Is honesty the best policy when giving placebos to patients?

Surveys of physicians in recent years have found that doctors frequently recommend placebo treatments to mollify patients and describe them in deceptive ways, despite ethical guidelines urging them to steer clear of those practices.

Now questions are being raised about whether it may be OK for physicians deceptively to use placebos in certain situations and what should count as a placebo.

Can patients benefit from the placebo effect if doctors honestly tell them the treatment will have no known pharmacological or physiological effect for their condition?

What if a physician recommends an intervention such as acupuncture that he or she believes will help alleviate a patient’s symptoms but is not sure whether improvement is due to a biomedical mechanism or the placebo effect?

These are a few of the questions raised in an essay by philosopher Anne Barnhill, PhD, in the latest issue of The Hastings Center Report, a leading bioethics journal. In the essay, Barnhill takes aim at the American Medical Association’s ethics policy, which defines a placebo as “a substance provided to a patient that a physician believes has no specific pharmacological effect upon the condition being treated.”

Doctors should use placebos in clinical practice only after obtaining consent from patients, the AMA policy says. Using placebos deceptively can “undermine trust, compromise the physician-patient relationship, and result in medical harm to the patient,” the policy says.

Barnhill is not the first to criticize the AMA Council on Ethical and Judicial Affairs opinion, adopted by the AMA House of Delegates in November 2006. A 2007 article in Yale Law & Policy Review said the policy was “overbroad, insensitive to patient preferences, and likely to have unforeseen consequences.”

Deceptive use of placebos should be done sparingly, but is not categorically prohibited, said Adam J. Kolber, professor of law at Brooklyn Law School in New York.

Barnhill argues that the AMA’s ethical guidelines ignore many treatment scenarios in which there may not be a clear medical consensus about how effective a treatment is, how it works and whether disclosing use of a placebo affects the patient’s outcome.

“These cases comprise a large gray area in between black-and-white extremes,” she wrote.

Clinical use of placebos is common

The debate is not academic. On a monthly basis, eight in 10 physicians recommend treatments such as vitamins principally to enhance patient expectations, said a survey of 679 U.S. internists and rheumatologists published in BMJ in 2008. The physicians described these recommendations using the word “placebo” only 5% of the time, most often characterizing it as treatment not typically used for the patient’s condition.

Meanwhile, a survey of 231 Chicago physicians in the January 2008 issue of the Journal of General Internal Medicine found that nearly half acknowledged using a placebo during the previous year. The doctors said they did so to calm agitated patients, control pain, supplement another treatment, stop patient complaints or respond to “unjustified demand for medication” or “nonspecific complaints.”

Two medical ethicists employed at the AMA responded in Hastings to the Barnhill essay, arguing that greater physician disclosure to patients about placebos is the best course. The response was written by AMA Ethics Policy Director Bette-Jane Crigger, PhD, and AMA Institute of Ethics Director Matthew K. Wynia, MD, MPH.

“The bottom line is that, even if an undisclosed placebo might be marginally more effective for a particular patient in the short term, over the long haul, the integrity of the patient-physician relationship relies on doctors being honest with their patients,” the authors said.

Peter A. Lipson, MD, a Southfield, Mich., internist in private practice, agreed. Recommending treatments to achieve a placebo effect could prevent patients from seeking appropriate care or lead them to pursue other unproven therapies, he said.

“It’s not medicine anymore when you’re doing that,” Dr. Lipson said. “It’s more like witch-doctoring.”