American doctors regularly prescribe placebo pills that are intended to have a psychological effect, a new survey finds.
However, the placebos reported by the 679 physicians in the survey often aren't the inactive substances used in controlled clinical trials, said Dr. Farr A. Curlin, an assistant professor of medicine at the University of Chicago, and a member of the team reporting the finding in the Oct. 24 issue of the BMJ.
"Most people when they say 'placebo' think of something like a sugar pill," Curlin said. "But doctors can use a treatment that may have some effects but that they think will not have a direct effect on the patient except by the placebo effect."
The placebo effect, well-established in countless studies, is a benefit produced by assuring someone that whatever is being given will benefit whatever the problem happens to be -- "optimism or confidence that something is being done," as Curlin phrased it.
Only 3 percent of the doctors responding in the survey reported prescribing sugar pills. But 41 percent said they used over-the-counter painkillers as placebos, 38 percent used vitamins, 13 percent used antibiotics, and 13 percent used sedatives.
The survey also found that only 5 percent of the doctors who prescribe a placebo treatment describe it as such. The great majority, 68 percent, describe it as a potentially beneficial medicine or treatment not typically used for the condition.
And almost two-thirds of the doctors in the survey said they believed the practice to be ethically permissible.
"It's a gray zone," Curlin said. "It is not ethical to actively deceive patients. But when doctors give something which they think will help but don't think it helpful to explain the full reasoning about why it will help, that's a gray zone."
Placebo treatment "is pretty common in the practice of medicine," said Curlin, who acknowledged using it. "I give people the information I think a reasonable person would want to know, trying to be as candid as possible," he said. "There are times when I have said, 'Yes, I think it might be helpful, why don't you give it a try,' when I don't have confidence it will help their condition."
What matters is that the treatment can help, Curlin added. "The placebo effect is a real effect," he said. "People do feel better. To the extent that it can be mobilized in a way that is restful and not actively deceiving patients, I think it is acceptable."
Placebo treatment "is part of an old but good medical tradition," said Dr. David Spiegel, an assistant chair of psychiatry and behavioral sciences at Stanford University. "The basic rule is: First, do no harm. If there is no toxicity, and it does some good, evidence supports its use," Spiegel said.
But straightforward lying about a prescription is wrong, said Dr. Andrew Leuchter, associate dean of the school of medicine at the University of California, Los Angeles.
"The cornerstone of what treatment is acceptable is full disclosure for the patient," Leuchter said. "If you explain to the patient what you are doing, and why you are doing it, that is right. If you mislead a patient, there is a serious problem with that."
The appropriate way to explain a placebo treatment, Leuchter added, is to say, "There is no reasonable medical evidence that this pill is effective for your condition, but some people who take this pill say it makes them feel better."
It is important to note that "deception is not a necessary part of the placebo effect," Spiegel said. "You can tell people that the treatment might benefit them, and that is not a lie."
And the placebo effect is often at work in medical practice, Spiegel noted. "A lot of factors go into the effect of therapy, some of which are specifically pharmaceutical, and some are not. You might feel better, because you feel you are doing something actively to treat the problem."
The argument about the ethics of placebo treatment can also be turned around, he added. "There are ways to present placebo treatment that do not involve deception," he said. "You are doing it because it can help a patient, and a certain percentage of patients will respond. Especially in conditions where we do not have a lot of treatments, is it ethical to withhold it?"