David Brill
US physicians regularly prescribe placebo treatments but are rarely open with their patients about doing so, a recent study suggests.
Sixty-two percent of physicians who completed a postal survey said that prescribing placebos was ethically permissible, and almost half reported doing so at least 2 or 3 times per month.
However just 5 percent of those who gave placebos said that they explicitly described them as such to their patients. The majority – around two thirds – usually described the treatment as a medicine which is not typically used for that particular condition but which might be of benefit.
“Our study seems to suggest that doctors may be using placebo treatments and they may be cutting corners in terms of how they describe them to patients,” said lead researcher Dr. Jon Tilburt, currently an assistant professor of medicine at the Mayo Clinic, US.
“I don’t think that these data show that doctors are actively deceiving their patients all the time,” he added, noting that the use of truly ‘inactive’ placebos was reported by less than 3 percent of the respondents.
“Physicians rarely use treatments such as sugar pills or saline in which there is no evidence that it could even possibly have a physiological benefit. Those treatments, I think, would be more closely aligned with overt deception,” he said.
Over-the-counter painkillers and vitamins were the most common choices of placebo in the study, with 41 and 38 percent of physicians, respectively, having recommended these treatments in the past year. Sedatives and antibiotics had each been recommended by 13 percent of physicians during that time.
Although the study did not address the complex issues that underlie physicians’ motivations for prescribing placebos, Tilburt believes that in general they have their patients’ best interests at heart when doing so.
“Physicians have a deep impulse to help but when you put them in a circumstance where they cannot fully realize that impulse they still want to do something, even if it comes at some expense to informed consent. And because we don’t have a healthcare system that reimburses for reassurance, good conversations and a quality relationship, we sometimes substitute pills for those more existential aspects of our caring,” he said.
Dr. Thiru Thirumoorthy, a former director of the Singapore Medical Association’s Centre for Medical Ethics and Professionalism, said that placebos have historically been an acceptable part of the healing process in all cultures – particularly among eastern traditions. He noted, however, that doctors need to exercise their judgment before prescribing placebos and must be able to show that they have acted in the patient’s best interests when called to account.
“Placebos must not cause harm, should not take the place of other effective medications, and should not be used unless all other proven treatments have been exhausted or are contraindicated,” he said.
“Placebos should not be used to create a dependency situation. Patient empowerment must be promoted in diseases that do not have effective treatments.”
The survey by Tilburt et al. was completed by 679 practicing rheumatologists and general internists. The researchers defined a placebo as “a treatment whose benefits (in the opinion of the clinician) derive from positive patient expectations and not from the physiological mechanism of the treatment itself.” [BMJ 2008 Oct 23;337:a1938. doi: 10.1136/bmj.a1938]
Future research is directed at understanding whether the power of the placebo effect can be harnessed without keeping patients in the dark, Tilburt said.
“There is some suggestion that even when we tell patients that they’re going to get a placebo there is still some placebo benefit. There’s probably some detriment in the degree of efficacy when you eliminate deception but it’s not totally eliminated, which is fascinating.”
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