Placebo debates go on…


It’s been a long time since I posted on placebo, but it’s a topic I keep returning to whenever I think about the complexities of carrying out randomised controlled trials on pain management. I’ve recently joined an on-line group called SomaSimple in which some of the most interesting debates I’ve seen in a while have been raging on… one of which is about placebo.

And it was while I was on there I was lead to this site which actually sells REAL small, inert, side-effect-free sugar pills that are often used in drug research as the control condition (otherwise called ‘placebo’).

One of my favourite sites is Ben Goldacre’s Bad Science site. He’s one of my favourite writers, and has been featured on BBC Radio talking about placebo. He’s written about it here and here’s the link to ‘listen again’ from BBC Radio 4. There are two parts to the discussion, and you can listen to part two here.

Another writer I particularly enjoy with regard to placebo is Dan Moerman. He’s written a book called ‘Meaning, medicine and the ‘Placebo Effect’. It’s been out since 2002, but the concepts haven’t dated one bit. He describes the placebo as being ‘inert’ – which it is, and states that the ‘placebo effect’ can’t be – because placebo is an inert substance. Therefore the term needs to be redefined, and he suggests ‘meaning response’ – something I won’t get into at all here, because he takes a whole book to discuss it, and I’m not about to attempt it. But at the heart of his thesis is that there is meaning ascribed to the relationship and interaction between someone seeking help and the person giving it. And this meaning is culturally-bound, susceptible to change over time, and profoundly involved in the ‘healing’ process, which is more than simply recovering from illness or injury. Worth thinking about really – he also adds that given that we can’t eliminate the meaning response in any healthcare situation, we should really learn as much about it and be effective with it, rather than pretending that it simply doesn’t exist.

A BMJ article just published discusses a recent survey of 1200 practising internists and rheumatologists in the United States. To quote a brief excerpt from the article, ‘Investigators measured physicians’ self reported behaviours and attitudes concerning the use of placebo treatments, including measures of whether they would use or had recommended a “placebo treatment,” their ethical judgments about the practice, what they recommended as placebo treatments, and how they typically communicate with patients about the practice.’

The results? Just over half of the 1200 participants responded (679), and of these ‘about half of the surveyed internists and rheumatologists reported prescribing placebo treatments on a regular basis’, they mainly thought this was ethical (Most physicians (399, 62%) believed the practice to be ethically permissible.). There are heaps of Rapid Responses to this article, well worth reading if you’re interested in the ethics of this sort of ‘treatment’. It’s certainly at odds with the American Pain Society position statement on the use of placebo, published in 2005.

Thoughts anyone?

3 comments

  1. Coming from the position as a layman, there are a number of things that struck me about this. I suppose the ultimate issue has to be the end result and the care and treatment of the patient. If a positive effect is achieved through the use of a placebo then it can be justified in the patient/physician relationship.

    I have a slight reservation though, a niggle that won’t quite go away. It is a very paternalistic approach perhaps but also the idea that a pill can cure all ills is one that isn’t necessarily fair. There are lots of elements to ‘treatment’ apart from just giving a pill.

    Very interesting stuff though!

  2. Hi cb
    To me I think it’s about ethics and honesty – I wouldn’t want to mislead a patient knowingly – but I do acknowledge there are heaps of things that we do in health where we don’t know (a) what the treatment is actually doing and (b) whether what we are doing is actually having the effect or whether it’s something else. It’s the ‘something else’ part that I think placebo or ‘meaning response’ is all about.
    I really do believe in patients having the right to informed consent – giving an inert substance in place of an active substance and not telling the patient smacks of paternalism to me!!

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