Are Placebos A Betrayal?




Drugs and Clinical Trials CategoryIn recent years, there’s been a resurgence of interest in placebos. Not the kind that are used to minimize bias in clinical trials, but the kind that doctors knowingly give to patients.

In a recent survey of more than 200 doctors practicing in academic medical centers, 45% reported that they had given placebos to patients in the course of providing clinical care. Nearly all the physicians surveyed agreed with the statement that “placebos have therapeutic effects,” and the condition for which they believed placebos offered the most psychological and physiological benefit was pain.

PlaceboThey endorsed a variety of suggested definitions for placebo substances: half agreed with the statement that placebos are interventions “that are not expected to have an effect through a known physiologic mechanism.” The primary reasons physicians used placebos were to calm patients (18% of the time) and as supplemental treatment (also 18% of the time). One of the particularly noteworthy things about this study is that 92% of the doctors believed that the mechanism of action of the placebo was psychological. They weren’t giving the placebos to anxious patients simply to shut them up; they were invoking a mechanism of healing — the mind-body connection — that they believed in, even though they couldn’t specifically identify how it operated.

This is a sea change from “old school” thinking about how placebos fit into clinical practice. In a 1979 study, a majority of academic physicians reported believing that the use of placebos helped expose patients who were “faking” their symptoms. In contrast, 80% of the doctors in the more recent survey disagreed with the notion that placebos can be used to identify symptoms that have a psychogenic origin.

All good news so far, but there’s more. Only 4% of the physicians told the patient that the substance they were receiving was a placebo. Most used vague statements like, “This may help and won’t hurt” or “It’s medicine with no specific effect.” Just over 10% of the doctors in the survey believed that the use of placebos should be categorically prohibited on ethical grounds.

I try to imagine how my internist, who I respect immensely, would respond. Would he use a ruse to invoke the healing power of my mind? He’s seen me through a number of minor crises over the last 15 years, and I can’t imagine a circumstance under which this wouldn’t feel like a betrayal. Is it just me? Are there circumstances under which you’d be glad to have your doctor deceive you if it made you feel better?

References

Sherman, R., Hickner, J. (2008). Academic Physicians Use Placebos in Clinical Practice and Believe in the Mind–Body Connection. Journal of General Internal Medicine, 23(1), 7-10. DOI: 10.1007/s11606-007-0332-z

Goodwin, J.S., Goodwin, J.M., Vogel, A.V. (1979). Knowledge and use of placebos by house officers and nurses. Ann Intern Med, 91(1), 106-110.

  • A fascinating question which I think is crucial to explore. Particularly interesting would be to understand whether the placebo effect would still work if patients signed a consent form to receive placebo medicine if the doctor felt it was in their best interest – if it did work, that might be a way out of the maze.

    There’s another side to this dilemma as well – when a doctor gives you medication they tend to explain the side effects and likelihood that it won’t work (e.g. 80% effective). But it may well be that this reduces the confidence of the patient in the medicine, and thus reduces the efficacy of the medicine… In addition, despite the weight of evidence supporting modern medicine, a patient may wrongly believe that a treatment prescribed by a snake-oil salesman is more efficacious because the snake oil is publicised as 100% effective.

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  • Yes, placebos are a betrayal. Except in those cases when the doctor reveals the nature of the placebo (is it even still a placebo then?) the doctor is knowingly deceiving the patient. Since trust is paramount in every doctor/patient relationship, how could you justify overt deception on the part of the doctor? If the patient were to find out, it would completely undermine their trust in their doctor. On a larger scale, if patients are aware, through studies such as this, that a significant portion of doctors use placebos, the average patient now has plausible justification to doubt whether the drugs they are receiving are real.

    Nevermind the issue of cost…the potential abuse that could arise by a doctor charging exorbitant rates for sugar pills. Placebo use is clearly wrong, potentially abusive, and should actively be investigated and expunged from medical practice.

  • CD

    I think the patient’s paramount interest is in getting better. A patient should be able to trust that a physician will use every tool in her toolkit, including techniques that bring the patient’s own inner healing system more strongly on line. A physician who ignores this extremely functional tool is not doing her job.

  • Evidence based medicine, or conventional medicine, is required to out-perform what can be done with placebos.

    To fairly assess if a new drug is effective and safe, most advanced drug trials conducted before the drug’s approval are designed as randomized, double blind, and placebo-controlled.

    A new drug can be approved only if it’s significantly more effective than the placebo.

    The visit with a caring physician has potential for some healing through suggestion, and I think physicians and other medical professionals should develop skills to make every encounter one that improves the positive thinking of their patients and eases stress, but suggestion is just the bonus you may expect from your doctor. The diagnosis and treatment that he’s trained and vowed to give you is supposed to be evidence based, and work because it has specific therapeutic activity for your disease.

    It probably helps if you believe in the treatment, but it’s designed to work even if you don’t, and even if the patient’s unconscious.

    I believe that doctors shouldn’t be engaged in giving placebos. The interaction and words of the doctor can instill hopefulness and relieve distress, but one has to trust that the doctor is practicing evidence based medicine, and fully informs the patient about every aspect of the treatment. If he recommends a medication, it’s because it has a good chance of treating the patient’s specific disease.
    To read my post on this subject go here.

  • sitco

    patient need to learn how to take their medication correctly. patients believe everything their doctors say, doctors should not betray that trust..

  • There is a lot more to be discovered about the placebo effect, especially in the area of self-healing and the knowing administration of placebos. We at Universal Placebos have been following the growing discussion about beneficial effects, or otherwise, of doctors giving placebos, even when both they and the patient know they are placebos.

    In a significant number of cases a sugar pill will often do the trick, without the risk of side effects and unecessary expense. That’s why we got it together to make placebos available for sale to the general public.

    We have experienced placebos working when taken as a support to one’s intentions for well being and relief from symptoms, by as you say ‘invoking a mechanism of healing – the mind/body connection’.

    In many cases focussing on the belief that we can allow a natural healing, with the aid of a tangible symbol or ritual (i.e. taking a placebo) is all that is required . . . and they work so well for children who need that extra bit of attention . . . some of our young users call them”magic pills” or “angel pills”!

    Of course they are not substitutes for the proper medical treatment of serious or life threatening conditions, but they do have a role to play in helping us reclaim our belief that in many cases we can heal ourselves without resorting to unnecessary medical interventions and their unwanted side effects.

    It is surprising how many ‘symptoms’ can be relieved before needing professional help by focussing our attention on health and well being with the help of a simple ritual . . . taking a placebo! So there is no need to be concerned about your doctor deceiving you. You make the choice yourself.

    If you are curious check out the testimonials on our website: http://www.placebo.com.au

Jennifer Green, MS

Jennifer Green, MS, is a freelance health care writer. A former nurse and college professor, she now writes about health care for clients around the world. She's particularly interested in research into the mind-body connection.
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