Background
In this article, the use of a placebo in a clinical setting is discussed through three separate cases. The first case references a 45 year old man that has suffered from diabetes and hypertension for numerous years. The man “underwent a second leg amputation. Severe pain following the surgery was treated…” The post-surgery pain was treated with proven medical techniques, but was unsuccessful in abating the pain. Hospital staff administered injectable saline that “had been used as an effective painkiller, and that they anticipated that it would help his pain…” The saline helped with his pain, which was just a placebo.
The second case refers to a 40 year old male complaining of diarrhea and abdominal cramps. This is a result of gastroenteritis. In desperation (and lack of medical knowledge and overall sense), the spouse of the man demands that her husband receive “a shot of penicillin in the butt”.
The third and final case addressed in this article discusses a 32 year old mother that is suffering from agitated depression. She is being treated with hypnotherapy. After a bad 
experience with the hypnotherapy, the patient refuses further treatment. The psychiatrist prescribes 25mg of a medicine that is only proven to have results with doses of 200-300mg. The patient begins to improve with this 25mg dose. (Lichtenberg, Heresco-Levy, Nitzan)
Dilemma
In research studies, placebos are used frequently in order to gauge a control group versus a treatment group. When dealing with research, subjects are not consulting their physician looking for a proven cure, but rather an experimental fix. Alternatively, when patients visit their physician, they come in order to receive improvement on their illness. The job of the doctor is to prescribe the correct and proven medication to aid in the health improvement of the patient. The dilemma with using placebo is a clinical setting is whether a doctor should be able to give his patients a pill or a procedure that has the possibility of working on a psychological level as opposed to the doctor being required to supply the patient with the scientifically tested and proven treatment that is certain to cure the ailment of the patient.
Discussion
There are numerous ethical considerations to ponder while analyzing the issue of clinical use of placebos. For every case, alternate considerations will be present, so each case must be looked at individually.
In case 1, since the hospital has exhausted their analgesic options, the only route left for staff to administer is a placebo. Since there are no scientifically proven alternatives left to attempt to administer, the next best option is to try a placebo. The placebo has no drawbacks in this case because it is the only treatment option left.
In case 2, no treatment options have been attempted. There are two placebo examples present here. The first is presented with the doctor. When the doctor says that he is certain that symptoms will subside within the upcoming 24 hours, the patient has in their mind the placebo effect that they will indeed improve condition in the next 24 hour period. The second placebo effect present in this case is that the wife is convinced that the only viable and cogent treatment is the penicillin that only treats bacterial infections. The penicillin would have rendered useless as antibiotics is not a treatment for gastroenteritis. “There’s no effective treatment for viral gastroenteritis (mayoclinic.org).” The wife’s insistence on the antibiotic administration forces the husband to also have the placebo effect in which he thinks he needs the penicillin to improve in health.
In case 3, again the doctor appears to have exhausted all possible proven treatments. The next option is to administer a placebo and see if symptoms persist.
Overall, the clinical use of placebos must be analyzed case by case because, of course, every case is different. In general, if the doctor has utilized every other possible proven treatment, then the doctor ought to prescribe a placebo in an attempt to see if symptoms persist or cease. Furthermore, if a patient has not tested all viable treatment options, the doctor ought to not prescribe a placebo until all other options have been tested. The doctor ought to do this because “The one thing of which we can be absolutely certain is that placebos don’t cause placebo effects.
Placebos are inert and don’t cause anything (Moerman DE, Jonas WB).” This statement may not be entirely valid, but the point is that placebos are not as effective as the correct treatment. “I don’t believe that the use of placebos is immoral or unethical. In reality, it seems that the medical profession’s lack of understanding and utilization of the mechanism of the placebo in the healing process is tragic, shortsighted and cowardly (wrf.org).” It may be easier for physicians to approach placebos and say that they do not work, but evidence proves that if used, placebos do work between 30%-60% of the time (wrf.org). As long as a patient is receiving the most beneficial treatments prior to administration of placebos, doctors ought to utilize placebos when no other viable treatment is present.
Works Cited
- “The ethics of the placebo in clinical practice” by P. Lichtenberg, U Heresco-Levy, U Nitzan
- http://www.mayoclinic.org/diseases-conditions/viral-gastroenteritis/basics/definition/con-20019350
- Moerman DE, Jonas WB. Deconstructing the placebo effect and finding the meaning response. Ann Intern Med 2002; 136:41-6
- http://www.wrf.org/alternative-therapies/power-of-mind-placebo.php
- http://familyrights.us/images/pills101/
- http://thedoctorweighsin.com/physicians-surveyed-gloomy-about-healthcare-reform/
This analysis on placebo usage is very thorough and I agree with a lot of what was written. My general view on placebos are that they should really only be used in research, and the patient should know that there is a CHANCE that they may be receiving a placebo. To tell a patient they are receiving true medication and then just giving a saline injection or pill is deceitful; in the case of research, the patient knows they have a chance of getting a placebo or the real medication, so they can consent to it. I do believe that a lot of times it is mental and that the placebo effect does help alleviate all types of pain at times. However I strongly would argue that the patient must know that this is a possibility in order for them to truly consent and have autonomy.
There is no doubt that research has shown placebos can be effective treatments- highlighting the mental side to illness and disease. I agree with your analysis of when using a placebo might be the best option versus when it might be lying to the patient or unethical. My biggest issue with placebos is the deception that often accompanies their use. While all three of these case studies use a type of deception, the most bothersome is Case 2, where the doctor says he is certain that symptoms will subside, when he is also certain that the patient is receiving a placebo. This deception is unethical. Patients are told to trust doctors, and lack of honesty– even saying that there is a possibility of a placebo– is a misuse of power and trust on the doctor’s end.
Placebo usage does violate patient trust in the sense that they are being given something they think is something else. The question here is basically the same idea behind what we call “white lies.” Is it okay to lie to someone to protect them? I would say yes. This is because mindset matters. Your mind, your will, your spirit, whatever you want to call it matters. That is how the placebo effect works. The patient believes in something and even if that belief is false it makes reality true. In this case I do believe that beneficence trumps honesty because honesty can lead to malevolence/harm. Should doctors actively use the placebo effect is a different story. This is because how you deliver the sell of the drug and what patient you are dealing with matters a lot. Currently there is no system in place or training for doctors to utilize placebo to it’s fullest and if the patient does find out this breech of trust can be damaging to the patient doctor relationship. Thus placebo usage in itself is not unethical, however he utilization of it needs to be studied further or standardized in a sense to become an effective tool.
In response to the second comment, I would like to approach this issue from a consequentialist viewpoint. If in the end the patient experiences a positive effect from a placebo treatment does the doctor not have a moral obligation to attempt such a treatment? In such a case we are placing the ideal of beneficence over the ideal of autonomy. While it is true that deception is required and is normally considered wrong, the patient has made a request to be treated by the doctor. In many cases we have seen that obligation of treatment on the part of the doctor has overridden many other moral complications in cases where competence is in question or differing opinions are involved. The doctor should obviously attempt all regulation and non-deceptive treatments before attempting to lie to his or her patients. However, while I too find the second case questionable, I believe in many cases the right of the patient to the truth can be temporarily suspended in favor a deceptive but effective treatment.
This is a thorough analysis of placebos. Personally, I tend to agree that placebos do “work” because (as you mentioned earlier) they have been shown to work. However, whether or not placebos is a moral option is worth discussing. From the perspective of non-maleficence and beneficence, sometimes the best option for treatment is to not give medication. However, most times patients have a desire to receive a cure (or some way they can take part in their healing process) and so they don’t want to walk away without something they can take to get better. From this perspective, placebos are actually a moral medical option in that it eases the mind of the patient while also not worsening his or her condition. On the other hand, if we look at placebos from the perspective of autonomy, we are essentially stripping the patient of the option to choose what treatment they want by withholding the facts. So again, we are in a situation where we need to determine whether or not we value non-maleficence and beneficence more or autonomy more.
Great and extensive analysis of the moral consequences and considerations of placebos! An additional concern of doctors giving placebos to patients in place of treatments is the potential for exploitation. Many products on the market claim to improve people’s symptoms, when really they only make people feel better psychologically because of the placebo effect. While this in itself is a concern, this is more associated with the capitalist market than it is with doctors and medicine. If doctor’s use placebos with patients, do the bill them as if they were providing an actual medical treatment or drug? It could become an issue where doctors and drug companies prescribe people with placebo treatments to make a larger profit than if it was a really treatment. While placebos may benefit some patients because of their psychologic effect, they open a new door to patient exploitation.
Great explanation of the ethical dilemmas Jonah. I do think it is permissible for doctors to give patients placebos once all other clinically proven treatments have been used, but the use of placebos needs to be heavily regulated. The doctor needs to always give patient the best treatment available based upon his/her specific case. My fear is that doctors will discriminate against a certain type of patient (no insurance, minority, gay, immigrant) and give that patient a placebo instead of a real treatment based upon discrimination rather than evidence. Doctors do need to have a certain amount of freedom to determine what the best treatment is for a patient, but doctors’ decisions need to be some how regulated without undermining their expertise.