Julian Sheather on placebos

Earlier this week, the fairly formidable Commons Science and Technology Committee published its report on homeopathy.  For anyone who likes a bit of evidence with their medicine, the results were some distance from surprising. The NHS, it concluded, should stop funding homoeopathy. In addition the Medicines and Health Care products Regulatory Agency (MHRA) should not allow homeopathic labels to make claims about efficacy. As they are not medicines, homeopathic products should no longer be licensed. There has been some fun along the way. Watching the MP Evan Harris quiz a practitioner on the correct amount of agitation the ingredient-free water should be subject to before it was effective was pure comedy. I’m not here to comment on the science though. Ben Goldacre has long been doing a merry job on homoeopathy, and for those with more time on their hands, there’s the report itself. What did intrigue me was the statement in the accompanying press release that the Government should have a policy on the prescribing of placebos. “The Government”, it stated, “is reluctant to address the appropriateness and ethics of prescribing placebos to patients, which usually relies on some degree of patient deception.”

The word placebo comes from the Latin for ‘I shall be pleasing’, and so it seems they are, for apparently as many as one in three people taking a placebo will experience relief of symptoms. But is their use ethical? As the Science and Technology Committee rightly point out, for placebos to be effective, the patient has to be deceived. The modern doctor patient relationship, however, is said to be founded on principles of openness, honesty and trust, which leaves little room for well-intentioned deception. (Interestingly, a recent post by my colleague Martin Davies on the BMJ’s doc2doc site suggests that many doctors still use them. He cites a US survey in which half of the respondents reported prescribing placebos on a regular basis with 38 per cent claiming they had prescribed vitamins as placebos)

Somewhat mischievously it would be possible to mount an ethical defence of their use on public health grounds. Placebos are cheap, harmless – although the same delightfully mysterious mechanism that accounts for their success can apparently also give rise to unpleasant side effects – and remarkably effective. Given that many patients regard the prescribing of a drug as the only satisfactory terminus of a consultation, placebos are presumably better than the unnecessary medicine that many doctors feel nudged toward prescribing. Their use could help tackle antibiotic resistance, and no one need fret about concordance or patient failure to complete the course.

But it won’t wash. A relationship, any relationship, based on deception is likely to be short-lived and, in the end, acrimonious. The use of placebos destroys trust. Instead of helping people to take control of their health, palming them off with placebos infantilises them. It reinforces the unhealthiest forms of power and knowledge differentials. It breeds paranoia. Although I can understand why a doctor would be tempted to use them, outside of randomised control trials they have no place in the medical treatment of competent adults. 
Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.