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Thursday, August 16, 2007

A Limited Defense of Clinical Placebo Deception

You may be surprised to learn that doctors sometimes give patients pure placebos (like sugar pills or saline injections) and claim or misleadingly suggest that the patient is receiving an active medication.  While this practice is probably on the decline, many doctors prescribe active medications (like antibiotics) for symptoms that they know the active medication doesn't treat.  In both kinds of cases, patient symptoms may improve by way of a placebo effect.  By deceiving the patient, however, the improvement arguably comes at an unacceptable cost.  Interestingly, there are virtually no published cases discussing whether the deceptive administration of placebos violates obligations to obtain patient informed consent.

The American Medical Association has recently revised its ethics policies to prohibit doctors from deceptively administering placebos.  This categorical prohibition paints with a rather broad brush, however.  In a forthcoming article in the Yale Law and Policy Review, I offer a limited defense of clinical placebo deception.  Here is the abstract (scroll down to download the full text).  The article is still in draft form, and I welcome comments on the piece by email.

Posted by Adam Kolber on August 16, 2007 at 06:33 AM | Permalink


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That was a very interesting and certainly provocative paper (I'm e-mailing a couple of comments). It reminds me of the following discussion from Jon Elster's Sour Grapes: studies in the subversion of rationality (1983):

"Sleep is another paradigm for the states that are essentially by-products. The attempt to overcome insomnia by sheer will is, like the desire to become natural, a paradigm of irrational plans.... The phenomenology of insomnia is complex, but the following stages seem to correspond to a common pattern. First, one tries to will an empty mind, to blot out all preoccupying thoughts. The attempt, of course, is contradictory and doomed to fail, since it requires a concentration of mind that is incompatible with the absence of concentration one is trying to bring about. Secondly, upon understanding that this is not going to work, one tries to induce a state of pseudo-resignation to insomnia. One acts, that is, as if one were persuaded that sleep is going to elude one, by taking up a book, having a snack or a drink, etc. But at the back of one's mind there is always the idea that one can cheat insomnia by ignoring it, and that the cheerful indifference to sleep will make sleep come at last. But then, thirdly, one understands that this is not going to work either. Next, real resignation sets in, based on a real, not a sham, conviction that the night will be long and bleak. And then, finally and mercifully, sleep comes. For veteran insomniacs, who know the game inside out, the last stage never arrives. They know too well the benefits of resignation to be able to achieve it.

Insomnia can be helped or cured in a variety of ways. One therapeutic technique is of particular interest in the present context. The therapist tells the insomniac that the next night he must note very carefully, every five minutes, all the symptoms of insomnia, such as dizziness, headaches, a dry throat. This, the therapist says, is essential if he is to be able to come up with suggestions for overcoming the insomnia. The patient, naively and obediently, does as instructed, and promptly falls asleep. Sleep has come, but as a by-product--and in this context it is essentially a by-product, since the effect would have been spoiled had the therapist told the patient about the point of the instructions."

This is clearly a case of deceiving the patient and I'm sure there's some bioethicists who might raise questions regarding the violations of the patient's autonomy. But I think here, as in your paper, other values and goals may be allowed to override or trump the concern with autonomy inasmuch as concrete gains in the person's health and well-being are achieved, gains the individual, in retrospect, can and probably would welcome, appreciate and, endorse.

Elster gives another, analogical example, from psychotherapy, wherein we ask "How are we to reconcile the following facts--or rather impressions--that (i) there is a great deal of successful therapy, (ii) therapists believe that a good theory is essential for success and (iii) very little of the variance in therapeutic success is explained in the therapist's choice of one theory rather than another?" [....] Crudely put: the therapist must believe in some theory for the therapeutic activity to seem worth while, and it will not be successful unless he thinks it worth while. Therapist and patient are accomplices in a mutually beneficial *folie a deux*." Self-deception of a sort here combines with the patient's ignorance, in other words, to achieve a therapeutically benefical outcome.

Posted by: Patrick S. O'Donnell | Aug 16, 2007 9:45:41 AM

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