The need to deliver ethical placebos
Clinical practice demands doctors provide the best available care. Some patients have non-specific complaints and there is no proven ‘active’ treatment. Placebos might benefit these patients. In other cases such as relieving pain placebos are known to have beneficial effects, while ‘active’ treatments have known side-effects. A problem is regulations all but forbid placebo use. But this is perverse – why would regulations prevent doctors from helping their patients?
Fortunately there other solutions. The reason placebos are considered unethical is they supposedly involve lying to patients. For example a doctors might tell their patient “this is a real treatment” when in fact it is a sugar pill. However placebos have been known to have effects even when doctors tell patients they are mere placebos. Hence doctors could simply inform patients that the treatment they prescribe is a placebo, and avoid the ethical problem. However it is likely that telling a patient that a treatment is a ‘placebo’ will reduce its effect.
But some patients may not care whether the treatment they are going to receive is a ‘placebo’, especially if such knowledge might reduce the benefit. These patients will undoubtedly want to know the treatment is safe, but have no interest in the ingredients or the label we place on the treatment. So, doctors could ask patients how much information they wish to receive about the treatment. The doctor could say, "Good morning Mrs Jones, my name is Dr Smith. This treatment has helped people with symptoms like yours, and it is known to be safe. We don't know exactly how it works, although some studies suggest it induces the body to produce various chemicals that can have benefits. Some patients like to know a lot about the treatments they use, while others don’t care and are willing to try and judge for themselves. If you would like to know more about the treatment I’m going to depend on you to prompt me. Does that seem like an acceptable way of proceeding?” Then, if the patients prefer to know more, the doctor might say that the treatment is sometimes referred to as a ‘placebo’, and add that much confusion surrounds the term. Or, if the patient doesn’t care, the doctor could refrain from revealing any further information.
This situation is familiar to us. Some Olympic athletes may wish to know everything about their opponents and the conditions, while others will find such information distracting.
As a patient, the amount of information you wish to receive about your treatments must be taken into account. Sometimes you will want to know everything, and at other times you may merely wish to know your treatment is safe.
Are placebos as good as 'real' antidepressant drugs?
The National Health Service in the United Kingdom spends over 300 million pounds per year on antidepressants (475 million USD).
Last Sunday night the research was discussed in a CBS 60 Minutes report. During her interview, reporter Lesley Stahl challenged Kirsch: "You're saying if (patients taking antidepressants) took a sugar pill, they'd have the same effect?"
Kirsch replied: "They'd have almost as large an effect, and whatever difference it would be, would be clinically insignificant."
Stahl was incredulous. "But people are getting better taking antidepressants, I know them. We all know them."
"People get better when they take the drug, but it's not the chemical ingredients of the drugs that are making them better. It's largely the placebo effect," Kirsch replied.
Kirsch’s research raises many provocative questions. If placebos appear to cure depression, is depression a real disease? How can a sugar pill cure depression? If sugar pills work as well as drugs and have fewer side effects, why not use them?
Nobody doubts that depression can be very serious. (And any patient taking or considering antidepressant medication should consult a qualified practitioner before making treatment decisions.) Instead, it means placebos are particularly good at curing depression. This can be achieved through several mechanisms. The sugar in the pill can influence insulin levels and induce a cascade of physiological effects. Moreover the doctor’s friendly manner, also part of the placebo, has been shown to make mildly depressed patients feel better.
The reason placebos aren’t prescribed is doctors deem them to be unethical. This is because (among other reasons) doctors should only prescribe treatments that are proven to be effective. But effectiveness is often established by demonstrating superiority to placebos; so to prove they are effective, then need to be more effective than themselves, which is impossible. Moreover, as Stahl noted, the ‘real’ drugs have known and serious side effects. So not prescribing placebos might be even less ethical.
Whatever the answers to these difficult questions, surely we can come up with an answer to the placebo ethics dilemma that costs less than 300 million pounds per year. More research, please!
The truth, the whole truth, and 'nocebo' effects
Good practice demands that doctors inform their patients about both known and suspected side effects of any medication they prescribe. (In ethics-speak this is because of the requirement to respect patient autonomy.) On the other hand, the very act of providing information about side effects can produce negative effects (these are called ‘nocebo’ effects)! For example in a trial of a drug for unstable angina, patients were divided into two groups. The first group was given a statement outlining possible gastrointestinal (GI) side effects, and the second was not. Six times as more patients in the first group experienced subjective GI side effects.
How can doctors respect patient autonomy by revealing all information about side effects, yet avoid doing harm by causing the very side effects they describe? One answer is to give the information in the right way. We all know people who give negative feedback in a way that tends to increase anxiety. Others give the same information to evoke positive responses. Good teachers, coaches, and doctors all know how to frame information constructively.
Another solution is to ask patients. Some patients do not want to be burdened with details of all known and suspected side effects (serious side effects do, of course, need to be revealed). In these cases we can respect patient autonomy and withhold some information because the patient requested to be (partially) ignorant. Other patients do want to know about each and every side effect, in which case there may be little choice other than to reveal them, albeit in the right way.
So what’s the take home message? Tell the whole truth that the patient wants to hear and nothing but the truth in a way that will maximize benefit and minimize harm.