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The need to deliver ethical placebos

Dr Placebo
Last edited 13th September 2012

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.

Placebo treatment

Thank you for this post.

While I am supportive of placebo trials (see my blog http://doctorskeptic.blogspot.com.au/2012/07/why-placebo-surgery-is-ethi...), there are many issues with placebo treatment.

Firstly, placebo treatment is given all the time. Much of mainstream medicine and most of alternative medicine uses this effect, often knowingly. But placebos do not usually have long-lasting effects, so they are less suited to some conditions. Also, there are issues like cost, and treading the thin ice around deceit and full disclosure.

My biggest issue though, is that recommending (or justifying) placebo treatment opens up the door to just about any treatment you can think of. Immediately, we can no longer criticise homeopathy and just about every other alternative medicine practice. Also, we open the door for doctors to continue expensive and invasive treatments on the basis that they "seem to work", even though they work no better than placebo.

The practice as you describe it happens now; I would be hesitant to expand it.

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