A placebo can be understood as a medical intervention that lacks direct specific therapeutic effects on the condition for which it has been prescribed, but which can nonetheless help to ameliorate a patient’s condition. In March 2013, a study by Howick et al. suggested that the vast majority of UK general practitioners (GPs) have prescribed a placebo at some point in their career. This finding was somewhat controversial and received national media coverage in the UK (here and here). Part of the reason for this controversy is that the use of placebos in clinical practice is often deemed to be morally problematic, in so far as it often involves the intentional deception of the patient.
In an open access paper published last month in the Journal of Medicine and Philosophy, I consider the moral permissibility of the clinical use of deceptive placebos in the light of this study. I argue that deceptive placebo use can be morally permissible, on the grounds that the deception involved in the prescription of deceptive placebos can differ in kind to the sorts of deception that undermine personal autonomy. By appealing to a thought experiment that is analogous to deceptive placebo use, I argue that deception can be morally permissible if it (1) is intended to enable the deceived party to achieve her own goals (and is thus compatible with the patient’s autonomy in a global sense) and (2) if the deceived party will only be able to achieve her goal if she holds the false beliefs that her deceiver leads her to hold. I suggest that if GPs follow certain guidelines in prescribing deceptive placebos, then this practice need not be morally problematic. First, the GP must prescribe the placebo with the intention of promoting her patient’s ends rather than her own, and she must be justified in holding the belief that the patient would value the amelioration of his condition over holding true beliefs about his treatment. Second, the prescribing physician must be justified in believing that a placebo is a necessary means of promoting the patient’s health. Such deception, I contend is compatible with respecting the patient’s autonomy all things considered.
How could (2) ever be true.. or more to the point: How could a GP ever know (2) to be true. I don’t believe a doctor could ever know their patient completely enough to know that a placebo would further their patients’ goals. So in theory I believe that what you state is correct, but in practice it could never be the case.. more than likely the placebo’s being used for the benefit of the GP, not for the benefit of the patient.
I have only skimmed through the paper itself but:
I can see see how 2 would be true, or at least, reasonably likely to be when you assume that the patient’s goal is improving their health (otherwise, why would they visit a doctor?).
So I am not criticizing the ‘placebo helps the patient achieve their goals’.
However… the whole attempt to justify deception as long as it’s in favor of the patient’s ‘autonomy’ seems quite patronizing to me; It reminds me of the idea that it’s alright to lie or deceive people ‘for their own good’, which I consider very patronizing (and likely to undermine trust).
When people are opposed to being lied to, is that truly about autonomy or about something else, such as a right to the truth (or at least, to not intentionally false information)? I lean towards the latter.
I do see how the paper itself mentions this potential side-effect(loss of trust), however, and I appreciate that.
Thanks both for the comments.
Airin – You are certainly right to highlight the epistemic limits that doctors will often face in assessing when a placebo is most likely to further their patients goals. This is especially so when there is an alternative active medication available. However, I believe that there are some circumstances in which the doctor can at least form a reasonable expectation that the patient would prefer the amelioration of their condition via a deceptive placebo to their not being deceived, when the placebo is the only way in which the patient’s condition can be ameliorated. In the paper, I suggest that a patient suffering from irritable bowel syndrome may be an example of such a case (p.13). I list other examples on pp. 3-4.
Davide – You raise an interesting question when you suggest that people may be opposed to lying because they have a right not to be intentionally deceived. If there were such an absolute right, then the whole idea of prescribe a deceptive placebo would not get off the ground ethically speaking. However, the first thing to say in response to this is that it is not clear that we have such a right – for instance, I do not think that we should endorse Kant’s claim that we have a duty not to lie to an axe-wielding maniac who is enquiring as to the whereabouts of one’s friend. Now one might respond to this case by claiming that the right to not be deceived is not absolute – however, then one would need to explain why the right rules out deceptive placebo use but not other forms of benign deception (such as the axe-murderer case). Moreover, even if there is such a right, one might also ask what actually grounds that right – I do not defend this claim in the paper, but my initial thought on this matter is that this right itself may be grounded by the value of personal autonomy. That is, perhaps we have a right not to be deceived, but only by virtue of the fact that deception (normally) violates autonomy.
With regards to the point about paternalism – I object to paternalism when a physician does something that is contrary to a competent patient’s autonomous wishes because the physician believes that they know what is in the patient’s interests better than the patient herself. However, the cases of deceptive placebo use that I consider in the paper are different. In the cases of a deceptive placebo use that I describe in the paper, the physician cannot ask what the patient would prefer without compromising the efficacy of the only treatment that has the potential to ameliorate the patient’s condition. In so far as the physician can have a reasonable expectation that the patient autonomously prefers the amelioration of their condition to not being deceived, then I believe that we can understand the use of deceptive placebos to be compatible with the patient’s global autonomy.
Thanks for the reply.
I don’t think bringing up the example of Kant and the axe-wielding maniac is very relevant here .
The the way I see it, it would be justified to lie to maniac for the same reason one might be justified in using violence: legitimate defense.
One is deceiving the maniac to save someone else; the lie is against the maniac (though I understand would also argue that it is for the maniac’s own good not to commit murder), and I think it is reasonable to say that because of their actions they ‘lose’ the right to the truth.
Which is obviously not the case for the patient here.
And speaking of autonomy, we do not exactly place that much importance on the ‘automony’ of would-be killers when that involves actually killing, do we?
So not a good comparison in my opinion.
In general I think lying needs similar justifications as violence – I think we should be only fully comfortable with lying to someone when we would also be comfortable doing violence against them.
Since I don’t think using violence against patients ‘for their own good’ would be acceptable, you can see why I am uncomfortable with doctors deceiving patients, even if the net result on their health might be positive.
I do think if one asked for permission to deceive the patient beforehand it would be fine, ethically – but of course, as you yourself wrote, that does strongly reduce (if not completely destroy) the power of the placebo itself.
I think the way to properly respect autonomy is to start with the default assumption that people should be told the truth EVEN IF it ends making them worse off; deceive them only if they have done actions which would weaken or negate their right to the truth or if they have beforehand accepted to be deceived for some reason.
The last two are, sadly, not really applicable in medical cases as a general rule.
I don’t think this is a special case of paternalism, either – a lot of paternalism is not really about knowing people interests or goals – assuming people want to be satisfied, healthy, content.. is not exactly unreasonable -, but about the MEANS to achieve them.
(The idea of someone intentionally agreeing to be deceived however does not sound ridicolous to me, aside from the interactions on the placebo effects – I do not have a lot of experience with this, but don’t patients sometimes ask doctors to not tell them the full truth/diagnosis if the situation is truly hopeless?)
“Global autonomy” that excludes “specific autonomy” smacks of casuistry to justify the otherwise unjustifiable position of the argument half-way down the proverbial “slippery slope.” In view of the mounting controversy in the US about whether fully informed consent of patients in randomized comparative effectiveness study of treatments within the so-called “standard of care,” should placebo “treatment” be added to the standard of care mix? Doing so would improve the quality of comparative effectiveness studies, e.g., placebo versus Levitra, Staxyn, Stendra, and Viagra. In this context, I find myself conflicted in face of so many medications that compete in the market place after FDA or equivalent approval on the basis of trials that rely on the comparison of a placebo versus single active comparator. As another thought experiment, what do you think would be the reaction if the government sponsor of comparative effectiveness studies were to include randomized use of placebos as part of the “standard of care?”
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