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Ethical framework for the use of sham procedures in clinical trials

Horng, Sam BA; Miller, Franklin G. PhD

doi: 10.1097/01.CCM.0000054906.49187.67

Ethical, professional, and financial considerations support the highest standards in demonstrating the safety and efficacy of new clinical interventions. Professional and regulatory mechanisms implemented to ensure that medical agents undergo a thorough process of systematic testing are lacking in the case of medical procedures. As a result, many procedures, including surgery, are rapidly introduced into the clinical setting without reliable evaluation of their efficacy. In many cases, a randomized, placebo-controlled procedure trial may be necessary to provide this data. We examine the major ethical objections to placebo-controlled procedure trials, including those involving sham surgery, and provide an ethical framework for assessing whether a placebo procedure is ethical to administer in the context of a clinical trial. A placebo-controlled trial of an invasive procedure can be ethically justified if: 1) there is a valuable, clinically relevant question to be answered by the research, 2) the placebo control is methodologically necessary to test the study hypothesis, 3) the risk of the placebo control itself has been minimized, 4) the risk of a placebo control does not exceed a threshold of acceptable research risk, 5) the risk of the placebo control is justified by valuable knowledge to be gained, and 6) the misleading involved in the administration of a placebo control is adequately disclosed and authorized during the informed consent process.

From the Department of Clinical Bioethics, National Institutes of Health, Bethesda, MD.

Address requests for reprints to: Franklin G. Miller, PhD, Warren G. Magnuson Clinical Center, Building 10, Room 1C118, National Institutes of Health, Bethesda, MD 20892-1156. E-mail:

The views herein are those of the authors and do not represent the views or policies of the Department of Health and Human Services or the National Institutes of Health.

Important scientific, clinical, and social interests support the use of placebo-controlled trials of procedures.

© 2003 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins