Wasn’t sure where I should post this, but my main interest is in the legality of the issue. If it turns into a debate, I’m sure the authorities will move it.
I am a pretty skeptical person, sometimes even a bit paranoid. Whenever I have had a doctor prescribe a medication, I always wonder if I have been given the real thing, or just a placebo. This is especially true when the drug doesn’t have any effect on me. For some reason, very few drugs/medications have much of an effect on me, so this may be a contributing factor as to why I feel this way.
First of all, is this a legal practice?
Second, is it ethical?
Hypothetical situation:
You are a doctor and you have a hypochondriac patient who keeps coming to you with new problems. Let’s say that, after much testing, there is no reason for you to believe that anything is wrong with the patient. Would you try to give the patient a “special, new drug” (sugar pill) and see if it cures what ails 'em? Why?
Is it leagal? Depends on what you mean. If you’re asking if it’s legal for a doctor to write a prescription and then call the pharmacist and tell her to give you sugar pills instead, no, that wouldn’t be legal or ethical.
If you’re asking if it would be legal for the doctor to open the drawer, pull out a bottle of unmarked sugar pills and instruct you to take one three times a day, why not? I’ve had doctors tell me to drink more fluids, so what would be illegal about telling someone to take sugar pills? It’s not a controlled substance.
Would it be ethical to represent placebos as drugs? Probably not. Would it be ethical (as in your scenario) to merely tell you to try these for a week? I wouldn’t be surprised if doctors haven’t been doing that for 100 years.
If there’s nothing demonstrably wrong with you, apart from “I don’t feel good”, the doctor is acting ethically to offer you a treatment which is, in fact, known to relieve symptoms under such circumstances. The placebo effect is very effective – so effective that there is a real need for the standard “double-blind” technique for determining a drug’s effectiveness. Simply applying medical treatment will usually result in measureable improvement, even if the “drug” is in fact an inert substance, or the treatment is all smoke and mirrors. Likewise, disbelief in the efficacy of a course of treatment will have what’s called a “nocebo”* effect. In this case, a treatment with known beneficial effects results in little or no effect due to the patient’s disbelief.
~~Baloo
I dunno whether it’s the “correct scientific term” or a manufacured one, but that’s the real word. Honest!
Your doctor, if in the U.S., could not “prescribe” a pure placebo because prescription drugs in the U.S. are regulated by the FDA which requires that prescription drugs be proven to be safe and effective for some specific indication.
However, doctors can easily get around this. For example, when they prescribe antibiotics for viral infections they are, in effect, prescribing a placebo, even if the doctor doesn’t realize it.
For general purposes, the easiest thing is for the doctor to do is to write down on a piece of paper the name of a brand name multivitamin and recommend that you take one a day. Vitamins make excellent placebos.
It depends what the doctor actually tells you about the medication.
We were taught that it is unethical to give a placebo medication. It is certainly unethical to give the patient a placebo in place of a well known drug.
Antibiotic use is out of control in the States. These are often given at the patients behest, and often are placebos.
I think placebos have a place in family practice. Lots of conditions get better when providing any treatment. But I can’t and wouldn’t tell the pharmacist to give you sugar and tell you I was given you Ativan. I might give your kid an antibiotic for his ear infection if it was painful, but I would tell you it is beneficial in less than 1 out of 7 kids not having ear pain. I might give you a vitamin shot, but I would say “I’ve had good experience giving vitamin B12 injections to many of my patients with complaints similar to yours. Although I have fouind it helpful, there are stronger medications you could take, and your other options include…” or something along those lines.
Placebo, from the latin, Placere, to please. That says it all. And i certainly agree with Dr Pap’s comments, hell, 9 tenths of what I do is placebo, as the patient would have gotten well anyway, whether they’d come to see me or not. But the reassurance they get helps them sleep better. I too would not represent a medication as something that it’s not.
Most of the time placebos are great because most of the time the patient will get well over time no matter what the health care provider does so if the health care provider prescribes a placebo and the patient takes it, the health care provider gets the credit.
But sometimes the patient has something that isn’t likely to get better and the health care provider doesn’t have any effective treatment to offer. Then the health care provider has to use a different kind of placebo. This is when you get prescriptions like: “Take a 30 min sitz bath in warm Epsom salts 6 times a day” or “limit your dietary intake of sodium to 400 mg/day” or some similar presciption that you can’t possibly comply with. This way, when you don’t get better you can’t blame the health care provider because, after all, you didn’t follow the health care provider’s advice.
Why wonder? You can look up the drug information in PDR, which some pharmacies will have available, or you can look up info on the web, including side effects and drug interactions. I recommend this as I’m a strong proponent of the idea that you should get as much information about the medicine (prescription and OTC) as you can get.
I don’t think that health care providers, in general, offer placebos when they don’t know what is going on – this would be very irresponsible if the problem could be serious. I think few physicians intentionally give advice they don’t think the patient could possibly comply with. Medications do have side effects and there is a place for symptomatic treatments such as Sitz baths.
In explaining advice to patients, ethical decisions resolve around the fact that the patient is not only fully aware of the treatment, other reasonable options, risks and benefits but has and can demonstrate a good understanding of these. This is not always easy in practice. Nevertheless, if a doctor knew a patient was unaware of “placebo” (and I think few patients would be), it would be unethical not to describe it.
Let’s say my elderly mother is a hypochondriac. Let’s say she’s insisting she has some kind of condition or disease. Let’s say her doctor, who has done everything he can to find cause for her symptoms, decides in his professional opinion to give her a placebo and mislead her, saying it’s a drug. Let’s say she starts feeling better.
maralinn, let’s turn that about a bit. Let’s say that you insist (i.e. you genuinely believe) that you have some kind of condition or disease. Let’s say that your doctor, who has done everything he can to find the cause for your symptoms, decides to give you a placebo and mislead you, saying it’s a drug.
How would you feel about that? How does that differ from the way your “elderly mother” would feel about that?
Your doctor has lied to you. He has not given you all the information that you might need to safeguard your own health. You say “Let’s say she starts feeling better.” That’s a big “let’s say.” Let’s say, instead, that she gets sicker, that her doctor missed his diagnosis. Does that not make his decision unethical in your mind? And, here’s the kicker–since he doesn’t know for sure at the time whether the placebo will make her better, what is really the ethical thing to do?
The only ethical option for the doctor to do is to admit that he doesn’t know why she feels bad. Then she can decide to get a second opinion, or to stick with this doctor and follow his suggestions for general healthy living . . . but it’s an informed choice.
I wonder a bit that you used an “elderly mother” as an
example. Is that because you think that demographic is more likely to be hypochondriac? Or that an elderly woman is less intitled to make an informed choice?
My boyfriend is an MD; so is a cousin of mine. Because I have a couple of friends who are sincerely hypochrodiacs, we have disussed this very issue.
Cousin (who has a family practice) recognises several things, First; the reason many people come to him is for sympathy and attention. They have a cold, have insurance, and feel entitled to medical care because they feel uncomfortable. He feels the best care for them is to prescribe something, be it antibiotics or OTC vitamins. Second, not only does this mollify his patients, it keeps them coming back to him. This is business.
SO has no patience for self~indulgence. He’s a radiologist, so any time he does a procedure on a patient it’s because the primary physician has ordered it. He admits he has little tolerance for patients who are seeking relief for silly things like colds; and would never prescribe a placebo treatment just to make a person feel attended to.
My cousin’s approach is good business and possibly also good medicine, in a social healer sense. My SO’s approach would not foster great relationships with some patients; but I have to say in a broader sense his may be the healthier stance.
I do not object to a doctor prescribing “something” for colds, like decongestants, antihistamines, or vitamins. However, prescribing antibiotics for a viral infection is dangerous and irresponsible because it encourages the proliferation of drug-resistant bacteria.
I was part of a study for a new anelgesic. I agreed to it out of a spirit of a spirit of “helping.”
This was following major heart surgery, and I didn’t want to say “no.”
I must have been one of the placebo receivers, because I never felt any of the benefits of pain reduction.
I had to answer qestionairres every day, and although the questioner was was well trained, my powers of observation quickly showed me that I was a “placebo.”
We’re perhaps not as stupid as they think we are.
As a sidenote, I don’t regret participating in this study. Perhaps something useful will come from it, even though I know that most studies of this type die in the water.
Surely in a properly run drug trial, the interviewer is unaware whether you are in the trial, placebo or control group. Maybe you were picking up on the interviewer’s guesses.
I would expect this to be minimised by stopping the interviewers from seeing a wide range of patients, that way they would have less chance to compare your experiences with others’.
Clairmont, are you sure that placebos were used in the drug trial you participated in? Normally, trials of pain relievers for people with serious pain do not use placebos but compare new analgesics with standard ones.
Well, I’m sure that they have a word for reduced effectiveness of a medication due to the fact that the recipient believes it to be a placebo. Or more broadly, the patient doesn’t think the medication will help, so it doesn’t, even if it should.
Clinical trials of drugs for serious medical problems will typically not include overt placebos. For instance, a a new anticancer drug will be compared to a standard chemotherapy regimen. A study of a new pain reliever might include a placebo if the patient didn’t have a condition causing severe pain.
One problem with prescribing placebos is that they have the documented capacity for causing serious or even fatal reactions, even if they are made up of innocuous ingredients. If you believe you’re getting a powerful drug, side effects are a definite possibility. That’s why the ads for prescription medications sometimes describe a laundry list of side effects but then claim that these effects “are not significantly greater than with placebo”.
Or more broadly, the patient doesn’t think the medication will help, so it doesn’t, even if it should.