Ethical Trickery?

Ethical Trickery?

04 February 2014

I recently came across this pearler in a blog post by a colleague on ultrasound:

“Lying is bad, but easing suffering is good – every school kid knows that.  But what if the lie eases someone’s pain, then it’d be good, no? But what if someone’s making lots of money out of it, that’d be profiteering wouldn’t it and that’s bad. Surely making money out of lying to people can’t be good?  But what if the act of handing over money helped convince someone the lie was true, which eased their pain, then it’d be okay, wouldn’t it?

Louise Parker

And it got me thinking...well would it?

Since then I've been reading a lot about the weird-and-wonderful world of placebos and I must admit, I'm hooked...

A placebo (by its technical definition) is a treatment with no known therapeutic value. When we think about placebo we typically think of the inactive substance given to participants in the control arm of a clinical trial. 

But the placebo story is far more interesting than just little sugar pills divvied up during RCTs. Things get really interesting when you start looking into the effects that those pills (or any other type of 'inactive' treatment for that matter) can you have entered the realm of the 'Placebo Effect' and things are about to get groovy...

The ‘placebo effect’ is what makes round pills more effective than square ones of the same dose, expensive medicines work better than cheaper versions with exactly the same ingredients and means that even placebos being addictive. This 3 minute video explains the effect brilliantly. And, you don't even need to actually receive a placebo to get a placebo effect.  Also called the ‘meaning  response’  the effect is driven by the cultural meaning we attach to a treatment, along with our beliefs and expectations. If you believe or expect a treatment to make you feel better it probably will.  If you have a nice, caring clinician, who you like and trust, you will probably do better than if you don't.  These ‘non-specific’ effects work alongside the specific effects of the treatment you are receiving and have the ability to augment or undermine even an established treatment. To borrow some words from Dr Ben Goldacre it is "not so much about the medicine, but the beliefs that we load onto it".

This video by Derren Brown is an entertaining look at just what the placebo effect might be capable of.  What Derren gets up to in this experiment tests not only the limits of the placebo effect, but also stretches the ethical boundaries surrounding them. Ben Goldacre, the author behind Bad Science agrees that the placebo effect creates an "interesting ethical hole". To give a placebo, by definition requires that you lie to patients.  In practicality deception on some level is kind of mandatory as to not undo the therapeutic effect through disclosure.  But if the evidence is pretty strong that lying to your patient can make them better, does that justify the lying? It's a good question....

The use of placebo pills is generally accepted to be unethical.  While it is probably not okay to prescribe someone a sugar pill, and tell them it is an active medicine, for those of use working in Allied Health the water seems infinitely muddier. We are not in the business of prescribing medication anyway, so we aren't likely to try and sneak a sugar pill past someone without their knowledge.  

But a lot of the treatments we do use, look like they might work primarily via the placebo effect. So my question to you: Is it okay to be delivering a treatment, that balance of the evidence indicates works only as well as a placebo and therefore is likely to be working via the meaning response/placebo effect?

Is this the same, or different to prescribing someone a sugar pill and telling them its medicine?

For me, its an ethically uncomfortable question and I experience this discomfort regularly when the topic of acupuncture comes up.  Neill O'Connor addresses the same question of the ethics of "magic kisses" in physiotherapy here. While there is still a deal of debate, when you look at the best quality evidence available there is a suggestion that acupuncture works only about as well as sham acupuncture using a telescopic needle that doesn't pierce the skin.  If acupuncture does work only as well as a placebo, then one can conclude that the benefit of this treatment is substantially (or even wholly) down to the meaning response, rather than the specific effect of the needles.  In this way, it is technically a "placebo".

(For the sake of this blog, let us just agree just for the moment that this indeed true and acupuncture is just a super dooper placebo - I'm trying to illustrate an ethical point here, not debate the efficacy of the treatment itself...if you are interested though you can find both sides of the acupuncture debate here, and here, and a summary here and decide for yourself)

So... Is it still okay to use it? Should I be offering it to my patients? Or at least giving it to them if they ask for it? And if a patient asks for an explanation of how the treatment works, should I tell them a lie to ease their pain? Or tell them the truth, thereby likely negating the mechanism by which it might help them? Or do I keep my fingers crossed and just hope they don’t ask?