The use of a placebo as a legitimate treatment in both a medical and research setting has been under scrutiny based on the nontraditional nature of the treatment. The Lichtenberg paper focused primarily on the controversy of whether or not physicians should be allowed to offer their patients “knowingly ineffective remedies … in order to assuage the patient’s discomfort” or if it is unethical to offer a placebo if alternative, traditional medications will suffice (Lichtenberg, Heresco-Levy, Nitzan 2004). In order to address this issue, it is first important to decide what exactly constitutes an effective treatment. Most people would deem medication as a sufficient treatment to virtually any medical condition due to its explicit physiological mechanisms and tangible effects, but is this the only “legitimate” form of treatment? The argument against the use of a placebo in medicine comes from a standpoint in which sufficient treatment is “purely biomedical” while all other alternatives are inadequate (Lichtenberg, Heresco-Levy, Nitzan 2004). Although modern medicine is both impressive and reliable, it is not the only means of recovery.
In some cases, such as depression, medicine has been observed to be equal or even less successful compared to some alternative methods, such as cognitive therapy. There is empirical data to support that therapy is “as efficacious as antidepressant medications at treating depression” and appears to have lasting effects (DeRubeis, Siegle, Hollon 2009). Cognitive therapy consists of identifying the cause or belief behind the depressive episode and then separating and questioning the reasons behind the belief. Antidepressant medication is also effective in managing or treating depression, but cognitive therapy provides an equally qualified treatment that does not require prescription drugs and also offers a protective method to prevent future depressive episodes (DeRubeis, Siegle, Hollon 2009). Unlike a placebo, the physiological mechanisms behind the success of cognitive therapy are known and respected among the healthcare field. However, is cognitive therapy, as well as other behavioral therapies, considered to be a biomedical treatment? If not, is it still considered to be a justified alternative treatment to medicine?
Another treatment that has been shown to reduce depressive symptoms is a method called Deep Brain Stimulation (DBS). DBS consists of implanting and stimulating electrodes in the brain. Although the mechanisms of these stimulations are not well understood, it seems to “improve mood and give the people an overall sense of calm” (Taylor 2016). Although it is recommended that patients try both therapy and antidepressants before DBS, it is still a viable option for patients.
Considering medication, therapy and DBS, which treatments are considered an effective treatment? Therapy is not considered purely medical, but the physiological mechanisms are well understood, while the mechanisms of DBS are not understood, but proven to be effective. Should either of these methods be considered an effective form of treatment? If so, I return to my initial question of what constitutes an effective treatment, both ethically and physically? Is it necessary for the physiological mechanisms to be explicit or is it just enough for positive outcomes to be observed? Although all of these treatments are different from the use of a placebo, I believe the same underlying principles apply in terms of effectiveness. While the controversy of deception is also part of the picture, it is important first to determine whether or not the treatment in it of itself is rendered effective enough. Based on the same underlying principles of cognitive therapy and DBS, I believe that although the mechanisms for why placebos work is not explicitly known, if it has positive effects and does not impose risks to the patient, it should be deemed a viable option for effective treatment.
DeRubeis, Robert J., Greg J. Siegle, and Steven D. Hollon. “Cognitive Therapy vs. Medications for Depression: Treatment Outcomes and Neural Mechanisms.” Nature reviews. Neuroscience 9.10 (2008): 788–796. PMC. Web. 4 Feb. 2017.
Lichtenberg, P., U. Heresco-Levy, and U. Nitzan. “The Ethics of the Placebo in Clinical Practice.” Journal of Medical Ethics 30.6 (2004): 551-54. BMJ, Dec. 2004. Web.
Taylor, Mara. “Deep Brain Stimulation (DBS).” Healthline. N.p., 10 Aug. 2016. Web.
The comparison of different treatment methods asks the question of properly defining a placebo. Though DBS is deemed effective, can it still technically be considered a placebo because we don’t understand why it works? Can we separate the benefits of placebo from the benefits of actual DBS? In this case, this doesn’t seem to be of much concern since it works. If a treatment — even of an unknown mechanism — outperforms a placebo, it should be considered a legitimate treatment and placebo should not be used. The case of cognitive therapy presents the possibility of using treatment combined with placebo. Perhaps a treatment/placebo combination could be more acceptable than using the placebo alone.
The argument that placebo effectiveness should be compared to the actual treatment’s effectiveness does allow for assessment on each individual treatment plan. While I said that placebo should not be used because of violation of patient trust, it is reasonable to consider placebo when its benefits are not much different that the actual treatment. As the use of placebos are examined in real circumstances, argument for or against use become increasingly nuanced. Notions of patient trust and autonomy become part of a larger discussion that includes the specific implications of the treatment. Hopefully the discussion in class will lead to hypothetical scenarios that demonstrate both support and opposition to the use of placebos.
Hi Gabby, wonderful post – thanks for that. One thought that came to my mind when reading this was that perhaps theres another way of looking at placebos. Placebos are usually seen as capacitating a mysterious possibility of an effect because we don’t understand how these causal relation of placebos even work in the first instance. However there might be a way of seeing placebos that don’t begin with causality, but begin with understanding a coherent effect. What I mean by this is that there was the case study where the patient regressed on her treatments, but the doctor eventually gave a low dosage of (perhaps a) painkiller to this patient who claimed that this given medication was working and the patient felt great ever since taking that medication. The issue here isn’t that the placebo ‘works’ from any kind of mysterious causality, but that there is an ‘effect’ for which the patient experiences that justifies the use of the placebo. The placebo acts as a ‘function’ for the ‘wellbeing’ of the patient. Perhaps there are several ways to look at placebos!
The lack of research and studies done on mind/body sciences in regards to health, I believe, is why the “legitimacy” of the placebo treatment—sometimes a psychological form of treatment—is in question. In my opinion, it is misleading, and perhaps even incorrect, to say that a placebo is “knowingly ineffective.” There are studies in mind/body sciences, which indicate psychology can result in physiological changes. Here are a few cases to take as examples:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695992/
https://www.ncbi.nlm.nih.gov/pubmed/12356618
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1337906/
https://www.cancer.gov/about-cancer/coping/feelings/stress-fact-sheet
To that end, I would hope and encourage our communities to keep perspective; what we consider as “nontraditional” medicine and/or treatment may be the traditional form for medicine/treatment for others. We should not limit the scope of medicine to what is presently considered traditional or best—this potentially discourages advancement in our understanding of human anatomy and physiology, effective medical treatment, diseases, and more.