The Ethics of the Placebo

by Scott Morrice on 09/05/2012

Much has been written about the placebo effect in the mind, body, spirit realm. It has always attracted a lot of attention, and there is no denying its importance. I have even previously referred to it in my What Is Biology Of Belief post. But I want to look at it now from another viewpoint, namely the ethics of the placebo.

I’m sure we all know what is meant by the term “placebo effect”—but out of abundance of caution, Wikipedia defines placebo as “…a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient.” And Wikipedia also writes, “ Sometimes patients given a placebo treatment will have a perceived or actual improvement in a medical condition, a phenomenon commonly called the placebo effect.”

So with definitions behind us, I want to focus a bit on the phrase “…intended to deceive…”.

But first, an acknowledgment, or a “hats off” so to speak—just so we know how powerful the placebo effect can be, and then perhaps imagine how significant a role in our lives it might play.

There are many well known, even famous examples of the placebo effect, but the one that I first read about when I first started to do some basic research was a study done by surgeon Dr. Bruce Moseley, for the Baylor School Of Medicine and published in the New England Journal of Medicine in 2002.

This study essentially focused on the role of the placebo effect in surgery—not an area where you would expect a placebo to have any effect at all! In particular Dr. Moseley was focused on knee surgery for patients experiencing dehabilitating knee pain.

For the study he divided his subjects into 3 groups. In one group he performed the traditional surgery—shaving damaged cartilage in the knee. In the second group he also performed traditional surgery—flushing out the knee joint and removing material thought to be contributing to the inflammation. But—-the third group got “fake” surgery. All aspects of what would have otherwise been a traditional surgery were duplicated—the patient was sedated, incisions were made, even the conversation around the surgical table was exactly the same, and about exactly the same surgical issues, as if a surgery were actually being done. After the normal amount of time had elapsed for this particular kind of surgery the patient was sewn up.

All three groups were given identical post-surgery rehabilitative regimes. And the placebo group didn’t find out that they were part of the placebo group for two years after the event.

At the end of the day, and you are probably expecting this, the improvement in each group was determined to be statistically identical! The placebo group, even though nothing had been done to their knees, other than the incision, improved as much as the other two groups!

In my mind, at least, the other area with the most startlingly powerful evidence of the power of placebos is in the treatment for depression. University psychology professor Irving Kirsch published an article in the American Psychological Association’s Prevention and Treatment titled “The Emperor’s New Drugs” in 2002 stating that 80% of the effect of antidepressants, as measured in clinical trials, could be attributed to the placebo effect. In fact, the data he unearthed showed that in more than half of the trials for six leading antidepressants, the drugs didn’t outperform a competing placebo!

The implications are enormous! And of course this is just where the mind, body, spirit troops weigh in.

Now don’t get me wrong—I fully believe in the power of the placebo. And I too wonder why our health systems are not more fully exploring and using this wonderful tool.

But my issue is this.

As I understand it, and I might not, the effectiveness of the placebo is directly related to the perceptions and expectations of the patient. In other words, the patient must believe, maybe even have learned—through some kind of conditioning, that the treatment is an active, real treatment. And the patient must expect that it will work.

And therein lies my issue. It is one of deceit.

On the one hand I acknowledge that the placebo can be used to perform a wonderful feat—it delivers a physically healthy end result, and one that didn’t depend on polluting our bodies with drugs the real and ultimate consequences of which oftentimes we only partly understand. And then there is the cost factor—buying placebos certainly won’t break the bank the way prescription drugs often do.

But on the other hand, for the placebo to work you need someone with credibility, and usually that would mean a doctor, telling you that you are taking an effective drug. But doesn’t that raise some real ethical questions? And beyond that, what happens to trust in the patient/doctor relationship? How will that relationship be affected. Apparently there are studies which indicate that approximately only 30% of patients are susceptible to the placebo effect, and that you can’t make that all important determination beforehand. Do you delay in providing a more conventional, but proven treatment? And is this delay ethical?

I am not sure where I am going to end up with this. I need to do a lot more reading and thinking about the issue.

But one thing for sure—it is an issue that calls for a lot of thinking. The placebo is a very powerful tool, and we need to be spending some quality time and effort trying to figure out its place in our world.

I’ll keep you posted.

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