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.

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3 Responses to The Second Coming of the Placebo Treatment

  • Peter Wicks says:

    It seems to me that the Shmuel Fennig study needs to be treated with extreme caution, for several reasons. One is that people may he more likely to accept the idea of a placebo for psychological disorders than for somatic ones. Another is that the study focused on "healthy students"; it's not clear to what extent this can reliably be extrapolated to the rest of the population. Thirdly, the fact that people responding to a questionnaire say they wouldn't mind (well 70% anyway, that still leaves the other 30%) doesn't mean it wouldn't undermine trust. The more it becomes known that doctors are allowed to prescribe placebos, the more people are going to doubt whether they are receiving the real thing.

    Some personal experience for what it's worth. I was prescribed a non-deceptive "placebo" for irritable bowel syndrome some years ago, namely Ericsonian hypnosis (basically a form of meditation), and it works wonderfully, and not only for IBS. And the great thing is that, because it doesn't rely on deception, I can talk about it, learning from the experience of others and encouraging others to benefit from it as well. It seems to me that anything amenable to (deceptive) placebo should also respond to this, at least for some patients, and that – at least for those patients – this is a far preferable way to go. But I agree it's an important debate, and that the "orthodox" position should at least be questioned.

  • Just a note to register respectful disagreement over the claim above that, "…if these studies are correct, it means we can overturn some of the orthodoxy on the clinical use of placebo."

    Evidence does indeed show that, in many contexts, "Placebos are effective and beneficial…"

    For instance, a large number of studies demonstrate that placebos are often effective when patients are participating in experimental trials and do not know whether they are in a treatment group or a placebo control group. It is no accident that the efficacy of placebos in such studies/situations correlate with how much the appearance, administration, and consumption of placebos resembles patient beliefs and expectations of effective nonplacebo medicines/medical treatments.

    I respectfully disagree with Dr. Foddy here on two points. First, I am much more confident than Dr. Foddy that placebo effectiveness requires deception (one kind of which I roughly describe in the paragraph above).

    The second point of disagreement involves the disvalue, or alleged lack of ethics, in using placebos to the extent to which effective placebos (allegedly) do require both deception and false beliefs if not regrettable ignorance among patients.

    I contend it is an educational failure when patients do not know enough biology and chemistry to understand the alleged active mechanisms of medical treatments (molecular biology in the case of drugs, physiology in the case of surgical procedures, and so on). I contend it is an educational failure when patients do not know enough natural and social science to make fully informed choices about their treatment options. I contend that a large part of education generally and medicine particularly should include patient knowledge and understanding of treatment options.

    The effective use of placebos that Dr. Foddy describes in his second to last paragraph in the post above seems to require patient ignorance and/or apathy about science generally and medical treatments particularly. I agree that sometimes we are so sick that virtually the only thing we want to think about is feeling better. Depending on the details, the efficacy of placebos still seems to depend on false beliefs, ignorance, and/or apathy about science generally and medical treatments particularly, though the subject may change from the patient, to a spouse, or to a parent or legal guardian.

    The effective use of placebos that Dr. Foddy describes in his last paragraph in the post above seems to assume that placebos are a better treatment for medical problems with difficult and uncertain treatments. I contend that the efficacy of placebos in these cases is unstable and unreliable – depending on such factors as how much information, knowledge, and/or understanding patients acquire/develop about their placebo treatments and nonplacebo medical/treatment alternatives. (The more information, knowledge, and understanding of treatment options – especially placebos – the less the efficacy of placebos in contrast to nonplacebo options. The less information, knowledge, and understanding of treatment options – especially placebos – the greater the efficacy of placebos in contrast to nonplacebo options.) We seem to have nonplacebo treatment alternatives for all of the examples that Dr. Foddy describes, such as particular diets/dietary changes, health professional monitored exercise, anticholinergics, smooth muscle relaxants, and various forms of psychotherapy or psychoanalysis, to name some quick examples. The effectiveness of these nonplacebo treatments does not depend on patient ignorance or deception. In contrast, it seems a plausible conjecture that the efficacy of placebos in such cases is unreliable to the extent to which the efficacy changes, for instance, in accordance with changes in patient information, knowledge, and understanding (of biology, chemistry, medicine, treatment options, placebos, how placebos work, etc.). It seems a plausible conjecture that educators generally and healthcare providers particularly should aim to raise patient education, awareness, information, knowledge, and understanding of their medical conditions and treatment options. These aims of education and medicine seem inconsistent with Dr. Foddy's claims about placebos. If such articulations of the aims of education and medicine are incorrect and/or confused, I welcome and look forward to correction(s) with clarification(s) and elaboration(s).

    I express similar sentiments and concerns in the comments threads to the two posts listed below.

    Herbal Placebos
    http://blog.practicalethics.ox.ac.uk/2011/02/herbal-placebos/

    Counterfeit Placebos
    http://blog.practicalethics.ox.ac.uk/2010/10/counterfeit-placebos/

  • In case anyone is interested and does not know about it, Daniel Groll's paper "What You Don't Know Can Help You: The Ethics of Placebo Treatment" has appeared in the Journal of Applied Philosophy, volume 28, issue 2, pp. 188-202, May 2011.

    Although the paper addresses many of the issues, claims, and concerns raised in the post(s) and comments above, my narrow mind prevents me from seeing the alleged contributions. Interested readers, please share relevant ideas if not correct/inform anyone writing on these matters!
    -
    What You Don't Know Can Help You: The Ethics of Placebo Treatment, by Daniel Groll
    http://onlinelibrary.wiley.com/doi/10.1111/j.1468-5930.2011.00517.x/abstract

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