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Placebo Therapies: Are They Ethical?

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.

Posted in: General, Medical Ethics, Science and Medicine

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27 thoughts on “Placebo Therapies: Are They Ethical?

  1. hatch_xanadu says:

    Interesting that the survey authors chose fibromyalgia — a relatively *subjective* painful condition. I wonder if the survey respondents were more able to suppress their guilt because there is already a bit of paternalism going on with conditions like fibromyalgia. The diagnosis is often made in patients who tend to keep seeking treatment for a nebulous set of systems.

    I wonder if physicians tend to doubt that any “real” condition, save a bit of psychosomatic neuroticism, exists in those patients. Indeed, the Mayo Clinic’s own description: “You hurt all over, and you frequently feel exhausted. Even after numerous tests, your doctor can’t find anything specifically wrong with you. If this sounds familiar, you may have fibromyalgia.” I’d like to see a similar survey conducted with, say, a broken bone as the example.

  2. hatch_xanadu says:

    Err, “systems” should be “symptoms”.

  3. badrescher says:

    I am SO with you on this one.

    I remember when this came up in the news a few months ago.

    I find this practice disgusting, arrogant, patronizing, and ethically despicable. I am surprised that AMA guidelines are even necessary to establish that. I think there is a good argument for legal action, too.

    It’s too bad that so few people value honesty and transparency.

  4. daijiyobu says:

    I for one think that ‘grossly overstating effect’ is equivalent to lying to your patient…if that ‘you’ is a doctor, which undoes the professional status of medicine.

    For me, it revolves around the ethical and legal position of ‘fiduciary duty’ wherein a patient has put huge trust in the professional to do their best based upon the best knowledge available.

    Perhaps it’s as polar a decision as whether:

    a) the ends justify the means [lying is okay if the patient is happy -- outcome is singularly paramount];

    vs.

    b) virtue ethics ['you' are defined by your actions in continuum with the outcomes those actions intend].

    I prefer (b).

    I left naturopathy school because – primarily — I couldn’t give a member of the public a sugar pill and tell them it was a profoundly potent homeopathic cure [means]…even if the self-selected population using such services out-of-pocket were ‘lactose-cure junkies’ completely content with the experience [ends].

    I couldn’t call nothing…something.

    -r.c.

  5. gotte says:

    Although I completely agree that honesty towards the human beings we tend to call “patients” is of utmost importance I am afraid that it will never be possible to eliminate the “placebo” effect completely as I consider it firmly rooted at the very base of the mutual attitude of trust and respect that since Hippocrates has been the fundamental characteristic of “care and cure” type patient doctor relationship. Care is an essential part of the cure and one simply cannot separate this. Part of being a doctor’s entanglement with patients is all about knowledge, science, but also empathy and compassion and those cannot be taken out of the picture without the risk of a negative dent on the quality of the cure. We do not treat robotic AI objects but humans endorsed with a cingular cortex and complex limbic nuclei and plasticity endorsed neural networks.
    The emotional cool technical doctor has a disadvantage as the quality of his cure will suffer. Of course this is in NO way a plea for esoterica, alterneutics or CAM bogus and deceit but it is a plea to claim back that what alterneutes and maybe administrators have been stealing away from doctor-patient relationships: time to listen, time to bond, time to care: Hippocrates regained.

    Dr. G. Otte

  6. Peter Lipson says:

    One cannot harness a “treatment” which is more of an artifact of a particular situation. It is neither predictable nor reliable. In fact, placebo usually behaves no better than, er, placebo.

    Remember, the placebo effect is not some dramatic improvement in a patient’s condition.

  7. ImperfectlyInformed says:

    Err, since when have no CAM treatments been shown to be effective beyond placebo? The latest Cochrane review on St. John’s wort (http://www.ncbi.nlm.nih.gov/pubmed/18843608) concluded the following: “”the available evidence suggests that the hypericum extracts tested in the included trials are superior to placebo in patients with major depression; are similarly effective as standard antidepressants; and have fewer side effects than standard antidepressants”. The Cochrane review on devil’s claw (Harpagophytum) for pain found that two high-quality trials were better than placebo, and one additional study found an equivalence to Vioxx (http://www.ncbi.nlm.nih.gov/pubmed/16625605). Valerian and melatonin are good for sleep; SAMe has numerous benefits, and 5-HTP indisputably converts to serotonin in vivo and most likely reduces depression. While kava’s safety isn’t certain (http://www.mja.com.au/public/issues/178_09_050503/mou10043_fm.html), its efficacy data is reasonably strong. Of the “core” altmed, certainly chiropractic temporarily reduces back pain. Extreme and false statements mainly reduce credibility; although no doubt they feed the choir, in science should strive for a little more than that.

    This question sort of reminds me of a JADA article I once saw discussing the ethics of removing dental amalgam fillings at a patient’s request. As far as I could find, the question of whether it was ethical to place dental amalgams without informed consent has never been asked — despite the fact that polls find 80% of Americans don’t know, and most say they wouldn’t consent. Despite, further, the fact that until 2007 no controlled trials had tested its safety, and few uncontrolled studies had been done previously. Early animal research actually indicated major problems (http://www.fasebj.org/cgi/reprint/9/7/504). Incidentally, updated results (http://www.ehponline.org/members/2007/10504/10504.html) from one of the RCTs has noted microalbuminuria (indicating possible renal damage), and another study of the results has surprisingly found greater excretion in girls (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2022658), underscoring how little we know about mercury’s metabolism. My impression of this website is that it would’ve been snickering at Needleman’s research on lead, just as it currently snickers at Needleman’s caution when it comes to dental amalgam.

    As far as whether prescribing placebos are ethical, it’s a tricky question. I would say that prescribing a homeopathic mixture (or a pseudo-homeopathic sugar-water mixture) for a viral illness which has no effective treatments is certainly ethical. Those who are knowledgeable will know it’s a placebo and get little benefit, while the majority who are not well-informed will benefit. Since it’s no secret that homeopathic mixtures are placebos, it’s not really deceptive. I would expect such a prescription to be sold for very cheap, however.

    Why is this question similar to the dental amalgam ethics question? Well, is it ethical to prescribe a medication long-term without rigorous, unbiased knowledge of its long-term safety, and without specifically informing the patient of those adverse effects? Particularly for children? I would say no, yet this is done frequently, whether it’s Ritalin, antidepressants, atypical antipsychotics (my coworker’s 13-year old boy was put on risperidone for throwing a pencil in class), statins, or whatever else. Is it ethical to prescribe medications from a company from which you are receiving gifts? Again, I would not say no. Yet I see no discussion on this website of Massachusset’s recent move to make the practice illegal. Is it ethical to prescribe drugs off-label, considering that much of the research on off-label drug uses is weak and tainted by bias?

    Considering the result on St. John’s Wort above (and the promising knowledge on SAMe and 5-HTP dating back to the 1950s) in conjunction with the rather serious adverse effects of mainstream antidepressants, one might regard the craze for antidepressants of the past two decades as one of the most damaging cases of medical fraud ever. I don’t think I need to remind you that it’s not only cranks who think that the pharmaceutical industry has engaged in massive fraud (Marcia Angell, George Lundberg); the altmed fraud is a just a drop in the bucket in comparison. Snake oil salesmen abound in both alternative and mainstream medicine. The past two decades in medicine have been a lot like the past two decades on Wall Street, with similar revolving doors and conflicts of interest. Substitute contract research organizations for credit rating agencies and physicians for investment bankers.

  8. pmoran says:

    One critical factor is routinely overlooked in these discussions — that there is no point at all in using a placebo if there is a completely effective and safe evidence-based treatment option. I don’t believe anyone envisages using them that way .

    Placebo ( more often simply not well-proved) medicines might be resorted to when “working better than placebo” EBM has no entirely appropriate answers and the practitioner sees the potential for negative consequences if he fails to respond in a proportionate manner to the immediate patient’s distress.

    Start from there and it all looks a bit different.

    It is interesting that when presented with the question in a certain way (and everyone seems to have their own peculiar image of what placebo use would be like) most doctors say they would use a sugar pill for fibromyalgia. They see the immediate patient’s interests as paramount, and will presumably worry just a little later about the splendid ethical considerations, the imposition upon the patient’s sovereignty, or the implausibility of that particular treatment.

    One thing is certain — the patient won’t mind if the doctor is prepared to try anything that might help them. Many will care if he does not seem to be regarding their illness with respect.

  9. daedalus2u says:

    I think that lying to a patient is completely unacceptable.

    A reason that fibromyalgia is so susceptible to placebos is because fibromyalgia is caused by low NO (my hypothesis).

    I think I have a more complex and I think more nuanced view of placebos and the placebo effect than do most others. I see the placebo effect as completely mediated through normal physiology. There is nothing magic or wooish about it. I see it as the completely normal allocation of metabolic resources. Under times of stress, as when running from a bear, the optimum organism will divert all resources to running and spend no resources on healing. Any ATP spent on healing is wasted if the bear catches you. Any damage that accumulates during escape from the bear can be repaired later provided the bear is escaped from.

    Physiology is really complicated. There are many thousands of pathways that are all regulated in sync. Allocating ATP and other metabolic resources between those pathways is critically important and is mostly not understood.

    There is a state called the ischemic preconditioned state, where ATP consumption is reduced. This state can be reliably induced by brief periods of ischemia, where it reliably reduces ATP consumption, and reliably increases survival of longer periods of ischemia during the ischemic preconditioned period.

    The ischemic preconditioned state can only be a temporary state. If it could be permanent, cells would be in that state all the time because it would free up more ATP for reproduction. Cells are not in an ischemic preconditioned state all the time, there must be something incompatible with life associated with long term ischemic preconditioning. I think that incompatibility is the “housekeeping” functions that can be turned off briefly when those resources are needed for more important things. I discuss my view of the placebo effect in considerable detail.

    http://daedalus2u.blogspot.com/2007/04/placebo-and-nocebo-effects.html

    We know that essentially every organ and tissue compartment can exhibit ischemic preconditioning. I would like to consider a thought experiment, what would happen if ischemic preconditioning was triggered in an organ and then never turned off? How would the organ respond in minutes (protective against longer ischemic events), hours (still protective), days (maybe protective), weeks (maybe/maybe not protective) months (likely not protective), years (definitely not protective). Long term ischemic preconditioning can’t be protective or cells would have evolved to be in that state permanently. If they are in that state permanently, then it isn’t “ischemic preconditioning”. I suggest that the organ would exhibit degeneration, that damage would not be repaired, that damaged proteins would accumulate, that mitochondria biogenesis would not be as robust. As these small effects accumulated, cellular function would degrade until it reached the point of no return and the cell died.

    If a tissue compartment is pathologically in the ischemic preconditioned state, any treatment that moved it out of that state would have healing effects. Those effects might be dramatic. Diverting a cell from a pathway that will lead to its death to a pathway that leads to its survival is a dramatic effect.

  10. user9999 says:

    This is a pretty good topic. My answer would have to be…it depends. There is a placebo effect present in any treatment, whether the physician likes it or not. If the patient trusts their doctor and believes they are going to get better, the clinical outcome is going to significantly improve. I remember reading a study on red pills vs blue pills (same medication) and the patients had a better clinical response when taking the red pills. No one told the patient that the red pill was more effective. It was just what the patients perceived. This would be nothing dishonest on the part of the prescribing doctor, but just using the placebo effect to maximize treatment.

    Is it ethical to lie to a patient? Absolutely not. Is it ethical to give them a drug which will give them numerous side effects when the same or a similar effect is possible by giving them an absolutely harmless pill. Maybe…. maybe not. I guess I could see the placebo effect being of much greater use for a patient with a chronic pain problem which is heavily influenced by cognitive factors in the first place.

    At any rate, I wouldn’t completely knock the patients perceiving a positive outcome and thus responding better (placebo effect as well), because it will always exist and be a tremendous benefit with any treatment.

  11. Dr Benway says:

    Placebos are little bits of you and your kindness. They can become addictive for some patients.

  12. botogol says:

    how about –

    ‘what you have is difficult to treat, and I don’t have at my disposal a medicine that is guaranteed to to treat your condition. The treatments you have had before don’t seem to have worked, and I am nearly at a loss.
    However I’d like – with your agreement – to try something unusual. I’d like to give you dextrose monohydrate. This is actually quite a common trace component of many pills you have taken before but I plan to give it to you in a purer form.

    To be honest it’s not known for producing any measured effect on your condition, but in my experience some patients have found it somewhat helpful, and it certainly won’t harm you. Would you like to try?’

    hmm. it’s hard isn’t it? I am squirming… but is it ethical to deny someone a placebo that may well help them to feel happier – because of your moral scruples?

  13. Versus says:

    Are inert treatments unethical? How about fraudulent? According to the Restatement 2d of Torts, Secs. 525, 526, (a sort of “best practices” for the law), “One who fraudulently makes a misrepresentation of fact . . . for the purpose of inducing another to act . . . in reliance upon it, is subject to liability to the other in deceit [that is, fraud] for pecuniary loss caused to him by his justifiable reliance upon the misrepresentation.” Whether the misrepresentation meets the definition of “fraudulent” depends upon the maker’s state of mind. A misrepresentation is fraudulent when the maker of the misrepresentation “knows or believes that the matter is not as he represents it to be; does not have the confidence in the accuracy of his representation that he states or implies” [sometimes referred to as making the statement “recklessly, careless of whether it is true or false”], or “knows that he does not have the basis for his representation that he states or implies” [for example, he implies the statement is based on personal knowledge when in fact it is not].
    Let’s apply this to CAM. CAM practitioner A tells patient B that acupuncture/adjustment of B’s vertebral subluxations/ craniosacral therapy will have a beneficial effect on B’s health by removing impediments in B’s qi/nerve flow/cerebrospinal fluid. These are clearly misrepresentations of fact by A made to induce B to act in reliance on them by accepting the treatment offered. The only question is whether the statements are fraudulent. Importantly, the fact that A believes in his misrepresentations does not relieve him of liability. The statements are still fraudulent if A doesn’t have the same level of confidence in them that he projects to B, or A is reckless in his statements, “careless of whether [they] are true or false.” I argue that A cannot ignore the settled, and widely available to anyone who wishes to look them up, principals of human biology, anatomy and physiology his statements violate, no matter how fervently he believes in them. Thus, A is liable in fraud to B for any pecuniary damage B has suffered in accepting these treatments, even if it is only the money he is out in paying for them.
    One monkey wrench in my analysis is that the states, in licensing various CAM practitioners, usually adopt CAM’s kooky ideas of human functioning into the practice acts, thereby raising the question: can the state legislature legalize the practice of what would otherwise be fraudulent? I’ll leave that for another day.

  14. SDR says:

    daedalus2u,

    With all due respect, I’ve never seen you comment on any story of any disease or medical issue and claim it doesn’t have to do with low NO. It’s, frankly, suspicious.

  15. daedalus2u says:

    SDR, the only thing I am well versed in is NO physiology, and I am very well versed in that. I don’t comment much on things that don’t involve NO because I don’t know much about them. When they do involve NO, then I comment.

    NO is involved in a lot of things, mostly as the signaling molecule that keeps all of physiology “in sync”. NO is the signaling molecule that triggers ischemic preconditioning (via low NO). It regulates the ATP level in cells, so that entire tissue compartments are “in sync”.

    The involvement of NO in the pathways I talk about is well known. It isn’t my idea or my data that shows their involvement, it is stuff from the literature. I am simply putting a lot of pieces together and appreciating that all the NO pathways are “coupled”, that is they all affect each other. This is more true for NO pathways than for most other signaling molecules because NO is a very small molecule that diffuses very rapidly and is active at very low levels (~1 nM/L) and is extremely reactive with some things (essentially diffusion controlled rate), and there are no barriers to NO diffusion. NO diffuses through lipid and aqueous phases with no difficulty. All NO sensors only sense the sum of NO from all sources.

    The importance of NO signaling is not well appreciated, largely because it doesn’t behave the way other signaling pathways do. The basal level of NO is important in ways that the basal level of other signaling molecules is not.

    To me, it seems plausible that when multiple pathways known to be mediated by NO are all skewed in the direction of low NO, that low NO is a likely final common pathway. If it is, then raising NO levels will shift physiology in a therapeutic direction. How much it will shift it is very hard to say because all NO pathways are under intense feedback regulation.

    Many social pathways are mediated in part through NO. They have to be because the archetypal social pathway, maternal bonding, has to be coupled to energy status because lactation is so energy intensive. That coupling to energy status is through NO. Low NO prevents maternal bonding because it mimics high stress where bonding is disadvantageous and where mammals don’t bond.

  16. pmoran says:

    Versus, it is also too suspiciously convenient to regard all use of alternative medicine as fraud, and therefore eligible for blanket condemnation. WHen a ciomplicaThere is no question that many of its practitioenrs are sincere, and little question that some patients derive benefits that are not easy to routinely provide wihtin a strictly evidence-based system.

  17. pmoran says:

    SOrry misfire again. I was about to add that when anything about a complicated human activity like medicine looks simple, it is time to reexamine one’s own biases and assumptions.

  18. daedalus2u says:

    PM, I completely agree, nothing about physiology is simple. Physiology is comprised of many coupled non-linear parameters. Such systems are inherently chaotic. They can only appear simple in a small portion of the relevant phase space, but that appearance of simplicity is an artifact.

  19. cphm says:

    Tricky question…I’d agree that it’s unacceptable to mislead patients, but if a patient can’t be helped any other way, and a sugar pill could relieve suffering at a very low cost, then why not try it? (Although there can be side effects, can’t there?)

    I have CFS, and there’s very little available in the way of treatment. When I was first diagnosed my parents asked the consultant about alternative therapies, and without saying explicitly that they were bunk, he advised us that some people had found them helpful for CFS but many had also found they didn’t work, that there was no evidence supporting one kind of therapy over any other, and most importantly that we shouldn’t spend anything we couldn’t easily afford on chasing spurious cures*. I think he struck a fairly good balance.

    The placebo effect may be unpredictable, unreliable and small compared to real treatments, but it makes people feel better than doing nothing. Here in the UK, prescribing dummy pills – perhaps along the lines suggested by botogol, but more straightforward and not assuming patients won’t be able to work out what dextrose is – could help people who’d otherwise pour hundreds of pounds into the coffers of quacks in an attempt to find relief.

    *Years later, I tried a few acupuncture sessions. It felt like having needles stuck in me. But then old age has made me cynical :)

  20. Versus says:

    Pmoran: I do not use the term “fraud” here as a personal condemnation (e.g., “all CAM is a fraud”) but rather as a legal term. My analysis was meant to show that under settled principals of tort law misrepresentations of fact made to patients in certain circumstances fit the legal definition of fraud. Those circumstances are described in my original comment, and include the situation in which the practitioner’s misrepresentations contradict well-settled science. If I have read the posts on this site correctly, that is exactly the problem with much of CAM. Whether you agree or not, legally the sincerity of the practitioner makes no difference in determining liability. If the patient benefitted, as your comment supposes he might, my understanding of the placebo effect is that the benefit did not actually come from the treatment itself, but from some other factor, so I suppose my analysis remains the same in that there is still a misrepresentation of fact made to the patient in giving the treatment.
    Dr. Jones’s post discusses whether the use of a placebo is ethical. I simply looked at the question from a legal standpoint.

  21. Dr Benway says:

    Prescriptions involve more than patient and physician. There are pharmacists, other MDs, family, friends, who will be aware of the prescription and who will comment.

    Imagine the scene at Man’s Greatest Hospital when the specialist hears your patient’s tale of treatment with an inert compound. He smirks and says, “WTF?” in so many words.

  22. Dr Benway says:

    Oh, my list ought to have said, “pharmacists, other MDs, family, friends, and Google.”

    Google will tell the patient, “Your doctor believes you are a nutter.”

  23. Tim Kreider says:

    I imagine different patients have different preferences along the autonomy-paternalism scale, and that some patients want only biologically active SBM whereas others would be happy with a placebo if it seemed to relieve symptoms.

    When a patient begins a new relationship with a primary care physician, the patient answers lots of questions about personal and family history. How about including a carefully worded question to the effect of: “Would you like your physician to give placebo treatment sometimes, of course only as a last resort or for self-limiting disease; or would you prefer to be given only scientifically proven or plausible treatment, even if that means sometimes leaving empty-handed?”

    You’d be asking in advance for permission to give sugar pill when the patient demands antibiotics for a viral infection. Or conversely, you’re getting permission to give neither treatment nor placebo when no specific treatment is indicated. Either way, ethical tension is relieved by the explicit statement of patient preferences. Could this possibly work?

  24. Harriet Hall says:

    A friend of mine tried to sign a permission like that, giving his doctor the right to judiciously give him placebos. The doctor refused.

  25. pmoran says:

    The closest I have come to using placebo is suggesting the use of evening primrose oil as a first line of treatment for cyclical mastalgia (rather than more potent and risky hormonal interventions) and peppermint oil for the irritable bowel syndrome.

    Both of these have produced positive results in at least one controlled trial, but I consciously used them thinking that most of their effect was likely to be placebo. They dignified the worrying presenting symptoms with a proportionate response, and even if ineffective in controlling symptoms, even as placebo, they offered something to use while the present bad patch of symptoms subsides as it almost invariably will with both conditions. In both instances they avoided using drugs that could make the patient sicker.

    This. along with the use of supplements as a “pick-me-up”, a few herbs and possibly acupuncture is what medical use of placebo medicines would look like. Get it out of your heads that it would involve the use of a sugar pill or even necessarily anything that explicitly “cannot work”.

    Towards the end of my medical carerr I was impressed by the number of patients, especially young women, who said “I don’t like taking drugs” very early on.

  26. Dr Benway says:

    pmoran, in the tiny context of you and your patient, I don’t have a problem with the evening primrose oil idea. I am of course assuming that nothing in the primrose product causes cancer, that the supplement makers aren’t adulterating their products, and that research into efficacy and safety is on going.

    Right now I’m listening to a doctor of sorts blathering on about co-enzyme Q and ATP on a streaming radio show, as I await Atheist Talk Radio. I don’t normally listen, but our pal PalMD is supposed to be on.

    Anyway, this quack is hawking some secret blend that will give you more energy. Apparently low co-enzyme Q makes you feel tired.

    I’m getting the feeling. You know the one. That strange urge to drive a spike into my eyeball.

    Sorry PalMD. Don’t think I’m gonna make it. If I hear the phrase, “all natural” one more time the rage will go critical.

    I fear that prescribing evening primrose oil may enable an industry of evil.

  27. yeahsurewhatever says:

    The usage of the term “placebo effect” is mired in misunderstanding.

    The common, non-professional, understanding of this term is that the act of convincing a patient that a given treatment will help them increases its effectiveness. Most of us have probably seen the MASH episode where they run out of morphine and convince their triage patients that their sham treatment (was it water or saline?) is a more potent painkiller, and everyone stays placated and appears pain-free.

    That’s fiction. It doesn’t happen. There’s no evidence for such an effect as that. There never was. It’s an urban legend.

    In reality, “placebo effect” refers to the fact that even in a situation where absolutely NOTHING is done by way of medical intervention, a consistent number of people report improvement anyway, even if there’s no reason to suspect improvement in terms of the prognosis, and even if they have not actually improved. So, even if they were given a treatment which is tantamount to nothing, that treatment would appear to show some non-zero rate of improvement. That appearance is a mere illusion, and does not actually reflect any form of efficacy in treatment. There is no benefit associated with such a treatment whatsoever compared to doing nothing.

    A given person cannot, by the sheer power of belief in a treatment, receive any additional benefit above what the treatment actually does. If the treatment does nothing, the belief will not matter in terms of the outcome. If the treatment does something, the belief will still not matter in terms of the outcome. What a patient might REPORT as a product of being deceived, and what is actually the case, often differ. Medicine is in the business of improving outcomes, not subjective reports.

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