It’s the New Year so I’m in philosophical mood. No, not really. But my blog today has been triggered by a piece a I read yesterday about the use of placebos in medicine, which got me thinking in a somewhat philosophical vein.
In a study published in the Journal of General Internal Medicine, researchers at the University of Chicago polled 466 hospital doctors about their practice, of whom 231 responded. Of this 231, almost half (45 per cent, actually) said they had used a placebo during their clinical practice.
Of doctors who reported using a placebo at some point, about a third said they told the patient the substance was something that “may help and will not hurt.” Another third gave other information to patients including, “this may help you but I am not sure how it works.” 19 percent said it was a “medication,” and 9 percent called it “a medicine with no specific effect.” Only 4 percent of the doctors came right out and called it a placebo.”
My first reaction to reading a report of this piece of research was surprise: I, rather naively perhaps, didn’t even know that placebos were available for prescription. I honestly wouldn’t know where to get my hands on some myself. I have no idea, for instance, what I would write on the prescription.
This aside, the research, I think, raises some important ethical questions. First of all, if you’re going to give a placebo, then one might argue that being covert about it by not declaring it is a placebo is deceiving a patient. One could argue that if you have your patients’ best interests at heart, then this does not necessarily matter. But giving a placebo and not explicitly stating that is what is being given is a deception, whichever way you cut it.
A small percentage of doctors chose a more candid approach, it seems, and declared their chosen treatment to be a placebo�. Some would argue that while this is transparent, it is self-defeating in that for a placebo to ‘work’, individuals need to believe it might or will work.
So, one option available to doctors is to deceive their patients into believing that the placebo is something other than a placebo, or the other option is to jeopardise the value of the placebo by being transparent about it. I don’t think there are any easy answers here.
And it gets even more vexed when we consider other questions such as: should treatments that have been shown to be no more effective than placebos be advised by doctors and made available to patients? The knee-jerk response to this question may be ‘no’, but consider this hypothetical but not far from reality scenario for a moment.
Imagine a situation where a new drug is developed for a rather nasty and debilitating condition for which there is no existing treatment. Let’s imagine now that this drug is tested in individuals with this condition, in ‘double-blind placebo-controlled’ fashion. Now, lets imagine that half of the people treated with the active drug see significant and meaningful benefit with little in the way of side-effects. Some would see that as a good result, which suggests that the treatment has merit. But now imagine that the results of this experiment show that those taking the placebo did just as well. Suddenly, for many in the fields of science and medicine the drug looks worthless.
Now think about this from a patient’s perspective. Remember that this is a nasty and debilitating condition for which no other treatment has been found. Taking the drug gives you about a 50 per cent chance of significant relief, but this option is denied to you because the drug performed no better than placebo in trials. You could imagine that as a patient you might not mind about the fact that the drug performed no better than placebo, if you thought that you had a 50 per cent chance of benefiting significantly from that treatment.
I have this week experienced this conundrum from a ‘patient’s’ perspective in my own life. On 2nd January I woke up with a cough and cold. My girlfriend very kindly offered to make me a honey and lemon drink. I gratefully accepted her offer, drunk the drink, as well as a couple more throughout the morning. I believe I felt better for my honey and lemon ‘therapy’.
The reason that I mention this is that about a month ago I wrote about a study which showed that honey had soothed children’s coughing at night. The honey found to be about as effective as a cough-suppressant drug. However, in some other experiments, this drug has not been found to be any more effective than placebo. So some would argue (and indeed did) that this provides good evidence that honey is no better than placebo for childhood coughing.
However, this study did find that giving honey was significantly better than doing nothing. So, now imagine that you’re a parent, your child has a cough, and you know that a study has found that giving honey is quite likely to relieve it. But you also know that the honey does not perform any better than placebo. Bearing in mind the fact that toxic side-effects from honey are low, would you give it? I suspect most parents would. If I were a parent, I think I would. And, as I’ve already admitted, I would not hesitate to down a honey-containing drink myself, working on the assumption that it may well make me feel better.
Now, the decision about giving kids honey is not as charged, perhaps, as one about giving people drugs or treatments that might be expensive and potentially hazardous that have been shown to be no better than placebo. But, at their essence, these situations present us with the same conundrum. And, quite frankly, I don’t know what the answer to latter one is.
What I do know is that the way in which treatments are assessed is, in the case of double-blind placebo controlled studies, quite an academic pursuit. Nothing wrong with that, of course, except that in my experience, sick individuals are generally less concerned with science, and more concerned with getting well.
The reality is, that there really is very little evidence for most of medical practice, conventional or otherwise, anyway. As a practitioner, I am well aware that a lot the approaches I suggest in practice have no ‘evidence-base’. They may have some logic and reasoning to them, and I may even find them to be generally effective in the real world, but practically nothing of what I do has been subjected to systematic study. So, I have no idea whether when someone feels better or benefits in some other way for taking the advice I have given them whether this is as a result of the action they took, the placebo response, or both. Oh, and even if something has been studied and found to be better than placebo, I still have no idea whether the benefits derived by a patient have come from any real effect, or the placebo response, or both. Do I care? No, is the honest answer. And neither, generally speaking, do my patients.
The ‘placebo response’ has, for a long time, been a bit of a dirty term in scientific circles. My suspicion is that most academics would regard the concept of advising treatments that have not been shown to be better than placebo to be wrong. I don’t expect they’d be thrilled about the idea of doctors prescribing placebos either. Yet, the recent Journal of General Internal Medicine study seems to show that many doctors have prescribed them. Maybe, that’s because doctors are primarily concerned with helping people get better, and unlike many academics, care less exactly how they get better?