Tuesday, 13 March 2007

Placebo quandary

In Daniel E Moerman's Cultural variations in the placebo effect: ulcers, anxiety, and blood pressure, Medical Anthropology Quarterly 2000;14: 51-72, (summary is publicly accessible here), you can read about the opposition to the use of placebos made in some quarters. What case can those opposed make? Explicitly it boils down largely to the claims (1) that placebos don't work, (2) that their use is a deception and hence unethical.

There's a vast body of research which suggests that (1) is incorrect. But this still leaves us with the quandary (2), as this passage from Grant Gillett's excellent Bioethics in the Clinic: Hippocratic Reflections (John Hopkins 2004) suggests:
I was recently consulted about a patient who had a long-standing and refactory clinical depression. She had tried most of the available antidepressants but had not really had any good relief for her depression until she had been enrolled in a trial of a new drug. Her improvement since starting the new treatment had been dramatic and sustained, much to the relief of her clinical caregivers. She had, however, been in a placebo group in the trial. I was asked what her treating clinicians should tell her.
We may presume that the patient was aware that the drug she was receiving might have been a placebo.

It seems likely that for some practitioners the problem really lies in placebos threatening their sense that they are people of science. A nobler concern would be that they are withholding information necessary to establish a trusting relationship with their patient. Elsewhere in Gillett's book we read a quotation from an essay by Ron Carson, which expresses such an ideal form of partnership:
The hyphenated space in the doctor-patient relationship is a liminal place of ethical encounter, alternating voices and actions - back and forth, address and response - seeking mutually satisfactory meaning by means of which an illness that has threatened to fray or sever the storyline of a life can be woven into the fabric of that life. The hyphen points to the prospect of overcoming silence with meaningful conversation. (p. 77)
Even if this is accepted as the aim of one's practice, there could still be a place for placebos within the process of arriving at such a point.

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