Following the American Psychological Association’s Guidelines
Placebos and Ethics
Introduction
The only thing second in the medical field to successfully treating a patient is doing it ethically. Ethics are supposed to be held in the highest degree by doctors and nurses in order for patients to feel safe and optimistic about the treatment they receive. Treatments, under the Hippocratic Oath and several moral and ethical maxims must be provided in a safe, ethical manner in order for them to be considered justified practices. Examples include delivering chemotherapy to cancer patients, and antibiotics to patients with viruses. Other instances may involve obtaining conscientious permission from the patient, or legal permission from the patient’s medical proxy, before administering tests or treatment. Many facets are involved in the ethics of medical practice. In the past several years, placebo drugs, their effects, and whether administering them is ethical has been called into question.
Definition A placebo, by definition, is a procedure, medication, or pill that is harmless in nature and prescribed only for the psychological benefit of the patient . Placebos are often included in double blind trials of drugs to either test the potency of a clinical medication, or to test the patient’s psychological stance toward the medication. This method is known as a control treatment. Typically, without the patient’s psychological belief in the drug, the placebo is rendered ineffective to treating the patient. Placebos are commonly known as “sugar pills .”
History The word “placebo”, according to, “The Moral Case for the Clinical Placebo,” was defined in 1811 as a medication created more for the pleasure than the benefit of the patient . During the 18th century, Dr. John Haygarth began testing this theory using a medical treatment referred to as Perkins Tractors. The medication were the sugar pills of its time. As he used them and tracked the patient’s positive results, he was able to show that as long as the patients thought they were given “real” medicine their health improved. Consequently, the results showed the power of the patient’s own mind in the healing process.
Placebos continued gaining popularity through the 19th and into the 20th century. They are still used today, but it was as early as 1900 that they were seeing as deceptive and unethical. Dr. Richard Clarke Cabot, a practicing physician in 1903, was taught to use placebos early in his career, for example. He later rejected them, expressing that he had never experienced a scenario where lying to a patient benefitted them more than telling them the truth . In 1920, The Lancet finally formally defined the “placebo effect” for the public, calling it “psychotherapeutic .” The new formal definition spurned more tests and experiments. As time wore on, the 1960’s saw a wave of placebo controlled trials as new drugs began to hit the market . Today placebo controlled trials are still used to test new drugs before they are prescribed to patients, but they are also prescribed therapeutically.
Placebo Treatment
Once only considered a form of drug trial, placebos are now a specific form of treatment for patients all over the world. The placebo treatment, as stated in, “Reevaluating the Placebo Effect in Medical Practice,” is any medical treatment involving that is inactive . The classic sugar pill is the normal example, however many holistic, or eastern, remedies have also been hailed as placebo treatments by Western medicine. For instance, acupuncture is considered a placebo treatment for stress because the acupuncturist will place needles in certain parts of the patient’s body that are meant to relieve stress. There is no medical evidence to back up claims such as these, but because the patient believes the acupuncturist, many feel a reduction in their stress level after a few sessions. Overall, as many as 40% of patients treated with placebos will experience an end to their symptoms .
Ethical Principles The ethics surrounding the use of placebos has been widely discussed for decades. One of the primary topics concerns placebos in their relations to beneficence. Beneficence in the medical practice demands medical staff to act out of kindness and goodness toward patients; it is defined as one of the core values of medical ethics by Tom L. Beauchamp and James F. Childress . Medical staff must always choose the treatment or action that serves in the best interest of the patient while remaining professional. One could use beneficence to argue for or against the use of placebos. It is true that 40% of patients see an end of suffering. However, it is never in the best interests to lie to the patient in order to obtain a result, and to do so would be considered unprofessional and, therefore, unethical.
Autonomy is often brought up when discussing placebo treatments, as well. Autonomy is equal to independence. In a medical sphere, it is the individual’s right to make an informed decision based on his or her options, as well as his or her care . Placebo deception is an obvious and direct infringement on autonomy, which is a professional obligation for medical staff to uphold. The success of the placebo effect depends on deceiving the patient, thereby allowing the psychology behind believing the patient will be cured to act as the cure itself . If the patient is notified of the placebo, and its subsequent ineffectiveness, they will understand the placebo is useless and will likely not believe it a cure any longer. However, to negate revealing the placebo’s ineffectiveness is to deny the patient’s respective right to autonomy. Administering the placebo treatment itself presents an paradox that renders either the physician unethical or the placebo useless. For instance, 2003 study performed in Israel showed that as many as 55% of physicians reported the use of placebos in order to shoo away patients who requested medication medical staff did not deem worthy of providing . Placebos were given in these cases to save time. To make matters more unethical, when staff does this, it is also in an effort to save money Placebos are not as costly for medical facilities to procure, yet they can charge the same amount as the clinical drug to the patient. Not only is the patient not notified that they are being given what amounts to a sugar pill, but it also may not work, might give them negative side effects without any chance of a cure, and they pay full price for it. When physicians do this solely to avoid the hassle of dealing with the patient’s medical needs, it is the height of unethical dealings.
In Latin, non-Maleficence means, “Do no harm .” As medical practitioners, helping rather than hurting should be the primary goal. Many hear this and believe that, because placebos have a chance to end their symptoms, that it is a sufficient argument for their use; this is not so and partially the reason that non-maleficence was indoctrinated as a principle. Essentially, non-maleficence means it is more important to avoid harming the patient, than to benefit them . Many physicians and nurses, or even holistic healers, become enthusiastic about treatments, procedures, or medicines, believing they may hurt the patient short-term, but they will help the patient over the long-term. Placebo treatments are no exception to this but the root of non-maleficence declares physicians must not practice these treatments. On average, only 40% of patients see an end to their symptoms, not to mention it completely defies the patient’s right to autonomy. While there are times when placebo treatments do benefit the patient, it is more important to avoid the risk of harming them at all. Not to do so is unethical.
Paternalism is in direct conflict with non-maleficence, but compliments placebo treatments nicely. Derived from the Latin word “Pater,” meaning father, its translates into being paternal, or fatherly toward another person, especially when they are suffering . There are several kinds of paternalism: pure paternalism, wherein the practitioner only cares for the patient’s wellbeing, and impure paternalism, which involves the welfare of the patient and the welfare of somebody else. There are also negative and positive paternalism, among many others. The argument concerning paternalism and the use of placebos seems complicated if one considers the doctor’s intentions. However, as medical professionals, the patient’s welfare should always come first. That rules out negative, indirect, and impure paternalism because the core principles of bioethics, such and beneficence, non-maleficence, and justice have already ruled that even if one intervenes on behalf of the patient, they must do so without causing more risk to the patient and without lying. Paternalism on its own may allow medical staff to initiate placebo treatments, but luckily paternalism does not stand on its own. Placebo treatments would still be deemed unethical.
Ethical Theories
If does not wish to rely on core medical principles, ethical theories can help explain the placebo treatment’s ethics. Take ethical relativism, for example. By definition, it is the belief that no action or thing is objectively right or wrong. Instead, the definition of right and wrong depend on the fundamental views of a particular individual, culture, or even a historical period . Based on ethical relativism, placebo treatments could be found ethical because it states that though this time period may find them to be unethical, the individual can decide this is incorrect. If the individual decides they are ethical, they are, and that is that. In contrast, deontology is a rule-based philosophy that judges an individual’s morals based on their actions, as well as the actions adherence to the rules. Consequently, if the rules say placebo treatments are just, administering them is also just. It does not make the rule unethical, but it does not leave the choice up to the individual. Utilitarianism enforces a philosophy that each action maximize utility; outcomes should maximize benefit while minimizing suffering. Concerning placebos, it is arguable about whether utilitarianism defends the treatments or not. If a patient is one of the lucky 40% to experience and end to their suffering, utilitarianism would applaud the placebo’s use. However, if the patient is one of the unlucky few who experience unwarranted side effects as a result of the placebo, the treatment would not minimize suffering and go against the philosophy. In a world where clinically proven drugs are available, the utilitarian might suggest simply going with the sure thing.
Argument
Despite the obviousness that placebos are unethical, many are still for their use. A 2012 study published in an article by Felicity L. Bishop and her associated assess the matter of the pro-placebo crowd more in- depth. Many believe that the placebo effect principally proves the Law of Attraction, and these physicians attempt to use this breakthrough to detract from the fact that lies and deception are involved in administering placebos . The Law of Attraction is more of a philosophy than a law, or even a principle. It simply states that what an individual focuses on in life is what will come to them eventually. Bishop and her colleagues believe that placebo cases prove the “law” a reality for a variety of reasons. Patients taking placebos, for example, believe they will get better and then they do, therefore, the Law of Attraction must be real. The patients focused their efforts on becoming healthy and overcoming their ailments; in the end a cure and relief is what they received, or attracted . For those who were not cured completely, Bishop and her colleagues argued that patients receiving placebos were less negative, focusing more on the positive aspects of their lives. That they were not cured, or sometimes experienced no relief at all, were merely circumstantial because the Law of Attraction became more important than treating sick patients did. While studies have proven that positive outlooks on life can prove one’s physical and mental health, insinuating that proving the Law of Attraction makes administering placebos ethical is not medically sound reasoning. Despite the supposed medical or philosophical breakthrough, the use of placebos remains unethical for several reasons.
There are seemingly insurmountable reasons why placebo treatments should be seen as unethical. The treatment itself is archaic, and became popular as a way to test the use of legitimate drugs that have the capacity to help people. The placebo treatment’s effectiveness hinges on lying to the patient, which not only denies the patient autonomy, but from a nurse’s standpoint, it damages the professional relationship one tries to build with the patient. Later, if the patient finds out their medical team lied to them, all trust is gone. The use of placebos also directly goes against the core bioethical principle of non-maleficence, which is states the risk of harm is not worth the prospect of benefit. Several ethical theories could arguably be for the use of placebo treatments, but philosophies are always malleable. Bioethical principles, however, are set in stone. Doctors and nurses are to look after the patient first, and make sure they have the best quality of care available. Placebos offer less than 50% of a chance at recovery, which is not enough to rely on. Clinical drugs are available that do not require doctors and nurses to lie to patients, or put them at potential risk. The responsible and ethical course of action in the medical profession is to forego the use of placebo treatments unless in a controlled trial.
Implications of Placebo Treatment
Several implications of placebo treatments have already been stated. 60% of patients can expect to not see any alleviations in their symptoms at all. An estimated 75% of patients will experience side effects as a psychological byproduct of taking placebos, as well . Doctors who agree to administer placebos are circumventing many bioethical principals, as well as violating a patient’s trust. This violation can put the patient and the medical staff in a precarious position later if the doctor is forced to tell the patient they have been given placebos; the patient may even choose to leave the doctor’s care.
Personal Position
Personally I am against using placebos, especially when treating very ill patients. From a nurse’s perspective, I recognize that oftentimes severely ill patients need immediate care. They are not cases in which to test whether or not the psychological impact of the placebo will work or not. Furthermore, many times very ill people are incoherent. Sometimes they need their medical proxy to make decisions based on previous decisions or the patient’s best interest. Neither of these decisions can be made if the doctor is lying to the healthcare proxy about the medication or procedure being a possibly placebo. Critically ill patients need clinical drugs and proven procedures. In these cases I consider it a matter of life and death; it appears that doctors who want to administer placebos want to toy with that which is completely unethical apart from the various bioethical principles they would be violating.
Proposed Resolution
Clinical trials have proved to make good use of placebos as a controlled treatment. Many new drugs have been put on the market, helping millions of people, all because placebos have helped doctors determine what is safe and what is not. Bioethics demand research participants are made aware they could receive placebos, and they sign a waiver agreeing to the possibility. Therefore, informed consent is given to the extent it can be without harming the research. I see no reason why placebos cannot continue to be used for clinical trials in order to find new medications for suffering patients. However, my proposed resolution for all other placebo treatments is that they end on the grounds that they harm the patient, put the patient at risk, deprive the patient of autonomy, and are generally unethical.
Conclusion
In sum, though placebos have helped doctors create new drugs for patients, their use as a treatment unto themselves is unethical. Sometimes the placebos fail to work. Other times, they have been known to cause negative side effects without providing the patient with any of the promised relief. The entire theory of placebo effects is based around lies, which undermines the trust between patients and the medical staff. Studies show that doctors sometimes give placebos to avoid dealing with needy patients, while still charging full price for clinical drugs. Perhaps most unethical of all is how the doctor/patient and nurse/patient relationships are used to manipulate the placebo effect by forcing the patient to feel safe and optimistic. The small penance paid out semi-regularly by placebos is the arguable proof of the Law of Attraction, which is not enough to deny that the use of sugar pills is entirely unethical from a nurse’s standpoint, or any other.
References
Beauchamp, T. L., & Childress, J. F. (2008). Principles of Biomedical Ethics. Exford: Oxford University Press.
Bishop, F. L., Jacobson, E. E., Shaw, J. R., & Kaptchuk, T. R. (2012). Scientific tools, fake treatments, or triggers for psychological healing: How clinical trial participants conceptualise placebos. Social Science and Medicine, 767-774.
Cohen, S., & Shapiro, H. (2013). “Comparable Placebo Treatment” and the Ethics of Deception. The Journal of Medicine and Philosophy, 696-709.
Colloca, L., Jonas, W. B., Killen Jr., J., Miller, F. G., & Shurtleff, D. (2014). Reevaluating the placebo effect in medical practice. Journal of Psychology, 124-127.
Gold, A., & Lichtenberg, P. (2014). The moral case for the clinical placebo. Journal of Medical Ethics, 219-224.
Horin, A., Colloca, L., & Kent, L. M. (2014). Placebo Effects in Therapeutic Outcomes. Current Clinical Pharmacology, 116-122.
Kanaan, R. A. (2013). Do Placebos Cause Their Effects and Does It Matter? AJOB Neuroscience, 35-36.
Marcus, D. M. (2013). Clinical and Ethical Aspects of Placebos in Clinical Practice. JAMA Internal Medicine, 711-712.
Tracey, I. (2014). Rethinking Placebos. Nature Medicine, 806-809.
