A teaspoon of sugar makes the medicine go down: in ethical defence of the placebo effect.
The use of placebos is controversial and has highlighted in the press regularly over the past several years as their use in clinical research has become more frequent. Their use in the medical practice is perhaps even more controversial, with the argument that their prescription undermines the trust between the patient and the doctor particularly prevalent. Arguments against their use tend to focus on two key issues: firstly, that because placebos are not themselves drugs they cannot actually cause any physical changes in the body and are thus redundant as a medicine, and secondly that their prescription involves the deceit of the patient by the doctor.
In this essay I shall focus on the use of placebos in medical practice rather than research, and argue that the key objections to their use, inefficacy and deceit, can be resolved and the prescription of a placebo by a medical doctor should be an accepted form of treatment in a relevant clinical situation.
The placebo effect occurs when the patient feels better in physical health, but has not actually taken a drug with any active ingredient. The patient believed they were being given a drug, but instead were given a harmless alternative that has no pharmacological properties. The doctor who gave the patient the harmless pill did so whilst creating the assumption or belief that the pill was in fact the relevant medicine.
Before addressing the principle objections to the use of placebos in medical practice, it is worth setting out what is meant by a placebo, and what aspects of its definition this essay will focus on. A study published in 2013 found that around 97% of doctors had used ‘impure’ placebo treatments while 12% had used ‘pure’ placebo treatments at some point in their career. The difference between ‘impure’ and ‘pure’ placebos is crucial to the scope of this essay. ‘Impure’ placebos include procedures such as ‘positive suggestions’, ‘non-essential physical examinations’, ‘unnecessary blood test’ and other treatments whose effectiveness is not evidence based. These placebos are not actually necessary and will not actually be clinically beneficial to the patient, but are rather designed to reassure the patient and to set them at ease. ‘Pure’ placebos are more controversial and will form the focus of this essay. ‘Pure’ placebos involve giving patients sugar pills or saline injections instead of actual drugs, but involve telling the patient otherwise, or at the very least withholding the total truth of the treatment from them.
There are four commonly used ‘pillars’ of medical ethics that should form a context to a practical ethical question surrounding the practice of medicine. These are autonomy (the ability of the patient to make their own informed choices), beneficence (promoting what is best for the patient), non-maleficence (not doing harm) and justice (thinking about the wider community, and what is right). Several of these principles may be challenged by the use of placebos, and they shall be explored below.
Efficacy:
The argument of effectiveness postulates that giving a patient a sugar pill or a saline injection instead of real drugs cannot actually ‘cure’ the patient or relieve their pain or suffering. Indeed, giving someone a sugar pill will not actually directly cause any physical changes in the body relevant to the patient’s disease apart from raising the blood glucose level slightly. If a placebo cannot actually positively impact on a patient’s health, then how is the doctor fulfilling their ethical obligation to do good – and in fact by not giving the patients the drugs they need are they then violating the ‘do no harm’ principle by prolonging the illness of their patient?
Studies over the years have shown that the assertion that placebos do not work is false – how they work however is what sets them apart as a treatment. There have been numerous reports that show that patients given a placebo instead of a drug do in fact report lower levels of pain and other disease-associated symptoms. Scientists and researchers believe that this is due to the state of the brain believing that it is being given drugs causes it to cause physical changes in the body that end up helping the patient – such as releasing hormones that then go on to elicit a physical response, for example. A study in 1996 showed that even the colour of pills can affect the patient’s reported outcome – illustrating a link between the patient’s perception of their treatment and their subsequent physical recovery. Simply because a placebo acts in a different way to normal drugs does not mean that it is unethical to administer them, as long as a positive outcome is assured.
Obviously, the exact science behind how the placebo effect works is still debated, as are the results of many of the reports that show positive outcomes. But as seen from the report above, a significant number of clinicians are utilising placebos with patients day to day. Whilst more studies should be done, it is clear that placebos can and do have day to day positive effects on patients.This is not to say that administering a placebo should be the course of action in any clinical scenario. But in cases where it has been proven that a placebo can reduce pain or other symptoms as effectively as a standard drug, and the doctor has personal experience of this fact, it seems logical that the placebo should be a viable and ethical course of action.
Deceit:
Even when we accept that in some circumstances placebos are indeed having positive outcomes for patients, the fact that the efficacy of the placebo is dependent on the doctor deceiving the patient about the true nature of the treatment remains. In fact, this is the true ethical problem facing the use of the placebo. In many cases the placebo may be effective in treating the issue, whilst at the same time the proper drugs may cause unwanted side effects, but even in these best scenarios the wilful deceit of the patient is still present. This challenges the principle of the autonomy of the patient – when given a placebo, the patient is not in possession of the full facts of case, and even more so they believe the full facts of the case to be something which they are not.
This dilemma forces us to weigh up two difficult options – to violate the rights of the patient to understand their treatment fully in order to give them a positive outcome, or to tell them the truth and not see an improvement in their condition. For most, the sanctity of the trust of the patient-doctor relationship is absolutely crucial and cannot be compromised in any way.
To resolve this dilemma there is a need to think about what exact role lying plays in the prescribing of the placebo. Rather than simply being a means to give the placebo, deceit should be thought of as part of the treatment itself. The very essence of the efficacy of the placebo is the belief on the part of the patient that the placebo is an actual drug – without this belief, sustained by the deceit, the placebo would not work as a placebo. To say that treatment is only down to the actual physical pill that is ingested is simplistic and reductive – in reality the treatment of the patient encompasses many more factors than the simple pharmacological tool that is administered. The way the clinician and healthcare staff interact with the patient eases their anxiety, their nutrition and lifestyle are important, as are their relationships with family and friends. The clinician’s act of letting the patient believe a different reality about the pill they are about to ingest, if it is a necessary part of the placebo treatment, is just another of these extra-pharmacological factors that contribute towards the positive outcome for the patient.
Crucially, this argument does not entail that doctors should be able to lie in order to give a patient any treatment. Say for example a patient needed a drug urgently in order to stay alive, but is refusing it and does not have any impairment of judgement. The doctor would not be entitled to mix the drug into the food of the patient, administering it against their knowledge. This would be a clear violation of the autonomy of the patient to make their own decisions – this differs from the deception involved in the placebo because the deception is not needed here for the treatment to intrinsically work because the deception would not be needed if the patient decided to want the drug treatment.
So far the ethical considerations of autonomy, beneficence and non-maleficence have been taken into account, but the consideration of wider justice is also important. A sugar pill or a saline injection cost far less than drugs do. If giving a patient the cheaper placebo alternative can still guarantee the same improvement and outcomes that the relevant drug can, then it makes sense to opt for the placebo because it saves the healthcare service resources that could be spent and allocated elsewhere to benefit others. This is particularly important when thinking about the practical ethics of resource allocation in the healthcare system. Lots of drugs are rationed or very expensive and thus it is not always possible for people to access the medicine that they require, especially in less economically developed countries. Beings able to save money and valuable medicines through the effective use of placebos could benefit the wider community without negatively affecting the patient – a result that is morally favourable.
To put the prescription of placebos into practice requires an ethical framework to which doctors should adhere. It would be ethically wrong, for instance, to prescribe a placebo in the knowledge that either the placebo would not work, or that another course of treatment would produce a better outcome. Similarly, evidence should be sought to prove that placebos are effective for any particular condition before prescribing them to patients in clinics.
In conclusion, I have argued that placebos, whilst unusual, can be an effective form of treatment for patients. I have also argued that the act of deceiving the patient about the true nature of their medication forms and intrinsic and essential part of the placebo treatment, and should thus be protected from accusations of it violating the principle of autonomy of the patient. I have also outlined how using placebos can be beneficial for the wider community as well as the individual, and have provided some guidelines to make the practice ethically sound. Hopefully, with this reasoning and further research, the practice of prescribing placebos can become more widespread.
References:
Howick, J., Bishop, F., Heneghan, C., Wolstenholme, J., Stevens, S., Hobbs, F. and Lewith, G. (2013). Placebo Use in the United Kingdom: Results from a National Survey of Primary Care Practitioners. PLoS ONE, 8(3), p.e58247.
de Craen, A., Roos, P., de Vries, A. and Kleijnen, J. (1996). Effect of colour of drugs: systematic review of perceived effect of drugs and of their effectiveness. BMJ, 313(7072), pp.1624-1626.