The ethics of placebos

[jdobbin]

The American Medical Association in 2006 said that "Physicians may use a placebo for diagnosis or treatment only if the patient is informed of and agrees to its use."

This decision came on the heels of the New England Journal of Medicine concluding that "outside of the setting of clinical trials, there is no justification for the use of placebos."

But is that the end of it?

The British Medical Journal did a survey of 1200 doctors and found that some still prescribed placebos? The reason? It sometimes works. For Parkinson's patients, it helped release dopamine. For people suffering pain, it helped with the natural release of opioids.

The problem that some ethicists have is that overworked doctors sometimes prescribe them rather than dealing with complaining patients.

Is there a balance to be had? Once the cat is out of bag on a placebo, it no longer works.

[Riverwind]

The problem that some ethicists have is that overworked doctors sometimes prescribe them rather than dealing with complaining patients.

This problem can be delt with by creating sugar pills that can be dispensed as if they are real drugs. It won't help with drug seeking patients that 'know their drugs'. The ethics of having people pay for sugar pills can be dealt with by ensuring doctors have a supply of 'free samples' that they can give the patient. If the patient comes back and claims the placebo worked then the doctor can ethically give the patient something that they might have to pay for.

The real issue is alternative therapies. If it becomes legal for doctors to knowningly lie to patients based on the premise that placebos sometimes work then it will be legally impossible to stop doctors from promoting any number of alternate therapies which are known to have no medicinal effect. This consequence is the bigger deal and why I think AMA recommendation makes sense.

[Guest webfltrs]

If it becomes legal for doctors to knowningly lie to patients based on the premise that placebos sometimes work then it will be legally impossible to stop doctors from promoting any number of alternate therapies which are known to have no medicinal effect. This consequence is the bigger deal and why I think AMA recommendation makes sense.

I think this is a very good point. Once you start redefining the lines of what doctors can and cannot say to their patients, without regards to the truth, then you open up to all of the legal ramifications of promoting or not promoting alternative therapies and drugs.

I don't think it is ethical to prescribe a placebo as a drug, not for the doctor or for the manufacturer.

[jdobbin]

I don't think it is ethical to prescribe a placebo as a drug, not for the doctor or for the manufacturer.

And yet doctors continue to it according to specific polling of doctors themselves.

A sympathetic doctor/patient relationship supposedly has a placebo effect in itself. However, what doctor has the time to offer such individual care?

The Economist magazine wrote on this subject last year and brought up French philosopher Michel de Montaigne who in 1572 said this: "There are men on whom the mere sight of medicine is operative."

The philosopher is correct in this.

So doctors themselves can be a placebo. Is that unethical? It is unethical for a doctor to say a pill might work and find that it actually does?

Edited March 31, 2009 by jdobbin

[Riverwind]

So a doctors themselves can be a placebo. Is that unethical? It is unethical for a doctor to say a pill might work and find that it actually does?

The ethical problems come from the consequences of the lie. In the case of a prescription, the doctor is forcing the patient to spend money on something that is not known work. If the doctor prescribes an active drug as a placebo the patient may experience negative side effects. In fact, the placebo effect can be negative too. Medical trials require full disclosure of possible negative side effects and researchers have discovered that reported side effects correlated strongly with the list provided. Edited March 31, 2009 by Riverwind

[jdobbin]

The ethical problems come from the consequences of the lie.

It is a lie to say a pill might work?

[Riverwind]

It is a lie to say a pill might work?

It is a lie of omission if you don't also say there is no known medicinal reason for the pill to work. Which is basically what the AMA requires. Give a patient a placebo. Say it might work but inform them that there are not any medical studies that show it should work. Edited March 31, 2009 by Riverwind

[jdobbin]

Give a patient a placebo. Say it might work but inform them that there are not any medical studies that show it should work.

I'd have no problems with that but the AMA believes there is no reason why a doctors should use them. Period.

The problem is that while there might not be known reason why placebos often work, the issue is that they often do work.

And while the AMA might say it is unethical, polling showed that a large chunk of doctors use them and will likely continue to use them.

Edited March 31, 2009 by jdobbin

[GostHacked]

The whole point of a placebo in clinical trials is to determine if the real drug actually works or not. Patients are not told if it is the real drug or a placebo. Once you start telling them what it is, you automatically taint the results of the whole trial.

Placebos don't work.

Althought this kind of goes against the Hipporatic Oath the doctor takes.

But if you volunteer for these kinds of trials, then you understand you could get a placebo ... if placebos are given to a patient and the doctor tells them it is the real drug, there could be a concern for fraud and tampering with results.

hmmm not sure what I think here.

[jdobbin]

But if you volunteer for these kinds of trials, then you understand you could get a placebo ... if placebos are given to a patient and the doctor tells them it is the real drug, there could be a concern for fraud and tampering with results.

Don't know that a doctors needs to say it is a real drug, just that it might work but there is no evidence of it yet. I believe that is as honest an answer as a doctor can give.

The Placebos themselves are not the medical cure, it is how a patient reacts to it. I'd hate for doctors not to have one more tool in the tool box to use when needed.

I don't think doctors should lie but doctors can honestly say they don't know if a treatment will work but that there is a possibility that it will.

[GostHacked]

Don't know that a doctors needs to say it is a real drug, just that it might work but there is no evidence of it yet. I believe that is as honest an answer as a doctor can give.

The Placebos themselves are not the medical cure, it is how a patient reacts to it. I'd hate for doctors not to have one more tool in the tool box to use when needed.

I don't think doctors should lie but doctors can honestly say they don't know if a treatment will work but that there is a possibility that it will.

I guess that is the reson why we have clinical trials. In these clinical trials it is know that you can get A or B. One is the test drug, the other the placebo. For blind tests, this is the best way to document good results.

[jdobbin]

I guess that is the reson why we have clinical trials. In these clinical trials it is know that you can get A or B. One is the test drug, the other the placebo. For blind tests, this is the best way to document good results.

And yet some people still get the placebo effect and that has to be calculated in many drug trials.

Something is happening, things have been documented and doctors continue to use placebos because they hope for a result that comes as an indirect result of the placebo.

[Riverwind]

I'd have no problems with that but the AMA believes there is no reason why a doctors should use them. Period.

According to your post the AMA said:

"Physicians may use a placebo for diagnosis or treatment only if the patient is informed of and agrees to its use."

which is basically what we agree is the best way to deal with the ethical issues.

Again, according to the information you provided, the AMA ruling was in response to a much more strongly worded journal artical.

Sounds like the AMA had the same discussion we are and came to the same conclusion.

[jdobbin]

Sounds like the AMA had the same discussion we are and came to the same conclusion.

What was undetermined is about what the patient is told about the placebo.

And in the polling taken about doctors who gave the pills out, it seems unclear what they were telling patients since they were still prescribing placebos in large numbers.

[Oleg Bach]

What was undetermined is about what the patient is told about the placebo.

And in the polling taken about doctors who gave the pills out, it seems unclear what they were telling patients since they were still prescribing placebos in large numbers.

It is un-ethical to lie or treat a patient as an inferiour by giving placebos. It is the same as administering a noxious substance with out the knowledge of the person..whether it is a NOTHING given though deciet - or a SOMETHING given though deception..both are deceptive ...and the last time I looked lieing was un-ethical! Next case please!