Download please click here. - Queen Anne`s School

Queen Anne’s School
Lower Sixth Essay
Chloe Naylor
SHOULD DOCTORS BE ABLE TO PRESCRIBE PLACEBOS TO PATIENTS?
“In the movie classic, The Wizard Of Oz, the wizard did not actually give the
scarecrow a brain, the tin man a heart and the lion courage, but they all felt better
anyway” Hale (2016). This relates to the power of the placebo effect: “a remarkable
phenomenon in which a placebo - a fake treatment, an inactive substance like sugar,
distilled water, or saline solution - can sometimes improve a patient's condition
simply because the person has the expectation that it will be helpful” medicinenet
(2016).
Numerous debates currently focus on how placebos are used in health research but
overlook its benefits in clinical practice. Biller (1999) quoted by Biller-Andorno (2004)
said: “Modern medicine focusing on specific interventions seems to be at odds with
this hard-to-grasp phenomenon that has existed in medicine from its very beginning.”
The long standing history of placebos in medicine have the reputation of being
involved with delusion and deception, sharing in the disrepute of traditional
paternalism but they are actually a phenomenon that is constantly trying to find its
place as a valuable component in the field of medicine.
There have been some valuable recent retrospective studies where considerable
numbers of double-blind trials have been carried out and critically analysed with
respect to the placebo effect. The fact that the placebo baseline is not zero is an
important concept that affects the final statistical reading of an active drug.
Interestingly those in the placebo group can experience as positive effects compared
to the effects of the real drug therefore, the questions to be addressed are thus; a)
how well do we understand the physiological impact of taking placebos, b) what are
the psychological reasons behind this and c) how to employ them in an ethically
acceptable manner. Arguments from opponents about the clinical use of placebos
will also be deliberated. This essay will discuss the above questions and issues
resulting to the conclusion that the use of placebos in clinical practice has great
potential.
A great deal of scientific investigation has been carried out by various researchers in
order to examine the effect of placebos on patients.
The most cited work of placebo effects was completed by Beecher in the 1950s. He
researched the effects of placebos on pain relief on a broad range of clinical
situations ranging from headaches to severe post-operative pain. His results showed
that half of the patients he studied felt better with placebo drugs. His double-blinded
study on placebo indicated that on average 35% patients received satisfactory relief.
Similarly, another study published later in 1985 by Evans confirmed this. Evans
carried out studies by comparing placebos to active drugs in his double blind trials
1
Queen Anne’s School
Lower Sixth Essay
Chloe Naylor
rather than treating the placebo as an analgesic. He discovered that the
effectiveness of a placebo is proportional to the effectiveness of the active analgesic
agent. Like Beecher he concluded that “placebo is about 55-60% effective
irrespective of the potency of these active medications.” (Evans 1985)
Moseley et al (2002) did an interesting investigation by conducting a randomised
placebo-controlled study that included 165 patients with osteoarthritis. He found that
simulated arthroscopic surgery (where just the skin is incised and no instruments are
inserted) was effective in improving pain and function as to arthroscopic lavage or
debridement over a two-year period. This placebo phenomenon has shown that “the
act of administering treatment, regardless of its properties, can deliver health
benefits.” (Darragh et al 2016)
One can challenge that the effectiveness of placebos can result in failure in
recognising the benefits of useful drugs and procedures. Heeg et al (1997) gave an
example of a study from a group of researchers at Scripps Clinic, University of
Michigan and San Diego State: “The group critically re-examined a massive amount
of data from five medical and surgical treatments that were once considered
beneficial but were subsequently abandoned as ineffective.” Furthermore, they
discovered over 6900 patients suffering from conditions such as duodenal ulcers and
herpes showed good to excellent improvement with useless treatments.
Placebo effect was so powerful that in a study of pain relief on bone metastasis by
Boreau et al (1988), he found that 51% out of 38 patients and 57% of doctors found
placebo effect helps relieves pain.
Gracely et al (1983), who were a group of dental researchers, investigated pain relief
from a group of 89 patients who had a surgical removal of an impacted molar. A
quarter were administered with a post-surgical placebo and the other three-quarters
were given no treatment. The results showed that the placebo significantly reduced
pain over the no treatment group and even had a strong effect on the swelling. This
is supported by another study where Hashish et al (1988) revealed, while extracting
a wisdom tooth from his patient; pain relief was effective whether or not his
ultrasound machine was switched on provided that the patient and clinician believed
that the machine was operational.
These numerous studies have proven to us that placebos can really have impressive
and powerful effects on patients that can sometimes trigger actual chemical changes
in the human body, but why? The chemical composition of the substance itself
cannot be responsible for the final outcome. In the following paragraphs we will
discuss how the genetic makeup of an individual, the substance design and the
doctor’s relationship with their client may stimulate the placebo effect.
2
Queen Anne’s School
Lower Sixth Essay
Chloe Naylor
The genetic makeup of an individual, suggesting some issue in their personality
relating to their psychology, has been (wrongly) thought to make them more
responsive to placebo effects. The ‘placebo personality factor’ was the center of
placebo study and was investigated for decades. However, there is still no solid
evidence that suggests placebos will affect certain people more than others.
Therefore, it seems reasonable that this effort was abandoned. On that account, this
supports the idea that placebos should be prescribed in clinics as a vast range of
patients with different DNA seek advice from doctors and genetic tests which many
people would not want done (due to privacy issues) to perhaps identify placebo
responders would not need to be carried out. What actually seems to aid the placebo
effect of an individual is their expectations and environment at the time.
The substance design of a placebo has also been studied and results interestingly
show that “coloured pills have more of an effect than white pills; injections were more
effective than tablets in certain populations and culture, higher priced items are
judged to be more effective than cheaper ones and branded pharmaceuticals appear
to be more effective than generics” (Arnold et al 2014). These findings illustrate how
certain factors can influence the patient’s view on the medication other than the
actual chemical composition of it. Therefore, even if the drug was active and not a
placebo, clients would already be judging the substance.
On the other hand, it is arguable that the interaction between the doctor and patient
has the largest effect on placebo response. An understanding patient-clinician
relationship where the patient’s concern is respected and supported nourishes the
placebo effect. This is further demonstrated by the nocebo effect. These responses
are opposite to the placebo effect and instead of having a positive effect; a negative
effect is experienced because the patient has a negative expectation. Clinician
actions that can trigger these responses are by being untruthful, uncompassionate
and unsympathetic. This highlights that clinicians need to be aware of their
responses and remember to engage with their patients, they need to be positive,
compassionate, reassuring and encouraging. Perhaps what we call the ‘placebo
treatment’ is just the virtues of the profession itself. Justman (2011) concluded that
clinicians’ approaches play an enormous role in the practice of medicine even
though neither doctors nor patients like to admit it. Maybe what we need to realise
here is that doctors’ attitudes to their patients have a massive impact on their
patient’s outcomes and for all one knows, this relationship is the real reason for the
psychological affect. “Eleven minutes may be enough to make an organic diagnosis
and write a prescription, but are they enough to heal?” (Justman 2011)
In the ‘placebo and nocebo effect’ article, Arnold et al (2014) thought-provokingly
concluded that doctors should be more conscious of patient care relationship and
3
Queen Anne’s School
Lower Sixth Essay
Chloe Naylor
what effect that has. Today, the post-modern clinician has limited time for patients
because of the vast increase of patients they consult and the short supply of doctors
in our society. It is arguable that if doctors were given more time to diagnose or talk
to patients, they could relieve some of the patients’ symptoms but this we know is
unpractical in the real world.
The time constraint and demanding patients expecting to take medication back after
their visit to a doctor, puts pressure on clinicians to simply prescribe antibiotics
without appropriate sampling. This is where a placebo could have been used
instead. One can also argue that this plays a significant part of why there is the multiresistant antibiotic dilemma today.
The evidence here proves many factors other than the chemical composition of the
drug psychologically affects patients which can affect how they respond to the
substance. ‘Real’ medication is already causing psychological effects on patients so
what’s not to say we can’t produce a placebo playing on these psychological effects?
A common misconception is doctors prescribing placebos to their patients are
hypnotising, deceptive liars prescribing harmful unknown medications – like a witch
mixing up ingredients in a cauldron and trying to poison her victims. Many of us don’t
see that the actual scenario is of a caring clinician who puts patients in their best
interest, prescribing natural, harmless substances. So under what circumstances can
we justify placebo treatment? “Given the considerable populations of patients that
medicine cannot provide with a cure or sufficient symptom reduction, medicine
cannot simply afford to neglect the therapeutic potential of the placebo effect.” (BillerAndorno 2004)
Placebos are encircled by plenty of moral issues but do we think it is morally correct
to “neglect” a patient? Do we give this person no active medication when knowingly
there is an “alternative” form of treatment available? Perhaps we need to look at the
phrase ‘fake treatment’ in a different light. Imagine if there is no cure for the patient
but the clinician believes that the very least he/she could do is prescribe a placebo to
relieve the symptoms so that the patient at the very least can feel better and believe
that something is being done to help them. We can argue that this is morally correct.
Placebos cannot be prescribed as openly as they once could have been. The
American Medical Association Code of Ethics firmly regulates the use of placebos in
clinical practice. However, if we think of placebos as a benefit arising from a
treatment, not something to treat a certain condition, then the employment of
placebos does not have to be so deceptive.
When we think of the word: ‘lying’ we imagine it in a pessimistic way. A liar is
someone who is associated with selfishness – they lie usually for their own benefit.
4
Queen Anne’s School
Lower Sixth Essay
Chloe Naylor
They know the truth but they purposely lie. However, if a clinician prescribes a
placebo do we class this as ‘lying’? My dad tells the time 10 minutes earlier than
what it actually is on school mornings to make sure I’m not late for school. He would
say it is “around” or “about” this time. He never says it is exactly this time – that, we
could say, is lying. The time he tells me is vague but he knows it will make me get
ready quicker. It is for my own benefit. Is this lying? A doctor prescribing a placebo
may be ‘vague’ about how he/she describes it but it is for the patients’ own benefit.
Of course offering a sham treatment pretending it is an active treatment involving the
deceit of patients is wrong. It is possible to use the placebo effect in a way that is
more ethically acceptable to our society. Another possibility is that the patient is
informed of respective therapeutic concept, the patients’ autonomy is respected and
the doctor genuinely is concerned and wishes to give the patient the best care and
support.
An article written by Ratini (2016) in a study by Tilburt concluded that from their
interviews with internists, rheumatologists and doctors who deal with illnesses and
pains that are difficult or impossible to cure said: “I don't think doctors have anything
but the patients' best interest in mind when they give a placebo prescription. They
are thinking about both the physical and psychological well-being of the patient.”
Biller-Andorno (2004) sketched out his ‘framework of preconditions for an ethically
acceptable use of the placebo effect in clinical medicine summarising it in these
words: “informed consent, trust, respect for patient’s autonomy, empowerment, best
therapeutic concept, care, support.” These words justify how placebos could be
employed in clinical practice.
There are many opponents who challenge the use of placebos in medicine and we
will discuss their opinions:
1) Not all studies show that placebos are almost as good as or as effective as
active medication.
Many opponents refer to the meta-analysis conducted by Hrobjartsson and Gotzsche
(2001) which came to the conclusion that placebos have no significant effect.
However, the meta-analyses indicate that placebo effects do exist and they cannot
be rejected as unimportant or irrelevant. In addition, there is a substantial amount of
bias in certain studies which try to hide the true effects of placebos. “Instead
researchers need to face placebo results without embarrassment and accept them
as a fact of medical research”. (Heeg et al 1997)
5
Queen Anne’s School
Lower Sixth Essay
Chloe Naylor
2) Placebos do not always work, only in certain conditions, and they do not even
affect everyone - some conditions will never respond to placebos.
It is true that there will not always be a response to placebos but there are many
conditions such as chronic pain which have very few alternative treatments. Is it not
worth at least giving a placebo a go with these patients? Prescribing a placebo to a
patient with chronic pain who then feels a lot better after taking it surely is better than
giving this person no treatment or letting them suffer side effects of a drug that won’t
help them thereby inducing extra financial costs?
3) Placebos are ethically incorrect. Some people claim it is always wrong for a
doctor to lie to their patient.
The thought of a fake substance making you feel better scares people and makes
them feel uncomfortable. However, is prescribing a placebo really classed as lying?
Can it be morally correct if it is for the patient’s own good? Even if your answers to
the first question is ‘yes’ and the second question is ‘no’, approaches where doctors
do not actually ‘lie’ to their patients about giving them a placebo have been
researched which showed the placebo effect still occurred. This may help to solve
some underlying ethical implications but the topic of doctors deceiving patients is an
urgently needed discussion and more evidence needs to be collected.
Clinical use of placebos has great potential. There is clear evidence that indicates
placebos can be as effective as active medicine physically and we are starting to
realise the psychological reasons behind this. We are certainly able to make
placebos as effective as possible by changing the colour, shape, size etc. of the
substance. Maybe we need to take a closer look at consultation times and remind
doctors to give patients as much support and care as time allows. There are still a
vast number of medical conditions that cannot be cured which have a huge impact
on people’s lives. For now, whilst scientists search for cures, surely placebo
prescription should be available to at least relieve the symptoms?
“It begins and ends in your mind. What you give power to, has power over you, if you
allow it” – Leon Brown
6
Queen Anne’s School
Lower Sixth Essay
Chloe Naylor
References
Anderson L (2013) What is a Placebo Drugs https://www.drugs.com/article/placeboeffect.html (assessed on July 2016)
Arnold M.H. Finniss D.G. Kerridge I. (2014) Medicine’s inconvenient truth: the
placebo and nocebo effect Internal Medicine Journal 44 p.398-405
Biller-Andorno N. (2004) The use of placebo effect in clinical medicine – ethical
blunder or ethical imperative? Science and Engineering Ethics 10(1) p.43-50
Darragh M, Yow B, Kieser A, Booth RJ, Kydd RR and Consedine NS (2016) A takehome placebo treatment can reduce stress, anxiety and symptoms of depression in
a non-patient population Australian & New Zealand Journal of Psychiatry Vol 50(9)
p858-865
Feinburg C. (2013) The Placebo Phenomenon Harvard Magazine
http://harvardmagazine.com/2013/01/the-placebo-phenomenon (assessed on July
2016)
Geers A and Ross J (2011) Treatment Choice and Placebo Expectation Effects
Social and Personality Compass Vol 5(10) p734-750
Gold A and Lichtenberg P (2014) The moral case for the clinical placebo Journal of
medical Ethics Vol.40 (4) p219
Hale J and M.S. (2016) The Amazing Power of the Placebo Effect PyschCentral
http://psychcentral.com/blog/archives/2011/08/15/the-amazing-power-of-theplacebo-effect/ (assessed on August 2016)
Hrobjartsson A and Gotzsche P (2001) Is the Placebo Powerless The New England
Journal of Medicine Vol.344 No.21 p1594 - 1602
Heeg MJ, Deutsch KF, Deutsch E. (1997) The placebo effect European Journal of
Nuclear Medicine 24(11) p.1433-1440
7
Queen Anne’s School
Lower Sixth Essay
Chloe Naylor
Hunsley J. Westmacott R. (2007) Interpreting the Magnitude of the Placebo Effect:
Mountain or Molehill? Journal of Clinical Psychology 63(4) p.391-399
Howick J. Friedemann C. Tsakok M. Watson R. Tsakok T. Thomas J. Perera R.
Fleming S. Heneghan C. (2013) Are Treatments more effective than Placebos? A
Systematic Review and meta-analysis Vol 8 (5) p1-8
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0062599 (assessed
on July 2016)
Justman S. (2011) From medicine to psychotherapy: the placebo effect History of
The Human Sciences 24(1) p.95-107
Louhiala P. Hemila H. Puustinen R (2014) Clinical use of placebo treatments may
undermine the trust of patients: a response to Gold and Lichtenberg Journal of
Medical Ethics 40(11) p.787-788
Lichtenberg P, Heresco-Levy U, Nitzan U (2003) The ethics of placebo in clinical
practice Journal of Medical Ethics vol.30. no.6 p.551-554
http://jme.bmj.com/content/30/6/551.full (assessed on August 2016)
Leon Brown Quote http://happymap.com/blog/wpcontent/uploads/2013/04/q01+your+mind+is+powerful.jpg (Assessed on August
2016)
MedicineNet (2016) Definition of Placebo effect MedicineNet
http://www.medicinenet.com/script/main/art.asp?articlekey=31481 (Assessed on July
2016)
NHS Choice (2016) The placebo effect and complementary and alternative medicine
NHS choices http://www.nhs.uk/Livewell/complementary-alternativemedicine/Pages/placebo-effect.aspx (assessed on July 2016)
National Cancer Institution (2015) Placebo Effect American Cancer Society
http://www.cancer.org/treatment/treatmentsandsideeffects/treatmenttypes/placeboeffect (assessed on July 2016)
8
Queen Anne’s School
Lower Sixth Essay
Chloe Naylor
Owens JE and Menard M (2011) The Quantification of Placebo Effects Within a
General Model of Health Care Outcomes The journal of Alternative and
Complementary Medicine Vol 17 (9) p 817-821
Ratini M., DO, MS (2016) What is the Placebo effect? WebMD
http://www.webmd.com/pain-management/what-is-the-placebo-effect (assessed on
July 2016)
Raz A.L, Campbell N, Guindi D, Holcroft C, Déry C, Cukier O (2011) Placebos in
clinical practice: comparing attitudes, beliefs, and patterns of use between academic
psychiatrists and non-psychiatrists PubMed.gov
http://www.ncbi.nlm.nih.gov/pubmed/21507276 (assessed on August 2016)
Smith G. (2016) The moral implications of placebos The British Pysocological
Society, https://thepsychologist.bps.org.uk/moral-implications-placebos (assessed on
August 2016)
Silberman S. (2009) Placebos are getting more effective. Drug makers are desperate
to know why. Wired http://www.wired.com/2009/08/ff-placebo-effect/ (assessed on
July 2016)
Wikipedia (2016) Placebo Wikipedia https://en.wikipedia.org/wiki/Placebo (assessed
on July 2016)
9