Mar 18 2009
Is it ethical to overstate the efficacy of a treatment option, if it might lead to a patient’s enhanced experience of that treatment? Your response to this question may reveal the degree to which you favor Complementary and Alternative Medicine (CAM). Let me explain.
As far as I can tell, no CAM treatment has been proven effective beyond placebo. (If you’re not convinced of this, I suggest you take a look at Barker Bausell’s book on the subject.) That means that treatments like acupuncture, homeopathy, Reiki, energy healing, Traditional Chinese Medicine (such as cupping), and others (like “liver flushes”) perform about as well as placebos (inert alternatives) in head-to-head studies. Therefore, the effects of these treatments cannot be explained by inherent mechanisms of action, but rather the mind’s perception of their value. In essence, the majority of CAM treatments are likely to be placebo therapies, with different levels of associated ritual.
For the sake of argument, let’s assume that CAM therapies are in fact placebos – the question then becomes, is it ethical to prescribe placebos to patients? It seems that many U.S. physicians believe that it is not appropriate to overstate potential therapeutic benefits to patients. In fact, the AMA strictly prohibits such a practice:
“Physicians may use [a] placebo for diagnosis or treatment only if the patient is informed of and agrees to its use.”
Moreover, a recent article in the New England Journal of Medicine concludes:
“Outside the setting of clinical trials, there is no justification for the use of placebos.”
However, there is some wavering on the absolute contraindication of placebos. A recent survey conducted by researchers at the Mayo Clinic asked physicians if it was permissible to give a dextrose tablet to a non-diabetic patient with fibromyalgia if that tablet was shown to be superior to no treatment in a clinical trial. In this case 62% of respondents said that it would be acceptable to give the pill.
The authors note:
“Before 1960, administration of inert substances to promote placebo effects or to satisfy patients’ expectations of receiving a prescribed treatment was commonplace in medical practice. With the development of effective pharmaceutical interventions and the increased emphasis on informed consent, the use of placebo treatments in clinical care has been widely criticized. Prescribing a placebo, it is claimed, involves deception and therefore violates patients’ autonomy and informed consent. Advocates of placebo treatments argue that promoting the placebo effect might be one of the most effective treatments available for many chronic conditions and can be accomplished without deception.”
How do you feel about placebos? Are they a legitimate option in some cases, or a violation of patient autonomy and informed consent?
I personally fall into the second category – I believe that willfully misleading patients is a violation of trust, and inappropriate in all cases. However, I respect the fact that some of my peers disagree, and feel that it’s sometimes ok to make a judgment call apart from the shared decision-making process. Perhaps some patients would like their doctors to do that for them as well.
However, there is something decidedly paternalistic about placebo-giving. The idea of willfully manipulating a patient’s perception of reality probably makes most providers squirm. And so this is why CAM proponents must contort themselves so as not to face the ethical conundrum that open acknowledgment of placebo treatment brings. The poorly designed studies, pseudoscientific explanations of mechanisms of action, and attempts to make plausible claims about implausible treatments are really just a way to maintain the “placebo effectiveness” of the therapy itself while shielding the prescriber from the ethical dilemma of compromising patient autonomy.
In other words, the only way to avoid paternalism and damage to patient self-determination is to convince oneself of the efficacy of the placebo. That exonerates the practitioner of guilt, because one doesn’t have to participate in willful manipulation of vulnerable people. And so, double-blind placeboism is the preferred way forward for practitioners who wish to offer unproven alternatives to effective medical therapies. Of course, this irritates scientists who seek an objective view of data – and who are not interested in using science to serve their preconceived notions. You may note that many of us here at Science Based Medicine are none-too-thrilled about the cooptation of science for the purposes of “validating” personal beliefs.
Are placebos unethical? I suppose it’s debatable, but I am more comfortable with telling my patients the truth, and letting them decide what treatment options are best for them. To me, it’s not just the right thing to do – it’s the essence of patient empowerment.
Coincidentally, the Washington Post just published an article on the connection between placebos and CAM.
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