Reexamination of the Ethics of Placebo Use in Clinical Practice

Abstract

A placebo is a substance or intervention believed to be inactive, but is administered by the healthcare professional as if it was an active medication. Unlike standard treatments, clinical use of placebo usually involves deception and is therefore ethically problematic. Our attitudes toward the clinical use of placebo, which inevitably includes deception or withholding information, have a tremendous effect on our practice regarding truth-telling and informed consent. A casual attitude towards it weakens the current practice based on shared decision-making and mutual trust between patients and healthcare professionals. Issues concerning the clinical use of placebo are thus intimately related to patient-provider relationships, the public's trust in medicine, and medical education. A review of recent survey studies suggests that the clinical use of placebo appears to be fairly well accepted among healthcare professionals and is common in clinical settings in various countries. However, we think that an ethical discussion is urgently needed because of its controversial nature. If judged to be ethically wrong, the practice should end. In the present paper, we discuss the ethicality of the clinical use of placebo with deception and argue against it, concluding that it is unethical and should be banned. We will show that most arguments in favor of the clinical use of placebo can be refuted and are therefore incorrect or weak. These arguments will be presented and examined individually. Finally, we will briefly consider issues relevant to the clinical use of placebo without deception.

The Use of Placebo and the Right of Autonomy

“…Banning such trials will harm the prospective participants' interests as well as the end-users' of new treatments. In the clinical practice context, contrary to what some ethicists argue (e.g., [2]), I contend that the deceptive use of placebo may not violate patients' right of autonomy and thereby can also be ethically justified.…”

“…For example, antibiotics are used as placebos with respect to viral infections. 2 I am assuming that autonomy admits a matter of degree.…”

“…Also very few studies have investigated the effect of open placebo use [2]. But suppose that a placebo treatment is effective only when it is used deceptively.…”

Placebos dans la pratique clinique : un aperçu éthique

“…According to this position, using deceptive placebos in clinical settings without patients' consent is never permissible. Over the years several commentators have defended similar positions and therefore the AMA Code of Medical Ethics is not alone in advocating a categorical ban of deceptive placebos in clinical settings [1,13].…”

“…A placebo is a medical intervention believed to be inactive for the patient's condition but administered by a health professional as if it was an active treatment [1]. Depending on the circumstances and on the biomedical theory assumed, a placebo can be a pill, an injection, a diagnostic or even a surgical procedure [2].…”