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The Ethics of Deception in Medicine

A recent study published in the Journal of General Internal Medicine and featured in a Time Magazine article, indicated that of 466 academic physicians in the Chicago area, 45% indicated that they have prescribed a placebo for a patient. This has sparked a discussion of the ethics of prescribing placebos in particular and deception in general in medicine.

A placebo is a biologically inactive treatment, such as a sugar pill. Any perceived benefit from taking a placebo is due to a combination of factors, mostly biased observation and non-specific effects, collectively referred to as the placebo effect. I discussed the placebo effect at length last week, and now will delve deeper into the question of deception in medicine more generally.

Historical Perspective

Prior to about 30 years ago the relationship between a physician and their patient was functionally paternalistic. This means that the physician did what they thought was best for their patients as a parent would for their child. It also meant that “benign deception” was often used, including prescribing treatments that were known to be inactive or ineffective. Sometimes the deception was one of omission – for example, not telling a patient that their disease was terminal and incurable so as not to upset them needlessly.

An illustrative example of this type of deception was the practice of prescribing methylene blue to patients as an active placebo. This substance is quickly filtered unaltered by the kidneys and will turn the urine deep blue. I was told first hand by older physicians of the practice of telling patients that their condition was caused by a benign tumor, and that the medicine (methylene blue) would entirely dissolve the tumor. The patients were told that they would know the treatment has worked when their urine turns blue. The purpose of this was to convince a patient thought to be a hypochondriac, or to have psychologically-based symptoms, that their fake ailment was treated, in the hopes that they would take comfort from this and their symptoms would resolve.

It is easy from our modern perspective to be judgmental of the paternalism of past generations, but I feel that it is proper to judge people in their own historical context. The fact that such practices seem so outrageous to modern sensibilities is not necessarily a marker of modern moral superiority but may simply reflect the general changes in American society in the last half-century.

The Physician-Patient Relationship Today

The more accepted model of the physician-patient relationship today (or health care provider-client, to be more general) is that of cooperation, with the patient as a full partner. This is based upon the principle that everyone has a right to be fully informed so that they can make the best decisions for themselves. Further, individuals generally wish to be more empowered to control their own health care. This trend has also been driven by the easy accessibility of medical information to the general public. It is not uncommon now for patients to present to their doctor with a hand full of pages printed from the internet.

In reality there is still a broad spectrum from old-fashioned paternalism to the modern cooperative model. This is partly regional – in the US the coasts tend to follow a more cooperative model, while in the mid west and a lesser degree the south still retain a degree of paternalism. It is therefore not a surprise that the above referenced study was conducted in the mid west, and I suspect that the numbers would have been different if conducted in the northeast.

There is also a generational difference, as we would expect, with older physicians tending to have an older style of practice. Superimposed upon these trends are individual differences among physicians. And, in my experience, I think that patients themselves largely determine the nature of the relationship they have with their physicians. Even when patients are fully empowered to control their health care, some will voluntarily surrender to a greater or lesser degree to the expertise of their physicians. Physicians have to, in fact, be in tune with their patient’s desires in this regard. Put simply, some patients want information, and other patients want to be told what to do, and most want some combination of both.

Deception

In the context of the modern physician-patient relationship deception is generally not acceptable. Within the practice of medicine there are various specific situations that need to be discussed.

Medical research is the easiest situation to deal with because there are specific regulations that remove most of the guesswork. Research involving humans requires adherence to strict ethical rules and the oversight necessary to enforce those rules. The guiding principle of medical research is informed consent. Subjects need to be told exactly what the potential risks of an experimental treatment are, what (if any) are the potential benefits to them, and the probability that they are receiving a placebo treatment. They need to be told exactly what will happen to them in the study, what the treatment alternatives are, what will happen if they have a negative side effect, and they need to be given the opportunity to ask any questions to their satisfaction.

Informed consent also applies to the practice of medicine outside of research. This means that patients have a right to similar information and to have any questions answered prior to agreeing to have surgery or receive a drug or treatment. However, the complexity here is that there is really no such thing as “full” disclosure. It is not practical for a physician to go over every possible consequence of a treatment prior to prescribing or initiating it. Potential side effects that are benign and/or extremely rare do not necessarily need to be discussed directly. Physicians do exercise judgment in deciding what patients need to be told.

Often, after the important facts about a new drug are discussed, patients may be referred to the package insert, which has the full prescribing information approved by the FDA. This way the patient can have as much information as they desire about a new drug, and then can ask their physician about anything that concerns them.

Keep in mind that I am not saying that what I described above is what always happens, but it is generally accepted to be good practice. Also, physicians that neglect to follow such good practices open themselves to liability if a negative outcome does occur.

Another context which is fairly straightforward is the need for full disclosure. This means that physicians are ethically required to tell patients any relevant information. In addition to having full consent prior to a treatment, patients are considered to own their health care information and have a right to access to it. Likewise, physicians have a duty to inform patients about anything relevant, such as test results or their diagnosis or prognosis.

I find this to be the most fuzzy area, however. Certainly, factual information needs to be given to patients. However, facts do not always tell the whole story, they must be put into a clinical context. Therefore, for example, a physician may emphasize the possibility for hope or they may downplay unrealistic hope in order to focus the patient on making practical decisions. Neither approach is objectively better – they represent trade offs, a balance between keeping the patient’s outlook positive to avoid depression or nihilism, while still giving them a realistic view of their condition so they can make rational decisions.

Also, when a patient is facing a difficult health decision, for example whether or not to have a risky but needed surgical procedure, the facts can often be used to support either decision. A physician may believe, and the facts may support the conclusion, that the patient’s best chance to avoid a bad outcome is to have surgery. The physician may therefore emphasize the risks of not getting the surgery. Exactly how much time and effort is spent going over the possible negative outcomes if a condition is not treated can affect the patient’s decision. In the end the physician’s clinical judgment determines what is proper disclosure to the patient.

On the other end of the spectrum, a physician may emphasize to a patient that there is ongoing research into their disease that may produce a treatment. Is this giving the patient false hope, or is this just good bedside manner?

A very common context in which the need for full disclosure comes up is when a physician believes that a patient’s symptoms are entirely psychiatric. (For the sake of this discussion I am considering situations in which the symptoms are actually psychological, not a misdiagnosis.) A brutally honest opinion given to the patient may sound something like this: “I believe that you do not have any real physical ailment. The symptoms you are having are purely psychological – they are nothing more than a delusion on your part. Therefore the real underlying problem is a mental illness, or perhaps simply a personality disorder. These are notoriously difficult to treat, but you may benefit from counseling or psychiatric treatment.”

I have, in fact, heard a colleague say almost exactly that to a patient – with perhaps just a bit more tact. There is evidence, in fact, that in certain situations brutal honesty, while uncomfortable for the physician and the patient, may result in the best outcome. The patient may protest, but then the symptoms will stop.

However, such honesty will often sacrifice the therapeutic relationship, so in most situations physicians will take a gentler approach. For example, I might state that certain symptoms are known to be caused by stress and that they tend to resolve on their own. This is completely true, but has a different tone and emphasis than the brutally honest statement above.

What about the outright deception of prescribing a known placebo to a patient? Today this is generally considered to be unethical, not only because it prevents informed consent but because it interferes with the trust that is a necessary prerequisite for the physician-patient therapeutic relationship. I agree with this position and would never prescribe a placebo or directly deceive a patient.

However, again there is a gray area. My perspective is biased in that I am a neurologist, so many of the medications I prescribe have multiple uses. A pain medication may also be an antidepressant, or a muscle relaxant may also be a sleep aid. I therefore might recommend a specific medication to a patient for one effect but partly base my choice on a secondary effect that I think will also be helpful. I may emphasize to the patient the effect they are more likely to understand and accept and will not necessarily get into all the details that led me to that specific choice. But if a patient asks me a direct question, I always give them a straight and truthful answer.

Another gray area is that physicians may be very optimistic with their patients about the potential of a new treatment in order to maximize (or so they think) the placebo effect. If a physician prescribes a legitimate pain killer for an appropriate situation and tells the patient “I think this is really going to help with your pain,” when a more accurate statement might be “there is about a 60% chance this will help with your pain” is that subtle deception justified on the grounds that it may enhance a placebo benefit from the medication? (As an aside, I am not convinced that it will, but that is a separate question.)

The same is true of negative side effects. Some physicians worry that if they go over every possible little side effect that patients will get side effects just because they are worrying about it so much or because they become hypervigilant to any slight symptom. While I disclose anything important, and point them to the package insert for full information, I may say truthfully to patients that most people I have prescribed this drug report no side effects. Again – there is wiggle room in terms of emphasis and detail.

To summarize, I think that within modern ethical medicine there is no room for deliberate outright deception. Informed consent, full disclosure, and honesty are necessary within the context of medical research and a cooperative therapeutic relationship. However, there is room for good bedside manner, compassion, and for balancing hope with realism in terms of what information is emphasized, but this is a gray area.

All of this, of course, is in the context of scientific medicine. It is impossible to apply these ethical standards when dealing with a health care system that is not evidence-based. Virtually all treatments given under the umbrella of complementary and alternative medicine (CAM) or integrative medicine would be considered experimental within mainstream medicine, yet are generally given without their experimental or unproven nature being disclosed and without all the other ethical guidelines that govern mainstream medicine.

Also, many CAM treatments, like homeopathy, are nothing but placebos. Some practitioners even acknowledge this, but argue that placebos have real effects. (Again, see my prior entry for a discussion of this.) Within scientific medicine this would amount to unacceptable deception. The sectarian views of many CAM practitioners, however, often means that they believe the misinformation they give to their patients.

It is therefore difficult to impossible to have a workable system of medical ethics within an unscientific sectarian health care belief system. Some ethics can only be applied within a system that relies upon verifiable and objectively established standards. Therefore only a system based upon transparent and objective science can be truly ethical.

Posted in: Medical Ethics

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37 thoughts on “The Ethics of Deception in Medicine

  1. Simon says:

    Dr Novella,
    Congratualtions on an insightful and thought provoking blog entry, as I have to come to expect from this high quality site.

    Where I live, in the UK, our National Health Service (NHS) is under increasing pressure to put more choice in the hands of the patients. Government surveys continue to show a large majority of the population favour having more choice about their course of treatment. In my opinion this is a very dangerous proposition, as it is unreasonable to expect patients to be able to make clinical decisions about their own treatment- that is precisely what doctors are for!

    Thus we end up with a situation where doctors have to guide their patients towards making the correct decision without outright telling them what to do. Thus we end up with patients suing the NHS because it refuses to pay for a drug therapy which they beleive will be of benefit to themselves but the NHS disagrees. A good example is Herceptin- an expensive drug of considerable value in treating some breast cancers, but much worse at treating others. Because breast cancer patients are usually not clinically minded enough to know that their disease is not succeptible to Herceptin, or why it is not, they feel that the state is cheating them of a miracle cure.

    I somehow feel that if the myth of patient choice was not so frequently banded about then patients may have more trust in their doctors to give them the course of treament they honestly thought was the best. A “Culture of Choice” just gives the impression that the patient is capable of making a better decisions than the doctor, and confidence is the first thing to suffer; the second is the patient.

  2. daedalus2u says:

    Very nice discussion of the ethics of deception in the context of actual treatment by well-meaning health care professionals. Imagine, choosing a medication based on the multiple symptoms a patient has and on the multiple therapeutic effects a medication has. That almost sounds like treating the “whole patient” (as if treating part of a patient could ever be successful).

    Certainly doctors today know more than doctors did a generation ago, certainly science based doctors know more than woo based practitioners. I think it is interesting that as health care providers know more, they adopt a more open and transparent style of practice.

    What you left out (perhaps because it is so anathema) is when deception is used to exploit vulnerable individuals. This is much more the business model the CAM providers use. It is a business model, not a health care model.

  3. BlazingDragon says:

    Thank you for the blog entry on this topic. This gets at a topic that is near and dear to me …. but it doesn’t fully address what I see as a big problem with medicine today.

    I have only witnessed the ethics that you describe a few times in all of my years of contact with the health care system (for myself and my wife). Most of the time, I see physicians who are too lazy or too beaten down by the health insurance industry to deliver on these high ideals. I have direct knowledge of a meeting of physicians where the speaker informed them “our patient approval ratings are down, research shows patients feel better if you ask them “how are you feeling,” so make sure to ask them how they are feeling 20 times in each visit so we can improve our patient approval ratings.” No exaggeration, no BS.

    Is there anything that can be done? Maybe it’s the region in which I live, but I seem to see the paternalistic side of medicine more than 95% of the time. It is very frustrating to have life-altering symptoms that don’t show up in common lab tests, therefore they are psychological (yes, that is the logic I have been fed for 15 years). The doctors I’ve seen have never sat down, listened to what I have to say, then order different tests to try to figure out what is going on. Each one orders the same set of tests that have been ordered before and gets very touchy if I suggest I don’t want to pay for a 6th MRI when the previous 5 have been normal (and all done within the last 3 years).

    I had always envisioned medicine as a big detective story where doctors want to use evidence (from reliable lab tests and their own intuition) to solve medical problems. What I have gotten in reality is people who can’t even be bothered to make a proper diagnosis before prescribing $200/month in co-pays of medicines that only treat symptoms. Any suggestion that a specialist referral or new lab tests are needed to try to find the actual problem are met with outright hostility. I don’t have any problem paying $200/month if there was any evidence that these were treating my actual condition or that there was no current treatment for my condition. But playing whack-a-mole with symptoms and paying that much to do it makes me feel pretty bad.

    This is very frustrating. I work as a scientist and I’m well-grounded in reality and tend to be brutally honest with myself and others, but after having been treated so poorly by the conventional medicine system, I can easily see the “siren song” the CAM practitioners use to lure their marks in and take their money.

  4. botogol says:

    Though you do allude to it, I think you need to say quite a lot more about the ‘nocebo’ effect: ie the idea that by being completely open with a patient about the risks, the downsides and the side-effect might actually cause them to experience some of those unwanted symptoms and actually make them more ill.

    First, do no harm, right?

    If it’s true that being honest with a patient may make them iller… then we have a very difficult moral problem to deal with.

  5. Fifi says:

    Great article. As a woman, I have one caveat though. The problem with the “paternalistic” model of medicine is that, well, it can be paternalistic. Historically women’s complaints have often been considered psychosomatic and imaginary. Add into this that even today a great deal of drug testing and clinical trials are done on men, and there starts to be a real danger that paternalistic physicians will dismiss very real symptoms as being psychological. I suspect this is also an issue for non-white patients of both genders in the US. Wasn’t there a recent study indicating that white patients were more likely to be prescribed pain killers than black?

    Doctors are people, they make mistakes and bring their own prejudices and ignorance into the office with them quite often. I know this because both my parents are doctors and I’ve seen this happen despite the best intentions. Medical history is full of cases of “paternalistic” doctors who think they know best, and even who wantonly ignore what their patients are telling them in pursuit of a pet theory. And let’s not get into the incredible issues surrounding privatized healthcare as it’s practiced in the US and how that compromises a patient’s best interest for profits and expediency! Not to mention that drug companies are notorious for both repressing poor results from clinical trials and hyping efficacy to physicians.

    I’ve long suspected that the popularity of CAM for many people is simply that CAM practitioners spend a lot of time actually listening and extending compassionate care to their patients. A lot of the medical complaints that people in rich nations have are a result of living unhealthy lifestyles so sometimes just a bit of help and emotional support changing to more healthy habits can have a big impact upon someone’s quality of life and health. Of course, CAM practitioners who are anti-science based medicine are dangerous in that they dissuade people from getting the treatment they need. However, if a physician doesn’t have the time or capacity to actually be compassionate with their patients, then perhaps this has contributed to rise of CAM’s popularity. (Well, along with some pretty serious lack of science education in many countries.)

  6. Roy Niles says:

    I would agree with the comment above that: “If it’s true that being honest with a patient may make them iller… then we have a very difficult moral problem to deal with.”

    But if the inference is that deception per se is immoral, and hence the difficulty, I would suggest that it’s the perceived consequence of the deceptive act that determines its moral nature.

    Of course even if the problem is correctly seen in that light, others may later judge these acts from the more traditional perspective.

  7. pmoran says:

    Not yet convinced.

    In recent surveys 45-80% of all doctors admit to the conscious use of placebos and nearly fifty percent use acupuncture, homeopathy or other unproven methods (at least in the UK). How come?

    The main purpose of informed consent is to ensure that the patient is aware of potential *negative* consequences of a treatment. Its importance varies relative to the seriousness of those consequences.

    So should informed consent dominate ethical considerations when there is negligible downside for the patient, as will apply to most use of placebo-type medicines by primarily evidence-based doctors? How can that be unethical, so long as the sole purpose of the doctor is to help relieve the patient’s present symptoms in the simplest and safest way possible?

    You have also not taken into consideration that placebo medicines will often be being tried out as a substitute for treatments that DO carry significant risks, such as surgery and many pharmaceuticals. Sometimes good medicine entails simply tiding the patient over a bad patch.

    The doctor does not need to lie to the patient and I don’t know why the use of placebo medicines becomes so strongly equated to lying when the available scientific evidence is at least permissive of the notion that placebo can have useful symptomatic benefits for patients. In fact, the doctor being prepared to explore any means that might help in tricky situations, even methods that he/she is openly dubious about, can only help cement a trusting doctor-patient relationship.

    Let me make it clear that I do not believe placebo medicines affect important disease processes. I am simply making the point that medicine is messy, especially in family practice, and it needs to be based upon compassion and tolerance for the quirks of human nature as well as science. There are very many instances within daily medical practice where there is no simple, entirely safe and 100% effective evidence-based solutions. Yes, make all the lifetyle suggestions you wish, but the very phenomenon of alternative medicine itself reveals how strongly we quaint human beings crave “something to take” for our ills and how we are programmed to respond very positively to that ritual.

  8. BenAlbert says:

    G’day Steve, thanks for a thoughtful discussion of deception and particularly the purposeful use of placebos.
    I am training in Paediatrics in New Zealand and have also worked in internal medicine as part of previous rotations. There have been a number of times when I have felt that it might have been to my patients benefit to prescribe a placebo and talk it up to boost its effect. I’ve never done it though, my dilemma has always been that this has felt unacceptably disempowering. I probably also fear the total loss of therapeutic relationship that would occur if the patient discovered such deception.
    Your discussion reaffirms my position, thank you.

  9. BlazingDragon says:

    Speaking as a patient who has been ignored because doctors thought I had “psychiatric symptoms” (with no psych work-up or any testing), I can clearly state that the use of placebos never be acceptable…

    A doctor needs to use evidence to find out why a patient is having symptoms. If a doctor makes a supposition and tries a placebo, it is quite possible they are missing a real disease (either early or atypical presentation). If it is psychiatric, it should be tested for and treated appropriately. If not, most doctors should not be in the business of prescribing anti-depressants unless the depression is obvious or strongly suspected.

    If doctors do not use evidence and logic and retreat into “I think it’s psychosomatic” or I’ll use a placebo to make a patient feel better about their situation, they have just made a mockery of evidence-based medicine.

  10. pmoran says:

    I see that I should have given some examples of the kind of medicine I have in mind. Placebo medicines (meaning, for me, basically treatments not fully validated to the standards of EBM) might ethically be used:

    -*after* full diagnostic assessment, although sometimes that can take time and some help with symptoms may be warranted in the meantime.

    And –

    - when all evidence-based treatment options have been exhausted and the patient still has symptoms needing control (an *extremely* common clinical situation)

    -or, for minor or likely self-limiting complaints where the doctor prefers to try simpler measures before resorting to unnecessarily powerful pharmaceuticals that can risk disproportionate side effects, such as NSAIDs (common enough).

    -or, if the patient wishes to try something that appears harmless, or if they start off the consultation with “I don’t like drugs” (also extremely common these days).

    Examples might include:

    - a liniment or massage, or even acupuncture instead of NSAIDs for many musculoskeletal complaints.

    - the use of evening primrose oil for cyclical mastalgia instead of potentially mroe harmful hormonal interventions.

    - peppermint oil for exascerbations of the irritable bowel syndrome.

    -a trial of acupuncture for cancer pain or nausea that is difficult to control with conventional drugs.

  11. daedalus2u says:

    I completely disagree with some of the comments here. Even if being honest with a patient exacerbates the patient’s symptoms, that is not a justification for being deceptive.

    A patient cannot give “informed consent” if they are lied to.

    I have done a lot of research on the placebo effect, and I think have a stronger appreciation of what it actually is and what it can actually do. There are lifestyle changes that can be prescribed, and which will be cheaper and more effective than any placebo. They include stress relief, exercise, weight loss, smoking cessation. None of those cost anything, all of them are extremely well documented to improve multiple different aspects of health.

    I have no doubt that some people do want to be given placebos. Some people want to be lied to. That is a major reason why the quacks have it so easy. People want something that is too good to be true. That is why it is easier to cheat some one who is dishonest. There is the saying “you can’t cheat an honest man”. The reason is because the honest man isn’t looking for something for nothing. If something is too good to be true, it probably is.

    I would say you can’t trick an intellectually honest person. If a person can’t handle reality the way it actually is, they should not expect their doctor to lie to them about reality. The person needs to learn to deal with reality as it is, not as they want it to be.

    Yes doctors can make mistakes, doctors can be ignorant of many things. They will make fewer mistakes and be less ignorant if they are always honest with their patients and with themselves.

  12. Fifi says:

    Daedelus2 – I tend to agree with you, for what it’s worth. Though compassion and discretion are also worth practicing. But, then, I’m not a doctor so it’s not a choice I’ll need to make from that side of the equation. I have, on occasion, had the unpleasant experience of dealing with a doctor that doesn’t listen or is clearly working from a bias. I truly appreciate a doctor that says, “I don’t know” or who takes the time to look something up.

    pmoran – Thanks for clarifying what you meant by placebo. I got the impression that we were discussing placebos that appeared to be a pharmaceutical.

    The reality is that GPs should be referring people with any form of psychological issues to someone qualified to diagnose them properly. I actually think it’s quite problematic that GPs prescribe for depression, the most obvious reason being that they aren’t really equipped to make a proper diagnosis nor prescribe ore provide the best treatment. Of course, the makers of Prozac are ecstatic about how good it has been for their sales. A GP prescribing a healthier diet and exercise to treat depression (hardly placebos and proven to help with many forms of depression) seems more appropriate. I don’t see what good it does for any doctor to play into the myth of magic bullets and downplay the role of prevention and self-care in personal health.

    I’m not quite sure that acupuncture or massage fall into the “placebo” category in the same way a sugar pill or homeopathic remedy or tincture would (though obviously some herbs do have medicinal value, and many pharmaceutical drugs are synthetic version of natural medicines or substances). The evidence seems inconclusive regarding acupuncture at this point, and massage may not “fix” something but can contribute to a person’s sense of wellbeing in a very real way via stress reduction (which may reduce some symptoms if they’re made worse by stress). Particularly if they’re isolated and don’t have any form of loving touch in their life.

    Anyway, interesting topic.

  13. Roy Niles says:

    Does a patient have more confidence in his doctor’s advice if in the process he is completely honest about the extent of his ignorance?

    Does truth include only the telling of what you believe will benefit your patient, or the telling of every step you made in reaching those beliefs, including all doubts you set aside along the way, and all the assessments of probability versus possibility, ad infinitum?

    Does telling what you believe is the truth actually constitute a lie if in fact you would concede the possibility of it being wrong?

  14. pmoran says:

    daedalus2u: “I have done a lot of research on the placebo effect, and I think have a stronger appreciation of what it actually is and what it can actually do.”

    Can you clarify this? Once I decided that the available evidence is sufficiently supportive of the view that placebo medicines can genuinely help patient’s perceptions of symptoms (i.e. that it is not all biased patient reporting and extraneous factors) and that they can probably also help with the other human needs that patients bring into medical consultations, my views changed.

    The question became whether it is ethical NOT to entertain their use with patients who, understanding their not fully proven nature, wished to give them a try under the circumstances I have described in a previous post.

    It is NOT necessary to lie to the patient. Most patients don’t regard trying out a medical treatment as making a critical scientific judgement, in any case. That is a notion that has been thrust upon doctors by the fiction that it is always possible to draw a clear-cut dividing line between treatments that work and those that don’t. That is actually true, or close to it, in many clinical settings and many meanings of the word “work”, but not in those where placebo treatments might have benefits (i.e. when dealing with human perceptions and preoccupations).

    Anyway, what is wrong with “some think this helps”?

  15. daedalus2u says:

    My understanding of the placebo effect is posted here

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

    I see the placebo effect as the normal mechanism which switches physiology from the “fight or flight” state where resources are diverted to (mostly voluntary) pathways in preparing to “run from a bear” into non-voluntary physiological pathways such as healing.

    Of course none of these states are simple, so the effects are not simple either. I see the low stress high NO state as the “default” state of physiology. Once you are in that state, a placebo will have no further effect because all a placebo can do is invoke that default state where healing is optimized because resources are maximally diverted to healing and not to “running from a bear”.

    My research is on certain bacteria which release NO and nitrite and which I think can be used to invoke the placebo effect pharmacologically by raising NO levels. Other methods of raising NO levels don’t work long term because they are non-physiologic and physiology adapts to neutralize them. Because NO can diffuse everywhere, all NO pathways are “coupled”, that is they all affect each other. You can’t change one NO pathway without affecting (to some extent) every other NO pathway. That coupling is one of the things that keeps physiology working so well under diverse conditions.

    I think that placebos based on trickery or false ideas of reality (such as homeopathy, life energy or chi) have no place in any evidence based treatment modality.

    I do have more confidence in my doctor if he is honest about the limits of his knowledge. That is the mark of a professional in any field, knowing the limits of their expertise and not practicing outside it except in emergencies where the alternative (to those most affected) is worse.

  16. David Gorski says:

    Does a patient have more confidence in his doctor’s advice if in the process he is completely honest about the extent of his ignorance?

    That’s a very difficult question and to some extent depends upon the patient and the doctor’s specialty. For example, from my anecdotal experience, surgical patients tend to want confidence from their surgeons.

    Early in my career, I learned through feedback that reached my Division Chief that patients actually didn’t like it when I presented options without a strong guidance about what I thought to be the correct approach. Maybe it has something to do with the fact that surgeons are going to cut into your body, and such behavior can, if not carefully managed, appear to be a lack of confidence–which is what my Division Chief told me I was projecting. I’ve tried since then to learn how to do the same thing (present the options and try not to interfere too much with the patient’s decision) except that I now tell them my recommendation more forcefully than I used to do before, but still with the reassurance that the other option is acceptable. I think I’m doing better now (at least I haven’t heard of any complaints in a couple of years at least), but it’s something that has to be worked at. It’s also a fine line between projecting confidence and being overbearing. However, once again in surgeons patients seem to tolerate an overbearing demeanor better than they do a perception that their surgeon lacks confidence. Certainly, however, these issues aside, a surgeon must be honest about what he/she does and does not know.

    I can’t comment from personal experience, but patients may tolerate more uncertainty from non-surgical specialists without concluding there is a lack of confidence. It also may have to do with the more “cerebral” nature of some medical specialties, where thought, options, and taking the time to think things through are not perceived in the same way.

  17. Roy Niles says:

    daedalus2u: You seem to see honesty as a categorical imperative – an unconditional requirement – justified as an end in itself.

    But I would argue that a patient would (or at least should) prefer a cure that necessarily involves trickery than no cure at all if trickery of any sort has to be involved.

  18. BlazingDragon says:

    pmoran wrote:

    “- when all evidence-based treatment options have been exhausted and the patient still has symptoms needing control (an *extremely* common clinical situation)”

    This situation is quite simple. Keep looking for evidence and treat symptoms in the meantime. Giving of a placebo of any sort in this situation is unethical and immoral.

    To do anything else means you are giving up on finding what is wrong. You will (sooner or later) miss something important and hurt someone if you stop looking for evidence of what is wrong.

    Another thing I have seen physicians do many times is mistake depression that comes because of symptoms (loss of function, inability to do what one “used to do,”) for the cause of the symptoms. This is common for symptoms that defy easy explanation. One does need to treat the depression (it is a symptom after all), but one should damned well keep looking for the reason why the person is disabled. If the cause for the disability can be found (and if it can be treated), the person can be gotten off unnecessary medications (the anti-depressant) because the depression will naturally go away when the actual cause of disability has been effectively treated.

    Obviously I feel strongly about this, but I pride myself on being intellectually honest with myself and others (to the point of being far too blunt most of the time). This is not my “imagination.” I’ve heard that my area (San Diego) has doctors that don’t seem to care about their patients (on average) as much as other areas. I don’t know if this is hear-say, but it certainly fits with my observations over the years. Has there been any kind of study done on doctor-patient relationships that is correlated with the city/town/state?

  19. daedalus2u says:

    I can only speak for myself. I have spent too much time and effort trying to get in touch with myself and with reality to try a non-reality based approach to anything. For myself or for anyone else.

    I suppose if you are a patient who wants to be lied to, you should make that clear with your doctor so there are no misunderstandings. We have seen in the blogosphere that there is no shortage of “doctors” willing to lie to their patients without their patients’ permission. If such “doctors” got permission first, no doubt they would be willing to lie also. I think for the most part, patients who want to be lied to naturally seek out such “doctors”.

    I don’t have a problem with doctors making mistakes, I have made a mistake or two in my life already (long ago when I was young and foolish). I do have a problem with people lying to me.

    I don’t want any doctor to do something for me that the doctor considers to be unethical. I consider that part of being a “good patient”, to not expect anything from a doctor that puts the doctor in a difficult position legally or ethically.

  20. Roy Niles says:

    As to ethics and expectations, human beings would appear to have emotional parts of their brains that operate best with a modicum of self-deception. There can be things these areas don’t want to know and trust that they won’t be told. And they distrust the motives of anyone or anything that insists on giving them this information regardless.

    So of course we humans are are all the more susceptible to being lied to, but in my view ethical decisions should ultimately be based on the nature and purpose of any such “lies” rather than on a belief that truth can never be unduly or prohibitively brutal.

  21. daedalus2u says:

    To me, facts are never brutal, they are simply facts. People can be brutal by trying to hurt.

    If I know what the facts are I can take action to mitigate (to some extent) what ever the facts may suggest is about to harm me or others. If I am lied to, I can’t. To me, the loss of that agency to potentially mitigate that harm is a worse harm than any fact.

    Once you start believing that lies can sometimes be ethical or better than truth, it is a slippery slope that leads into an abyss. You can’t know how I will respond to the truth. You can’t know how I will mitigate what ever potential harm might be suggested.

  22. Roy Niles says:

    Well, I know this is not the place for a prolonged debate on this issue, but I can’t help but point out that all slopes are not necessarily slippery, and to believe that they are may be one of the self-deceptive shibboleths that most of us fall prey to.

  23. BlazingDragon says:

    There are no place for lies in medicine. There is a place for tact, saying things in ways that are productive, but any placebo is a lie. Period. In this case, lies are a slippery slope, no matter how one might rationalize it otherwise. Doctors who start out with little, truly harmless placebos will (being human), notice how much easier it makes their lives if the “whiny” patients shut up for awhile (or leave their practice entirely because they figured out that they’ve been had). Human nature being what it is, a lot of doctors will follow that at least part of the way down the road from harmless to “not so harmless.” It’s just easier to prescribe something and make a patient “go away” than it is to spend years (possibly) trying to figure out the truth.

  24. Roy Niles says:

    Tact is a form of deception and therefor a lie if you want to believe that all lies, no matter how harmless, grease up the old down-slope.
    Since neither of us believe that tact is never called for, the question is, and always was, what other types of “lying” might be called for and under what circumstances.

  25. BenAlbert says:

    In response to Fifi (I apologise for not knowing how to quote correctly):

    “The reality is that GPs should be referring people with any form of psychological issues to someone qualified to diagnose them properly. I actually think it’s quite problematic that GPs prescribe for depression, the most obvious reason being that they aren’t really equipped to make a proper diagnosis nor prescribe ore provide the best treatment. Of course, the makers of Prozac are ecstatic about how good it has been for their sales. A GP prescribing a healthier diet and exercise to treat depression (hardly placebos and proven to help with many forms of depression) seems more appropriate. ”

    I disagree with you strongly here. Perhaps it is because I work in a different system (In New Zealand). GPs are formally trained to recognise and treat depression. Part of the assessment is to search for features that suggest that the patient needs further specialist assessment or support. GP’s should be able to safely diagnose depression, and treat with appropriate medication, dietary advice, exercise advice and address social issues. Provided the GP is properly trained and follows up the patient regularly to assess effect and suicidality I think this is safe and appropriate.

    Furthermore patients often have a good rapport with their GP, particularly if they have known him/her a long time. In contrast seeing a psychiatrist carries with it a social stigma. If I had a mild major depressive disorder I would far prefer to see my general practitioner than go to a psychiatric clinic.

    Separate to the above comment, and not a real part of my argument; Psychiatrists are too few in number in New Zealand to see all patients with a mild, major depressive disorder. They are completely overwhelmed with managing severe depression, psychotic disorders and personality disorders in particular. The clinical psychologists I believe are stretched as tightly. I say this point separately because limited resources do not change the ideal we should be working towards.

    I still believe that even if we had plenty of available psychiatrists GP’s would have an appropriate role in the diagnosis and management of depression.

  26. daedalus2u says:

    The problem with virtually all slippery slopes is you don’t know how slippery they are until it is too late. As they say, “the road to Hell is paved with good intentions”. A well meaning lie can have consquences that are irreversible. A well meaning truth can also, but it is a perverse individual or society that faults a well meaining truth. The fault lies not with the truth, but with those who can’t handle the truth.

  27. David Gorski says:

    Another problem with slippery slopes is the tendency by almost all who invoke them to think they are way more slippery than they are. There’s a reason that the slippery slope argument is considered by many to be a logical fallacy. As Fallacy Files puts it:

    This type is based upon the claim that a controversial type of action will lead inevitably to some admittedly bad type of action. It is the slide from A to Z via the intermediate steps B through Y that is the “slope”, and the smallness of each step that makes it “slippery”.

    This type of argument is by no means invariably fallacious, but the strength of the argument is inversely proportional to the number of steps between A and Z, and directly proportional to the causal strength of the connections between adjacent steps. If there are many intervening steps, and the causal connections between them are weak, or even unknown, then the resulting argument will be very weak, if not downright fallacious.

    In other words, the slippery slope argument is a powerful rhetorical advice but is hard to make in a non-fallacious manner. It’s possible, but very, very difficult and requires the few steps between the action and the feared outcome, each of which has a very high probability of being true.

  28. Fifi says:

    Ben Albert
    My apologies if I wasn’t clear. I wasn’t trying to say that GPs don’t have a role in treating depression, particularly mild depression. What I was trying to point out is that depression is a psychological as well as biological condition and just writing up a prescription for Prozac is a very common, and often the only, way that it’s treated by GPs (in North America at least, it may well be a much better situation in New Zealand).

    GPs can actually have a very crucial role in managing and treating depression, particularly if their approach is educational and they’re making sure they’re actually aware of the latest research and not just drug company propaganda (it’s worth noting that the most recent blog on this site is about the manipulation of data regarding the efficacy of this kind of medication). Mild depression is often easily treated through exercise and diet, and this is an area where a GP can be hugely influential in educating and supporting a patient to make lifestyle changes that have a huge long term impact upon physical health and psychological well being. Particularly if a patient has an established and trusted relationship with their physician. Of course, if a doctor doesn’t eat well and exercise themselves, it will be hard to convince a patient that this is important!

    In Canada general physicians and psychologists (who don’t have the right to prescribe unless they also pursued a degree in physical medicine) often work together. It’s not always necessary to bring a psychiatrist into the equation – and certainly they should usually be spending their time treating patients with more difficult and less easily managed illnesses with more complex biological features. Also, in Canada a lot of people don’t actually have a family physician and see a different doctor each time they visit a clinic. All these factors complicate and confound treatment.

    And to clarify some more… I’m certainly not saying there aren’t times where medication isn’t necessary or beneficial. Just that talk therapy – which takes longer and is much more costly for private insurance companies so therefore often not covered by insurance in the US – is also very useful in helping people to uncover the roots of their depression and learning how to manage it without drugs that invariably have side effects. There’s a very real tendency to medicate symptoms rather than treat causes in the US (and by extension here in Canada). In Canada there’s the additional problem that our medical system is extremely overloaded, and many psychologists and psychiatrists opt to work outside of the medicare system (which means not everyone has access to treatment).

    Depression is, of course, one area where placebos can actually be quite effective (at least in the short term) since thoughts and beliefs do tend to be a salient feature of many depressions. I would highly suspect that the combination of a “homeopathic” placebo and the compassionate attention of many CAM practitioners actually does provide some relief for a patient. Since many CAM practitioners do actually promote lifestyle changes, this too can be helpful. I’m not advocating CAM treatments here, I personally believe that it’s much better that people truly understand why things work than believe they received a magical cure. If only because then they don’t become dependent upon the “magician”.

  29. Fifi says:

    I wrote above that “Depression is, of course, one area where placebos can actually be quite effective (at least in the short term) since thoughts and beliefs do tend to be a salient feature of many depressions.”

    Which is kind of silly since thoughts and beliefs tend to be a feature of being alive! At least alive and not in a comma. What I meant to convey is that negative thinking and pessimistic ruminations tend to be a feature of depression – with feelings of hopelessness contributing to a person’s inability to take the actions needed to improve their condition. So, by giving someone hope and instilling the belief that the placebo will help them feel better, they actually sometimes do. Just as medications are often used to give people the motivation to make the changes necessary to improve their situation and start an “upward spiral”.

  30. PalMD says:

    One of the difficulties in the U.S. is that to get truly good psychotherapy you pretty much have to be rich, and, at least here in Michigan, not that many people are.

    I would prefer to refer many patients for therapy, but most of my patients with, for instance, auto industry insurance might get a few brief sessions paid for. Then it’s out of pocket which they cannot afford.

  31. Fifi says:

    PalMD – Obviously you and other GPs can only do what you can with the options available and give the best care possible within these constrictions, so I’m not trying to criticize anyone doing the best they can with what’s possible. I think most of us would agree that it’s a shame that not everyone can get the best treatment and it’s reserved for the rich. It’s pretty clear that profit driven business is antithetical to best care. Canada’s public healthcare system isn’t optimal (and nowhere near how good it used to be) but a large part of that is due to it slowly being strangled (private medicine is big business and has been lobby government for a long time here). Paper pushers – be they public servants or servants of a corporation – tend to care more about pushing papers and counting numbers than healing people.

    The amount of TV advertising by drug companies doesn’t help either when it leads to people believing that if they “just ask for the purple pill’ all their ills will be cured.

  32. daedalus2u says:

    David, you are absolutely correct that the “slippery slope” argument should never be used to justify doing something bad to prevent something claimed to be worse from happening. I was using it in the opposite sense, to justify not doing something bad (being deceitful) because we don’t know if that puts us on a slippery slope to doing things that are worse. It is exactly the uncertainty in future causal chains that justifies (to me) strict adherence to being non-deceitful (in virtually all circumstances).

    There are circumstances where being deceitful is the appropriate course of action (a doctor patient relationship is not one of them). I consider those circumstances to be unfortunate and problems in the larger society that should be corrected but which may be beyond the individuals’ control. I was once in a father’s group talking about our children lying (in the ~6 yo range) and everyone said they wanted their children to always tell the truth. I said I wanted my children to be able to lie when appropriate, such as if the Gestapo ever came to the door and asked “are there any Jews here”. I think that all the other fathers did agree with that sentiment, they just didn’t want it to be expressed in such a stark way.

    Preventing such circumstances from happening is much more effective than dealing with them once they have happened. That is the slippery slope of “First they came…”

    http://en.wikipedia.org/wiki/First_they_came

  33. Roy Niles says:

    Again with the categorical imperative!
    I would have thought it obvious to anyone who deals with medicine and the nature of the humans they are attempting to help that everything we do involves some aspect of deception.
    If intentional, it’s defined basically as lying. But if deemed acceptable under particular circumstances, numerous euphemisms are substituted that avoid the pejorative aspect of words like “lie” and avoid labeling perpetrators of such deception as liars.
    There may be a hundred or more such words in our language that serve to categorize deception according to its use and appropriateness. Words such as tact, discretion, circumspection, guile, hypocrisy, insincerity, pretense, sophism, equivocation, and cunning, to name a few.
    And then there’s the daunting task of dealing with self-deception which keeps all skeptics in business. But I digress.

  34. daedalus2u says:

    Roy, I have no doubt that there are many who agree with you that some amount of deception is a “normal”, even essential part of human interactions. I don’t agree that it is for me. Many rationalize to themselves that it is “necessary”, or even “good” or for the “greater good”.

    No doubt that is what Bush thought as he deceived the country into going to war in Iraq. How much of his deception was filted through his own self-deception we will likely never know because the records have been destroyed.

  35. Pingback: Ethics Exercise
  36. BlazingDragon says:

    Tact is not the same as deception. Tact means finding a way to communicate a fact that will likely upset the person who is the target of said fact in the least disruptive way. Maybe you think tact is not telling someone something for their “own good” because they “couldn’t handle the truth,” but I think of it as being gentle vs. being obnoxious when communicating something.

    Saying that slippery slope arguments are fallacious is a dodge. Slippery slopes to exist and are followed down the rabbit hole more times than most people want to admit. It’s just that most slippery slopes don’t end up leading to very harmful places, so they are tolerated.

    I would argue that the slippery slope of prescribing anti-depressants and/or anti-anxiety drugs is very often followed by GPs with too little time and too much stress to actually practice medicine properly. For some of the patients, they do work, but that still doesn’t justify how often I’ve seen them happen (to myself and many others). My mother has been tried on all sorts of crap over the years for “psychosomatic illness.” While I’m quite sure PART of her problem is psychosomatic, she’s down to about 65 lbs and has a 50:50 chance of dying in the next 5 years (she’d be no more than 68 if she died in 5 years). She obviously has a disease condition that is worsening her condition, but no attempt to sleuth out her condition has ever been made (other than “let’s do a colonoscopy, oh, we didn’t find anything unusual, so it must be all in your head.”

    If you think these things don’t happen often in the exam room (for “difficult” patients), you are either fooling yourself or you practice medicine at a much higher level than I have ever witnessed. I wish I could see that level of medicine in my area. It would be a welcome change.

  37. Roy Niles says:

    My comments have been about what I considered the mistaken position that anything involving deception is wrong regardless of the anticipated results. I didn’t personally make reference to the slippery slope fallacy because I was concerned more with the accuracy of the conclusion than with the mechanism used to reach it. Nevertheless I would concur with the assertion that the use of that mechanism helps prove or disprove nothing.

    As to tact, it certainly is a form of deception, and the propriety of its use only goes to show that deception per se is not the real issue here.

    The issue was the propriety of a particular type of deceptive tactic, and whether the expectations will be commensurate with the consequences.

    And the ends really do on occasion justify the means.

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