How often do you prescribe a placebo for your patients? .
By placebo, I don't necessarily just mean a sugar pill, but something that you know will have little or no real therapeutic efficacy - a vitamin or an OTC cough and cold remedy perhaps, or maybe a suboptimal dose of a drug.
According to a survey in the BMJ last month ((link), about half of doctors in the US 'admit' to using placebos on a regular basis. This set off a predictable chorus of protest in the media, with doctors accused of duping their patients and breaching the doctor-patient bond of trust.
But is it really? As one critic noted in the follow up online responses ((link), the loose definition used by the survey authors didn't really show that use of placebos was all that common - if you include things like reassurance as a placebo. But even so, is there anything wrong with using an intervention that has been so widely tested and found to be at least as good as some of the most powerful medical and surgical interventions ever devised?
After all, just because something is 'no better than placebo' doesn't mean that it is no better than nothing. Only this week, neurologists at the Women's and Children's Hospital in Adelaide have shown that placebo has a pronounced effect on migraine in children.
In a trial of high dose riboflavin they found that the number of migraine attacks was cut by at least half in 14 out of 21 children using placebo, and in 12 of 27 children who were given riboflavin. Rather than just showing that riboflavin is useless, the neurologists say their trial shows that the placebo effect is strong and needs to be taken into account when measuring the efficacy of other migraine treatments.
Which to me raises the question that if a treatment has a high response rate, is it unethical to use it, even if this means 'duping' the patient? For better or worse we live in an age when open-ness and accountability are deemed to be paramount. And yet these conditions will negate the benefit of what is otherwise a very effective, safe and freely available treatment.
It seems odd that so many untested and unproven health interventions (super clinics anyone?) get official backing. It's time we put placebos on the PBS.
Comments
Careful Michael, next you'll be promoting Homeopathy - the most widely used placebo in the world! In my opinion, there is no question that it is unethical to use treatments that you know are useless. Let the placebo response be in the way you care for your patient.
Posted by BillyJoe on Tuesday, 11 November 2008
Regarding the use of placebos, I am uncomfortable lying to my patients. If I claim that a treatment will work, I ought to give some form of credible answer to the patient's next reasonable question - "How?". I've got no problem using the placebo effect to augment a treatment, but that treatment should be valid in it's own right.
After all, so much of the placebo effect is based on the fact that the patient trusts the advice of their physician - why would I want to violate that trust and thereby reduce the potency of my placebo effect? Posted by Darren Kennedy on Tuesday, 11 November 2008
