The concept of hysteria is traced from Hippocrates, where it was thought to be caused by a wandering uterus, through Galen and up to Freud. Throughout the history of medicine from the early Greeks up to the end of the nineteenth century, the definition and diagnosis of hysteria had a function similar to that found in the persecution of witchcraft: it sought to eradicate the outbursts of nonconforming and emotionally threatening conduct of women. At the beginning of the twentieth century, (...) however, the category virtually disappears from psychiatric nosologies. (shrink)

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)

A frequent feature of pharmaceutical research is the open label extension study, in which patients participating in double blind placebo controlled trials of new medications are invited, on completion of the initial trial, to take the study drug for some further period. Patients are openly given the active substance at this stage, regardless of their assignment in the initial trial. Investigators are typically reluctant to unblind the patients’ assignment at the point of entry into the open label phase, on the (...) grounds that this may introduce ascertainment bias in the main study.It is argued that patients invited to participate in open label extension studies cannot give a proper consent to such research unless they know to which arm of the main trial they were recruited. It is further argued that to recruit certain groups of patients from placebo controlled trials into open label extension studies may also be unethical for clinical reasons. (shrink)

This paper argues that epistemic errors rooted in group- or identity- based biases, especially those pertaining to disability, are undertheorized in the literature on medical error. After sketching dominant taxonomies of medical error, we turn to the field of social epistemology to understand the role that epistemic schemas play in contributing to medical errors that disproportionately affect patients from marginalized social groups. We examine the effects of this unequal distribution through a detailed case study of ableism. There are four primary (...) mechanisms through which the epistemic schema of ableism distorts communication between nondisabled physicians and disabled patients: testimonial injustice, epistemic overconfidence, epistemic erasure, and epistemic derailing. Measures against epistemic injustices in general and against schema-based medical errors in particular are ultimately issues of justice that must be better addressed at all levels of health care practice. (shrink)

Physicians commonly recommend ?placebo treatments?, which are not believed to have specific efficacy for the patient's condition. Motivations for placebo treatments include complying with patient expectations and promoting a placebo effect. In this article, we focus on two key empirical questions that must be addressed in order to assess the ethical legitimacy of placebo treatments in clinical practice: 1) do placebo treatments have the potential to produce clinically significant benefit? and 2) can placebo treatments be effective in promoting a therapeutic (...) placebo response without the use of deception? We examine evidence from clinical trials and laboratory experiments bearing on these two questions. The conclusion is reached that based on currently available evidence, it is premature to judge whether placebo treatments are ethically justifiable, with the possible exception of acupuncture for pain relief. (shrink)

As a culture, we have a tendency to measure motherhood in terms of a set of signal moments that have become the focus of special social attention and anxiety; we interpret these as emblematic summations of women's mothering abilities. Women's performances during these moments can seem to exhaust the story of mothering, and mothers often internalize these measures and evaluate their own mothering in terms of them. "Good" mothers are those who pass a series of tests—they bond properly during their (...) routine ultrasound screening, they do not let a sip of alcohol cross their lips during pregnancy, they give birth vaginally without pain medication, they do not offer their child an artificial nipple during the first six months, they feed their children maximally nutritious meals with every bite, and so on. This reductive understanding of mothering has had counterproductive effects upon health care practice and policy, encouraging measures that penalize mothers who do not live up to cultural norms during signal moments, while failing to promote extended narratives of healthy mothering. (shrink)

In this paper we argue that ill persons are particularly vulnerable to epistemic injustice in the sense articulated by Fricker. Ill persons are vulnerable to testimonial injustice through the presumptive attribution of characteristics like cognitive unreliability and emotional instability that downgrade the credibility of their testimonies. Ill persons are also vulnerable to hermeneutical injustice because many aspects of the experience of illness are difficult to understand and communicate and this often owes to gaps in collective hermeneutical resources. We then argue (...) that epistemic injustice arises in part owing to the epistemic privilege enjoyed by the practitioners and institutions of contemporary healthcare services—the former owing to their training, expertise, and third-person psychology, and the latter owing to their implicit privileging of certain styles of articulating and evidencing testimonies in ways that marginalise ill persons. We suggest that a phenomenological toolkit may be part of an effort to ameliorate epistemic injustice. (shrink)

Until recently, the medical community assumed that placebos required either concealment in randomized controlled trials or deception in clinical practice to elicit placebo effects. Henry Beecher emphasized this orthodoxy, when he stated that placebo pills only work "as long as it is not detected as a placebo by the subject or the observer" and therefore, patients "believe it [is a drug] and consequently the expected results occurs". The time was ripe for such ideas: Norman Vincent Peale's The Power of Positive (...) Thinking was already in its fourth year on the bestseller list when Beecher published his landmark paper. As time went on, the use of placebo pills became trapped in an... (shrink)

In general, we think that when it comes to the good of another, we respect that person’s will by acting in accordance with what he wills because he wills it. I argue that this is not necessarily true. When it comes to the good of another person, it is possible to disrespect that person’s will while acting in accordance with what he wills because he wills it. Seeing how this is so, I argue, enables us to clarify the distinct roles (...) that the wills of competent and incompetent people should play in third-party deliberations about their welfare. (shrink)

Testimonial injustice occurs when bias against the credibility of certain social identities results in discounting of their contributions to deliberations. In this analysis, we describe testimonial injustice against women and how it figures in macroallocation procedure. We show how it harms women as deliberators, undermines the objective of inclusivity in macroallocation and affects the justice of resource distributions. We suggest that remedial action is warranted in order to limit the effects of testimonial injustice in this context, especially on marginalised and (...) disadvantaged groups, and propose three areas for action, whose implementation might feasibly be achieved by those immediately involved in macroallocation. (shrink)

While a significant body of bioethical literature considers how the placebo effect might introduce a conflict between autonomy and beneficence, the link between justice and the placebo effect has been neglected. Here, we bring together disparate evidence from the field of placebo studies and research on health inequalities related to race and ethnicity, and argue that, collectively, this evidence may provide the basis for an unacknowledged route by which health disparities are exacerbated. This route is constituted by an uneven distribution (...) of placebo effects, resulting from differences in expressions of physician warmth and empathy, as well as support and patient engagement, across racial and ethnic lines. In a discussion of the ethical implications of this connection, we argue that this contribution to health disparities is a source of injustice, consider ways in which these disparities might be ameliorated and suggest that this conclusion is likely to extend to other realms of inequality as well. (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)