The Debate over the Placebo Effect

One of my colleagues who trained in a rural residency in the Deep South related his experience with the use of placebos. In the area where he practiced, there was a deeply-rooted belief in the power of curses placed upon people by those who may wish them harm. Those who had been placed under a curse often suffered from a range of both mental and physical ailments.

In his desire to offer some relief, he concocted a medical treatment to purge a person of a curse. The first step was to take a tablet of niacin followed by a tablet of pyridium. The niacin caused predictable flushing (the curse rising out of the body) and the pyridium caused the patient’s urine to turn orange (the curse being flushed out of the body). I laughed when he told me of his “cure,”  but it is a great example of the challenge of placebo use.

Recently, I discussed the hypothetical example of using a placebo for a medical condition that was largely psychiatric. The patient believes they are experiencing a physical symptom but the symptom is actually a manifestation of the mind. How far is it ethical to go to alleviate suffering? Is it permissible to give a relatively harmless treatment (for example, a saline infusion) if the end goal provides diagnostic clarity or provides relief for an affected patient?

The AMA cautions us against the use of placebos, advising in its opinion statement on the use of placebos in clinical practice that they should only be used after patients have been both informed and are agreeable to the use of one. The logical mental leap is that a placebo of which a patient is knowledgeable may fail to exert its desired effect. The AMA does give examples of ways to both inform the patient and try to maintain a placebo effect.

One argument against the use of placebos is that, if a patient finds out his physician used a placebo, his trust will be eroded and future care will be compromised. One argument for the use of placebos is that it can be a low-risk way to alleviate human suffering. While I’ve never used a technique like my colleagues mentioned above, I have taken advantage of the placebo effect to highly endorse a proven therapy in order to increase the patient’s confidence in a treatment. I’ve also used it to downplay possible side effects that I do not think are actually related to a medication - indeed some side effects occur with equal frequency in those receiving an active drug and those receiving placebo.

There was a time when physicians could act with broad authority to do pretty much whatever they believed, in their expert opinion, would help the patient. This sometimes resulted in outright harmful or dangerous treatment. In our current climate, we feel compelled to act with diligence based on not only our opinion but also based on medical knowledge and what most of our peers would do. The standard has changed.

I understand the concern the AMA expresses in the use of placebos, but I also respect the compassion my colleague demonstrated by using his magic cocktail of “curse cure” to alleviate the heavy burden his patients were carrying.