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Why Neurologists Prescribe Placebos

ARTICLE IN BRIEF

Neurologists discuss the situations in which they might prescribe placebos — and the ethical implications.

About half of US internists and rheumatologists prescribe placebos despite longstanding ethical qualms about the practice, according to a report that appeared online Oct. 24 in the British Medical Journal (BMJ).

The investigators, led by Jon C. Tilburt, MD, assistant professor of medicine at the Mayo Clinic in Rochester, MN, who was previously a staff scientist at the NIH Department of Clinical Bioethics, surveyed 600 internists and 600 rheumatologists – physicians who commonly treat patients with debilitating chronic conditions. Of the 679 respondents, about half reported routinely recommending placebos such as vitamins or mild analgesics, while a smaller number prescribed antibiotics and mild sedatives. Although not inert, these drugs were prescribed primarily for their effect on the psyche, the physicians reported.

The results of the BMJ survey are almost identical to a similar study conducted in 2003 in Denmark, and to smaller surveys conducted in Israel, Britain, Sweden, and New Zealand.

The American Medical Association (AMA) discourages doctors from representing a placebo as helpful. “In the clinical setting, the 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 policy states.

But because placebos can be so effective with neurological disorders, some neurologists are tempted to suggest them, even though the practice raises ethical concerns.

THE ‘PLACEBO-LIKE’ QUANDARY

“A lot of what we do could be construed as placebo-like, and that's not necessarily wrong,” said John Corboy, MD, co-director of the Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus, “but it has implications morally and financially, and we need to own up to these conflicts.”

For example, Dr. Corboy said some patients with multiple sclerosis (MS) may want to be treated even though they have a form of the disease that does not respond to standard medications.

“They really want to be treated, so you may want to treat them, but these are expensive drugs that may cost $20,000 a year,” he said. “Is this placebo treatment, or is it malpractice, or both? Another duty to the patient and to society involves controlling health care costs. If you're talking about something that costs two cents a day, that's one thing, but $20,000 a year is a mighty expensive placebo.”

Because he finds deceiving patients unethical, Dr. Corboy tells the patient when he prescribes a medication with a low likelihood of being effective. Glatiramer acetate (Copaxone) for the treatment of primary-progressive MS, for example, may arouse an expectation of benefit in a patient, but a 943-person study has shown that the drug is not effective for that form of the disease.

“It's our ethical duty to be honest with the patient and say, I don't think this is going to work, or at least that data from studies does not support its use,” Dr. Corboy said. “Now, if you do that, are you destroying any potential placebo effect by altering their expectations? I think that's a confusing aspect. To make a placebo work you'd have to make patient believe it will work, but I've made a major effort to stick as much as possible to the data because data are dispassionate. I think being honest with the patient is paramount.”

THE ROLE OF ATTENTION AND CONCERN

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DR. JONATHAN MORENO: “A lot of this is about what people used to call the art of being a physician. … We probably could achieve the same effects (as placebo) simply by having doctors talk to their patients more.”

Jonathan Moreno, PhD, a bioethics professor at the University of Pennsylvania, agrees that it's never a good idea for a physician to mislead patients, but he believes that many of the benefits provided by the placebo effect can be achieved by the physician's attention and concern.

“A lot of this is about what people used to call the art of being a physician,” Dr. Moreno said. “Our system is geared to undermine this. Doctors are not paid for their time; they're paid for what they do. We probably could achieve the same effects (as placebo) simply by having doctors talk to their patients more.”

So the placebo effect triggered by vitamins, over-the-counter analgesics, sedatives, and other active substances may actually be the result of a physician's attention, according to James L. Bernat, MD, professor of medicine in the department of Neurology at Dartmouth Medical School in New Hampshire and author of Ethical Issues in Neurology, 3rd ed. (Lippincott Williams and Wilkins, 2008).

“Often doctors are not thinking about such treatments as a placebo, but they might involve the placebo effect,” Dr. Bernat said. “The patient's expectation of improvement, the care and concern shown by the doctor, the relationship that the doctor has established with the patient — all of those things have therapeutic value.”

That's why he believes a better term for the placebo effect might be the “meaning response,” coined by Daniel E. Moerman, PhD, and Wayne B. Jonas, MD, in a 2002 paper in the Annals of Internal Medicine. “The benefit produced comes from the meaning that the prescription carries,” Dr. Bernat said. “They have an illness; the doctor gives a placebo and says it may help — there's a certain meaning in that. The interaction creates an effect.”

According to Dr. Bernat, employing the placebo effect is not inherently unethical if certain criteria are followed. For example, placebos should be given to assuage suffering, and they should not be prescribed in place of standard treatments. Also, placebos should not be discontinued if they're effective, but they should be discontinued if they produce no benefit.

“The placebo effect for pain is powerful and may be mediated by the endorphin system,” Dr. Bernat said. “The patient's expectation of benefit is a powerful ingredient. People have a tremendous capacity to cure themselves.”

REFERENCES

• Tilburt JC, Emanuel EJ, Miller FG, et al. Prescribing ”placebo treatments”: Results of national survey of US internists and rheumatologists. BMJ 2008; E-pub 2008 Oct. 24.
    • Wolinsky JS, et al. Glatiramer acetate in primary progressive multiple sclerosis: Results of a multinational, multicenter, double-blind, placebo-controlled trial. Ann Neurol 2007;61:14–24.
      • Hróbjartsson A, Norup M. The use of placebo interventions in medical practice — A national questionnaire survey of Danish clinicians. Eval Health Prof 2003;26(2):153–165.
        • Moerman DE, Jonas WB. Deconstructing the placebo effect and finding the meaning response. Ann Intern Med 2002;136:471–476.