Using placebos in day-to-day practice is an ethical problem. This paper summarises the available epidemiological evidence to support this difficult decision. Based on these data we propose to differentiate between placebo and "knowledge framing". While the use of placebo should be confined to experimental settings in clinical trials, knowledge framing--which is only conceptually different from placebo--is a desired, expected and necessary component of any doctor-patient encounter. Examples from daily practice demonstrate both, the need to investigate the effects of knowledge framing and its impact on ethical, medical, economical and legal decisions.
Over the last 10 years there has been an increasing awareness of the limitation of resources even in the Health Care System and that rationing can, therefore, not be avoided. However, it is possible to reduce "hard" rationing by introducing rationalizing techniques. To achieve this goal it will be necessary to assess the values of medical interventions. In the present paper, we describe a method for rationalization of health care services which has been applied in a health centre. This includes the explanation of the concept of Evidence-based Medicine, the six steps in which this concept is realized and the criteria which have to be met to gain support from physicians for this project. The results which have been made so far are discussed.
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