Is it dishonest to give patients placebo?
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Is it dishonest to give patients placebo?
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We are all committed to honesty, I hope, both to ourselves and our patients. And yet repeated studies of the placebo effect show that our honesty can deprive patients of large subjective benefits. Fo
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Is it dishonest to give patients placebo?
posted at 20/7/2011 1:36 PM BST
on bmj.com
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Posts: 77
First: 21/7/2010 Last: 10/5/2012 |
We are all committed to honesty, I hope, both to ourselves and our patients. And yet repeated studies of the placebo effect show that our honesty can deprive patients of large subjective benefits. For example, we all know of patients with real or presumed asthma who consume enormous quantities of beta-adrenergic inhalers without any objective evidence of severe bronchoconstriction. A few of them probably die as a result. Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma is a NEJM study which should make all doctors squirm a bit. Aims In prospective experimental studies in patients with asthma, it is difficult to determine whether responses to placebo differ from the natural course of physiological changes that occur without any intervention. This study compared the effects of a bronchodilator, two placebo interventions, and no intervention on outcomes in patients with asthma.Methods In a double-blind, crossover pilot study, 46 patients with asthma were randomly assigned to active treatment with an albuterol inhaler, a placebo inhaler, sham acupuncture, or no intervention. Using a block design, one each of these four interventions was administered in random order during four sequential visits (3 to 7 days apart); this procedure was repeated in two more blocks of visits (for a total of 12 visits by each patient). At each visit, spirometry was performed repeatedly over a period of 2 hours. Maximum forced expiratory volume in 1 second (FEV1) was measured, and patients' self-reported improvement ratings were recorded. Results Among the 39 patients who completed the study, albuterol resulted in a 20% increase in FEV1, as compared with approximately 7% with each of the other three interventions (P<0.001). However, patients' reports of improvement after the intervention did not differ significantly for the albuterol inhaler (50% improvement), placebo inhaler (45%), or sham acupuncture (46%), but the subjective improvement with all three of these interventions was significantly greater than that with the no-intervention control (21%) (P<0.001). Conclusions Although albuterol, but not the two placebo interventions, improved FEV1 in these patients with asthma, albuterol provided no incremental benefit with respect to the self-reported outcomes. Placebo effects can be clinically meaningful and can rival the effects of active medication in patients with asthma. However, from a clinical-management and research-design perspective, patient self-reports can be unreliable. An assessment of untreated responses in asthma may be essential in evaluating patient-reported outcomes. We suspect that they would get equal symptomatic benefit using a harmless placebo inhaler, and this pilot study from Harvard goes some way to demonstrating that. I say “some way” because the study seems to have timed the interventions to suit the investigators, not the patients. They received inhaled albuterol, inhaled placebo, sham acupuncture or simple waiting in cross-over fashion for a total of 12 visits. Inhaled albuterol was the only intervention that improved FEV1 but sham acupuncture and placebo inhaler were as good at relieving symptoms. For thousands of years, doctors were safer using placebos than active treatments; and that probably applies in certain areas today. But to use placebos deliberately is to become a charlatan and to undermine the scientific basis of medical progress. Discuss. P.S. One of the authors of this study declares direct payments from 20 pharma companies and grants from 9: it would be nice to think he will be doing similar studies on all their products. |
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Re: Is it dishonest to give patients placebo?
posted at 20/7/2011 7:27 PM BST
on bmj.com
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Posts: 24
First: 12/2/2011 Last: 17/4/2012 |
No but it would be a good idea to tell the patients about the inexplicable beneficial effect of many drugs without blinding them with pharmacology . I used to tell my patients in 2-3 sessions the therapeutic value of drugs,family/friends' support,and the patients positive attitude. I am retired . In essence, I think we should not oversell our therapeutic armamentarium but provide patients with hope,encouragement and examples of successful outcomes in other patients. |
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Re: Is it dishonest to give patients placebo?
posted at 15/8/2011 5:23 PM BST
on bmj.com
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*Moderator*
Posts: 869
First: 10/9/2009 Last: 10/12/2011 |
Here is an interesting editorial written by a child and adolescent psychiatry fellow and an associate professor of medicine suggesting clinicians and family members may also have emotional responses when patients receive placebo treatments |
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Re: Is it dishonest to give patients placebo?
posted at 3/9/2011 8:07 PM BST
on bmj.com
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Posts: 5
First: 26/8/2011 Last: 17/3/2012 |
In my opinion it may be dishonest just in case, when you don't give your patients real drugs, which are given usually in emergency in responce to evidence-based medicine. But in many cases harmless placebo play a great role in the process of treating. In Russia medical care is free of charge everywhere, that's why old people, who don't have family or have children-alcoholics, being tired and melancholy in evenings and nights can call 911, and medical practicioners are bound to come in any case. Then when such people have problems with food and paying for house they go treating to hospital without real emergency. That's why in Russia we use placebo effects widely, using an old principle : No nocere! |
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Re: Is it dishonest to give patients placebo?
posted at 5/1/2012 9:55 AM GMT
on bmj.com
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Posts: 1
First: 5/1/2012 Last: 5/1/2012 |
The shameful lack of research. The mention of asthma as a purportedly scientifically understood and treated disease shows the reliance on a how many angels on the head of a pin type of surrealistic argument here, betraying the aims of the authors to confirm the medical wisdom on the disease.. The extensive scientific writings on inspiratory muscle training and the widespread use of the respective appliances clearly indicates not only that asthma symptoms may be eliminated by such training but also that the muscle deconditioning effects of asthma drugs must be responsible for the epidemic. Furthermore all too relevant is the shameful utter absence of any serious enquiry about causation due to treatment even despite the alarming increase in asthma morbidity. Obviously anyone afflicted by the disorder should consult a physician aware of the developments. RF |
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Re: Is it dishonest to give patients placebo?
posted at 5/1/2012 2:36 PM GMT
on bmj.com
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Posts: 1173
First: 25/1/2009 Last: 7/5/2012 |
I recall a patient on my ward some years ago with what my registrar was convinced were pseudo-seizures. One day when she started fitting on the floor in front of the ward entrance the Registrar called for the IV lorazepam and a saline flush. He clearly held up the saline flush for all to see and said - "this will stop her fitting" - and indeed it did! Dishonest? He never said he was giving the lorazepam. In effect he gave the patient placebo and in doing so made the firm diagnosis of pseudoseizures. I think if you can clinically justify your actions (for example for diagnostic reasons) then it can be justified to give a patient placebo - you just have to be very careful around the legal aspects |
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