The Second Coming of the Placebo Treatment
The German Medical Association has recommended that doctors should sometimes make use of deceptive placebo treatments when those treatments may be more effective than pharmacologically active alternatives. This recommendation stands at odds with the position of nearly every other international medical association, including the British Medical Association and the American Medical Association, which ruled in 2007 that it would always be unethical for doctors to prescribe placebos without informing their patients.
There is a gathering controversy on the placebo issue; for a long time it has been assumed that placebo treatments are both unethical and/or ineffective, and that widespread use of placebo treatments would grievously undermine the trust between doctors and patients. But a series of recent studies has been undermining the orthodox opinion:
First, Bingel’s recent breakthrough experiment shows beyond doubt that 1) placebo treatments may be as effective as real treatments, at least for treating pain, and 2) regular drugs may have a placebo effect which outweighs their pharmacological effect (I blogged about this study when it was released).
Second, Irving Kirsch has conducted a series of studies which seems to show that fluoxetine (marketed as Prozac), a billion-dollar drug and the foundation of the antidepressant industry, both 1) is effective and 2) operates entirely through the placebo mechanism, at least when used to treat mild to moderate depression.
Third, Shmuel Fennig’s team recently reported at a conference their finding that around 70% of patients would not object to being given deceptive placebo as a first line of treatments for either depression or other complaints.
Where does that leave us? Well, if these studies are correct, it means we can overturn some of the orthodoxy on the clinical use of placebo. Placebos are effective and beneficial, and this is proven most dramatically in the antidepressant industry. Placebos will not undermine trust in most patients, even though patients are strongly encouraged to believe that deception in the clinic is always wrong and that placebo treatments are unethical.
The last remaining question is whether placebo deception is necessarily unethical. There are two components to this question. First, is deception required? And second, is placebo deception wrong in the same way that other kinds of clinical deception are wrong.
We simply don’t know the answer to the first question. Kaptchuk’s recent paper in PLOS One purports to show that placebos can be effective even if patients are told they may receive a placebo. But since that paper (and every other paper on the subject) does not compare open placebo to deceptive placebo, we have no way of knowing how important deception is to placebo benefit.
But whether deception is required or not, I have argued that it placebo deception is not always unethical. Clinical deception is wrong, when it is wrong, because it violates the autonomy of the patient. The patient has a set of goals that she cannot pursue if she does not know what the doctor is prescribing. Even if the doctor is trying to promote the patient’s welfare, deception runs the risk of being paternalistic, since the doctor’s conception of the patient’s welfare may differ from the patient’s conception. But placebo deception can be a special case. When I come to a doctor, I express a wish to feel better. If the doctor gives me a placebo in order to satisfy this wish, there is no way my goals can be frustrated, and no way for my autonomy to be violated. It is simply a case of the doctor doing what I have asked, albeit in a deceptive, underhanded way.
Patients are right to prefer a placebo treatment for a certain range of disorders. The best examples will be disorders which cannot be diagnosed, disorders for which there is no treatment, or disorders for which standard treatments are ineffective or very burdensome relative to their effectiveness. We are right to prefer a placebo for irritable bowel syndrome, for mild to moderate depression, or mild to moderate anxiety. Depending on how the controversy pans out, doctors in some places may eventually be permitted to give us such treatments.