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Using placebo in medical practice – an ethical conundrum

Social entrepreneur Daniel Jacobs raised US$50,000 to develop a “placebo” iPhone app that he says will help people make positive changes in their lives for health, joy and love. No deception is involved…

New research shows that deception is not necessary for a placebo to work its magic. Cupcake Heart/Flickr

Social entrepreneur Daniel Jacobs raised US$50,000 to develop a “placebo” iPhone app that he says will help people make positive changes in their lives for health, joy and love.

No deception is involved. And the user will get to choose their type of placebo, such as (an image of) a pill, a magic wand, or a communion wafer.

But how much deception is involved in more conventional forms of placebo used in medical practice?

The effect

The placebo effect is caused by an expectation (people taking a placebo may experience something that they expect to happen, such as pain relief) or through classical conditioning, or both.

Classical conditioning is based on the idea that we form an association between a stimulus and a response. In Ivan Pavlov’s famous experiment, dogs were conditioned to salivate when a bell was rung because they had been taught to associate the bell with food.

This kind of conditioning or expectation leads to biochemical reactions in the brain, so placebos involve the same mechanisms and biochemical pathways as drugs, such as activating different neurotransmitters.

Studies show that placebos can alleviate symptoms of illnesses that involve pain, fatigue, nausea, and anxiety and functional disorders in the digestive, pulmonary and urinary systems, among other illnesses.

Many medical doctors use placebos regularly. A UK survey of primary care practitioners published earlier this year, for instance, found that three out of four use placebos at least once a week.

In particular, the use of impure placebos appears to be common. Impure placebos involve substances with pharmacological effect but not on the condition being treated, such as antibiotics for viral infections or vitamins.

Using deception is often considered necessary for a placebo to be effective. Indeed, the use of placebos in clinical practice usually involves deception. But research shows that placebos can be used without deception and still work.

Using deception for the placebo effect violates the ethical principles of respect for patient autonomy and informed consent. It can also undermine trust and damage the patient-physician relationship.

Is it ethical for doctors to hand over placebos without telling their patients? Alex E Proimos/Shutterstock

There are arguments both for and against the deceptive use of placebos in peer-reviewed medical literature as well as advice from professional organisations.

An argument for placebo with deception

One of the arguments for the deceptive use of placebos is that, in some situations, they are the best available treatment. In these instances, the principle of beneficence takes priority over patient autonomy, and deception is justified when it serves the patient’s welfare.

From this viewpoint, paternalism is justified.

Medical ethicist Daniel Sokol suggests such deception is justified when:

the reasons include the prevention of great physical or psychological harm (including death), the exercise of kindness or compassion, the emotional or cognitive incapacity of the patient, and the reliable belief that the patient wishes to be deceived.

To help practitioners decide when deception is appropriate, Sokol has published a deception flow chart in the British Medical Journal. He restricts the use of deception to rare occasions when “benignly deceiving patients can be morally acceptable”.

Arguments against placebo with deception

Medical practitioners use placebos sometimes to calm people when they can’t make a firm diagnosis but the patient expects a tangible treatment. In these situations, the American Medical Association cautions against the use of placebo.

It advises:

placebo must not be given merely to mollify a difficult patient, because doing so serves the convenience of the physician more than it promotes the patient’s welfare.

Another reason against the use of placebos is that it amounts to disease mongering where healthy people are seen as requiring treatment and thus converted into patients.

Impure placebos can be unsafe; antibiotics, sedatives and analgesics can cause serious adverse reactions. And although the risk of adverse reactions might be low, the use of impure placebos without informed consent is problematic.

Placebos are not a guaranteed safe option. klesta

The unnecessary prescription of antibiotics also carries the risk of leading to antibiotic resistance, affecting not just the person who takes the drugs, but a much broader group of seriously ill people.

Even pure placebos can be unsafe; the sugar in sugar pills is often lactose, for instance, and some people are intolerant to it.

The guidance of medical associations

Some medical associations provide advice on the ethical use of placebos, such as the advice of the American Medical Association mentioned above. It generally guides its members against the use of placebos.

But others, such the Australian Medical Association, are quiet on the topic.

The German medical association, the Bundesärztekammer, advises that placebo treatments outside of clinical trials are ethically justified:

  • if there is no current proven (drug) intervention for that particular medical condition;

  • for minor conditions in circumstances where the patient expresses a wish for treatment; and

  • if it seems likely that a placebo treatment will be successful.

The chairman of the British Medical Association’s Ethics Committee expressed disappointment on learning of the extensive use of placebos by British GPs. He is quoted in a British newspaper as saying, “[P]rescribing something that you know is of no value is not ethical.”

How do patients perceive placebo use?

A recent survey from the United States confirmed what previous surveys (for example, from Switzerland and Hungary) discovered: most people found the use of placebo acceptable and valued honesty and transparency with such treatment.

Medical practitioners may be underestimating the openness of their patients toward the use of placebos.

The clinical use of placebos appears to be fairly well accepted and established by medical practitioners, given the extent of placebo use reported in several surveys. A systematic review of empirical studies found that between 41% and 99% of physicians and nurses had used pure or impure placebos, or both.

But without consensus on ethical use and without international guidelines, the use of placebos that involve deception continues to be an ethical conundrum.

Perhaps we can take guidance from the surveys and the placebo app. If the app proves to be effective and popular with users, it would confirm the open attitudes found by the surveys.

Medical practitioners should feel encouraged to explore their patients' views on placebo treatments as part of clinical decision making, and be open and transparent about their use of placebo treatments.

Join the conversation

19 Comments sorted by

  1. Sue Ieraci

    Public hospital clinician

    This is a fascinating area. Thanks for the article.

    One area of interest to me is how the placebo fits into the various models of therapist-patient relationship.

    In the past, doctors often acted in a directed, paternalistic style, in that they were expected to use their knowledge and judgment to help the patient feel better, with the patient trusting them to act in their vest interests. Deception, in the form of intentional placebo, was sometimes used.

    That style of doctor-patient relationship…

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    1. Sue Ieraci

      Public hospital clinician

      In reply to Sue Ieraci

      oops - 3rd para 3rd line - in their BEST interests, not ''vest''! (I'm SURE that's not Freudian!)

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    2. Mia Masters

      person

      In reply to Sue Ieraci

      Yes. But the 'slip' is not quite unexpected! The title of the article is 'Using placebo in medical practice – an ethical conundrum'. How, in few short sentences you end up bashing 'alternative' practices is rather boring but well within the realm of 'expected'. Dr Ieraci, direct your attention at the 'ethical' 'conundrums' within your field for a start. That is the subject of this article.

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    3. Sue Ieraci

      Public hospital clinician

      In reply to Mia Masters

      Thank you for the advice, Ms Masters, but I am already actively involved in many 'ethical' 'conundrums' within my field. Which ones in particular do you feel I have neglected?

      And do you feel that medical practitioners should be held to different ethical standards than other health care providers? If so, how should they differ?

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  2. John Crest

    logged in via email @live.com.au

    It should also show a glass of homeopathic water.

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  3. George Michaelson

    Person

    I think using an explicit placebo is morally in the same place as CBT, and should be both normal, and encouraged.

    It amazes me how easily I can be 'fooled' by participation in formalised health. I totally reject informal, pseudo medical home remedies and find them dissatisfying but participation in a waiting room and consultation with a GP or other health professional "just works" for me.

    I hadn't realized that I could in principle be given explicit placebo. I'd be very interested in controlled trials of patients being told "this is a harmless pill which will make you feel better but has not active ingredient, if you chose to believe it can work" or some formula.

    I have little doubt in my case, it would very probably work.

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    1. Sue Ieraci

      Public hospital clinician

      In reply to George Michaelson

      George - why not just use the reassurance of the GP or other health professional's opinion, and forget the pill?

      I suspect this type of placebo, which I agree is ethical, is happening every day in GP clinics around the world.

      The advantage of doing this through your GP is that they can make a competent physical assessment as well as provide the reassurance. There's really no need for an unnecessary ''remedy''.

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    2. George Michaelson

      Person

      In reply to Sue Ieraci

      So the first thing is that as I understand it, giving a placebo without informing the patient its a placebo is technically the 'non ethical' version because of both lack of consent, and the (really slight but there you go) risk of lactose intolerant or sugar-diabetes "its not harmless" side of things.

      Secondly, there is an aspect to CBT which requires modelling of behaviour to reinforce ideation and realization of the outcome. Sure, attending the clinic and paying the medibank fee is part of my particular shaman-ritual. But if a pill re-inforces it, then thats also part of the CBT.

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    3. Colin MacGillivray

      Architect, retired, Sarawak

      In reply to George Michaelson

      George I'm almost certain such an experiment has been done. One group got the drug, one group got the placebo and weren't told, the third group got the placebo and were told. Can't see how it can be controlled or blind. I'll try and google it- don't hold your breath.

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    4. Monika Merkes

      Honorary Associate, Australian Institute for Primary Care & Ageing at La Trobe University

      In reply to Colin MacGillivray

      Hi Colin, yes it has been done. I noted this in my previous article on placebos:
      "For this, Professor Benedetti uses a “balanced placebo design” involving four groups. The first group receives a placebo, but is told it’s the active drug. The second group of patients receives a placebo and is told it’s a placebo. The third group receives the active treatment and is told it’s a placebo, while the fourth group receives the active treatment and is told the truth." http://theconversation.com/not-just-smoke-and-mirrors-placebos-place-in-modern-medicine-4587

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    5. Reema Rattan

      Health + Medicine Editor at The Conversation

      In reply to George Michaelson

      My question when editing this article was - won't the placebo effect not work once I'm told it's harmless/inert?

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    6. Monika Merkes

      Honorary Associate, Australian Institute for Primary Care & Ageing at La Trobe University

      In reply to Reema Rattan

      Hi Reema, there is evidence that placebos without deception – also referred to as ‘open label’ placebos – can be effective for some people and for some symptoms, and perhaps enhanced by certain environments. You’d have to check out for yourself what type of placebo in what circumstances would work for you.
      The research on open label placebos is still in its early stages and it’ll be interesting to follow the publications of people like Benedetti and Kaptchuk and their teams.

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  4. Gary Cassidy

    Monash University

    One of the issues with recommending placebo is the huge cost of the treatment. Many supplements come in at around a cost of $30 per month, while the active ingredients are worthless.

    Perhaps the government should set up a placebo pill scheme - $2.00 p/m flat cost for red pills, yellow pills, orange pills, blue pills, and $3.00 for the yellow and black pills because they are better.

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    1. Sue Ieraci

      Public hospital clinician

      In reply to Gary Cassidy

      Actually, Gary, they could be much cheaper than that. If you go to a homeopathic wholesaler on the net, you can buy lactose or sucrose ''pillules'' in bulk - by the kilo.

      At one site, I found ''Homoeopathic and Schussler Cell Salts Globules - size 20'' - at $32.80 for 4000 globules, or 8.2c for 1000 globules (not sure of the colour, though). (source available on request)

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    2. Reema Rattan

      Health + Medicine Editor at The Conversation

      In reply to Sue Ieraci

      Perhaps that's the secret to their success! But my understanding is that the more you pay (think multivitamin injections from clinics in fancy parts of Sydney) and the more formal the procedure looks (white coat, machines that go bing or is it ping), the more effective the placebo...

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  5. Sue Ieraci

    Public hospital clinician

    There are lots of interesting phenomena in this area. There is also the so-called NOCEBO effect, where an inert substances is reported to cause an adverse reaction or side-effects.

    I also found this comment on a homeopathy website:
    "The more our patients know about homeopathy the better our results are. The more they read and learn, the more they take on the role of partner and the better the outlook becomes!" (http://hpathy.com/homeopathy-papers/before-starting-homeopathy-read-this/)

    I guess, the more you have invested in a particular therapy, the stronger the placebo effect might be. Is there any evidence of this?

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  6. David Carwardine

    Checking at A818

    I find it interesting that some Health Care Professionals give a placebo, as if they believe in them and when it seems to work laugh and say its conformation that there is nothing wrong with you. Maybe in time the public will loose so much faith that no medication from these people will work. Kind of like a placebo effect in reverse!

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  7. Gary Cassidy

    Monash University

    A while back I was watching a video lecture from University of California and the question of Glucosamine/Chondroitin supplementation for knee pain was raised. The response was along the lines of "there is no evidence that it works, but if you try it and it works for you then keep taking it" sounds like an ethical use of placebo.

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  8. Andrew Kewley
    Andrew Kewley is a Friend of The Conversation.

    Student

    The 2010 Cochrane meta review of Placebo as an intervention for any/all medical conditions concluded that it is mostly ineffective.

    http://www.ncbi.nlm.nih.gov/pubmed/20091554

    Much of the supposed observations of the 'placebo effect' relate to changes in reporting of symptoms, rather than measurements showing a change in biological state.

    Those "biochemical reactions in the brain" mentioned by the article, are simply pathways of the brain associated with the anticipation of relief. It is this anticipation which is also associated with the change in symptom reporting behaviour.

    If you have some trivial short term medical malady, then sure take a placebo. If it is serious however, it is not ethical to treat it with something that is not going to touch the underlying disease.

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