Patients’ attitudes about the use of placebo treatments: telephone survey
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f3757 (Published 02 July 2013) Cite this as: BMJ 2013;347:f3757
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Having recently read 'Bad Pharma' by Ben Goldacre ISBN: 978-0-00-735074-2 (which I recommend any colleague reads, if only the short passages on 'drug reps'), it would appear we are navigating the challenges of drugs being impotent in the face of Long Term Conditions and having to swing back to relying on optimising our carcasses', and the carcasses of our patients, inherent abilities to heal, or cope with their illnesses, alongside the judicious use of compassion and science.
EBM appears to be called into question in the book I mention above due to publication bias lethally skewing fundamental data on which EBM relies.
Whilst this direction of travel may be uncomfortable for commercial interests it would appear to be wholly sound and beneficial to suffering fellow human beings and the re-establishment of the importance of Hippocratic Oath based health care provided by professional Physicians and Surgeons at the bedside or in consultation.
Given the Keogh and Francis Reports and the recent shenanigans and broohaha in Parliament and press, as professionals (the most trusted by the public), adhering to the GMC expectation of our first and over-riding concern being to our patient, is it not time clinicians took over, leading from the front, rather than waiting for committees or managers to appear from over the horizon like white chargers in a fairytale to make everything 'all right'?! More power to the CCGs!
Competing interests: No competing interests
'Placebo' is a derogatory misnomer for the body's astounding inherent ability to heal.
'Nocebo' interventions are able to compromise, arrest and reverse the body's astounding inherent ability to heal.
Competing interests: No competing interests
This paper presents further evidence that the ethics of placebo treatments is an open debate, and not to be dismissed as a case of necessarily deceptive treatments that are therefore unethical.
Of the two broad strategies arguing for ethical placebo treatments – (1) that they do not have to be deceptive; or (2) that being deceptive is not, in fact, unethical – this paper contributes to mostly to the first; showing that many patients found the idea of knowingly being given a placebo acceptable, under different information scenarios.
At the heart of this paper however is the question of how this data should feed into ethical debates. As noted, mixed responses and diverging intuitions are evidence of the conceptual and ethical problems associated with discussions of placebo effects. But even if there was consensus, attitudinal data has no automatic claim to show what is ethically acceptable.
This is made more important by the finding that patients crucially valued the honesty of doctors, and disagreed about the whether placebo treatments could be called 'real medicine'. The subtle differences between scenario 1-v1 and 2 on the one hand, and scenario 3 on the other provide a nice example. Scenario 3 calls the treatment a placebo according to the stated definition; whereas scenario 2 includes the recommendation that this “medicine might help you [… and] some people get better when they take it”. If honesty should be the norm for doctors in these situations, then is it permissible to create what looks like the false (or is it false? placebo effects are tricky) expectation of a 'specific' effect in scenarios 1-v1 & 2? And if patients happen to find this acceptable, does that make it permissible?
The results of this paper do not just suggest that doctors should explore their patients' attitudes to placebo treatments as part of clinical decision making. They also show that there are important unanswered questions about how attitudinal data like this should be integrated with ethical theory that has traditionally lacked empirical input.
Competing interests: No competing interests
Re: Patients’ attitudes about the use of placebo treatments: telephone survey
It has been expressed by many physicians that the use of a placebo as part of medical care is ethically controversial.
It is indeed controversial most of the times, but as with all other truths, there are important considerations: if the placebo outweighs the possible benefits of its use, there should not be any doubt about its ethical problems; but in some other cases, cultural, logistical or regional aspects should be taken into consideration.
Many cultural aspects should be considered, mainly outside the US and developed countries, but also within their territory: let's consider a mother concerned with his baby having been touched by someone who just arrived from a funeral. It is a quite popular belief that the baby will be sick and that something specific for that condition must be used.
The physician who faces this request is presented with two choices: either he tries to explain to the concerned mother that there is no ground for that myth (with a very low probability of success), or he gives the child some vitamins or an innocuous placebo. No harm is done to the child, the mother is relieved since she believes that her child's main problem is being solved and no cultural conflict is raised.
A popular position may be that it is the physician's duty to educate their patients. However, saying that is one easy thing, and trying to modify deeply rooted beliefs is another. It is highly likely that if the mother is not satisfied with the answer from her doctor, she will look for someone else, perhaps with less ethical concerns. Not only will he give the placebo to the child, but will also charge the mother a significant amount of money.
Limits should exist, of course. But flexibility and attention to aspects besides medicine should also be considered.
Competing interests: No competing interests