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Skeptimedia is a commentary on mass media treatment of issues concerning science, the paranormal, and the supernatural.

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Prescribing Placebos

October 25, 2008. Muriel wrote to express her shock at the headline of the New York Times story: "Half of doctors routinely prescribe placebos".

"Just imagine," she wrote, "if I were a mechanic who did a 'placebo' repair on your car. Yet that's exactly what they're doing on our bodies!

"Can a patient sue for deception?

"Could you please try to follow this up? I simply can't, having been evacuated a few weeks ago at 3 AM from a burning building -- and still in the hostel, with no end in sight. (Probably an excuse you haven't heard before -- more imaginative than the dog eating my homework -- but this one's actually true -- unfortunately.)"

That's a pretty good excuse, but what's to follow up? The topic's been covered by some pretty knowledgeable folks: Steven Novella, Harriet Hall, Ben Goldacre, to name a few. So, I don't know what I can add to the mix. Is it ethical to deceive patients? Probably not, most of the time. Might there be times when it would be ethical to deceive a patient. Yes. Not very helpful, I know. Should physicians routinely prescribe inert substances to patients with the implication that the substances are effective for whatever is ailing the patient. No, that would be wrong. Do physicians do that? No. Even the Times article admits that is not what doctors are doing.

If you read the Times article you find out that 'placebo' is being used loosely. Anything a doctor prescribes for its psychological rather than physical effect (even if it is not an inert substance) is considered a placebo for the purposes of the study the Times reviews. So, if a doctor prescribes vitamins, thinking it will placate the patient, even though the scientific evidence indicates that most people will not benefit from taking vitamin supplements, then the doctor is prescribing a placebo.

One thing the Times article doesn't address is the fact that the clinical setting, the anticipation of getting treatment that will relieve pain or symptoms on the part of the patient, the manner of the physician, the conditioning that has come from visits to the doctor in the past, the ritual and theater of the clinical visit, etc. are considered part of the placebo effect. (These components were teased out nicely by Ted Kaptchuk et al. in their innovative study on irritable bowel syndrome, published in May 2008.) Yet, no one would advocate that a physician be gruff and dismissive, lest the patient be getting relief from the manner of treatment rather than from the pill or the therapy. Furthermore, does anyone want to argue that unless a doctor can be comforting and hopeful without acting, she should give it up? Do you really want to require that your doctor be sincere as well as comforting? Hey, if good acting will help relieve my symptoms, then let my doctor act.

The Times article also makes it clear that most of the time the doctors used language with their patients that is difficult to fault, even if weaseling:

In most cases, doctors who recommended placebos described them to patients as “a medicine not typically used for your condition but might benefit you.”

Of course, the patient may hear "will" instead of "might," due to desire. Some doctors probably tell their patients, truthfully, when they prescribe a known placebo that "some of my patients have reported that this really works for them."

The real issue is do doctors routinely lie to their patients to appease their symptoms? The answer from this survey seems to be no. Do they sometimes provide treatment that they know is pointless but which their patients demand? Yes. Most of the patients who demand an antibiotic are probably not going to be tested to see if they have a bacterial infection, and the doctor will often prescribe antibiotics, knowing that the problem is most likely viral. Is this a major moral issue that we should sound the alarm over? I don't think so. Patients are often morons and the doctor would be wasting time and money doing pointless tests and trying to explain why the antibiotic isn't likely to help.

The Times article points out that 30% to 40% of depressed patients get relief from placebos, but the survey says nothing about doctors routinely prescribing drugs they know are placebos to depressed patients. Putting this statistic in the article might be misleading.

The article doesn't mention that most so-called alternative therapies like acupuncture, hypnotherapy, and homeopathy work by the placebo effect even though their proponents don't accept this fact. What's worse? Deceiving yourself to the point that you don't realize your treatment is a placebo or deceiving your patients by knowingly giving them placebos? Since, as the Times article correctly points out, the doctor-patient relationship is based on trust (what social relationship isn't?), anything that destroys that trust is a bad thing. Self-deception isn't likely to destroy the doctor-patient relationship, so I guess it is worse to knowingly give a patient a placebo, i.e., an inert substance that you prescribe only to appease the patient's psyche. Fortunately, it doesn't look like that is a common practice among physicians.

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