Back in July of 2002 the New England Journal of Medicine published a study on arthroscopic surgery. This study featured the usual division between the control group and the experimental group. The experimental group received real surgeries and the control group went through placebo surgeries. Somewhat surprisingly, patients who received the placebo surgery reported both feeling better and performed better at walking and stair climbing than patients who had received the real surgery. After reading this study, I wrote “Lies…the Best Medicine?” and it appeared in my What Don’t You Know? While working through my massive backlog of magazines, I came across a 2018 update on placebo surgeries in Scientific America in which Claudia Wallis argued in favor of fake operations. Reminded of my ancient essay, I decided to revisit my thoughts on the ethics of using placebo surgeries.
As in my old essay, I think that there is a decent argument against using such surgeries. The basic idea is that treating a patient with a placebo requires deceiving the patient. If the effect requires that the patient believe that they have received a real surgery, then the patient must be convinced of an untruth: that they received real surgery. If the medical personnel are honest and tell the patient that the surgery was fake, then they would not benefit. If it is generally wrong to lie, then this deceit would be wrong. What would make it even worse is that medical personnel, as medical professionals, should be honest with patients. Thus, even if placebo surgery is effective or even more effective than real surgery, then it should not be used.
One interesting counter to this argument is to note that even when patients know they are receiving a placebo, it can still be effective. As such, medical personnel could be honest with patients about their receiving a placebo surgery and still maintain the effectiveness of the non-treatment. This would allow the use of placebo surgery while avoiding the moral problem of deceit. However, this does not solve the problem in cases in which patients must be kept in the dark about whether they are receiving the real surgery or not. To be specific, placebo surgery is often used to test the effectiveness of surgeries in a rigorous manner. If the real surgery is no better (or even worse) than a placebo, then there would be no medical reason to use the surgery over a placebo or no surgery at all.
It can be argued that deception in such situations is acceptable. One approach is to point out examples of acceptable, beneficial deception. Obvious examples include the benign deceits about Santa Claus, the Easter Bunny and the Tooth Fairy. As another illustration, there are the lies people tell so to avoid causing others suffering or to spare their feelings. If this sort of benign deceit is acceptable, then so is the use of deceit to produce the placebo effect or to conduct a study for the greater good.
A second approach is to focus on the purpose of the medical profession. While philosophers and scientists are supposed to seek the truth, the end of medicine is to relieve pain and prevent or cure ills. If deception, in the form of a placebo, can achieve the end of medicine, then it is just one more tool—like a scalpel or drug. In fact, it could be argued that effective placebos are even better than drugs or surgery. Surgery always involves some risk and even mild drugs have side effects. Placebos would, presumably, involve little or no risk. That said, it is worth considering that there could also be mental side-effects with placebos.
Since placebo treatment is usually not free, it could be objected that it is still wrong: patients are charged, and nothing has been done for them. If medical personnel were using placebos to cover up illnesses and injuries while pocketing profits from fake treatment, then that would be a problem. However, if the treatment is honest and works then it should be as legitimate as any other form of treatment. So, if a patient needs to see a doctor to get the placebo effect working properly and it works as well or better than the “real” treatment, then it is as reasonable to bill for the placebo treatment as the “real” treatment—although the price should be adjusted accordingly. If the placebo effect could be created without involving medical personnel, then charging patients for it would be morally problematic.
In the case of studies in which the subjects are not paying, then there would be no special moral concern for the use of the placebo—that would, in fact, be required for conducting a proper study. This does raise the usual moral concerns about conducting studies, but that is a subject worthy of consideration on its own.
How much detail must there be in the description of a procedure or a treatment to be called “truth” or “lie”?
“I’m going to prescribe a pill for you – you need to take this three times a day for a month. There are no side effects, and we believe that after a week you’ll begin to feel better, and after the full month you stand a very good chance of being cured completely”
Or, how about this one –
“There are two accepted procedures for your condition – both are somewhat invasive and must be done under a local anaesthesia, but one is far less invasive than the first. We’ve had a lot of success with the less-invasive procedure, and we’d like to start with that one”.
I think maybe your illustration of doctors “pocketing profits from fake treatments” is a bit harsh. Medicine has often been described as an art, not a science – and if a treatment is carefully established in the belief that it will work, and it does work, then doesn’t that qualify as a treatment, whether it uses an antibiotic or a sugar pill?
Physicians aren’t (for the most part) charlatans – they don’t perform some sleight-of-hand in the clinic, handing the patient some “fake” elixir while slipping the real one into one pocket of their lab coat and the cash in another, snickering at the nurse and inviting her out for drinks later on the patient’s dime.
The study of placebos is one that is little understood but is being heavily studied. It’s an area of medicine that produces some very positive response. I think that if you ask any physician about placebo treatment, they will say that it is no less real than the other options – that it has been clinically studied, there are measurable results, and in their estimation, the patient has as good a chance for a good result with a placebo as they do with option A or B, and probably with less drug interaction or unwanted side effects.
And while the patient may be in the dark as the details of the treatment, you can be sure that the insurance companies aren’t.
Best? No. If placebo worked in general, medicine could have stopped with chicken soup and homeopathy. Placebo will do nothing for infections and serious conditions.
Speaking of which, consider a placebo emergency room: https://www.youtube.com/watch?v=HMGIbOGu8q0
Placebo effects comfort patients, and make them feel better as a result. They can relieve distress and some pain, and thus suffering, and that can be a good thing when there is no available treatment of the cause.
However, in doing that, administration of placebo can mask the real problem, and prevent people from getting genuine treatment that they need. From respectfulinsolence com /2013/01/16/ more-credulous-reporting-on-placebo-effects/ (munging URL to avoid filter)
“Basically, the placebo intervention produced the illusion of improvement, which in the case of a disease like asthma, where it is function, not symptoms, that determine how sick a patient is. It is not hard to imagine a situation in which a placebo intervention falsely leads a patient to feel better, even though his pulmonary function hasn’t improved. Given the nature of asthma, such a false sense of confidence could easily lead to a patient’s death, because it’s not too uncommon for asthma patients to be reasonably functional up to a certain point of lung function deterioration and then be “tipped over the edge.” In other words, it’s not good to give asthma patients a sense of feeling better if their lungs are not actually functioning better.”
That same blogger, an MD/PhD surgeon and researcher, frequently covers tragic cases of people dying from possibly treatable cancers when given ineffective treatments that are tantamount to placebos.
See also sciencebasedmedicine org / the-placebo-narrative/ (munging URL to avoid filter)
I can believe it is possible that in some cases, prescribing a placebo is the best answer a doctor may have. However, it comes with the significant risk – and more significant in these Intertoob days – that the patient may look it up, realise what’s going on, and feel that their doctor has broken faith with them.
The other issue that study raises is that, if standard-of-care treatments are no better than placebo, they should be discontinued. However, I never jump to a conclusion based on one study.
Michael LaBossiere says
Good points; if the placebo is worse than the real treatment, then it would be wrong to use the placebo.
But, I do stand by the idea that placebo “treatments” can be morally fine. I use them on myself. For example, I have a collection of knee and leg injuries that would not be improved with surgery. Taping my knee with KT tape works best in ways that have nothing to do with providing real support-yet I feel better and run better because of the psychological effect of the tape. I also always race in black shorts, because they make me fast–that is, I think they make me faster. Even though I know they do not.
This is scratching the surface of a whole lot of ethics issues in medicine – in this case, I’m talking about testing treatments and using methods other than the old standby “tried and true”.
For example, if a doctor has a particular treatment protocol that is indicated for a particular condition that he’s familiar with, one that he knows to have say, a 65 – 85% effective rate – but learns of another, less tested and less familiar protocol that maybe boosts the effective rate to 75 – 95% in studies, what are the ethical considerations?
Maybe the side effects of the first one are well studied and heavily documented, whereas those of the second are less so …
“if the placebo is worse than the real treatment, then it would be wrong to use the placebo. But, I do stand by the idea that placebo “treatments” can be morally fine.”
I agree, but with some reservation. I think the details can definitely affect the moral assessment. For example, what, exactly, would constitute a placebo being “worse” than the “real treatment” – and what, exactly, is the “real treatment”?
One might say that “worse” means “less chance of a cure”, but would we say that a placebo is “worse” if, even thought the cure rate might be lower, it presents far less risk of complications or counter-indications than other choices?
I also think that in some cases, a placebo might be considered the “real treatment”, so I might be more comfortable calling that treatment “more mainstream”. And of course, “mainstream” differs as well – there are many Eastern remedies that are far from “mainstream” in the West – does that make them less “real”?
I have gone through a whole series of tests and treatment for some peripheral neuropathy in my toes. I’ve done blood tests and nerve conduction studies, been screened for diabetes and more – but traditional medicine has been unable to find a cause or a cure. They call it “Idiopathic Neuropathy”, and explain that “some things just have no discernible cause”.
So I tried acupuncture – and it has been a lifesaver for me. I don’t go to a board-certified guy, I go to a very holistic, “peace and love” center and get my needles there. Almost from the very first treatment, the neuropathy has subsided. So when people ask me “Does the acupuncture work?” my answer is that it does – but i don’t know if it’s my Qi or my belief that it’s working – and I really don’t care. My toes don’t hurt, and I can sleep at night. I certainly don’t think there’s anything other than anecdotal or empirical evidence from me that would indicate that it’s working – and I don’t think an MRI would show any physiological difference … so maybe that in itself is just a placebo.
As an orthopedic surgeon, my father had some strong opinions about chiropractic medicine. This was back in the ’60’s and ’70’s, of course, and the field has grown substantially since then – but he voiced his opinion thus:
(Paraphrasing, of course) “Chiropractic medicine can have some tremendous benefits. There is a lot to be said for “manipulation” and the kind of physical therapy they offer – in fact, I routinely refer patients to chiropractors for certain issues. However, the problem that I see is that there are many practitioners who do not know their limits – who believe that a spinal adjustment can cure ailments that really require a pharmaceutical or surgical intervention – and if the transition is not made at that point, they will do more harm than good.”
With a nod to CoffeeTime, I think that treatments with placebos are similar. There are areas where they work, areas where they definitely don’t work, and areas where they could work that have not been studied.
I would also say that there is a tremendous amount that we don’t know about the connections between psychology and healing, and the study of placebos and so-called “alternate medicine” are illuminating that area. The problem, of course, becomes one of ethics – to approach problems with nonstandard, unproven methods that may have a tremendous effect on many, many people in the future – or to forego that kind of research to stick to more conservative treatment that has less chance of making such a large impact.
One anecdote here –
My brother-in-law was diagnosed with a squamous-cell carcinoma on the base of his tongue. It was one of those cases where they did not “catch it early”, but maybe early enough. None of the treatment options were particularly rosy – surgery could have left him without a tongue, radiation and chemotherapy had their own issues …
Long story short, he opted for a combination of radiation and chemotherapy, and went through well over a year of futile treatment – they were able to keep the growth at bay, but not able to do anything to reduce it. Meanwhile, he went through all of the awful side effects these treatments create – weakness, nausea, headaches – he suffered tremendously, but definitely fought the good fight.
After about 18 months (may have been longer), he decided to just stop treatment. It wasn’t getting him anywhere, it was causing him to suffer greatly, and his hopes were rightly very low. It was an agonizing decision for him, one which he discussed with his wife, my wife (his sister), his mother, his kids … we really talked it out – and his decision stood.
So he stopped.
And … he went into remission. Completely. How did this happen? Could it have been that the treatments were actually exacerbating the cancer? Could it have been that the destructiveness of the chemo and radiation had compromised his own immune system to the extent that they could not fight the cancer? All possibilities. Also possible was a psychological element that we just don’t understand – maybe it had something to do with faith in the right decision, and that his increasing doubt and lack of belief in the “traditional” treatment was keeping it from working. Once he let go, his mind and body were more in harmony, and he was able to cure himself.
All I’m saying is that there is a lot we don’t know; I’m not willing to dismiss anything.
By the way, if you’re interested in the general subject of knowing whether what we believe, or test, has real effects or is distinguishable from chance, searches for “Sokal Squared” and “Many Labs psychology” might bring up some suggestive material.
Oops. Forgot about the effect of quotes. Try Many Labs 2 psychology replication without quotes.
“Ironically enough, it seems that one of the most reliable findings in psychology is that only half of psychological studies can be successfully repeated.”
Michael LaBossiere says
I’m impressed they could replicate half. 🙂
I came across an article that offered another angle to this discussion. The article was about some new medication for something or another, and the effectiveness of this drug was described in terms of its clinical results “as compared to a placebo”
I don’t know the math, but I’m willing to accept that in any clinical trial of a medication, there will be a “placebo effect” that makes results a little more difficult to interpret.
I also understand that by introducing an actual placebo into the trial, it can help to evaluate the data more accurately.
So it just puts the idea of a placebo in a somewhat different context. On one level, it can be judged on the lie that it tells, which is balanced against the potential direct benefit it might provide on some psychological level we don’t understand.
But even though we might not understand that psychology, we can observe and track it – and use it to evaluate other “real” pharmaceuticals – ones that have the potential of saving countless lives, alleviating mountains of pain, and even saving millions of dollars for every day it gets on the market earlier than it might otherwise have been approved.
From a utilitarian point of view, that would put the placebo into a completely different context when discussing the ethics or morality of its use, wouldn’t it?