The other day, Kim asked me if I’d ever consider prescribing a placebo. I replied that I would not, as I would consider doing so unethical.
In a lovely piece of symmetry, I came across an article on that very subject in The New Yorker a few days ago, probably from the issue that was current at the time of Kim’s question. Titled “The Power of Nothing.” Michael Specter’s piece focuses on Ted Kaptchuk, a professor at Harvard Medical School who has spent years studying the placebo effect, and who clearly believes that there is value in exploring the use of placebos in medical practice.
Unfortunately, the article has already been archived in the online version of the magazine, and their archiving system makes it nigh impossible to cut and paste quotes. For those of you who are interested enough in the article to read it, it’s their “Annals of Science” article from the December 12, 2011 issue, and starts on page 30 in the paper version.
As far as I am aware, there is really no established ethic for prescribing a placebo. To the contrary, doing so conflicts with several of the ethical principles I was taught in medical school. Prescribing a placebo generally indicates a certain degree of deception, giving the patient the impression that you believe the medication to have a pharmaceutical effect that it does not. This is pretty obviously paternalistic. While a certain degree of paternalism in medicine is probably unavoidable given the information and power differential within the physician-patient relationship, and one could argue that certain circumstances warrant a limited amount of benign paternalism, in general paternalism is something to be avoided or minimized. Misrepresenting the benefits of a prescription also makes genuine patient autonomy impossible, as the patient is making a decision to take the medication without correct information about what it will (or won’t) do for them.
This isn’t to say that I don’t sometimes prescribe medications that I don’t think are necessary. A common example is prescribing antibiotic drops or ointment for conjunctivitis (“pinkeye”), an illness that is overwhelming due to viral infections and is therefore self-limiting. I’ve heard from ophthalmologists that the number of cases of bacterial conjunctivitis (the kind that would respond to and genuinely warrant an antibiotic) that they’ve seen in their careers number on one hand. That said, pediatricians in general are pretty liberal with the eye drops. This is, in part, because daycare centers treat conjunctivitis like ebola for some reason, and won’t let kids back in without a prescription. Many providers justify medicating by arguing that putting kids on an antibiotic lessens the risk of bacterial infection, which is at least plausible.
What keep these drops (or, if you prefer, a prescription for an oral antibiotic that I have been mau-maued into writing) from being an outright placebo are two things. First, they have an actual pharmaceutical effect, which may confer come benefit, even if I don’t really think it will be significant. It’s possible that I’m simply wrong about the diagnosis, and am covering my bases (certainly some patients would likely argue so). But moreover, whenever I write a prescription whose value I question, I say so explicitly. I tell parents the drops are almost certainly more of a hassle than they’re worth (you try getting a drop onto the surface of a struggling toddler’s eyeball), though otherwise benign, and they don’t have to fill the prescription if they’re disinclined to do so. It’s conceptually quite different from gussying up some saline solution and telling parents it will be curative in a few days’ time.
An interesting aspect of the placebo effect seems to be that some patients experience it even when they know they’re taking a placebo. Some part of the therapeutic process helps alleviate illness, including in some cases taking a medication known to be physiologically inert. If there were to be a developed ethic of placebo use, I cannot see how to make it square without honesty. Arguing from a quality of life perspective still assumes too much paternalistic privilege for me to feel comfortable about deluding a patient. If a body of evidence develops to support the use of an openly-prescribed placebo for relief of certain symptoms, I would at least admit the possibility of prescribing them in select circumstances.