“Is This a Real Treatment?”: The Placebo Conundrum

by Anthaea-Grace Patricia Dennis

Graphic design by Anne McGrath

Media coverage has drawn attention to the ongoing practice of prescribing placebos to treat medical conditions.¹ There are competing views on the current methods and the ethical quandary. Patients and prescribers should clearly understand the positions and issues associated with placebos to resolve current conflicts. “Placebo” originally meant a “medicine given more to please than to benefit the patient” in the 19^th century.² Since then, placebos have been routinely used in clinical trials as controls to confirm the efficacy of treatments. The basic blinded study consists of groups receiving a “treatment” option that is being tested for its utility against a “placebo” control. These studies do not evaluate the placebo itself.

The “placebo effect” refers to the positive psychological and physiological effects observed when a treatment with no active ingredients is directed at a patient’s medical condition.³ A patient who anticipates negative results experiences the nocebo effect. Placebos take many forms, including sugar pills, vitamins, antibiotics, saline injections, and any treatment method where there are no known effects on the condition for which they are prescribed.⁴ Meanwhile, placebos’ utility has been shown in a range of contexts including treatment for pain, depression, irritable bowel syndrome, epilepsy, and Parkinson’s disease.^3,5

In some situations where placebos have been prescribed and found to be effective, cognitive behavioral therapy has also been used to develop awareness, help patients change their behavior, and address their circumstances. In one study, patients with depression were found to respond better to placebo pills when they were told it was a fast-acting antidepressant.⁶ The researchers acknowledged that patients who believe their prescriber is invested in treating their depression may be more likely to experience positive sentiments towards their treatment, benefiting their prognosis.⁶ By comparison, patients with depression who were aware they were receiving an inactive control did not benefit from the placebo.⁶ This study suggests that, in some cases, disclosing the nature of the treatment may have negative effects. Notwithstanding the potential for placebos to ameliorate quality of life, prescribers may not fully inform their patients. Some prescribers deny that they are prescribing placebos, painting a problematic and unethical picture.

In a few surveys, primary care doctors, internists, and rheumatologists have admitted to prescribing placebos regularly.⁷ Recent studies have found that the use of placebos and noneffective medications is 79±7% in Canada and 52±6% in the United States.^5,7 Harris, Campbell, & Raz (2015) reported that while 40% of Canadian prescribers admitted to prescribing “unwarranted” vitamins, about 75% of prescribers claimed they had never prescribed a placebo.⁷ This discrepancy suggests that prescribers do not view “impure” placebos (e.g. vitamins & antibiotics) as placebos, even when their use has no “demonstrated or expected clinical efficacy”.⁸

The Canadian Medical Association’s Code of Ethics provides standards for physicians, including responsibility to “communicate with and help the patient assess material risks and benefits before consenting to any treatment or intervention”.⁹ By comparison, the American Medical Association’s Code of Ethics explicitly states that physicians should explain the utility of the placebo to the patient before prescribing it.¹⁰ Both Codes suggest patients should know they are receiving a placebo. The ethical principle of beneficence obligates prescribers to choose treatments that are best for the patient. In 2015, 59% of Canadian doctors believed that prescribing placebos for pain management had a positive impact on a patient’s psychological and physiological health.⁵ Some prescribers believe that placebos will not benefit the patient if they disclose that the treatment is a placebo. However, other studies have revealed that even when patients are aware they are receiving a placebo, (referred to as an “open-label” condition), the placebo effect still occurs, negating the need for deception.^11-13 In fact, research supports that open-label placebos may lead to psychological and physiological improvement, benefiting the patients more than the standard treatment.^14,15

Doctors may be disinclined to explain the details of their decisions to their patients, dreading appointments will be longer because the patient will want to know everything about why a medicine is chosen. Despite this, lack of transparency affects more than just the time prescribers spend explaining treatments to patients. Patients have the right to “make decisions about the care a physician recommends”.¹⁶ Patient autonomy allows a patient to refuse treatment and engage in unhealthy behaviors; patients should be allowed to refuse a placebo treatment and opt for something else.

If patients’ awareness of placebos within their treatment protocol does not negatively impact the placebo effect, then it is counterproductive to keep patients uninformed. Prescribers should seek patients’ consent to prescribe placebos, and if refused, provide an alternative treatment. Prescribers should limit recommendation of placebos to circumstances when placebos are likely to improve symptoms, not just placate the patient, to avoid masking conditions and delaying real treatment. Ultimately, open communication may assist in resolving the ethical dilemma of the use of placebos. Through discussion between patients and their prescribers regarding their viewpoints on placebos and patients’ desired transparency, an agreement can be reached between patients and their prescribers unique to each patient.

References

1. Silva B. McGill study reveals the placebo effect of personalized treatments. National Post. 2023 Jul 19;

2. Beecher HK. The powerful placebo. J Am Med Assoc. 1955 Dec 24;159(17):1602–6.

3. Newman T. Is the placebo effect real? Medical News Today. 2017 Sep 7;

4. Fent R, Rosemann T, Fässler M, et al. The use of pure and impure placebo interventions in primary care – a qualitative approach. BMC Fam Pract. 2011 Mar 24;12:11.

5. Harris CS, Campbell NKJ, Raz A. Placebo Trends across the Border: US versus Canada. PLoS ONE. 2015 Nov 25;10(11):e0142804.

6. Peciña M, Bohnert ASB, Sikora M, et al. Association Between Placebo-Activated Neural Systems and Antidepressant Responses: Neurochemistry of Placebo Effects in Major Depression. JAMA Psychiatry. 2015 Nov;72(11):1087–94.

7. Tilburt JC, Emanuel EJ, Kaptchuk TJ, et al. Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists. BMJ. 2008 Oct 23;337:a1938.

8. Harris CS, Raz A. Deliberate use of placebos in clinical practice: what we really know. J Med Ethics. 2012 Jul;38(7):406–7.

9. Canadian Medical Association. CMA Code of Ethics and Professionalism [Internet]. 2018 [cited 2023 Sep 28]. Available from: https://policybase.cma.ca/viewer?file=%2Fmedia%2FPolicyPDF%2FPD19-03.pdf#page=1

10. American Medical Association. Use of Placebo in Clinical Practice [Internet]. AMA Code of Ethics. [cited 2023 Sep 26]. Available from: https://code-medical-ethics.ama-assn.org/ethics-opinions/use-placebo-clinical-practice

11. Blease C, Colloca L, Kaptchuk TJ. Are open-Label Placebos Ethical? Informed Consent and Ethical Equivocations. Bioethics. 2016 Jul;30(6):407–14.