Deception as treatment: the case of depression

Abstract

Is it ever right to prescribe placebos to patients in clinical practice? The General Medical Council is ambivalent about the issue; the American Medical Association asserts that placebos can be administered only if the patient is (somehow) 'informed'. The potential problem with placebos is that they may involve deception: indeed, if this is the case, an ethical tension arises over the patient's autonomy and the physician's requirement to be open and honest, and the notion that medical care should be the primary concern. This paper examines the case of depression as an entry point for understanding the complexities of the prescription of placebos. Recent important meta-analyses of antidepressants claim that they are not significantly more effective in a clinical setting than placebos. Given that antidepressants have numerous adverse side effects and are hugely expensive, this provocative research has serious potential ethical and practical implications for patients and medical providers. Should placebos be prescribed in place of antidepressants? The case of depression highlights another important issue which medical ethical codes have hitherto overlooked: well-being is not synonymous with being realistic about oneself, one's circumstances and the future. While severely depressed individuals are unduly pessimistic about themselves and the world around them, treatment of depressed individuals can be deemed successful when patients have successfully attained those positive illusions that are indicative of psychological health. This is exactly what successful psychological treatments of depression seem to achieve. It is therefore possible that there may be a limited unavoidable role for deception in medicine.

Brain grey matter abnormalities in medication-free patients with major depressive disorder: a meta-analysis

“…Thus studies of unmedicated patients could better elucidate brain abnormalities that are directly related to the disease itself. Direct study of unmedicated depressed patients faces substantial practical and ethical problems (Blease, 2011). Although published VBM studies on medication-free MDD patients have recently become sufficiently numerous to warrant specific metaanalysis, no such meta-analysis of grey matter volumes has yet been published.…”

Talking more about talking cures: cognitive behavioural therapy and informed consent

“…vii In response, it not clear that this information does accurately describe the procedure—it may be a description of the intentions of therapy but: (1) in practice therapists may routinely stray from rigidly adhering to these techniques;22 and (2) (more importantly) we can contest whether it is even possible to implement these techniques—the phenomenon of depressive realism shows that mild–moderate depressive thoughts are realistic even if they are unhelpful (see footnote v ) 42. In short, the debate about informed consent in psychotherapy proceeds with the assumption that the various and distinct models of psychotherapy are correct on their own terms.…”

Placebo treatments, informed consent and ‘the grip of a false picture’

“…Defenders of placebo treatments have tended, in the main, to reject this deontological reasoning and to argue that such violations of informed consent as are involved in their prescription are morally justified in view of other considerations and that patient autonomy is therefore not a moral absolute 4 10 12 18. Nevertheless, physicians’ intuitions do not appear to support such claims: 82% of British general practitioners reported that they believed placebos to be ethically unacceptable when they involved deception 14.…”

“…the titles of these references 10 11 18 26. The placebo does not act on the body, on this view, but merely ‘fools’ the mind into believing that the body has been treated, thereby causing it to trigger or accelerate the body's own supplementary healing mechanisms.…”