The ethics of placebo medicine and Alternative health care

[Daedalus685]

This topic is something that is rather pertinent in my life and I wanted to see if we could have a good chat about it here.

Full disclosure: I have a degree in physics, I work in the Nuclear industry doing R&D so I do understand the principles of science. I have previously been on a wide array of mental health oriented drugs prescribed wisely and unwisely by various MDs. My partner is a newly graduated (in the last year) Naturopathic Doctor (ND) with an undergrad in Chemistry. For those unaware, a naturopath is a regulated health care provider who learns such things as botanical medicine, lifestyle and general counseling, traditional Asian medicine, pharmacology (they can prescribe in some provinces), some massage/chiropractic treatments and everyone’s favourite homeopathy among other things.

Fundamentally I want to ask you all whether you believe it is ethical to prescribe or incorporate a placebo intentionally and why or why not. So stop right here if my rambling opinion is not of interest .



I believe that it is ethical, and that it is predominately what alternative medicine is. It is a framework that can be used to maximize the placebo effect in patients, specifically important in the treatment of subjective illnesses such as emotions, fatigue, and pain. Here is a quick survey of doctors (http://www.bmj.com/content/337/bmj.a1938) 63% of who believe it is ethically permissible to treat with a placebo, and about half of which prescribe them regularly.

Acupuncture, some massage, homeopathy (which is really just counseling if you go to a practitioner), and chiropractics all get lambasted in our society because they have no medical benefit above and beyond a placebo (ignoring the fact that several of them may be comforting and relaxing which likely has an objective worth on its own). Yet if they do help some folks feel less pain, feel talked to, and generally feel better, then what on earth is the problem with them? There is an objective increase in health with these, it is simply not any higher than any other treatment you can produce, even one designed specifically to do nothing. It is not equivalent to having no treatment at all which is a mistake many seem to make when treatments are brushed off as “nothing more than a placebo”. A patient who stays home never getting help for their headaches is statistically worse off than one who is a part of a placebo group in a trial, by definition.

The magnitude of the placebo effect is extremely varied. I don’t feel I am qualified to explain it to you as I am by no means a doctor or biologist, but I found this article helpful, specifically the summary at the end. (http://pharmacology.ucsd.edu/graduate/courseinfo/placebarticle.pdf) We are moving forward as a medical culture to accept that the way a treatment is presented is VERY important.

So I wonder, if a treatment can be formulated to maximize the placebo effects of it and a practitioner can dedicate the time to perform it what exactly is the problem? Why is there such vicious hatred from the skeptic community against ‘alternative medicine’ when it is really just a mainstream cropping up of an isolated placebo treatment?

I feel really strongly that instead of demanding all alternative medicine stops that we as a culture move forward and investigate if we can improve the patient outcome by treating with such placebos. Maybe we should research how to better integrate traditional medical health care with more patient focused one on one time intensive care (that may or may not actually have an active medical component).

Obviously I’m biased, even though I try to have a clear open mind to all sides. Make no mistake about it, a homeopathic ‘remedy’ is nothing. It is just water or a sugar pill. There is 100% absolutely guaranteed no active physical, chemical, mystical, or blah blah blah in it at all. It is a placebo and I have no problem with a regulated health care practitioner using the homeopathic intake method as a way of improving patient outcome if they so choose to do so. I’ve been given any manner of mood altering drugs, and you know what always helped more than any of them (once I was stabilized enough)? Talking to someone who had my best interest at heart and the time to listen in a relaxing environment (massage, acupuncture, and counseling; placebos the lot of them).

A treatment is important because it is a treatment in a vast array of subjective conditions. This is separate entirely from the active component of a treatment being useful. I don’t see the harm in allowing these issues to be maximized on their own, and if we could all get along a bit better patients might even be better off if experts at both are allowed to work cooperatively together.

Obviously financial exploitation is important here. The ethics is not nearly as cut and dry as I let on. All health care has to be closely regulated.

 

[DaveSimmons]

Some of the disdain comes from knowing the treatment only works because the patient is ignorant, gullible, and being lied to. Then charged for it.

Also, some of these quacks offer their placebos as substitutes for treatments that work without the placebo effect. A vial of water instead of chemotherapy or surgery.

 

[Daedalus685]

Some of the disdain comes from knowing the treatment only works because the patient is ignorant, gullible, and being lied to. Then charged for it.

Also, some of these quacks offer their placebos as substitutes for treatments that work without the placebo effect. A vial of water instead of chemotherapy or surgery.

It is undoubetly horrible for a practitioner to advise a patient to take a sugar pill to treat their cancer. However, I see this as an issue of regulation and would hate to see benefits of such treatment modalities lost forever because a few folks were greedy and stupid. I do hope the truely anti medical 'quacks' do not hold us back for ever .

But it is a big issue, how do you prevent unscrupulous or ignorant folks from abusing it. I don't think it is a good idea to buy a sugar pill for 29.99 at the drug store. And cost becomes a big issue. How much is ok to charge for your time if 'all you do' is set up a nice comfortable place for a patient to vent.

 

[ivwshane]

I see placebos as only appropriate for studies.

To relate it to a patient/doctor interaction, I'd have no problem if the doctor said, "let's have you try this pill and tell me if the problem persists". So long as its not prescribed as a cure or something that it's not and is meant to gather more information I don't have a problem with it.

 

[woolfe9998]

If I'm sick, I honestly don't care how the doctor cures me. The only caveat is that I wouldn't want to be charged for a placebo as if it was a real drug.

 

[Craig234]

I think you hit on a good ethical issue, the heart of which is that placebos can have benefits, but can also pose a risk to the honesty from the doctor and 'informed consent'.

I'd agree regulation is important, and I do lean towards preferring honesty and disclosure, but there might be a role. 'This treatment has been found to help' is accurate.

 

[Hayabusa Rider]

Funny thing about placebos. If someone takes them and they work then they learn they are placebos they still work. Weird eh?

 

[zinfamous]

I think the fundamental principal of medication and treatment is to make every attempt to improve the patient's condition. Of course, "do no harm" also applies.

If a placebo is knowingly prescribed in an attempt to improve that condition, and it works, then all the better. Patients may come in with an array of symptoms that present little or no known pathology, and so the condition may not be one of physical illness.

homeopathy is certainly not medicine, but if it works to improve the patient's disposition, then that seems fine. I wouldn't worry about it killing the patient, either, seeing as how the patient is merely consuming water.

 

[TheVrolok]

Fundamentally I want to ask you all whether you believe it is ethical to prescribe or incorporate a placebo intentionally and why or why not. So stop right here if my rambling opinion is not of interest.

Simply put, no, I do not believe it is ethical. I make this statement assuming the knowledge that it is a placebo is withheld from the patient. Knowingly prescribing a placebo certainly sounds like outright lying to me.

 

[TheVrolok]

I think the fundamental principal of medication and treatment is to make every attempt to improve the patient's condition. Of course, "do no harm" also applies.

If a placebo is knowingly prescribed in an attempt to improve that condition, and it works, then all the better. Patients may come in with an array of symptoms that present little or no known pathology, and so the condition may not be one of physical illness.

My problem here is that you are removing the patient's choice (informed choice) from the treatment. A patient should always have choice. Always.

 

[colonelciller]

But it is a big issue, how do you prevent unscrupulous or ignorant folks from abusing it. I don't think it is a good idea to buy a sugar pill for 29.99 at the drug store. And cost becomes a big issue. How much is ok to charge for your time if 'all you do' is set up a nice comfortable place for a patient to vent.

interesting thing about the placebo effect... the more money you spend for it the better it works.

 

[justoh]

I think the fundamental principal of medication and treatment is to make every attempt to improve the patient's condition. Of course, "do no harm" also applies.

If a placebo is knowingly prescribed in an attempt to improve that condition, and it works, then all the better. Patients may come in with an array of symptoms that present little or no known pathology, and so the condition may not be one of physical illness.

homeopathy is certainly not medicine, but if it works to improve the patient's disposition, then that seems fine. I wouldn't worry about it killing the patient, either, seeing as how the patient is merely consuming water.

Sounds very reasonable, especially the first two paragraphs, since it's indisputable that often it can be hard to diagnose problems outside of princeton plainsboro teaching hospital, and more harm is caused by unnecessary conventional treatments than the few cases of someone opting for homeopathy to treat cancer or, say, being shot in the face. It's not necessarily harmful to treat many things with alternative medicine.

It does seem necessarily unethical, however. At best, for ambiguous "psychological" or non-life threatening conditions, or if used alongside conventional treatment, it's arguably still unethical because it's necessarily dishonest. Maybe i'm missing something but wouldn't someone's knowledge that it's only working because they're gullible break the spell and render its benefits 0, therefore necessitating deception to be effective? At worst, if taken instead of conventional treatment, it's arguably highly unethical and dangerous. I guess maybe it could still be effective with a generally positive attitude and open mind, but then you probably just need the positive attitude and can dispense with the associated ritual/process.

That said, there are likely at least a few "alternative" treatments which may just be poorly understood by science, which may actually have something to them and be more effective than a placebo. There's also every reason to be skeptical of private organizations like the AMA who get to dictate what conventional medicine means, because that's how it works in many places, and if you don't conform you are automatically and sometimes unfairly labelled unprofessional or a fraud.

 

[TheVrolok]

There's also every reason to be skeptical of private organizations like the AMA who get to dictate what conventional medicine means, because that's how it works in many places, and if you don't conform you are automatically and sometimes unfairly labelled unprofessional or a fraud.

Fortunately, the direction of modern medicine is evidence based. The AMA isn't defining standards of practice, the data is. Sure we could argue biases in academia all day, but it's hardly like someone is bringing down medical practices from on high.

 

[Black Octagon]

interesting thing about the placebo effect... the more money you spend for it the better it works.

I think this is a key point. The price, and other aspects of the 'treatment's' presentation, play a key role in the patient's reaction. This applies both to placebos and evidence-based medications and therapies.

As I recall from what I've read on the subject, one such key aspect of the treatment's presentation is the therapist's own (apparent) conviction that the treatment will work effectively. So, decreasing the price of placebos (or making sugar pills look cheaper / less fancy) may be one thing that reduces their 'efficacy'. But one thing that's sure to kill the efficacy is being honest with the patient and disclosing that the therapy is a placebo.

Assuming I've remembered all that correctly, it would seem to me that we can never divorce the placebo effect from the conscious act of dishonesty.

Whether the net result is 'ethical' thus depends on how you personally see dishonesty and efficacy balancing each other out? DO they balance each other out? If not, do you think the dishonesty or the efficacy is the more relevant factor? In short, are you more concerned by ends or means?

As you see, this is part of a larger debate about ethics and morality in general

 

[Sheep221]

There is considerable difference between the two not how they are performed but also for what they are intended.
The prescription synthetic drugs are used for treating acute illness, while placebos, acupuncture, homeopathics, massages, wellness and more, are used for improving lifestyle and wellbeing rather than treating illness.
I'm not fan of either method, but i don't think that massages or acupuncture would help person with schizophrenia, or cancer, or cardivascular illness.
The placebo methods may help in feeling better overall, having more energy or being emotionally better, where the over the counter drugs would be unnecessary, but that's all. If the individual is ill inside they won't change underlying problem.

 

[Daedalus685]

The thing that is really thought provoking is that a lot of the more modern studies have tried to isolate what we used to call a 'placebo' and what we called the 'placebo effect'.

The presentation of the treatment makes a huge difference. It improves the efficacy of drugs and it improves the efficacy of a placebo. To the point that the old belief that the placebo (an inert item) was the cause of the effect is going out the window.

It could very well be that comfort, and any array of 'personal' variables make people feel and report improvement. At least where more subjective health issues are concerned, the ones alternative medicines generally target.

It would not surprise me at all if for a vast array of conditions the majority of the benefit to the patient is from the ancillary aspects of treatment and not the actual treatment.

It would be quite interesting if what we call the placebo effect (in the respect of treatment presentation and the 'human touch') is actually a huge part of what makes alternative medicine work.

If that is the case does it become ok to allow someone to treat with 'nothing' if the actual benefit is coming from everything else (even if that everything else includes some sort of belief that the nothing is something)?

The more I think about it the more I figure its quite complicated. Though I wonder if we will start to see studies to find out how much information a patient can have/how intelligent they can be before the effect goes away. It would certainly make the ethics easier if there was still a great benefit even with knowledge.

It starts to become an issue of bed side manner really. Comfort at the doctor and time to be heard could make a huge difference , though likely not cost effective for an MD.

 

[DaveSimmons]

Perhaps then we should continue to research the effects of counseling and other human interaction to see how they can supplement traditional medicine.

If the part that really matters is being able to interact with another human being, that might be a treatment that's given honestly without the quackery and placebos.

Something like prescribing massage with the goal of making you feel less isolated rather than claiming it will "align your chi" or "balance your muscles."

 

[TheVrolok]

The presentation of the treatment makes a huge difference. It improves the efficacy of drugs and it improves the efficacy of a placebo. To the point that the old belief that the placebo (an inert item) was the cause of the effect is going out the window.

It would not surprise me at all if for a vast array of conditions the majority of the benefit to the patient is from the ancillary aspects of treatment and not the actual treatment.

Presentation certainly makes a massive amount of difference. In today's technological/evidence based society , people often overlook the still heavily subjective nature of medicine.

I wouldn't necessarily agree that the benefit to the patient is likely from ancillary aspects rather than treatment itself, but that the PERCEPTION of benefit may be. It's a somewhat pedantic but important distinction, especially when discussing things like "chronic pain" or other extremely subjective conditions for which alternative medicine is sought.

It starts to become an issue of bed side manner really. Comfort at the doctor and time to be heard could make a huge difference , though likely not cost effective for an MD.

The cost of medicine is a whole different discussion, but much of the problem is that society wants a more patient centered and relationship driven doctor and yet the business folk that run the industry want more patients seen more quickly. In my opinion it's downright criminal to ask a provider to give excellent patient centered care in a 15 minute appointment. It's an absurd juxtaposition.

 

[DaveSimmons]

It might even be counter-productive financially: the short visits make each appointment cost less, but then poor patient care leads to additional visits later for some fraction.

That's just a guess, but I wouldn't be surprised to find the business side is focused on short-term per-visit costs instead of lifetime care costs and long-term quality of life for a patient.

 

[Madwand1]

Fundamentally I want to ask you all whether you believe it is ethical to prescribe or incorporate a placebo intentionally and why or why not.

Questions of ethics are generally not black and white, and are better examined contextually in detail from a variety of perspectives. In general however, I believe that it is not ethical for a medical doctor to prescribe a placebo, except perhaps if it's suggested as something which may or may not help. Rigor is expected and required of medical doctors, and patients go to them not for faith healing, but for scientifically-based help, where the standard of measured success is that which is greater than a placebo in a controlled study. Of course exceptions apply to the cases where patients know that they are participating in a study which requires a chance that they might be given a placebo.

Doctors have a level of trust given to them on the basis of common knowledge and expectation of the rigor of their methods, and that trust should not be abused by prescribing something under a pretense. I think doctors should leave the faith healing to others who have genuine faith in their methods; even to those who claim to heal by faith alone.

In my experience, doctors here do do that -- they won't comment negatively or positively on treatment methods outside their area of expertise. So they leave the faith healing aspects to others, and neither promote nor undermine them.

 

[Moonbeam]

If I'm sick, I honestly don't care how the doctor cures me. The only caveat is that I wouldn't want to be charged for a placebo as if it was a real drug.

Which is why I would lie to you if I were your doctor. Part of getting well is paying for treatment because you only value what you pay for.

 

[woolfe9998]

Which is why I would lie to you if I were your doctor. Part of getting well is paying for treatment because you only value what you pay for.

By that logic, a system of socialized medicine would have very poor medical outcomes. Yet they do not.

 

[Black Octagon]

Well, socialized medicine IS still paid for through our taxes (e.g., here in northern Europe).

 

[Moonbeam]

By that logic, a system of socialized medicine would have very poor medical outcomes. Yet they do not.

You make a good point but one that can't overcome my own life experience. When I was young I delivered papers to buy a fish tank because my parents, who could have easily paid for it, wanted me to comprehend for myself the value of things. I never did become magnetized by having money but I did learn to appreciate my capacity to earn it and to value and care for what I could buy. The greatest gift I ever game myself was paying for my own psychotherapy. I must be a truly incredibly valuable person because I've spent a fortune on me, all paid for by my own capacity and not a dime from anybody else. The hidden gift in health is the attitude you bring to living. You can buy that with money just by paying your own way only. It's part of the placebo effect. It begins with a decision that you are worth something and the manifestation of that reality achieved by paying.

You are thinking of health as a physical state and fail to factor in a more subtle psychological dimension I think.

 

[randomrogue]

There´s a difference between a placebo and the placebo affect. After moving back to Europe you see a lot of the placebo affect with things like magnet therapy, healing codes, and other alternative medicine. I never saw that in the states.

Let me give two real world examples of alternative medicine though.

1. Good friend of mine who moved back to China had high blood pressure and was prescribed medicine to be taken for the rest of his life basically. He gets to China and they tell him that the medicine is fine but they can try a herbal remedy and probably have him healthy in a couple years. So he mixed some herbal powder into his drinks at meals and it cured him perfectly.

2. I ran out of DEET mosquito repellent in India. I was in a smaller town and they had none available but insisted I buy their Ayurveda mosquito repellent. This is their ancient herbal remedy. Next morning I wake up with 50 mosquito bites and I had to suffer as a mosquito meal for days before getting some actual insect repellent. Complete snake oil.

That´s two ancient cultures. One herbal remedy worked. The other didn´t.

All our medicine is basically derived from plants and then synthesized to be sold to us. Penicillin is a fungus synthesized in nice tablets.

Where I have a problem though is with the new age shit that is obviously just taking advantage of people. Magnets? Crock of shit. Yet these people believe it helps them. I don´t think you can even call it the placebo affect since if you ever meet someone who uses them they lack the ability to judge the results properly. If you were to take antibacterial antibiotics and it only worked a couple times and the rest of the time you shit for weeks you would clearly say it´s ineffective right? Yet with magnets it´s ok for it to not work. I love how people say "Well it makes my back feel better". Well why then are you still bitching about your back and why is it not really better? Compared to physical therapy and real pain relievers it´s obviously ineffective.

What you´re really dealing with is people who are simply afraid of modern medicine. They think it´s chemically dangerous and would rather rely on faith to heal them. Add to that people who lack real cognitive skills and it´s a recipe for exploitation.

Now I have some smart friends who are into this stuff too so it´s not just dumb people subscribing to it. It´s like a cult. It´s faith based healing. They think that if they believe the magnets work then they will. If it doesn´t work then it wasn´t meant to work. They literally believe that they can send positive energy to heal the sick. They of course ignore the fact that it works maybe 1% of the time and that 1% doesn´t necessarily have anything to do with their healing waves.

Ever heard of the healing codes or shamanistic healing? This is voodoo medicine at it´s finest. They basically take people who are susceptible to brainwashing, have them pay money for their books, courses, and seminars, and then make them do these drills to heal themselves and others. It doesn´t work at all. This is as unethical as it gets. It probably has some placebo affect though since if you have someone who is emotionally in a very bad placed then believing in something, anything, probably helps. I have a problem with it though since practitioners insist it works and that they don´t need science yet they don´t even understand science most of the time. If you are in a room with 30 people and 28 of them are clearly in the 80-99 IQ range you really are just exploiting them for money.

There´s also a correlation between the same people who are into all these things and them falling for the correlation/causation fallacy. The anti-vaccine movement is from these same people and that results in deaths each time they scare up the public. From what I´ve seen these types of alternative medicine are not something used in conjunction with modern medicine. These people shun modern medicine and would rather die or let their kids die than get vaccinated, take antibiotics, etc.

So in a nutshell do I have a problem with a placebo or the placebo affect? Do I have a problem with herbal remedies? No. I really don´t. It can work but we need to understand it better. I do have a problem with people though who sell a placebo as if it works or shun modern medicine and it leads to people dying.