Monday, March 6, 2017

Placebo 4

Prescribing a Placebo-like Treatment

Doctors want to help their patients. They also want to keep them happy: Patient satisfaction is becoming an increasingly important component of physician compensation. At the same time, however, doctors want to be conservative in their prescribing habits, particularly with regard to pain medications.

One upshot of those trends is that many doctors (45%) say they have or would prescribe "placebos" and innocuous treatments to demanding patients. Another 38% said they would not, and 17% said "it depends." (To be clear, the question did not refer to providing a literal "sugar pill" or completely inert treatment, but referred to a treatment "unlikely to help the condition, but unlikely to harm," such as aspirin or vitamins.)

Prescribing placebo-type treatment presents a needling ethical dilemma. Unless a physician tells a patient that they are prescribing a placebo—and many say they would do so—they are deceiving the patient. But this also calls into question a physician's motivation.

One family physician summed up the point: "My first responsibility is to do no harm. If my perception is that the patient will suffer because of lack of treatment, then I should provide some sort of treatment that will not harm the patient. If I am providing placebo treatment so that the patient will be happy with me and come back to me as a patient, thus preserving my income base, then that is not an adequate reason to do so."

Many doctors say they advocate everything from vitamin B12 injections and vitamin C to yoga and complementary therapies, often couching their recommendations in such disclaimers as "It can't hurt" and "There's no evidence, but some people say it helps." They argue that these treatments help patients feel empowered. "Patients love having something to do. Just being told to drink plenty of water and get enough sleep and treat their symptoms makes them feel like we're doing something, so why not? We're alleviating suffering of a less medical sort," says a family physician.

A pediatrician agrees. "I do it all the time. Rituals, such as [get a] special massage or keep a diary or jump up and down three times, etc, help. I would call it being a healer."

But many physicians note that there is a self-serving element to soothing patients with innocuous treatments. "I do it all the time, thanks to patient satisfaction emphasis and ties to income, etc!" writes one doctor. "It's ridiculous, but patients are happier if you do something."

"Placebo is in its infancy," says Arthur Caplan, PhD, professor of bioethics and director of the Division of Medical Ethics at New York University Langone Medical Center. "I think it is going to be explored more because it is cheaper and has far fewer risks," but doctors opting to use it are going to have to find a way to do it without deceiving patients.

What's more, Caplan says, intention matters. Prescribing a placebo because you think it may help a patient is one thing. Prescribing it to simply appease a difficult patient is something else entirely.

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