The American Medical Association's Code of Ethics prohibits physicians from giving substances they believe are placebos to their patients unless the patient is informed of and agrees to use of the substance. Various questions surround the AMA policy, however. One of these has to do with what should be disclosed. The AMA holds that any treatment that the physician believes is a placebo should be identified as such to the patient. But consider a more restrictive policy that requires physicians to (...) defer to the medical community's consensus view about which treatments have a specific effect on the condition being treated. In light of the ethical goals that the AMA identifies—namely, concerns about patient trust, autonomy, and benefit—there are potential advantages to the more restrictive policy. (shrink)

The problem is a simple one. A placebo is “a substance provided to a patient that the physician believes has no specific pharmacological effect upon the condition being treated” (AMA 2007). 1 But i...

Psychogenic movement disorders (PMD) mimic known movement disorders, yet cannot be attributed to an underlying neurological substrate. PMD has been reported to affect up to 15–25% of patients who visit specialized movement disorder clinics. The lack of mechanistic understanding of this disorder contributes to the hesitation of physicians to give a diagnosis of PMD, and patients often experience inordinate health care costs and multiple referrals between psychiatrists and neurologists who have differing views on the diagnosis and terminology of PMD. Given (...) that the prognosis for PMD is poor, that the success of standard treatment for PMD is highly dependent on the patient's belief in the diagnosis and treatment regimen, and that case studies suggest the efficacy of placebo for PMD, placebo therapy has recently been advocated for PMD. Recent surveys report a high percentage of physicians administering placebo therapy. Therefore, perhaps the ethical question in PMD should be, “Are we harming patients by withholding placebo treatment?” In order to determine whether placebo therapy would be a viable option for PMD, we must first rigorously assess the factors contributing to the medical contexts in which placebos are offered. We conducted in-depth interviews with neurologists and psychiatrists to assess the attitudes that contribute to ethical norms and to assess physician attitudes and practices surrounding placebo therapy to psychogenic patients. These data will serve to inform the future treatment of patients with PMD, to make recommendations for clinician training and healthcare policy, and to reframe and deepen our discussion of the value of placebo therapies. (shrink)

In this paper, I argue that deceptive placebo use can be morally permissible, on the grounds that the deception involved in the prescription of deceptive placebos can differ in kind to the sorts of deception that undermine personal autonomy. In order to argue this, I shall first delineate two accounts of why deception is inimical to autonomy. On these accounts, deception is understood to be inimical to the deceived agent’s autonomy because it either involves subjugating the deceived agent’s will to (...) another’s authority or because it precludes the agent from acting effectively in pursuit of their ends. I shall argue that providing an agent with false beliefs is not inimical to their autonomy if they are only able to effectively pursue their autonomously chosen ends by virtue of holding those particular false beliefs. Finally, I show that deceptive placebo use need only involve this latter sort of deception. (shrink)

This opinion piece aims to situate the placebo effect within the field of psychiatric treatment. To accomplish this, the placebo is explored at the centre of an often heated debate between three discrete perspectives: the clinical trial researcher, the placebo researcher and the clinician. Each occupational perspective has its own vested interests and practical concerns that drive how the placebo concepts are negotiated and applied. It is argued that because the trial and placebo researchers typically represent opposing viewpoints, clinicians are (...) generally uncomfortable or even baffled by placebo concepts, and this three-way tension has crucial implications for the field's progress. (shrink)

Placebos are arguably the most commonly prescribed drug, across cultures and throughout history. Nevertheless, today many would consider their use in the clinic unethical, since placebo treatment involves deception and the violation of patients’ autonomy. We examine the placebo's definition and its clinical efficacy from a biopsychosocial perspective, and argue that the intentional use of the placebo and placebo effect, in certain circumstances and under several conditions, may be morally acceptable. We highlight the role of a virtue-based ethical orientation and (...) its implications for the beneficent use of the placebo. In addition, the definitions of lying and deception are discussed, clarified and applied to the clinical placebo dilemma. Lastly, we suggest that concerns about patient autonomy, when invoked as a further argument against administering placebos, are extended beyond their reasonable and coherent application. (shrink)

Health care providers are expected both to relieve pain and to provide anticipatory guidance regarding how much a procedure is going to hurt. Fulfilling those expectations is complicated by the cognitive modulation of pain perception. Warning people to expect pain or setting expectations for pain relief not only influences their subjective experience, but it also alters how nociceptive stimuli are processed throughout the sensory and discriminative pathways in the brain. In light of this, I reconsider the characterization of placebo analgesia (...) as pharmacologically inert and the use of it as deceptive. I show that placebo analgesia exploits the same physical mechanisms as proven analgesics and argue that it should be utilized to relieve pain. Additionally, I describe factors to help identify situations in which clinicians have the obligation to disclose the potential for pain coupled with ways of mitigating the risk of high-intensity pain by setting positive expectations. (shrink)

This paper offers a critical analysis of several accounts of the placebo effect that have been put forward. While the placebo effect is most often thought of as a control in research and as a deceptive tool in practice, a growing body of research suggests that it ought to be thought of as a powerful phenomenon in its own right. Several accounts that aim to draw boundaries around the placebo effect are evaluated in relation to current evidence and it is (...) argued that none of them adequately capture the variability and potency of the phenomenon. Two accounts, however, that point towards the underlying mechanisms of the placebo effect, are shown to offer promise in terms of developing a more comprehensive account of the placebo effect. (shrink)

Among medical researchers and clinicians the dominant view is that it is unethical to deceive patients by prescribing a placebo. This opinion is formalized in a recent policy issued by the American Medical Association (AMA [Chicago, IL]). Although placebos can be shown to be always safe, often effective, and sometimes necessary, doctors are now effectively prohibited from using them in clinical practice. I argue that the deceptive administration of placebos is not subject to the same moral objections that face other (...) forms of deception in clinical practice and medical research. Although deception is normally objectionable on the grounds that it limits autonomy and breaches trust, these grounds do not apply to placebos when they are prescribed within appropriate ethical limits. Patients have reason to prefer that doctors can prescribe placebos in ethically responsible ways. Hence, the AMA has an obligation to endorse and to promote the responsible use of deceptive placebos in clinical practice. (shrink)

In medical practice, physicians are often faced with tough ethical and moral dilemmas, one such example is the reoccurring conflict between a patient’s hope and the truth. This paper explores two ethical dilemmas centered on compassion and the reduction of suffering: truth-telling with terminal patients and the clinical use of placebos. In each case the disclosure of truthful information could interfere with hope and suffering relief.

Objectives -/- Surveys in various countries suggest 17% to 80% of doctors prescribe ‘placebos’ in routine practice, but prevalence of placebo use in UK primary care is unknown. Methods -/- We administered a web-based questionnaire to a representative sample of UK general practitioners. Following surveys conducted in other countries we divided placebos into ‘pure’ and ‘impure’. ‘Impure’ placebos are interventions with clear efficacy for certain conditions but are prescribed for ailments where their efficacy is unknown, such as antibiotics for suspected (...) viral infections. ‘Pure’ placebos are interventions such as sugar pills or saline injections without direct pharmacologically active ingredients for the condition being treated. We initiated the survey in April 2012. Two reminders were sent and electronic data collection closed after 4 weeks. Results -/- We surveyed 1715 general practitioners and 783 (46%) completed our questionnaire. Our respondents were similar to those of all registered UK doctors suggesting our results are generalizable. 12% (95% CI 10 to 15) of respondents used pure placebos while 97% (95% CI 96 to 98) used impure placebos at least once in their career. 1% of respondents used pure placebos, and 77% (95% CI 74 to 79) used impure placebos at least once per week. Most (66% for pure, 84% for impure) respondents stated placebos were ethical in some circumstances. Conclusion and implications -/- Placebo use is common in primary care but questions remain about their benefits, harms, costs, and whether they can be delivered ethically. Further research is required to investigate ethically acceptable and cost-effective placebo interventions. (shrink)