The Placebo effect? An ethical dilemma or not?

I decided to write this article more as a question than an answer because I don’t think anyone truly knows the answer. First things first, what is a placebo?

Placebo:

“A medicine or procedure prescribed for the psychological benefit to the patient rather than for any physiological effect.”

Or

“A substance that has no therapeutic effect, used as a control in testing new drugs.”

Or

“A measure designed merely to humour or placate someone.”

(Oxford Dictionary)

Straight away we have encountered a problem in the first sentence “prescribed for psychological benefit rather than for any physiological effect.” Well if you look at the argument about placebo used in research or clinical practice some people say “that’s just a placebo” but the patient has gained physiological benefit in a lot of cases. For example:

Yang et al (2014) found that both placebo and real acupuncture, were found to be more effective than the control group but real acupuncture when compared with sham was found no more effective. The interesting thing here is that they say that because of these findings, there was not enough evidence to prove the efficacy of acupuncture for the treatment of fibromyalgia. This is technically incorrect because sham and real acupuncture were both effective.

The other thing is that if a treatment has a psychological benefit then this is still a good thing isn’t it?

The second definition implies that we are using the word incorrectly because if the placebo treatment had no therapeutic effect then there would be no such thing as a placebo effect, meaning the term wouldn’t exist!

Now the final definition would be considered unethical, without question.

So already just the word placebo raises questions.

So what is the placebo effect then?

“A beneficial effect produced by a placebo drug or treatment, which cannot be attributed to the properties of the placebo itself, and must therefore be due to the patient’s belief in that treatment.” (Oxford Dictionary)

So this implies that the placebo effect is purely psychological, being based on the patients beliefs. I believe there is truth in this, as this piece of evidence shows:

Linde et al (2007) found a significant association between better improvement and higher outcome expectations with placebo treatments.

However, in reality this also means a placebo and its effect can’t exist in Physiotherapy or may at least struggle to exist. Think about it, if I am using sham acupuncture then there will be an effect from touch, which will have a physiological effect on the body. This was found by Mancini et al (2013), who found pain was reduced by touch. So you see by definition this can’t be a placebo nor can it have a placebo effect because touch is involved.

Another interesting effect is shown in this piece:

Kaptchuk et al (2008) actually found that patients did better if the practitioner was caring, warm, attentive and confident even when they offered the exact same placebo treatment.

So the patients’ belief before and during treatment is the same but if the practitioner is interactive and personable then the positive effect is greater. So not belief driven!

Now let’s say for arguments sake, that placebo and placebo effect do exist, is it unethical to use it to your advantage?

If I said to a patient “I have a treatment that can benefit you but I can’t tell you how it works then I bet every patient would say “go for it!” Besides if you ask a patient how and why a treatment works they wouldn’t know or even care as long as it worked.

The ethical dilemma comes when you consider the fact that you could be considered to be lying to the patient or at least shielding the truth, which is an issue when it comes to INFORMED consent!

I think there is a fine line here and this line is a matter for debate.

Not all placebo effects are created equal:

The reality is that not all placebo effects are equal and in fact it is likely that a treatment considered to be no better than its placebo version may still be more effective overall than a treatment that is considered better than its placebo counterpart. So what are we to do in this case? Do we use the lesser effective treatment that is not just a placebo or do we choose the treatment that is essentially a placebo but is actually more effective? I know what I would choose as a patient but it’s different as the practitioner.

Here is an example of different placebo effects that highlights that they aren’t all equal:

Sham acupuncture & sham surgery are associated with higher responder ratios than pharmacological placebos for migraine (Meissner et al 2013).

In a way, the future of health may try to learn how to access and exaggerate the placebo element of treatment to maximise therapeutic effect. Who knows there may be such a thing as a Placebo Therapist!?

Even surgery has been found to have quite a placebo effect:

Placebo surgery is just as effective as real surgery according to Wartolowska et al (2014).

And

Arthroscopic debridement for osteoarthritis of the knee doesn't improve pain any better than placebo (Laupattarakasem et al 2009).

Recently there has been research done on athletes showing that if they believed that they were using performance enhancing drugs then they would perform better even though they were taking placebos!

In fact placebo can be better than the real thing in some cases:

Corticosteroid injection versus placebo injection resulted in worse clinical outcomes after 1 year with Tennis elbow (Coombes et al 2013).

Overall Placebo effect or something like it, is probably the most effective thing we can cause as practitioners. The problem is that some practitioners could be misleading their patients by making up stories that sound impressive to rationalise their treatment that has no evidence base. So care is needed when considering treatment choice, whether you are trying to maximise the placebo effect or not! Remember that we can also have a negative effect from how we communicate, the words we use etc. This is called a nocebo effect and we don’t want that although it happens more than you might think!

If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866195914

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