Let’s say a physician concludes, after interaction with a patient and a sufficient battery of tests, that the patient’s symptoms are imaginary products of hypochondria. May the physician “prescribe” a placebo, if the physician believes that the placebo will resolve the symptoms? Or would the required dishonesty be an insurmountable ethical obstacle?
It’s not just the dishonesty that’s a problem. What if the physician is wrong? By tricking the patient into believing he’s receiving medication, the doctor may be preventing the patient from seeking out another doctor who might find something the first doc missed.
If the doctor were honest and told the patient he believed the problem was “in his head”, the patient could choose to seek a second opinion, or to accept the doctor’s view and perhaps seek counseling instead. Which might be a more reliable and effective way to deal with the problem, anyway.
Tim314, those are good points, but they don’t resolve the issue totally for me. What if we are talking about the doctor giving the second opinion? Or the fourth opinion? Or a doctor who has already advised counseling but found that the patient refuses to take that advice, or accept that the symptoms are imaginary? I assume that a hypochondriac doesn’t easily go on his merry way after he is told it is “in his head.”
What if the doctor earnestly believes, in his or her professional judgment, that a placebo is the best course? (Presumably, the doctor would tell the patient to let him or her know if the symptoms persist, of course, just as the doctor would do with any other prescribed course of treatment.)
I can’t think of any circumstances that would convince a doctor that giving the patient a placebo really was the best course of action. Hypochondria isn’t necessarily a trivial condition and convincing the patient to seek help for the real problem is not only legally safer, it’s in the best interest of the patient.
As it turns out, there has been some debate in the medical community on this issue. See, e.g., these competing views.
Doctors do prescribe placebos all the time. It is just that they happen to be valid treatments in other contexts. It used to be very common for doctors to prescribe antibiotics to patients that obviously had something other than a bacterial infections. In that context, it is a placebo.
I imagine that quite a few doctors would, when patients demand medication for a condition that will resolve on its own, quietly steer them towards ‘complementary therapies’, viz. homeopathy. This has a few advantages. One, the patient gets what they want and is out of the physician’s hair. Two, the ‘treatment’ at anything over 25X ‘strength’ is unlikely to have even a single molecule of the active substance in it; this makes it as inoffensive as water, and makes it highly unlikely that any harm will result from partaking. Three: when the patient gets better, they will say ‘What a fine doctor I have, who cured me of this illness!’, as opposed to what they’d say otherwise, which is ‘That wretched quack refused to even give me the time of day!’.
And finally, who knows? They could actually get better faster due to improved mental state. Honestly, I have trouble thinking of this as unethical. You do no harm, you possibly help the patient, the patient is happy, you are happy, and the ‘treatment’ is dirt-cheap - so the pocketbooks of everyone involved are happy. The only thing losing out in this exchange is the patient’s understanding of the world - and if the patient kept badgering for medications after continued explanations for why they’d do no good, then even that will suffer little.
I suspect my doctor gave me some back in the seventies, during a flu epidemic. I had a cold that was persistent and followed all the recommendations he prescribed but I came back two weeks later. I asked if their was anything else I could do or take and he left the room and came back with a vial of tablets and told me to take two twice a day for a week. These pills were big honkers and stark white. After my cold went away, I tried looking up in a PDR what the label said they were but couldn’t find them. I showed them to a friend of mine who was a nurse and he laughed and asked if the doctor gave them to me directly, or did I have to pick them up at the pharmacy. He told me sometimes doctors have cold or flu kits made up to give patients during such “epidemics” as a convenience for their patients. And sometimes to alleviate the problem of patients over-medicating themselves on over-the-counter medications, they give out placebos they they can take instead. :eek:
I think the patient’s wishes have to trump the doctor’s judment. What if the doctor thought the best option for a particular patient was surgery, but the patient refused? Should the doctor be allowed to perform the surgery anyway?
Of course, the risks for surgery are probably higher than the risks for giving someone a placebo, but as I tried to illustrate in my post above, the placebo is not without its own potential dangers.
I suppose a doctor could argue that unlike my example of unwanted surgery, the patient might actually be OK with being given a placebo. But I can’t imagine how the doctor could know this, and asking the patient if they’d accept a placebo of course defeats the point.
Actually this is the case in all mis diagnoses. The patient thinks he or she is being treated and so doesn’t go to another doctor and continues taking ineffective madecine.
A physician’s job is to help heal the patient. In the specific circumstance which you describe, most of us would not consider it “unethical” per se. It certainly is not illegal. It would be more common to prescribe a relatively benign and low-dose but legitimate “medication.” To many standard physicians, homeopathic medicine has created an entire industry out of prescribing what are, practically speaking, placebos.
Physicians are less likely these days to have the close paternalistic relationships they have had in the past. There was a time when it was more common for Granny to come in for her monthly B-12 injection–used as a placebo proxy. The visit was more about making her feel valued and worthy of care than it was in curing her disease. I suspect it would be rare in today’s world to have a physician prescribe a genuine placebo for any but her closest, most valued patients with who she has had a long relationship. Everyone else, particularly the hypochondriacs, would get shuffled off to another practice or else given one of the many anti-anxiety drugs on the market.
Similarly, you will often get Humibid if you go to the doctor with a cough. Same active ingedient as Robitussin, but it comes in a pill and you get a prescription.
Not that it doesn’t help a cough, but it treats specific causes of a cough, and does nothing if those aren’t the causes.
i.e. prescribing a antibiotic for the flu. Not gonna do anything, but it makes the patient feel better.
OTOH, I really wish doctors woulnd’t prescibe antibiotics for things that don’t call for them, especially considering how many people don’t finish them.
The problem is that of informed consent. The reason that medical placebos are ethically viable in clinical trials is that the subject/volunteers have exercised informed consent: they are aware that they might get a masked, randomly assigned placebo.
The problem with therapeutic placebos is in a lack of informed consent: presumably, the message from the physician to the patient is that the prescribed medication is reasonably expected to safe, appropriate and effective.
While “off-label” use of medications pushes this doctrine, placebo completely blows past any ethical boundaries: 1)the patient usually thinks that they are getting an active treatment, 2)the physician is likely lying to the patient.
If a condition does not require a treatment, or if appropriate treatment does not exist, the ethical thing is to inform the patient.
We’re well past the days of snake oil, Perkins Tractors and sugar pills. Patients at this point are, or should be, partners in the process, not puppets to be manipulated or managed by misinformation. And science and evidence should serve as the criteria for assessing treatment, not tradition or popularity.
If a patient wants to wander off into “complimentary/alternative medicine”, the least the properly trained physician/nurse/PA/whatever can do is to not apply inappropriate gravitas to these other avenues. If a patient wants to piss in the dark, so be it. But let’s be sure that they know that they’re off in scientifically blank corners.
I think it is a little unethical to prescribe placebos. If you consider giving an antibiotic when you know there is only a fifty per cent chance it will help, to be the same as prescribing a placebo – then I do this, sometimes.
First I don’t agree that ‘complementary therapies’ are cheap. These costs are in UK £, so double for dollars.
First Consultation: £70
Follow – Ups: £40
Telephone Prescriptions: £20
(unless it replaces a follow-up consultation in which case it is £40)
Packages:
3 Consultations: £135
With unlimited telephone prescriptions in between visits: £170
4 Consultations: £155
With unlimited telephone prescriptions in between visits: £210
http://www.vital-homeopathy.com/html/cost.html
They also make unsupported claims.
Used to be? Sadly enough, this continues pretty much apace.
In my medical community, which is full of uneducated patients with free prescription coverage (Medicaid) and a glut of primary care providers (mostly PAs and NPs) competing for them, a patient with the sniffles is likely to get a dose of IM Rocephin and a week of Avelox. Patients have come to see this as standard of care, and anything less means that the doctor is not taking them seriously. (I don’t do this, but patients make it clear every day what they expect.)
The justification from the medical side is that there is always a chance that the cause is bacterial–namely, acute bacterial sinusitis or strep pharyngitis. Of course, it’s not that hard to distinguish these entities from the much more common viral upper respiratory infections, but the truth is that no one really cares about my opinion.
I believe this is only ethical if you make it clear to the patient that the antibiotic is highly unlikely to have any effect. Any implication otherwise is crossing the line.
(What can we do about it? The only thing I can think of is to make patients pay for those $150 antibiotic regimens out of their own pockets.)
[hijack] This reminds me of the time some doctor told my wife to stop taking Cipro after only using three days worth of the two week regimen. Yes she had a bacterial infection. For some reason they determined Cipro wasn’t going to help, but to tell a patient to stop taking one of the most powerful antibiotics available? Were they trying to make a superbug? Later she told her regular doctor about this and she said whoever told her to stop taking it was an unqualified moron.[/hijack]
True, but in most cases the patient at least knows what their diagnosis is, and can read up on the condition and decide whether they really believe that’s what they have or if they should seek a second opinion. If they don’t know what the doctor has actually diagnosed, this is impossible. And even patients who wouldn’t normally be skeptical of a doctor’s diagnosis might be skeptical if they knew the doctor thought the problem was essentially “all in their head.”
It’s one thing if the doctor makes an honest mistake, the patient believes them, and they suffer for it. It’s another thing if the patient suffers because the doctor withheld information and effectively denies them the option of making an informed decision. People have a moral right to know what medical treatment they’re receiving and to decide whether to accept it.
Doesn’t it depend on the type of placebo?
I would think it’s one thing to give an ineffective medicine (like the antibiotic example given upthread), but quite another to give sugar tablets or the like (what I normally think of when I hear the term ‘placebo’). In this latter case, it would be rather tricky. The first thing I do when given medication is to look at the label to check the active ingredient(s), and maybe even to later Google it. Either the label would have to list “flour, sugar, oil of snake” (in which case I’d be pretty pissed off), or it would have to falsely list items of medicinal value - and that’d have to be illegal.