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.

Link : Des placebos prescrits par la moitié des médecins américains Link : Prescribing "placebo treatments": results of national survey of US internists and rheumatologists Link : Rapid Responses to: Prescribing "placebo treatments": results of national survey of US internists and rheumatologists Link : The Placebo Prescription Link : Overt versus covert treatment for pain, anxiety, and Parkinson's disease

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