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.