Julian Sheather: Should doctors prescribe placebos?

With considerable media fanfare the BMA has declared its opposition to the NHS providing homeopathic remedies. Not entirely a surprise, given the BMA’s explicit support for evidence-based medicine. The consensus seems to be that in so far as homeopathy works it works because of the placebo effect. In brief, patients who anticipate benefits from a drug receive them even where they contain no active ingredients. Time then, according to Martin Robbins in The Guardian, to debate whether placebos have any place in medicine, excepting presumably clinical trials.

Although journalists can appear to inhabit a permanent present, this is not by any means a new debate. It is timeworn in two senses. The ethics of the use of placebos specifically has itself long been discussed – here’s a link to an article revisiting the topic: http://jme.bmj.com/content/35/7/407.abstract. It is also a reprise of a very old debate indeed about the rights and wrongs of benign paternalism. Placebos involve deception. They are benign in that they provide a benefit without the risk of biochemically induced side effects – given that we are complex creatures whatever psychological trick brings the benefit might also induce a side-effect, but I’ll put that to one side. In short the question is whether, in relation to competent adults, it is ever acceptable to deceive them in their best interests. Should an adult’s right to make informed choices ever be side-stepped for their own good?
 
In my twenties, struggling under the burden of a psychogenic disorder of the eyes that prevented me from reading, and gently informed by my lovely GP that there was unlikely to be an organic origin to the problem, I did the round of alternative therapies. For a large sum a genteel lady in Notting Hill tickled my feet and told me that it had once changed her life. An osteopath athletically popped my spine on several occasions. A faith healer somewhere on the south coast, attended by a pair of elderly vestals, eyes shining with divine light, hovered his hands above me, although the effect was somewhat spoilt by the repeating of his fish lunch. At one point I went to see a homeopath, who introduced me to the phenomenon known as TEETH – Tried Everything Else, Try Homeopathy. By and large, those who have spoken in favour of homeopathy have invoked some version of TEETH. What, they have asked, are GPs to do with those plentiful patients whose complaints lie beyond the reach of orthodox medicine? If homeopathy helps, whatever the mechanism, where on earth is the harm in it? Difficult not to have sympathy for such a pragmatic view. The truth can be a slippery fish and heaven knows how much orthodox medicine itself benefits from some version of the placebo effect. But I remain uneasy. There is much talk of encouraging people to take responsibility for their own health, and deception, however benignly intended, can hardly help. There is also a risk that deception will be uncovered and trust will be shattered. But there is another question that troubles me. On the basis of what criteria, clinical, or ethical, would a doctor decide that a particular patient should be prescribed a placebo? How does a doctor decide that this particular patient should be deceived? The thought of being that patient chills me. The overwhelming majority of professional and regulatory bodies publicly support truth-telling by doctors, and I am not convinced in this case by the arguments to the contrary.

Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.

  • TQMdirector

    Placebo therapy is a serious ethical question. Personally, I believe it has little room in medical care. Very recently I dealt with a case of an elderly gentlemen who has nearly 50 visits to our A/E over a two month period for complaints of body pain. I was alerted as Quality Director and upon my investigation I discovered this man had a presumed (and recently learned to be a false) diagnosis of ca of the colon and osteoarthritis. On each A/E visit he was given IM pain medications, including placebos. One of my objections to the use of placebos is the unintended dependency the providers were developing in this patient. This is for me one of the serious outcomes of placebo use and if a patient does discover this deception the emotional impact may be quite heavy leading to a lack of trust in the medical system. Getting to the root causes of what the placebos are being given for are far more important than pacifying a patient with empty injections or capsules. There may limited use for placebos and perhaps in the right hands can be helpful, however, I feel many providers may leave the often labor intensive work required to avoid placebos when they discover (short-term) relief from a patients persistence in seeking pain medication and may continue placebo more for their own benefit.

  • J Narayan

    If Health is deemed as a state of physical and mental welbeing, then wanting to acquiring that state of welbeing cannot be all bad. The placebo effect is pervasive and part of active treatment. Many surgical interventions have no established evidence base yet, but are undertaken through the surgeon's and patients belief that they work. There is no evidence base to show Homeopathy works. Perhaps it only has a placebo effect. The placebo effect may trigger the mind's healing influence on the body and therefore health. Whether patients should opt for Homeopathy is their choice. However the NHS does not practice Homeopathic medicine and should not offer it.

  • bowrbird

    If prescribing placebos is such a ethical dilemma, what is the common practice of pretending that “statistically significant” therapies are “clinically significant?”

    Seems like there are a number of common therapies in that category: antibiotics for most sore throats, angioplasty, statins for people who haven't had heart attacks, back surgery for most back pain, aggressive chemotherapy with very little chance of helping.

    I would be all in favor of being clear with patients as to the actual facts of how much difference the therapy being offered will probably make. This seems a much bigger ethical problem that occasionally offering a placebo.

    btw, I enjoy your posts