The concepts of placebos and placebo effects refer to extremely diverse phenomena. I recommend dissolving the concepts of placebos and placebo effects into loosely related groups of specific mechanisms, including (potentially among others) expectation-fulfillment, classical conditioning, and attentional-somatic feedback loops. If this approach is on the right track, it has three main implications for the ethics of informed consent. First, because of the expectation-fulfillment mechanism, the process of informing cannot be considered independently from the potential effects of treatment. Obtaining informed (...) consent influences the effects of treatment. This provides support for the authorized concealment and authorized deception paradigms, and perhaps even for outright deceptive placebo use. Second, doctors may easily fail to consider the potential benefits of conditioning, leading them to misjudge the trade-off between beneficence and autonomy. Third, how attentional-somatic feedback loops play out depends not only on the content of the informing process but also on its framing. This suggests a role for libertarian paternalism in clinical practice. (shrink)

In the field of placebo studies residual disagreement about the terminology ‘placebo’ and ‘placebo effect’ still persists. We differentiate between the conceptualization of placebos in clinical trials; and placebo effects understood as a psychobiological phenomenon. With respect to the latter, we argue that a scientific ‘placebo paradigm’ has emerged, indicating that—at least among placebo scientists—there exists relatively stable consensus about how to conceive of placebo effects. We claim that existence of a placebo paradigm does not protect concepts from revision; nonetheless, (...) we argue that scientific progress is dependent on, and guided by relative conceptual stability. Therefore, to mount persuasive arguments for conceptual revision in respect of ‘placebo effects’ we argue, critics either need to defend the claim that a placebo paradigm is not underway, or that there are major scientific failings in respect of it. With these considerations in mind we examine three alternative proposals for conceptual reform: Grünbaum/Howick’s relativity models of placebo concepts; Moerman/Brody’s meaning response; and Nunn/Turner’s proposal for conceptual eliminativism. We derive two conclusions from this evaluation. First, we conclude that no convincing arguments have so far been presented for conceptual overhaul of ‘placebo effects.’ Notwithstanding this analysis, we conclude that refinement of this concept is likely. Second, we agree with Turner and Nunn that the term ‘placebo’ in the context of randomized controlled trials remains a source of confusion for many researchers, risking the design and scientific integrity of clinical findings. Therefore, in these contexts, replacing the term ‘placebo’ with ‘control’ is justified. (shrink)

A common observation in placebo studies is that definitional disagreement is rife. Philosopher and historian of science Robin Nunn recently argued that "Nobody who came and saw the placebo has conquered its definition". Nunn insists that "the placebo construct conceals more than it clarifies," and that we need to prepare for "a post-placebo paradigm". Pronouncements that disagreement is endemic are often the prologue for new definitions of placebo and "placebo effect": for example, in the opening of a recent philosophical paper (...) on the issue, Jeremy Howick observed that debates about placebos "rage," and that "there is currently no widely accepted definition of the 'placebo'".... (shrink)

The use of ‘placebos’ in clinical practice is a source of continued controversy for physicians and medical ethicists. There is rarely any extensive discussion on what ‘placebos’ are and how they work. In this paper, drawing on Louhiala and Puustinen's work, the author proposes that the term ‘placebo effect’ be replaced in clinical contexts with the term ‘positive care effect’. Medical treatment always takes place in a ‘context of care’ that encompasses all the phenomena associated with medical intervention: it includes (...) the particular method of treatment, the interpersonal relationships between medical staff and the patient and other factors, including physicians' and patients' beliefs in the power of the treatment. Together, these phenomena can result in a full spectrum of therapeutic effects to the patient—from no effects, to small effects, to large effects. In cases where there are significant therapeutic benefits to the patient, ‘positive care effects’ may be spoken of. Since the ethical codes of the General Medical Council and the American Medical Association demand transparency with respect to patient treatment and insist on complete openness in ‘placebo’ usage, the author argues that, as a matter of conceptual rigour and consistency, if the term ‘placebo effect’ is replaced by ‘positive care effect’, these ethical codes appear to insist on transparency about all such beneficial components of treatment. Given that this appears to be a counterintuitive obligation, the author concludes the paper with some comments on the clinical consequences of this conceptual revision, including a brief discussion of how this important debate might develop. (shrink)

The doctor-patient relationship is built on an implicit covenant of trust, yet it was not until the post-World War Two era that respect for patient autonomy emerged as an article of mainstream medical ethics. Unlike their medical forebears, physicians today are expected to furnish patients with adequate information about diagnoses, prognoses and treatments. Against these dicta there has been ongoing debate over whether placebos pose a threat to patient autonomy. A key premise underlying medical ethics discussion is the notion that (...) the placebo effect necessitates patient deception. Indeed, the American Medical Association guidelines imply that placebo treatment necessary entails a form of deception. As a consequence of this assumption, the fulcrum of debate on the use of placebo treatment has hinged on whether that deception is ever justified. Recently performed experiments with open-label transparently prescribed placebos have begun to challenge the notion that deception is necessary in eliciting the placebo effect and such effects necessarily involve a binary distinction between autonomy and beneficence. In this article we focus on the content of disclosures in distinctive open-label, transparently disclosed placebo studies and inquire whether they might be said to invoke deception in clinical contexts, and if so, whether the deception is unethical. We find that open placebos may be said to involve equivocation over how placebos work. However, drawing on surveys of patient attitudes we suggest that this equivocation appears to be acceptable to patients. We conclude that open placebos fulfil current American Medical Association guidelines for placebo use, and propose future research directions for harnessing the placebo effect ethically. (shrink)