Tool Module: Ethical Issues Raised
by the Placebo Effect
The combination of the placebo effect’s proven power in certain
applications and its reliance on deception raises some interesting ethical
issues. The placebo effect confronts physicians with two conflicting
ethical imperatives: to relieve their patients’ suffering, and to tell
their patients the truth. In clinical drug trials, when subjects are
warned that they may receive a placebo, the placebo effect is reduced
considerably. Hence the key ethical issue is whether it is acceptable for
doctors to prescribe a placebo to their patients without telling them that
it is one, so as to preserve its potential effectiveness.
Some physicians think that nothing justifies lying to a patient. In
their view, using a placebo without telling the patient may undermine the
patient’s trust and compromise the doctor-patient relationship. Another
example of the risks they cite is that of administering a placebo to a
patient who is suffering from depression, and then commits suicide because
he or she has not received proper treatment. In short, according to this
position, which is often taken by the organizations that oversee medical
research, a study in which some patients receive nothing but a placebo is
acceptable only if the disease being treated is relatively benign and the
drug being tested is designed to relieve its symptoms or shorten its
duration, or if the disease is a serious one for which there is not yet
any effective treatment.
At the other end of the spectrum, there are some therapists—often
practitioners of alternative medicine—who are not really interested in
knowing whether the treatment that they are providing to their patients
actually has a specific effect or is only a placebo. Their position is
that so long as the patient gets better, knowing whether the treatment was
real or only a placebo doesn’t matter very much.
But their detractors retort that on the contrary, it does matter,
because often patients may get slightly better without being completely
cured, and so the search for a proven treatment for their illness must not
be abandoned too hastily. Some detractors also point out that therapists
could recommend many changes in lifestyle—such as eating a healthier diet,
getting more exercise, losing weight, and reducing stress—that might prove
far more effective and reliable than a placebo.
And then there are all kinds of positions somewhere midway between
these extremes. Some doctors think that prescribing placebos may be
justified for conditions that are known to be highly sensitive to the
placebo effect and in which the patient’s distress is a significant
aggravating factor. Other doctors think that prescribing a placebo may be
all right if they explain to their patients that they might get a better
understanding of what is wrong with them if they try various medications,
including a placebo.
These kinds of attitudes, according to which the ethics of prescribing
placebos depend on the individual circumstances, were found to be common
in a study published in the British Medical Journal in 2008 (see
link below), in which the authors surveyed practicing internists and
rheumatologists in the United States. Nearly half of these respondents
reported prescribing placebo (inactive) treatments on a regular basis, and
62% believed the practice to be ethically permissible.
According to this survey, the placebos prescribed by the highest
proportions of the respondents were over-the-counter analgesics (41%) and
vitamins (38%). Some of the respondents reported using antibiotics and
sedatives as placebos (13% in both cases), while only 3% reported using
sugar pills. Of those physicians who prescribed placebos, 68% described
them to their patients as a “potentially beneficial medicine or treatment
not typically used for their condition”.
This study concluded that prescribing placebos was a common practice
within the community of physicians surveyed, despite the potential adverse
consequences for both patients’ and public health (for example, the
development of resistant strains of bacteria if antibiotics are prescribed
when they are not medically indicated).
As might be expected, the results of this study set off some vigorous
debates. Some critics contended that the high rates of prescribing
placebos reported in this study could be attributed to the authors’ rather
broad definition of placebos. Prescribing a placebo when a patient
requests a non-prescription painkiller and telling him or her that it can
indeed help some people feel better is quite different from prescribing a
sugar pill and falsely telling the patient that this is the best molecule
on the market for treating his or her condition.
Other critics have disputed the study’s conclusion, often described
sensationalistically in the media as being that half of the physicians in
this study prescribed placebos “routinely”. The data from this study show
that half of the physicians recommended placebo treatments 2 to 3 times
per month. Given that physicians may see around 400 patients per month,
these critics argue that the expression “routinely” may thus be an
overstatement, to say the least.
Beyond the debate generated by this particular study, the medical
community generally agrees on at least two things. First, prescribing a
placebo to get rid of a troublesome patient does more to make the doctor’s
life easier than to promote that patient’s well-being. Second, however, it
would be equally bad medicine not to take advantage of the placebo effect
inherent in any medical interaction based on good faith, good
explanations, and mutual trust.
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