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Placebo Prescriptions

Whether it’s acupuncture, homeopathy or the latest supplement, placebo effects can be difficult to distinguish from real effects. Today’s post sets aside the challenge of identifying placebo effects and look at how placebos are used in routine medical practice.  I’ve been a pharmacist for almost 20 years, and have never seen a placebo in practice, where the patient was actively deceived by the physician and the pharmacist. So I was quite surprised to see some placebo usage figures cited by Tom Blackwell, writing in the National Post last week:

The practice is discouraged by major medical groups, considered unethical by many doctors and with uncertain benefit, but one in five Canadian physicians prescribes or hands out some kind of placebo to their often-unknowing patients, a new study suggests.

The article references a paper in the Canadian Journal of Psychiatry which, sadly, does not have much of a web presence. The article continues:

McGill’s Prof. Raz and his team conducted a survey of specialists throughout Canada, receiving responses from 606 doctors, 257 of them psychiatrists. About 20% of both psychiatrists and non-psychiatrists said they had used placebos in treating patients. The specific treatments they confirmed using included actual placebo tablets, sugar pills and saline injections. Some — including 35% of psychiatrists — said they also used “sub-therapeutic” doses of real drugs, amounts too small to have any chemical effect on the patient.

One in five physicians actively using placebos? Even if they’re being used sporadically, that’s a lot more use than I would have expected, and what my own practice would suggest. Is my experience typical? I put a short post on my own blog and on Twitter, and I was surprised by the responses. While use seems to be uncommon, it’s definitely  still happening, and some pharmacists participate in the charade. I was surprised to see that there are even some impressive-looking commercially-manufactured placebo capsules out there, too. (I wonder if they’re covered by insurance plans?)

I was able to obtain a full copy of the article, and it provided some context to the prevalence numbers. The web-based survey (still online) was sent to 7600 academic physicians, plus an undisclosed number of psychiatrists. Given the response rate was so low (though perhaps not unexpected for a survey), there is no information to suggest that the sample that responded is representative of the broader physician population. Given the subject matter, I’d expect that supporters of placebo use might be more inclined to respond. All of this leads me to conclude that, yes, it is happening, but no, it’s probably not one in five physicians.

The usage of placebos in active practice is one that David Gorski has discussed before, and he had some serious ethical problems with their use. Gorski reviewed a paper by Tiburt et al, which was a survey of 1,200 internists and rheumatologists, and noted that among the 57% that responded, about half reported prescribing placebo treatments on a regular basis. Big numbers, and a much better response rate. But  it also could have been skewed towards placebo prescribers.

I turned to the biomedical literature for some prevalence information. PubMed looked kindly upon my request: A 2010 paper entitled Frequency and circumstances of placebo use in clinical practice – a systematic review of empirical studies. In their study, Fässler and colleagues searched the literature with a wide net, looking for articles on the frequency of placebo use and attitudes among health professionals, students or patients.

Before we dive into the results, it must be noted that not all placebos are the same. And this might explain the disconnect between the surveys, and my pharmacy observations.  “Pure” placebos are truly inert: they contain no active ingredients. These are the sugar/lactose pills, saline injections, and most homeopathy (products diluted beyond 12C, at least).  “Impure” placebos, on the other hand, actually contain active ingredients, but are ineffective for the condition being treated. This could be because of a sub-therapeutic dose, or the active ingredient has no effectiveness against the condition being treated (e.g., antibiotics for viral infections, or the less-dilute homeopathic products). So perhaps those prevalence numbers may not be so wrong – subtherapeutic doses or antibiotics are less obviously detectable as being prescribed with placebo effect intent.

The review identified 22 studies of relevance, some dating back as far as 1973. (The Tiburt paper referenced above was among them.) Most were quantitative studies, based on interviews or questionnaires. Studies were conducted in a range of countries, with North America being reasonably well represented. The data quality was not impressive. Most of the sampling was non-random, none of these surveys used consistent questions, and response rates were all over the map. Even the definition of placebo varied between studies.

All of the studies that looked at frequency of placebo prescribing reported some use: 17-80% for pure placebos, and 41-99% for impure placebos. Pure placebos seemed to be more commonly used in hospital settings, and impure placebos were reported more in the primary care setting. The frequency of use of both pure and impure placebos was low: less than once per month in most studies. So overall, it seems consistent with the Canadian data reported last week.

Under what circumstances would deceiving a patient be felt to be acceptable? Without a systematic survey, it’s impossible to quantify the conditions and reasons for use. But some of the themes identified include:

Pure Placebos

  • pain, insomnia, anxiety, risk of substance abuse
  • difficult/demanding patients

Impure Placebos

  • desire of patients to receive a prescription
  • take advantage of placebo effects
  • avoid conflicts with patients
  • as a supplemental treatment for non-specific symptoms

Respondents in the different studies generally believed that placebo could be effective in a subset of patients, ranging from 5% to 42%. Among physicians and medical students, up to a third believed that placebos can induce objective, physiological changes. The overall appropriateness of placebo use led to some divergent opinions. From an ethical perspective, very few thought the use of placebos should be prohibited, though many considered the use problematic. A surprising number considered the use of placebos acceptable if used for patient benefit.

Another interesting paper, not included in the Fässler review, was published in 2010 in the journal Family Medicine. Kerman et al reported on a survey of 412 physicians in the paper Family physicians believe the placebo effect is therapeutic but often use real drugs as placebos [PDF]. Again, the response rate (43%) was poor, but among responders, 56% reported using a placebo in active practice, with 19% doing so more than 10 times per year. The most common placebo cited was the use of antibiotics (43%) followed by vitamins (23%) and herbal supplements (12%). Pure placebos were infrequently used.

Survey responders had very positive opinions of placebo use, with 85% believing that placebos have psychological and physical benefits. Remarkably, 92% supported placebo use in clinical practice. Only 8% felt placebo use should be prohibited. The most common reasons for placebo use were “unjustified” demand for medication (32%) followed by the desire to calm the patient (20%) and after therapeutic options were exhausted (20%).

It’s the impure placebos that concern me the most. The popularity of antibiotics as placebo treatments is alarming. While generally well tolerated, they’ve got a long list of side effects, which can be serious in rare cases. And antibiotic resistance, driven by misuse, has public health consequences. The use of vitamins and herbal supplements is also troubling: it’s increasingly clear that these products can cause harms, too. And it leaves me wondering what proportion of physician-recommended use of vitamins and supplements that I see is just a deliberate attempt to harness placebo effects.

The literature can tell us much about the placebo, but much less about how these products are actively used in the practice of medicine. The data are poor, but there’s enough to suggest that deliberate placebo prescribing is taking place, albeit with some ethical discomfort for many prescribers. Outside of perhaps a hospital setting where a “pure” placebo could be evaluated somewhat more objectively, I can’t imagine any situation where their provision would be ethically acceptable. As a pharmacist, my responsibility is to the patient, not the physician, and in a community pharmacy setting, I’d refuse to provide any treatment that would require me to deceive the patient about true nature of  prescription. The idea of placebo effects may be tantalizing, but not at the cost of patient autonomy, or inappropriate prescribing.

References

ResearchBlogging.org

Fässler, M., Meissner, K., Schneider, A., & Linde, K. (2010). Frequency and circumstances of placebo use in clinical practice – a systematic review of empirical studies BMC Medicine, 8 (1) DOI: 10.1186/1741-7015-8-15

Kermen R, Hickner J, Brody H, & Hasham I (2010). Family physicians believe the placebo effect is therapeutic but often use real drugs as placebos. Family medicine, 42 (9), 636-42 PMID: 20927672

Posted in: Clinical Trials, Medical Ethics, Science and Medicine

Leave a Comment (41) ↓

41 thoughts on “Placebo Prescriptions

  1. windriven says:

    “[P]lacebo effects can be difficult to distinguish from real effects.”

    “I can’t imagine any situation where their provision would be ethically acceptable.”

    The power of the placebo effect has been discussed in these pages repeatedly. Patient autonomy is an important goal. But in 20 years as a pharmacist I am sure you have encountered countless patients who aren’t engaged in their care – they just expect the physician to ‘fix it.’ Ultimately, isn’t the goal the well being of the patient?

    An old aphorism holds that, “Sometimes it takes a hammer and sometimes it takes a rose.” Isn’t it possible that sometimes it takes a placebo?

    It would certainly be unethical to prescribe a placebo saying it will cure cancer. But it seems to me quite another to prescribe a placebo saying, “and this will help with some of the …”

  2. tommyhj says:

    I’m not at all surprised. When I have touched on the subject of using placebos as active treatment with colleagues, many of them seem to think it’s fine. Arguments range from “whats the harm” to believing in the magical mind over matter effect. Some say that we have no evidence of most of what we do, so why not placebo, if it “works”? Classic fallacies, but i was always unable to deconstruct them effectively in the course of lunch or a cup of coffee…

    But the real problem is that patients have no idea if they are recieving treatment or are being conned into paying a scammer, dressed as a professional. And the professional can change sides in a heartbeat. So it undermines what is very crucial and central to the medical establishment: Trust. If you can’t trust your doctor, who can you trust? Answer: Whoever is best at convincing you. And we all know who wins that bet – the CAM movement…

  3. CarolM says:

    Didn’t antidepressants also come under some kind of placebo cloud too, so to speak? I notice my last two docs are not pushing those like they used to, to their credit.

  4. vicki says:

    I wonder how my GP would answer that question. About a year ago, she diagnosed me with mild arthritis, and gave me a prescription for Mobic (an NSAID) and recommended that I use glucosamine and chondroitin. I think I went through one bottle of each and then stopped, the Mobic because I was using stronger NSAIDs to deal with the knee issue at that point, and the glucosamine/chondroitin after reading here and elsewhere that they were a waste of my money.

    The question is, did my doctor actually believe in the (unspecified) studies of glucosamine and chondroitin that she invoked, or was she sending me off to buy a placebo?

  5. Lytrigian says:

    I’m fairly certain I was prescribed a placebo as a child. Our doctor — he was a GP, not a pediatrician — kept a selection of bottles with blank labels in the cabinet behind his desk. On one occasion he pulled one out, wrote something on the label, and gave it to my mother for me. I very much doubt she was in the dark about it. They had a conversation at the time, but I don’t remember what was said, and it’s possible it was phrased either so that I wouldn’t understand it, or they took advantage of a minute or so of inattention on my part.

    I was a fairly high-strung kid, and it’s very probable that many of my childhood “colds” were really stress-related. In such a situation, and with the responsible parent fully aware that the medication was pure placebo, would the ethical situation be any different?

  6. nybgrus says:

    I agree with you Scott – it is unethical to knowingly prescribe placebo. I say knowingly because there is a gray area where, for example, you might presrcibe antibiotics to someone you suspect may have a viral infection but legitimately think there may be a bacterial etiology and so you just treat empirically. I wouldn’t call that unethical but I would call it sloppy or lazy doctoring. I the former is unexcusable but the latter, well, I can envision certain situations where one might excuse lazy doctoring, though we should always strive to be above and beyond that.

    I have also used the placebo effect with friends and even with patients – I use it to heighten the effect they are looking for. Essentially, you prescribe the appropriate drug with an actual effect and then simply reinforce the effect for the patient. “Yes, it will help your nausea. Just give it about 15 minutes and it will start to kick in. Then your nausea will progressively get better till it goes away.” Then, 15 minutes later “Are you starting to feel it?” Response: “Maybe a little….?” Then I say, “See! It is starting to kick in, now you can relax and just let the medicine do its job and not worry about the nausea.” I haven’t lied, haven’t decieved, simply heightened the expectation and given the person permission to relax and feel better. Sometimes it doesn’t work and they stay nauseated. Then I try and stress that it helped at least a little and to focus on that and (if possible) try another route of help, commenting that sometimes it is tougher but we can try [X]. If all fails, then just admit that you’d hoped it would work like it was supposed to, but sometimes things just don’t work out that way.

    However, when it comes to prescribing something which you are certain will not have the effect you proclaim it (either pure placebo or impure) that, in my book, is completely unethical and should never be done. Period. That is the basis of our respective professions – being ethical and trustworthy, always.

    @Lytrigianon: Your case is a bit more interesting. Considering that technically small children do not have autonomy and are under their parents agency, what if the parent knew it was a pure placebo and then lied to you about it for effect? Technically the doc didn’t decieve in his prescription, but I would say that he did by extension since his patient was decieved by his actions. For some reason, I feel that intellectually that is just as unethical but my gut is telling me there is some leeway here. I may have to think on this one for a bit, but I would have to say my default answer would be that the ethical situation is no different since the very nature of calling placebo prescription unethical is based on intention and the spirit of the prescription. If a physician genuinely thought [X] would work then I can not say (s)he is being unethical for that – I can at best say (s)he is sloppy, lazy, not well read enough, or perhaps a woo-meister (like Dr. Oz) and that is a whole different category.

  7. pmoran says:

    However, when it comes to prescribing something which you are certain will not have the effect you proclaim it —

    That is not a fair representation of any likely placebo use by doctors.

    Firstly, placebos do seem to help many symptoms, if only via the power of suggestion. You regard that as an acceptable “deception” when used along with treatments that you yourself clearly suspect may not work as you try to represent to the patient.

    Secondly, I think many common treatments for nausea work mainly as placebo, if they work at all. There is often a very fine line to be drawn therein. In the largest study of one FDA approved treatment for IBS the drug produced improvement in 3% but also caused diarrhoea in 3%.

    Thirdly, placebos may be offered to avoid the negative consequences of not prescribing in certain settings. They can be significant.

    Fourthly, placebos can be chosen for their safety. Inappropriate use of pharmaceuticals is a worse option that some doctors are driven to by the pressures of medical practice.

  8. Lytrigian says:

    I don’t know that I could say I was lied to. I recall no one making any specific claims about what that red flavored syrup would or would not do.

    In retrospect, I’m pretty certain I felt “sick” rather more often than I actually was sick. To add more context, this was the early 1970s. Psychiatry was not applied for cases like this, and there was still a stigma attached to mental health treatment of any kind. So what should have been done instead, if this was unethical?

  9. Jan Willem Nienhuys says:

    About 18 months ago I collected opinions from about half a dozen Dutch physicians that were active in the Dutch antiquackery organisation.

    The first one said: doctors may not cheat patients. The doctor should always give treatments for which the scientific basis can be explained. The patient should be informed. If the doctor claims it makes no sense to talk to the (or this particular) patient instead, s/he is probably taking the easy way out.

    Playing witch doctor may sometimes seem to work, but in the long run it is counterproductive.

    The second one said: if you want to use the placebo effect, then you should seriously listen to the patient, examine thoroughly for underlying serious causes; in many cases it is also effective to give simple advice that takes the particular situation of the patient into account.

    A third one said: placebo treatment is never the treatment of first choice, you might consider it if the complaint itself is mostly the result of suggestion, but if you try it and it doesn’t work right away, then you must stop.

    The fourth one observed: when you give a placebo as last resort, you risk that the patient comes back for more, and as physician you always must think about what would happen to the relation with the patient if you had to confess that it was just a placebo. The patient may think ‘I don’t care, as long as I get better’. Precisely. But when the patient does not get better s/he certainly doesn’t think so, and if teh patient finds out it was a placebo, s/he will be angry, and justifiedly so. Moreover the placebo effect is unpredictable, weak, and mostly restricted to nausea, pain and tiredness.

    Further remarks were:
    1. the placebo effect may partly be illusory, it may be (in some cases) a folie à deux between doctor and patient
    2. the placebo effect is like ‘kiss and make it right’, so relying on it is treating the patient as a child.
    3. in medical research placebo’s are given, but only when the end justifies that means: there should be an a priori plausibility that the experimental treatment works.

    In the Netherlands homeopathy is or was popular, and in the 1980s about 40 percent of family practitioners confessed to occasionally prescribing homeopathy. Nowadays the percentage is 10-20, depending on whether you exclude or include homeopathy believers in your sample. A friend of mine asked about 600 family practioners without known alternative sympathies in an anonymous written survey about their use of homeopathy. The response rate was poor: 99 returned the form and 11 said they occasionally prescribed homeopathy ( <20 times per week).

  10. nybgrus says:

    That is not a fair representation of any likely placebo use by doctors.

    Really? What about the use of antibiotics when a physician knowns the illness is viral but wants to placate his patient? What about the emergency physician who does a CT brain study knowing there is no clinical indication for closed head trauma but wants the patient to feel better that something was done? What about the doctors that prescribe homeopathy as in Jan’s description? Seems to me that is the thrust of this article in the first place….

    You regard that as an acceptable “deception” when used along with treatments that you yourself clearly suspect may not work as you try to represent to the patient.

    No, I do not. I view that no deception is acceptable. Having a drug with documented effects and using suggestion to heighten and reassure your patient is patently different.

    Secondly, I think many common treatments for nausea work mainly as placebo, if they work at all.

    Then I suggest you tell your oncologist friends to stop prescribing ondansetron with their chemo regimens. Somehow, I doubt they (or the patients would agree). However, the fact that you think they are placebo is not the point. The mechanisms are reasonably understood (or do you also not believe in 5-HT3 receptors in the CTZ?) and studies have shown that it can and does relieve nausea. If you want to pick a bone with a specific IBS drug being less effective or not effective enough, that is fine, but it has nothing to do with the conversation.

    placebos may be offered to avoid the negative consequences of not prescribing in certain settings.

    So you are saying that when there are no evidence based therapies available and the patient is wailing and complaining, that offering a placebo prescription you know will do nothing (which you just claimed is “not a fair representation of any likely placebo use”) is perfectly reasonable? I’m not following you here Dr. Moran…. and besides, that is still unethical.

    Fourthly, placebos can be chosen for their safety. Inappropriate use of pharmaceuticals is a worse option that some doctors are driven to by the pressures of medical practice

    Um, no. The solution is not to prescribe placebos. The solution is not to prescribe anything. Because, as you may guess by now, prescribing placebos (which once again, you said is an “unfair representation”) is unethical.

  11. I like the “personalized simple advice” of Jan Willem Nienhuys’ colleague.

    People want to have something they can do about a problem. My grandmother used to drink half a teaspoon of vinegar in a cup of hot water for her arthritis. She knew perfectly well it was nonsense but she needed to do something. My grandfather – a doctor – would never have prescribed it for her but simply made sure that her placebo of choice wasn’t dangerous.

    I don’t go to a doctor to be told about half a teaspoon of vinegar in a cup of hot water. I have friends and the internet for that. But reassuring me that I’m not hurting myself, yes. And even if my doctor can’t prescribe anything that will fix me, she can presumably suggest simple ways for me to look after myself. These might take on the status of healing ritual in my mind, but if they are good things to do that’s not a problem.

  12. Lytrigian,

    I would say that was unethical use of placebo. If you needed a ritual when you were feeling poorly, the doctor could have instructed you to walk up and down the stairs exactly five times and then lean over and touch your toes for 45 seconds. That’s something you can take with you into the world – you aren’t dependent on your mother’s special syrup. It reinforces your idea of yourself as strong and it’s good exercise. It doesn’t have to be presented as a cure.

    Some people lie to their children as a way of managing them. It’s not a good approach and doctors should not appear to be encouraging it.

  13. windriven says:

    pmoran said:

    “Fourthly, placebos can be chosen for their safety. Inappropriate use of pharmaceuticals is a worse option that some doctors are driven to by the pressures of medical practice.”

    And it isn’t simply the safety of the patient at hand. Had placebos been prescribed in place of real antibiotics to placate patients with viral diseases perhaps there would be fewer resistant strains today.

  14. # Alison Cummins “I would say that was unethical use of placebo. If you needed a ritual when you were feeling poorly, the doctor could have instructed you to walk up and down the stairs exactly five times and then lean over and touch your toes for 45 seconds.”

    Alison,
    Sorry to jump on you for this, but, No, and no again. :) Rituals like that are the seed of a counting compulsion in obsessive compulsive disorder. The key is, if you don’t have a tendency toward ocd, a ritual like that probably won’t make you feel better at all. If you do have a tendency, it’s highly possible that you will become a slave to it (like hours a day on rituals).

    Of course, relieving stress through exercise is excellent, but any sort of ritual where one must be precise or get it right, etc to relieve a “bad feeling” is risky to one inclined toward anxiety.

    It’s kinda a funny balance with anxiety disorders. My understanding is, it’s good to find ways to relieve stress, but in some ways, just tolerating the stress and finding out that you can tolerate it and move on, is going to be just as, if not more, therapeutic.

    I agree with you that “medicine” given to a child to relieve stress related symptoms is not a good idea. Best to find an way to cope with the stress that does not hold the risk of dependency in the future.

    Once again, sorry for jumping on you or sounding like a “know it all” when clearly, I don’t know it all. (I do not know the emoticon for apologetic facial cringe.)

  15. micheleinmichigan,

    Oh, I’m sure you’re right.

    I’m also pretty sure there’s a way to do this that avoids that trap. My grandmother had no OCD at all but she still derived comfort from the feeling of doing something for herself. There must be a way to direct that constructively.

  16. Alison Cummins
    “I’m also pretty sure there’s a way to do this that avoids that trap. My grandmother had no OCD at all but she still derived comfort from the feeling of doing something for herself. There must be a way to direct that constructively.”

    Yes, I agree that one can counsel someone on ways to cope with stress or do something comforting for themselves when needed and avoid the trap. Even rituals of all sorts can be healthy and comforting. Counting raises alarm bells because it’s so prominent in OCD, but even counting can works great for some people, like counting to ten when you are anger to keep from venting your temper.

    I only mean to make people aware that there is a trap to avoid. Somewhat like shopping or having a drink with dinner. Some people it’s fine and helps them relax a bit, some people, not so much. It can be handy to know that the possibility of a problem is there.

  17. pmoran says:

    People want to have something they can do about a problem. My grandmother used to drink half a teaspoon of vinegar in a cup of hot water for her arthritis. She knew perfectly well it was nonsense but she needed to do something.

    I have written previously about the compulsiveness that lies behind a lot of treatment-seeking behaviour. This, together with the risks of even some over-the-counter pharmaceuticals is why it may do more good than harm for the public to have access to harmless placebo-type medicines such as homeopathy, in those societies with a strong tradition of such, and where the public has had time to position such remedies within their personal medical options.

    So, what evidence is there of harm from homeopathy in European countries, where homeopathic remedies are advertised by every pharmacy ?

    To even ask this is heretical within these walls, but we are supposed to be a science-based group. What does the actual evidence show?

    I suspect that our antipathy towards homeopathy is a reaction to its addled “science” rather than its potential for harm in the modern world.

  18. nybgrus says:

    what’s the harm in homeopathy? That has been asked and answered so many times I have trouble believing you don’t already know the answer. Besides the fact that I judge wasting money on someting that doesn’t work and relies on false advertising to be harm, perhaps you’d be keen to peruse

    http://whatstheharm.net/homeopathy.html

    Or perhaps a more philosophical discusssion on the fact that authoritative endorsement of such magical thinking is inherently deleterious to the general well being of society by engendering a lack of critical thinking and education?

    But you seem to be quite paternalistic, Dr. Moran. “If the people are so stupid as to need to seek this behavior, lets just give the child-like minded masses what they need to help them feel better, pat them on the head, and send them on their way.”

    Never mind holding a standard as a stalwart against magical thinking and actively encouraging more education and more critical thinking around the world. Lets us, those experts who (should) know better, cave to the demands of those magical thinkers since that is easier and causes less angst and trouble.

    Growing pains – it happens on a social, cultural, and worldwide level. They are not an excuse to stop growing and go back to medieval thinking.

  19. pmoran says:

    JWN: About 18 months ago I collected opinions from about half a dozen Dutch physicians that were active in the Dutch antiquackery organisation.

    Can I ask what kind of medical practice each of these physicians are engaged in?

    Those in specialist referral practices will find it easy to avoid using non-EBM-endorsed treatments (that’s what we are really talking about, surely rarely ever an actual sugar pill!).

    It is family practitioners who can be under most pressure to cement the doctor patient relationship by being prepared to try anything that might help their patient (even if only as placebo).

    I think all doctors would rather not use “placebos”, that they feel uncomfortable about having to do it (less so whenever the treatment chosen has some credibility in some circles), and that they would never use them if our much-vaunted scientific medicine had provided simple, entirely safe and effective remedies for many common complaints. (Let’s not overlook the obvious. )

    In fact, I wonder whether the mainstream’ s obsessively error-averse brand of applied science has destroyed more practitioner treatment options than it has produced new ones.

    What do other older doctors think?

    That is even sadder when so often the yardstick is scraping barely over the line in one set of double-blinded placebo controlled RCTs, possibly to be later contradicted by yet others, and with it often requiring a select committee to pronounce one way or the other.

    That is a fine line on which to be basing black and white moral judgments.

  20. Lytrigian says:

    @Alison Cummins

    I have never heard of any doctor, then or now, suggesting any such thing. It would have struck me even then as ridiculous, and doing it would have made me feel stupid.

    Rituals like that never do anything for me in general. Neither do most over-the-counter medications for things like cold symptoms.

    And frankly, I can’t see any kind of ethical difference between handing out an inert syrup and laying down an empty ritual. Except that, perhaps, the syrup may well have some kind of effect.

  21. Harriet Hall says:

    I can sympathize to some extent with pmoran’s position, since I have been on the front lines with patients in a primary care practice and can appreciate the gray fuzzy areas. We sometimes deviate from rigid scientific rules in the process of our human interactions with patients, but I think we are better off having rules in the first place and knowing that we are breaking them. So: No Placebos – Except Maybe Sometimes, Sort Of.

  22. pmoran says:

    Yes, indeed, Nybgrus, what’s the harm?

    Most of those cases are due to people not being prepared to entrust the mainstream with their medical care, or simple-minded behaviour that no amount of public education or regulation will change.

    I suggest that rather than trying to support our usual smug, self-reassuring stance of “what is wrong with these people?” , we should be examining why on earth some people elect not to trust us. That is something we might be able to do something about, right here and now, and every time we open our mouths.

    One fairly rational reason is that many common ailments are less dangerous than the act of stepping into some doctor”s offices, or ingesting some pharmaceuticals that doctors may suggest. That’s the truth.

    If we cannot see ourselves with a clear unbiased vision, we have no hope of understanding the complexities underlying CAM use, and we cannot hope to respond in an apt manner to concerns that are distancing us from what we regard as our rightful clientele.

    Another stumbling block is the belief that CAM use is mainly a matter of defective scientific understanding. That is a product of the very cognitive traps that Harriet has just been talking about. That idea even ignores the evidence that is available.

  23. nybgrus says:

    You’re absolutely right, Dr. Moran. There is a lack of trust, and problems with standards of care, etc etc.

    So the solution to fixing a lack of trust is…. prescribing a placebo? Fix the lack of trust, by making it impossible for patients to know if they are getting an evidence based effective treatment or just a “kiss it and its all better” treatment? I hardly follow the logic there.

    You cling to this notion “that no amount of public education or regulation will change” these things. I disagree. Look at the types of practices we thought were reasonable and effective 100 years ago. Look at various 3rd world countries and compare all of that to where the 1st world is now. Are you still so sure that there is no difference made by education? You must think I’m so dull as to assume this is an issue than can be resolved in my lifetime. No, Dr. Moran, this is something that will be ameliorated, and likely never fully resolved, on a scale of decades and centuries. Unless, of course, woo-meisters and placebo peddlers are given free reign, since “we don’t have all the answers.”

    You’re correct that we don’t see our own selves with a clear and unbiased vision. But once again, the answer is not to subvert our own progress by letting that vision cloud with magical thinking. The answer is to fix the problem. I try and do my part, as best I can. Every week I teach 25 first years how to prepare for board exams – and every week I stress to them critical thinking, scientific thought, and to feel proud and comfortable to hold no quarter for magical thinking. To be completely open and willing to change your mind and your practice in the face of good evidence – and how to evaluate that. Hopefully they will take this to heart and spread that ethos. That is how change is made – not by finding more gray areas to squeeze ourselves into and placate the magically thinking masses.

    And you clearly have not been listening to me if you feel that I believe the reason for the existence of CAM is a lack of scientific understanding. Certainly, it is a big contributor, but not the sole cause. However, I do think that the biggest blow that can be made to CAM can be through scientific knowledge and a development of critical thinking at an early age. You need not kill the roots to destroy a weed – sometimes plucking off all the leaves will leave it to wither and die.

    @Dr. Hall – I can’t fully appreciate your sentiment, having never actually been in your shoes there. However, I reckon that on an individual level of interaction, certain times exceptions can be made. As long as we know it is an exception and breaking the rule, of course.

    My mother once said it quite well. When I was about 11 or 12, as most boys of that age tend to be, I was quite curious about sex and occasionally managed to get my hands on a Playboy or two. Every once in a while, my mother would clean my room, find the magazine and throw it away, never saying a word to me about it. Finally, after some time of this going on I asked her, “Why do you throw them out, if you aren’t going to punish me for having them?” Her response? “Because it is normal for a young boy to want to see these things, but it is not normal for a mother to actively support it. So know that you are breaking the rules, and I will continue to act in my role as your mother.” I still think that was a pretty insightful thing for her to have said.

  24. pasulj says:

    I just yesterday had a heated discussion with one of the other PhD students in my department about this (we’re both pharmacists too). I took the same stance; it’s deceptive to sell patients placebos, I don’t feel right doing it, claiming something will have an effect when I clearly know it doesn’t. She had the opposite view, stating that if a patient has used, for instance, a homeopathic product for years and it ‘works’ we should just give it to them. I feel this gives legitimacy to a pseudoscience shown time and time again that it doesnt work… Then she went on to say something along the lines of we don’t need evidence for everything we use in medicine – why she is doing research in pharmacy practice is beyond me…

  25. Harriet Hall says:

    @pasulj,
    What if the patient who believes in the homeopathic remedy is a 98 year old poorly educated woman with terminal cancer and mild dementia, with a very short life expectancy, and you know she is incapable of understanding your reasoning and would be hurt and distressed, even desperate, if you refused her the medicine she believed was helping her? Isn’t it kinder to let her keep her false belief? Aren’t there situations like this where breaking the rules is justified?

  26. nybgrus says:

    Dr. Hall – That is an excellent example of when it would be acceptable to “break the rules.” Another is a time when a very scared woman in a trauma grabbed my hand and asked me to pray with her (I did – well I faked it I have no idea how to pray). But there is a distinct difference between withholding the homeopathic medicine (or prayer) from said patient and actively prescribing homeopathy and prayer.

  27. BillyJoe says:

    nybgrus,

    I would just like to offer you my support.

    Like Jerry Coyne, PZ Myers, David Gorski, Richard Dawkins, Christopher Hitchens, and others in their respective fields, I see you are are non-acommodationalist.

    In my opinon, change cannot come any other way.

  28. BillyJoe says:

    …shit, I spelled it incorrectly :D

  29. nybgrus says:

    thank you BillyJoe. You have listed a large sampling of some of my favorite writers and speakers. I have taken a lesson from each of them, but I have also seen these things in my own experience.

    The thing that often gets confused (as pmoran seems to do) is that non-accomodationist does not mean cold heartless bastard who will slap the airborne out of grandma’s hand or beat up children for playing with unicorns and santa claus. It seems to me, in my limited experience, that people tend to find it difficult to realize you can hold a strong line whilst still tailoring what you say and do to the nuances and needs of a particular situation.

    I think it stems from the false notion that “holding to your guns no matter what” is a virtue and that people who can change their mind or act differently to different people in different situations are capricious and two faced. How many movies end with the protagonist being the hero because no matter what (s)he never changed his/her mind and was triumphant in the end? IMHO, that stems from religious dogma and faith above all else and is a patently wrong thing to teach people. From this stems the mantra that science is always changing its mind and we can’t trust it. A completely nonsensical statement to those who actually know what science is, but from the framework of our current cultrual milieu and popular media, makes sense. Hence, my stance on education, education, critical thinking, more education, and topped off with a pile of healthy skepticism and a cherry of critical thinking on top.

    Sadly, my prolific writing has been my standard long before I read Gorski or Hitchens, so I thank you once again for your support and taking the time to bother reading my extensive posts.

  30. pasulj says:

    @hall

    You give a far fetched rhetorical example. I was more concerned with everyday practice and the fact that someone thinks it’s justified to use ‘therapies’ with no evidence ‘just because they’re used’. I feel it’s my duty to educate my patients on appropriate therapy, those who don’t have the cognitive capacity to understand will have to forego the education.

  31. Harriet Hall says:

    @pasulj,
    “You give a far fetched rhetorical example.”

    No, I gave a strong example of the kind of practical dilemmas primary care doctors encounter on a regular basis. I hope that every doctor would allow that woman her homeopathic crutch, but there are lesser examples where some doctors would give in while others would stand their ground. My point was that we shouldn’t be dogmatic: we should have rules but we should be willing to break them when it would be kinder to the patient and would do no harm.

    “those who don’t have the cognitive capacity to understand will have to forego the education.” Ah, if only it were limited to those without the cognitive capacity! If only education were consistently effective! The big problem is those who have good brains but stubbornly refuse to use them.

  32. Jan Willem Nienhuys says:

    I think Harriet Hall gave a good example of a dilemma that a doctor can meet.

    But here is another example. The patient’s family doctor is a card carrying homeopath (he probably converted to homeopathy when it became fashionable and many of his patients believed in it). The patient is a 90 year old man with beginning dementia, but otherwise quite fit, but who keeps asking to be cured of a quite imaginary prostate problem. The homeopath prescribes some homeopathic nostrum, let’s say Agnus castus C6; the patient is aware of the fact that homeopathy is controversial, tries to take the medicine (but forgets it) and buys every month at the drugstore a well known supplement with saw palmetto ‘for the maintenance of a healthy prostate’ (you known the kind of quack miranda statement) after asking the drugstore owner something for prostate complaints. He then takes one capsule and forgets about it. (Many years the family finds a veritable hoard of full bottles with such capsules.) Meanwhile he keeps going to the family doctor complaining about his situation.

    Is there really no other way for the homeopath than to fob off the patient with nonsense remedies (which the patient actually doesn’t believe in at all)?

  33. pmoran says:

    Nybgrus: So the solution to fixing a lack of trust is…. prescribing a placebo?

    Oh, give me a break! Respond to what I actually say, please.

    This is part of the problem. We might do well to spend more time actively listening, and less “educating”. We might find that the key to trust is a modicum of mutual respect wherever we can find it.

    But you must learn to read between the lines a bit when talking to CAM users.

    Don’t take the rationalizations that they offer for what is essentially instinctive behaviour too seriously. (Medical skeptics have the same instincts but we have learnt to suppress them, even to the extent of not risking ANY trial of CAM lest we be misled by placebo responses and other illusions. This is a reflection of the level of error-aversion within applied medical science).

    So it is, that when CAM apologists go, ” blah, blah —”medicine kills people too” — “we are all individuals” —- “science doesn’t know everything” — “other ways of knowing” — etc, these are not in any way carefully thought-through positions. They are feeble post hoc attempts at self-justification in response to dimly understood science-based attacks on their medical choices.

    If so, what is really going on? I have tried to get at this.

    I suggest tentatively that the basic paradigm for CAM use involves a person with medical needs for which science-based medicine has not yet produced an entirely safe and reliable solution. They are inclined to try anything else that might help, typically alongside at least some conventional care. They are bombarded with advice from all sides and respond to it on instinct.

    There are obviously other elements involved. Some skeptics are preoccupied with the role of fraud. Frauds and even the deluded can certainly produce a piece that exactly fits the CAM user’s puzzle, but there is always a willing collusion. Every CAM user I have ever talked to understands that there are frauds and nut-jobs out there; they merely lack a nose for them, being inclined by instinct to give “healers” the benefit of the doubt. In any case, it is personal testimonial keeps the wheels of CAM (and folk medicine) well oiled.

    Now if this is accurate, it is also critical for the medical skeptic to appreciate that science (as we know it) has already, more or less, done its dash. Not only that — its error-averse approach is quite unsuited to the present purpose. The CAM user is quite happy to try anything that might help, according to their own lights, and will blissfully go on to try something else if it doesn’t, with no deeper internal reflection than “It didn’t work for me”.

    Now that is not as anti-science an activity as the common rationalizations (see above) suggest. It IS science, but at an extremely primitive level, engaging in-built survival instincts .

    It will of course not often deliver reliable medical knowledge but it does seem able to satisfy some human needs. We have no basis on which to claim otherwise, while having a very strong case against many specific claims and an onus to warn against certain dangers. So this is not meant to discourage the provision of staunch opinion on matters that do matter.

    The above is partly why I think EBM/SBM is almost irrelevant to CAM, and why it may indeed be impossible to educate it out of existence.

  34. pasulj says:

    @hall

    It seems you have misunderstood me, I appolpgose if I have caused confusion. I certainly don’t believe that putting my patients in distress is anywhere near ok, I’m a little upset that you suggest otherwise. My point is that these types of medications are considered ok to give just because they’re in pharmacies, I disagree.

    The point you make about people with good brains who refuse to use them, that is the patients prorogative. I have countless of times explained to patients what homeopathy is any they choose to take it off the shelf regardless. I can’t stop them, it’s their right to make a choice about their health. Its the same when people walk in and they obviously need to see a doctor but refuse to despite my best efforts to explain why. Or telling your patients to stop smoking or using drugs. At the end of the day it’s up to the patient.

    I hope you understand my stance a little better, I am just frustrated, as many other skeptics and pharmacists are, that homeopathy and other quackery is sold in pharmacies next to legitimate medications, and THIS is one of the roots of the problem. If they weren’t sold, we would not have had our discussion about whether it is ethical or not to deny sale to a 98yr old with her array of medical issues. It wouldn’t be so much of a problem.

  35. Harriet Hall says:

    @pasulj,

    I agree completely. Pharmacists should not be selling homeopathic remedies and the laws should be changed. I’d like to see one evidence-based scientific standard for approval of everything with health claims: prescription drugs, OTC drugs, herbal remedies, diet supplements, devices, and homeopathic remedies. That would be a step in the right direction, but it still wouldn’t eliminate homeopathy. Patients would find unauthorized sources. Prohibition didn’t work for alcohol. If prohibition were a viable option, the highest priority would be prohibiting tobacco, the leading preventable cause of death.

  36. pmoran says:

    Harriet: I agree completely. Pharmacists should not be selling homeopathic remedies and the laws should be changed. I’d like to see one evidence-based scientific standard for approval of everything with health claims: prescription drugs, OTC drugs, herbal remedies, diet supplements, devices, and homeopathic remedies. That would be a step in the right direction, but it still wouldn’t eliminate homeopathy.

    True. Then again, maybe we should concentrate on trying to control the claims along “this may make you feel better but it is not known to affect the progress of any disease” lines.

    That is easier to argue out on scientific grounds, with so many “alternatives’ turning up the odd positive study on subjective complaints.

    You won’t have so many nice people telling their politicians how much the remedies have helped them.

    You are allowing personal choice.

    You cannot be seen to be protecting Big Pharm and Big MD turf.

    It recognizes that billions are going to be spent on such remedies for innumerable minor and self-limiting complaints, whether we like it or not. Without them there may be more unneeded ADRs, public medical costs and medical misadventure.

    It even allows for the possibility of beneficial placebo responses from utterly safe remedies such as homeopathy.

    It is one asnwer to “what the most important, realistic objective here?”.

  37. Isn’t there also a philosophical question here?

    What I mean is that, in general, we as individuals want absolute knowledge. We want to be told that “there is a cure” or “there is no cure.”

    I think the hurdle here is evolving our culture to understand that what we know is only what we know so far.

    “I’m sorry, we don’t have a cure, but we’re trying. We know so much more than we used to about your affliction, but we don’t know everything.”

    Solid answers are not always possible. And prescribing placebos amounts to lying to an individual in a way that has no benefit to the community. Acceptance of the limits of our knowledge, in the long run, benefits everyone.

  38. nybgrus says:

    This is getting pedantic and annoying, Dr. Moran.

    Oh, give me a break! Respond to what I actually say, please.

    Firstly, placebos do seem to help many symptoms, if only via the power of suggestion. You regard that as an acceptable “deception” when used along with treatments that you yourself clearly suspect may not work as you try to represent to the patient.
    Secondly, I think many common treatments for nausea work mainly as placebo, if they work at all. There is often a very fine line to be drawn therein. In the largest study of one FDA approved treatment for IBS the drug produced improvement in 3% but also caused diarrhoea in 3%.
    Thirdly, placebos may be offered to avoid the negative consequences of not prescribing in certain settings. They can be significant.
    Fourthly, placebos can be chosen for their safety. Inappropriate use of pharmaceuticals is a worse option that some doctors are driven to by the pressures of medical practice.

    followed by:

    Most of those cases are due to people not being prepared to entrust the mainstream with their medical care, or simple-minded behaviour that no amount of public education or regulation will change.

    So how was I off base in my assertion that “…the solution to fixing a lack of trust is…. prescribing a placebo?”

    I do listen to what you are saying, Dr. Moran. Are you saying that I cannot take two of your posts, each asserting your stance on the topic, and then use that to contradict your stance? Are your posts meant to be completely independent thoughts from two different people? It seems very clear you say there is a lack of trust. You also CLEARLY state that there are 4 “acceptable” uses for placebo. Since, by definition, placebo requires decption (intentional or not) I was calling into question the two notions – I assert you cannot have both, your refutation is that I am not addressing what you are saying. My turn to say “Oh give me a break!”

    They are feeble post hoc attempts at self-justification in response to dimly understood science-based attacks on their medical choices

    The arguments you cite are not from the casual CAM user you decsribe. You describe the Dr. Oz’s, Joe Mercola’s, and other active pseudioscientists and the proteges they have culled. The average CAM user doesn’t make such post-hoc justifications. The average casual user is of the mind that “natural is better” and “it’s on the pharmacy shelf and so-and-so said it works so I gave it a go.”

    They are bombarded with advice from all sides and respond to it on instinct.

    Now you are actually referring to the average CAM user – and I agree, hence why I think we should be more active and vocal in making sure they get advice from the best informed side to make decisions, not all sides. If the best informed side begins to support, prescribe, and be otherwise shruggie to CAM then what hope does anyone have to make any other sort of decision?

    There are obviously other elements involved. Some skeptics are preoccupied with the role of fraud.

    What a surprise! We are preoccupied with the area of CAM which is the most delibertaly deceptive and harmful! I can’t imagine why that would be. Nevermind it also happens to be the easiest to attack, you know, it being rooted in fraud and all.

    Every CAM user I have ever talked to understands that there are frauds and nut-jobs out there; they merely lack a nose for them, being inclined by instinct to give “healers” the benefit of the doubt

    Indeed, a better reason for good education and scientific understanding I have yet to hear. Such is the nature of expertise – most people aren’t an expert in your field. However, an understanding of critical thinking and the scientific process is all you really need. My girlfriend is an engineer – she knows very little about biology and medicine – yet she can (and has) looked at a claim, thought something sounded fishy about it, and asked me for an opinion. She withholds judgement and opinion, and by default assumes something to be false if necessary, because she was taught critical thinking and the scientific method from an early age. Why you seem to think that such education is impossible is beyond me. Either that or you aren’t listening to what I am saying and think I mean everyone should have high level education in a specific science, such as medicine. Once again, my turn for an “Oh give me a break!”

    Now that is not as anti-science an activity as the common rationalizations (see above) suggest. It IS science, but at an extremely primitive level, engaging in-built survival instincts .

    And once again you conflate groups and intentions. You are describing the casual CAM user, once again, yet seem to think that my attacks are against such a person – in the same breath as saying that the likes of me are “pre-occupied with fraud.” Well, which is it then? Nevermind that I think you are wrong in describing that as science, you aren’t even addressing the point. Those that teach CAM in medical schools, those that offer classes in reiki, acupuncture, homeopathy, naturopathy and claim they are science based and use equivocal studies to try and gain some traction…. those are the anti-scientists I fight most vociferously against. Not the casual average person with imperfect post-hoc analysis of their own personal experience. Third time for “Oh give me a break!”

    So this is not meant to discourage the provision of staunch opinion on matters that do matter.

    It would seem you and I differ on “what matters.” You say that certain things don’t matter. I say they always matter, just sometimes less, and certainly more or less in different circles and to different audiences; something else that you can’t seem to undertand – my point, vernacular, tack, and level of “staunchness” if you will, can and do vary depending on my audience. Are you a CAM user that I am trying to convince, or are you an educated, science based skeptic? If the latter, then why must I change my vernacular as you describe necessary when addressing a CAM user/patient?

    It even allows for the possibility of beneficial placebo responses from utterly safe remedies such as homeopathy.

    And now I am pretty much done. Utterly safe? How about the homeopathic teething tablets with belladonna toxicity? I’d expect such black and white statements from a lay person or someone with an ideology, but as someone claiming to be a physician who understands science, and especially someone who calls me out for being to stern in my vernacular, I would expect at least a little nuance. With that, my 4th and last “Oh give me a break!”

  39. pmoran says:

    Let others judge whether whether my “Give me a break!” comment was apt.

    In this you again try to elide statements of mine in such a way that suits your purposes but not my meaning.

    Another example of non-responsiveness. –

    You said.–

    And you clearly have not been listening to me if you feel that Ibelieve the reason for the existence of CAM is a lack of scientific understanding. Certainly, it is a big contributor, but not the sole cause. However, I do think that the biggest blow that can be made to CAM can be through scientific knowledge and a development of critical thinking at an early age. You need not kill the roots to destroy a weed – sometimes plucking off all the leaves will leave it to wither and die.

    That was in response to my saying –

    Another stumbling block is the belief that CAM use is mainly a matter of defective scientific understanding. That is a product of the very cognitive traps that Harriet has just been talking about. That idea even ignores the evidence that is available.

    How is your response not simply restating much the same stance that I criticised? I have offered up some of the reasoning behind my position, and have a lot more than that. What have you got?

  40. pasulj says:

    @ Hall

    I agree that prohibition does not eliminate problems – it’s been an epic fail when it comes to illicit drug use; we have endless phone calls of addicts wishing to join the methadone program and we just do not have the capacity accommodate for them. However, taking homeopathy away from pharmacy shelves removes some of the legitimacy of having the product there in the first place. The number of times I’ve heard people say “oh, I got it from the pharmacy – it must be good” is amazing.

    I don’t know what it is like in the USA, but in Australia there are drugs only sold in pharmacies, and no where else (these are not script items, but pharmacy and pharmacist only, each with their own set of rules and regulations on supply, storage, etc..) and so just by having a potentially “therapeutic” item in the store, we add this sense of “oh it must work” to it.

    Banning things outright rarely works, but banning their sale in a legitimate health professional setting may help take away some of the notion that the stuff actually works JUST because a pharmacy sells it…

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