potential to expedite this mutation? I'm no doctor, nor a scientist, yet this seems counterproductive if it is on such a large scale basis.

"They don't work, plain and simple"
That is unfortunately wrong: a saline placebo has been proven to have the same efficacy as 6-8mg of morphine in treating post operative pain. Haven't got a link to hand, but there is a link to the paper on the wikipedia article on placebos I think...