Links and placebo


I’m going to ‘cheat’ a little today – I want to link to someone else’s blog and an article I’ve previously posted on to discuss placebo.

It’s a vexed question for people working in pain management – the ‘meaning response’, or interpretation of the meaning the patient and clinicians place on the health care interaction and the context in which it occurs, is at the heart of so much of pain relief that we can’t ignore it. But at the same time, we know so little about the ‘meaning response’ and have incredible difficulty studying placebo especially in the field of persistant pain.

I did discuss this article a couple of days ago, but I think the questions it raises are worth considering again.

This blog post by Jake Young, who writes in ‘pure pedantry’ (a name I admire!!) discusses his response to the article by Tilburt and colleagues, and says this ‘I don’t think I would be comfortable deceiving my patient under any circumstances. I see my role as a future physician partly as a healer but also as an educator. Patients — particularly patients with intractable chronic illnesses — want to understand what is happening to them. I almost feel like in deceiving them, I would be denying them that small measure of control — that small measure of dignity — that is vital to feeling like a complete person, even in the face of a life destroying illness.’

One persons response to this comment is this: ‘ in sum, placebos are unpredictable. They cannot be effectively prescribed in any rational manner. One placebo “effect” is the relationship between doctor and patient—this should always be used anyway. Prescribing a pill, elixir, etc and giving false information as to it’s effectiveness is unethical.’

Another said ‘oh please. how many medications do we have where we do not really and truly understand how they work? Just because you have a handful of acute pharmacological effects to report doesn’t mean you really understand the critical mechanism. How the hell does Ritalin work? How about Prozac, which takes many weeks for efficacy?’

While yet another said ‘The placebo effect may very well depend on generating a false belief in the patient. If lying works, why is this necessarily unethical? It should be subject to cost/benefit analysis like any other therapy…”

Hmmmm.

Given that we don’t know how many modalities in pain management ‘work’, we could be accused of using ‘placebo’ in many situations – how does CBT work? how does exposure therapy work?

But neither of these are inert treatments, which is what placebo is. And they don’t involve deception.

And it’s the latter that really bothers me the most.

If I intentionally choose not to disclose what I’m doing and why, how can I be assured I’m providing patients with ‘informed consent’?  Don’t patients (ie, you and me when we seek health care…) have the right to know their options, and choose?

There is an attitude amongst some providers that says ‘the ends justify the means’. Do you want that for yourself as a consumer?

I don’t know how my antidepressant medication works – but I know I’m taking a specific medication, and I’ve read the evidence that says it has a good effect, and my options were explained to me very clearly by my GP and specialist.

Deliberately providing me with an inert substance in the name of an active substance without informing me is deception, and if I ever found out, my trust in my health care provider would be betrayed. And I wonder whether one of the ‘active ingredients’ in the meaning response is actually trust.

Do you really want to abuse that? It could be you next…

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