What is really unethical about the use of placebos?
This week’s class discussion regarding the history of drugs touched upon an area that in the context of today’s modern medicine, has become crucial in determining the success and failure of any new drug intervention. We explored the nature of placebos in our previous class meeting and observed how an innocuous treatment such as a sugar pill can influence people’s recovery and impact their perception of health and well-being. Our discussions led to me to explore this subject in greater depth, specifically, with the intent of analyzing the ethical implications of using a placebo in clinical trials. And, the first thing, I did was to look up the etymology of the word, and found that it derives from the Latin word, “placere”, which means to please. So, then it makes sense that patients or research subjects who are given a pill that achieves that end (specifically, allows them to experience some kind of improvement in their existing condition experience) is for that reason called the “placebo effect”.
But prompted by our class discussions with my peers and Dr. Bhattacharya, the question that I was now pressed to consider was this - is the use of placebo acceptable in one setting but not the other? Is it reasonable to utilize placebos in research, but not in medical practice? What permits its use in either case? Is it its idea of efficacy or the potential of a placebo treatment to cause harm to the subjects receiving the treatment - that should receive superiority when determining the ethical implications of its use? A kiss on the cheek from my mother after I fall from the stairs is also a placebo for it makes me feel better by alleviating my pain in some way. Yes, I’m still hurting, but sometimes this might very well help one to heal better or faster. Then, would that also not count as a kind of placebo? The question that now comes to mind is, if there already exists an effective treatment or cure for a given medical condition, should we still prescribe a placebo (in our situation, the mother’s kiss) to a patient and/or research subject simply because it has those physiologically pleasing, not to mention, pain relieving effects? Following that logic, would it mean that it is proper to undertreat somebody by not prescribing them the proven cure that already exists on the market?
In my view it’s indisputable that for finding the right cure for any disease, we will always require powerful research, but I think our concern should be more to do with modifying the design of future studies in a way that reduces the possible health risk to patients, rather than getting rid of the whole notion of placebo-aided studies. Without utilizing placebos in clinical trials, how can the doctors know if a given medication is truly effective and safe? This paper published in the PLOS journal indicates how clinical researchers are advised to compare their interventions with placebos when initially there exists uncertainty about the effectiveness of a treatment. Doing otherwise would mean that the researchers run the risk of approving drugs based on flawed science and that would be something just as unethical as the deception involved in administering placebo in such control studies.
The authors in this paper indicate how stemming from this rigid concern to be ethical, advocating testing of new interventions against proven effective treatments, puts researchers and clinicians at the risk of actually being unethical. Stang et al. point out in this paper, and rightly so, that diverse features of a clinical study’s design, including, but not limited to, sample size, quality of study conduct and patients' compliance can all have significant impacts on the results of successive trials. The idea of new treatments and drugs to be tested against existing effective treatments, instead of placebos should, therefore, prompt us to take the term “proven effective trials” with a grain of salt.
As I was researching this topic of the placebo effect, I also found this interesting reference to one of the episode from the famous TV Series (which we incidentally, also watched briefly in our class meeting, discussing War and Medicine) MASH. In this episode, the doctors run out of morphine and convince the triage patients that their false placebo treatment (who knows if it was water or saline) was a more powerful painkiller. Of course, the doctors make use of the healing powers of caring and compassionate nurses and other staff to convince their patients, and as one would expect, everyone appears pacified. Watching this episode, I wondered, what was it that made the patients pain-free - the nurses and the doctor’s conduct while administering the placebo, or the placebo itself? And, does it matter, so long as the placebo effect serves to prolong the patient’s survival?
But, like we discussed in our previous class meeting, there are cases, in reality, however, where the patient may only be feeling superficially relieved, while on the inside, his/her biological condition may actually be deteriorating. At the end of the day, I believe any subjective reports about enhanced health conditions must be verified with scientific laboratory tests because our primary concern must be to improve the final outcomes, and people’s subjective feelings alone cannot be the basis for advancing medicine. If anything is clear on this subject so far, it is that we need both caution and care when considering the application of placebos and assessing their ethical implications, because, ultimately, the clinician’s and the researcher’s focus must be on safeguarding the best interest of the patients who are on the receiving end of healthcare.
I still can’t help but wonder, that if the power of belief is such a potent factor in determining the recovery of a patient, then if one were to take deception out of the equation (and therefore, to an extent, settle the question of what is acceptable and what is not by allowing for informed consent), don’t we still encounter a similar conundrum? If a patient or a research subject believes that a given treatment is less effective or not real because he/she now knows he’s being given a placebo, I wonder, is that individual less likely to heal as opposed to someone who got a placebo, believing it was a real proven and effective treatment?
Seems like the catch-22 of belief to me!
