Placebos are probably the most frequently prescribed drugs in the history of medicine, which is understandable as they really do work. Even so, Leiden ethicists claim that it is not acceptable. “A GP who prescribes something he knows won’t work is actually committing fraud.”
September 1943: the allied troops had arrived in Southern Italy, a region they regard as “the soft underbelly of the Axis”. But they had underestimated the softness: bridges had been destroyed, and road blocks and land mines delayed the advancing troops for so long the Germans had time to bring in reinforcements. The invasion proved to be more difficult than anticipated and one of the people who ran into difficulties because of that was Lieutenant-Colonel Henry Knowles Beecher.
Beecher was an anaesthetist in a military hospital full of wounded soldiers and he was running out of morphine. One of his nurses, in absolute desperation, gave the soldiers injections of lightly salted water, telling them it was morphine – and it helped.
After the war, Beecher returned to Harvard University, but his experiences had left an impression and in 1955 he wrote a historic article about them: The Powerful Placebo.
In the article, he explained that at least part of a drug’s effect relies on the suggestion that it will work. If you want to know whether a medicine really works, you have to compare it with a suggestive fake treatment: the group with the real treatment has to recover better than the group with the placebo.
Beecher deserves much of the credit, but he did not discover the placebo effect; it is thought that the very first shaman-healer ever probably realised how much could be achieved with some rituals and a convincing explanation.
For centuries, doctors have been handing out prescriptions for placebos, partly because they simply did not have anything else. And it still happens: in February, German researchers published a paper in the medical journal Family Practice on a survey among Bavarian GPs. 88 per cent of the GPs had prescribed a placebo as recently as the previous year. The placebos were not necessarily milk-sugar pills: a doctor who prescribes antibiotics – effective against bacteria – for viral infections is using a kind of placebo, in the same way as a doctor who prescribes Prozac or Seroxat for mild depressions, as these drugs are only really effective against serious depressions.
This kind of prescription behaviour is understandable, because the effect of a placebo is still better than no effect. The sugar pills and saltwater jabs are cheap, they have few side-effects and thanks to Beecher, there are thousands of studies proving their effect: a temporary and limited effect, but still, if you have nothing else, why shouldn’t you resort to placebos?
“If a doctor suggests to the patient that he could take a placebo, that’s acceptable”, explains ethicist Dorothea Touwen. “But that doesn’t usually happen in those cases and the doctor just prescribes something that he knows won’t help. Actually, he is committing fraud, although the doctor-patient relationship should be based on trust; the patient ought to be told what is going on.”
Touwen and her colleague Professor Dick Engberts have written an article on the ethics of using placebos in the medical journal European Journal of Neuropsychopharmacology. And it is not only doctors, the Leiden ethics experts claim that researchers also rely too easily on placebos. If a remedy has been found for a certain illness, it should be used for the control trial instead of the placebo because the people in the control group will receive a better treatment and the results will be more significant.
The ethicist is fascinated by the placebo effect: “The pain-killing effect is very strong, but it doesn’t affect everyone equally. Red pills work best, but blue placebos are more calming. And even stranger, they seem to have a temporary effect on high blood pressure. How people experience pain is subjective, but you would think that blood pressure is purely physiological. The relationship between body and mind is fascinating.”
However, it must be said that a major retrospective on the placebo effect was published in 2010, comparing all the studies that used placebos but also studies that did not apply any treatment.
The effect on high blood pressure is an exception: if you check measurable things, placebos do not do very much. The effect is particularly noticeable in disorders that patients have to describe to the researcher: pain, itching, depression, exhaustion – exactly the things any GP – whether he’s in the Netherlands or in Bavaria – sees plenty of.
In fact, patients often ask for placebos for these complaints, or at least for something of which the doctor knows that it won’t work any better than a placebo: flower therapy, homeopathic remedies, treatments with “healing crystals”, laying hands, etc. and the majority of these patients will swear that the treatments helped.
Touwen adds: “GPs will say, ‘Well, of course, homeopathic doctors can give them plenty of attention, we don’t have time for that.’ Alternative therapists lay bare your entire past and we could use much of that in regular care too. It sounds obvious, but it just doesn’t fit into the current system for funding healthcare.
“Placebos put some strain on our honest intentions and certainly must not be used to get rid of a difficult patient. The patient is not like a customer at a kitchen appliance shop and the patient certainly cannot decide exactly what will be done. It is up to the doctors to assume professional responsibility, but placebos really are the other extreme.”