When my daughter hurts herself, her placebo of choice is a “magic kiss”. This therapeutic intervention must be applied with care specific to the area of injury. Anecdotal evidence suggests that it is very effective. I use placebo freely at home but is it right to do this in the clinic? In a recent post I suggested that we can be more confident that acupuncture is essentially a placebo treatment. Still, patients feel benefit, so is it still OK to use it? I have often heard clinicians declare “I don’t care if it is a placebo if it works”.
Franklin Miller from the Department of Bioethics at the NIH considers these kinds of questions for a living. He has published a number of papers around this topic including this great review with his colleague Luana Colloca on the ethics of placebo in clinical practice. I was lucky enough to have a correspondence with him that had me thinking about this more deeply.
The big tension around offering a treatment that we know to be just a placebo lies with the competing interests of being committed to reducing suffering and the need to be transparent and offer informed consent. Offering a known placebo usually requires an act of deception that in its way, undermines the relationship between clinician and patient. Of course if you could offer a placebo, be honest about what you were doing and still have a powerful effect there would be no problem.
Thinking about the ethics of all this in the therapies I see something of a division. We have many passive modalities that may well work by placebo (acupuncture, maybe manipulation, electrotherapy etc: let’s call these “magic kisses”). Any placebo effect of these therapies in part rests on the effects of expectation, belief in the treatment and possibly a re-evaluation by the patient of their symptoms. Then we have therapeutic approaches like advice, pain education, CBT, lifestyle adaptation, which again seek to push patients to re-evaluate their symptoms and alter their behavioural responses (let’s call these “rational hugs”). Even with a partially shared mechanism of effect there seems to me to be a clear difference – rational hugs do not require a belief in a mystery magic ingredient, and aim to empower the patient by offering a solution that they might control. Even if we found that the effect sizes were similar between the 2 types, there are no fibs being pushed in the second.
Two other points occurred to me. The first lies around the issue of patient choice. Why do patients choose acupuncture or manipulation or ultrasound etc? I guess they do because each treatment has passionate advocates who promote them, advertise them, spread the word about them, often with a willing media tagging along like an enthusiastic labrador. So the treatments help because patients expect them to, but patients only expect them to because the culture that delivers those treatments has propagated that belief! It’s a fabulous business model (it all costs) but I smell a conflict of interest. Patient choice is difficult in a world where good information is so elusive.
The second point lies in the possible long-term harms of offering passive treatments of limited efficacy. These are much harder to measure than the short-term benefits. Treatments such as manual therapy that are based on models of pathology (that might not be identifiable or relevant) might lead to increased catastrophising and negative beliefs about what should be relatively benign conditions. Recently a number of big studies have suggested that therapies for whiplash associated disorder are a risk factor for poor outcome or delayed recovery. This isn’t the clear support for my theory of the superiority of rational hugs over magic kisses as it at first appears. Not only passive therapies like chiropractic but also therapies including advice, pain education and clinical guideline-based management (see here and here) show this trend. Maybe offering any treatment increases vigilance and attention to symptoms and thus perpetuates symptoms in somatic syndromes? I wonder whether any short-term benefits of placebo might be offset by these dangers. It seems that any therapy may have the capacity do harm, even where it is not immediately obvious.
Given the generally small clinical effects of placebo, the potential for undermining trust in the therapeutic relationship and a sinking feeling that it’s a bit demeaning for all involved, I think that if we know a treatment is essentially a placebo we might give it the elbow. We should celebrate the fact that the placebo effect is still there offering a helping hand when we deliver effective treatment with care. So let’s hear it for rational hugs.
PS: For a nice little chat about placebo from Ben Goldacre click here.
Miller FG, & Colloca L (2009). The legitimacy of placebo treatments in clinical practice: evidence and ethics. The American journal of bioethics : AJOB, 9 (12), 39-47 PMID: 20013499
Cassidy, J., Carroll, L., Côté, P., & Frank, J. (2007). Does Multidisciplinary Rehabilitation Benefit Whiplash Recovery? Spine, 32 (1), 126-131 DOI: 10.1097/01.brs.0000249526.76788.e8
Côté P, Hogg-Johnson S, Cassidy JD, Carroll L, Frank JW, & Bombardier C (2007). Early aggressive care and delayed recovery from whiplash: isolated finding or reproducible result? Arthritis and rheumatism, 57 (5), 861-8 PMID: 17530688
Hróbjartsson A, & Gøtzsche PC (2010). Placebo interventions for all clinical conditions. Cochrane database of systematic reviews (Online) (1) PMID: 20091554
Pape E, Hagen KB, Brox JI, Natvig B, & Schirmer H (2009). Early multidisciplinary evaluation and advice was ineffective for whiplash-associated disorders. European journal of pain (London, England), 13 (10), 1068-75 PMID: 19181548
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