Doctors use placebos but don't tell patients
■ Physicians are taking advantage of the placebo effect in clinical care, but the AMA warns that deceptive use could undermine patient trust.
Nearly half of physicians use placebos in clinical care, and only 4% tell their patients the truth about it, according to a survey of Chicago academic physicians that was published this month in the Journal of General Internal Medicine.
Only 8% of the 231 physicians surveyed used placebos more than 10 times during the last year, but experts were alarmed by doctors' self-reported, less-than-straightforward conversations with patients about placebos.
The study is troubling because deceptive use of placebos is "inconsistent with what we now understand as the rights of patients to decide on treatment in a knowledgeable way and the duties of physicians to disclose to patients the treatments that they are providing," said Paul S. Appelbaum, MD, director of the division of psychiatry, law and ethics in the psychiatry department of Columbia University College of Surgeons.
Dr. Appelbaum was one of several experts who reviewed the American Medical Association Council on Ethical and Judicial Affairs' 2006 report on placebo use in clinical practice. In November 2006, the AMA House of Delegates adopted the report, which said, "Use of a placebo without the patient's knowledge may undermine trust, compromise the patient-physician relationship, and result in medical harm to the patient."
The AMA's ethical policy said doctors should ask for patients' permission to use placebos but vary the timing of when they are given so the placebo effect is not undermined. The new survey was conducted before the AMA adopted its current policy.
In the survey, doctors opted for placebos to calm agitated patients, control pain, supplement another treatment, stop patient complaints or in response to "unjustified demand for medication" or "nonspecific complaints." The AMA says placebos should not be used to mollify patients.
Among the placebos doctors used were antibiotics (prescribed for nonbacterial diagnoses), vitamins, ibuprofen, subtherapeutic medication doses, herbal supplements and saline infusions. Only 2% used prepared placebo tablets, and 1% used sugar pills.
Changing views of placebos
Though interest in the therapeutic value of placebos has grown, little research has been done recently to examine physician use of placebos in clinical settings. A 1979 Annals of Internal Medicine study of physicians at two U.S. teaching hospitals found that 78% of doctors ordered a placebo for pain relief, and 60% thought placebos were useful as a diagnostic tool to determine the reality of patient-reported symptoms.
"My impression was that placebo use had declined substantially over time to become an extremely uncommon practice," Dr. Appelbaum said. "One thing this [new] study does is to shatter that belief."
The Chicago study's lead author said results show how doctors' thinking about placebos has changed in the last 30 years, with 96% agreeing that "placebos have therapeutic effects."
"In 1979, a majority of physicians believed placebos could be used to determine whether the patient had real symptoms or was faking," said Rachel Sherman, a fourth-year medical student at the University of Chicago's Pritzker School of Medicine. "There was this sense that mind and body were divisible. Today, the belief that mind and body are connected is more widely embraced."
Scott M. Fishman, MD, chief of the pain division at the University of California, Davis, Health System, said doctors have the right instinct.
"There is no question that placebos are pain relieving, and in some cases the pain relief from a placebo might be more profound than pain relief from a standard analgesic," said Dr. Fishman, a past president of the American Academy of Pain Medicine, who said he uses placebos about once a year.
But he warned that physicians ought to take care in using placebos.
"To use a placebo ethically, it must be with the patient's informed consent," he said. "Otherwise, it is very possible that you're using the placebo to fool the patient and prove they're faking. But the placebo doesn't do that. Placebo response has been shown to be profound and pervasive. ... If someone responds with pain relief and we believe they're making it up, it shows more about us than them."