A few months ago I wrote about Fabrizio Benedetti’s research on the neurobiology of the placebo response, and a discussion about placebos and ethics ensued in the comments. Now Dr. Benedetti has written about that issue in a “Perspective” article in the journal World Psychiatry, “The placebo response: science versus ethics and the vulnerability of the patient.”
We have learned that verbal suggestions can activate neurotransmitters and modulate pain perceptions, and positive expectations can activate endogenous opioid and cannabinoid systems. A complex mental activity has objective effects on body physiology. Words and drugs can activate the same mechanisms. Drugs are less effective without therapeutic rituals. We are delving deep into human foibles and vulnerable traits at the center of human interactions. What implications do these insights into mind-body interactions have for patient care?
Things used to be simpler. Placebos are inert by definition. Prescribing an inert treatment constituted lying to a patient, implying that it would have a specific effect when the provider knew it would not. It might fool the patient into thinking he felt better, but it would not actually improve the course of illness, and it involved deception. Prescribing placebos was unethical, period.
But now we are learning that while the placebo itself is inert, the act of giving a placebo is not: it can produce actual physiological effects through suggestion and expectation. So is it legitimate to prescribe sugar pills or lie to patients if we know it can produce objective health benefits? What was once black and white has now become a gray area.
Another question arises: how can we apply this knowledge to mainstream medicine? When we prescribe drugs, should we be using rituals and words to ensure that they are maximally effective? What limitations or guidelines might govern that practice?
If a syringe filled with distilled water and handled by a doctor may induce expectations of benefit, then the same expectations can be induced by talismans, mascots and bizarre rituals carried out by quacks and shamans…Deception is at the very heart of a placebo procedure, and indeed it makes no difference if this deception comes from a doctor or a quack or a shaman.
New knowledge about neurophysiology is being used to justify using any procedure that increases expectations and beliefs, no matter where it comes from. This is worrisome, to say the least. CAM and quackery are trying to exploit this new knowledge in ways that tend to throw medicine back to its pre-scientific days. Acupuncturists who have acknowledged that their procedures are no better than placebo have argued that we ought to use them anyway, since placebos really do work to make patients feel better. Manufacturers of bogus health products have argued in court that they know their products can only have placebo effects but placebo effects help people and they have to lie in their advertising in order to elicit those placebo benefits. What if this line of reasoning were carried over to pharmaceutical research? If a new drug fails in clinical trials, might the manufacturer try to justify marketing it anyway for the placebo effect?
My personal opinion is that lying to patients or misrepresenting the state of the evidence in any way is always unethical and must be scrupulously avoided. Telling the patient that what you are prescribing is a placebo wouldn’t excuse you, because the very fact that you are giving it has persuasive meaning for the patient. I think attempts to elicit a placebo effect should be only used in conjunction with an effective treatment. Words should be used carefully, and the focus should be on general measures that bolster the doctor/patient relationship and enhance the patient’s trust, like spending more time with the patient and showing a greater interest and sympathy.
We face two major challenges. First, we need to improve the ways in which we communicate the results of placebo research so the public won’t think we are willy-nilly recommending placebo deceptions of any kind in clinical practice. Second, we need to answer some difficult questions about the ethical limits of taking various actions to increase expectations. The answers will not be easy. Let the discussion begin.