The American Medical Association (AMA) Council on Judicial and Ethical Affairs (CJEA) has defined a placebo as a “….substance that the physicians believe has no known pharmacological activity against the condition being treated” (Bostick, Sade, and Steward 1). Even though a placebo does not contain any ingredients proven to help with a patient’s sickness, it does, in fact, alleviate patient’s symptoms and/or condition; however, the question of its ethics still remains. The AMA has established guidelines for doctors to follow in order to ethically prescribe placebos as a form of treatment or a way to diagnose a patient; it requires doctors to attain the permission of the patient to prescribe a placebo before administering it and to administer the placebo for the patient’s benefit (Bostick, Sade, and Steward 1). However, these protocols have not been fully adhered to by the doctors of the United States. Although the AMA has established supposedly “ethical” guidelines, the possibility of ethically prescribing placebos deems impractical.
Before the ethics of administrating placebo can be scrutinized, impertinent information regarding the placebo and placebo effect must first be established to be able to fathom the ethical arguments. There are two principle theories behind the placebo effect, and they are identified as the psychological mechanisms. The first theory includes expectancy, in which the patient expects to feel relief and subconsciously alters his/her reaction to feel the alleviation he/she expects (Freeman). This means that the higher the expectation the patient possesses to feel alleviation, the greater relief the patient will experience. The second theory involves classical conditioning. Because patients have repeatedly felt better after taking a medication throughout their life, they believe that all it takes to make them feel better is to take a pill (Finniss et al. 687). As the general information of the placebo and placebo effect has been made, the ethical debates of placebo prescription can now be analyzed and understood.
Some medical ethicists argue that ethical placebo administrations cannot be achieved with the AMA protocols and declare that placebo prescriptions are harmful to the patients. The reason why the AMA requires doctors to inform their patients before prescribing a placebo to them is to prevent the deception that damages the doctor-patient relationship. If a patient was to discover the deception that doctors have used to prescribe placebos to him/her, it crumbles both the patient’s trust for doctors and the future relationships between the patient and physicians (Louhiala, Videoconference interview), yet the AMA actually allows the deception that may be detrimental to the patient-doctor relationship. The AMA guidelines permit doctors to prescribe a placebo to a patient without disclosing when they will; however, this may as well still be considered as deceptive because physicians are tricking the patient into believing that the placebo he/she is given by the doctor is something that it is not (Brody). Since the patient does not know when he/she is being administered a placebo, the physician could fool the patient into believing that the placebo is an ordinary medication. If the patient no longer has any trust in their doctor, this “…potentially diminish[es] the therapeutic effect of any medication [a doctor] prescribes in the future” (Freeman). As stated before, patients are classically conditioned to feel relief when they are given a medication as a result of their experiences with medications in the past (Finniss et al. 687), and they expect to feel better because the doctor is showing concern and prescribing the medication the patients may need (Freeman). However, if they know that the medication that was supposed to be prescribed in their benefit was never meant to actually work, the patient’s trust in the treatments of all doctors dwindles due to this deception. This ruins all future doctor-patient relationships (Louhiala, Videoconference interview), and the effectiveness of any medication given by a doctor diminishes. This deception also infringes upon patient autonomy, the patient’s right to know and consent to the treatment the doctor recommends, because doctors mislead their patients into believing that he/she will be receiving a medication different from what he/she think it is.
Instead of always providing the beneficial effects placebos are claimed to have, they may induce harm upon the patients as a result of a doctor’s careless administration. Because doctors are permitted to prescribe any active medication by the AMA guidelines, they may even prescribe medications that will endanger the patient’s health instead of providing the relief that the patient may need. In a survey created for physicians in the United States, the most frequently prescribed placebo were antibiotics for viral or other non-bacterial diagnoses, where 40% of the 412 physicians admitted to prescribing it to their patient (Kerman et al. 638, 639). Antibiotics are extremely dangerous and harmful to prescribe as placebos because they may cause serious allergic reactions and “…unnecessary development of bacterial resistance, creating potential problems for future patients who are in true need of antibiotics” (Hrobjarsson 67). This demonstrates the adverse effects of prescribing active medications like antibiotics as placebos. Furthermore, when doctors use medications as placebos, it implies that “…there is a pill for every ill” (Miller and Colloca 41), meaning that patients will come to believe that all their illnesses can cured with a prescription of a medicine. Patients will then develop an unhealthy reliance upon medication, and they will seek it every time they need alleviation for their symptoms. This conveys the negative effect the placebo can have on the mentality of the patient. Additionally, active medications prescribed as placebos can be harmful to a patient’s health because “[t]here are can be interactions with other medications…” (Barnhill); therefore, doctors should be discouraged from prescribing placebos as active medications because it can damage the well being of the patient instead of improving it. The harmful and negative impacts of prescribing these active medications outweighs the benefits the patient receives even though the AMA guidelines require that doctors only prescribe placebos for the patient’s benefit (Bostick, Sade, and Steward 2).
Placebos cannot be prescribed ethically under AMA guidelines as doctors have proven to administer placebos without following the AMA’s policy. A survey conducted by a group of scholars has illustrated how inadequately American doctors are following the AMA guidelines. Of the 412 physicians that participated in the survey, only 2% directly informed their patient that they were prescribing a placebo (Kerman et al. 638). The survey results implicate that doctors prescribe placebos that may put patients in harm’s way because the physicians choose not to inform their patients that they are prescribing a placebo to the patient, which could potentially lead to the previously mentioned adverse effects that come from placebos prescribed under deception. In addition, the survey has shown that 15% of the surveyed physicians have administered a placebo to their patient solely to end their patient’s complaints (Kerman et al. 639). Stated earlier in the introduction, the AMA requires that doctors prescribe placebos for the benefit of the patient;; however, instead of prescribing it for the patient’s benefit as the AMA demands, doctors have administered placebos for their own benefit, clearly violating the AMA guidelines. The survey results demonstrate and show that AMA guidelines need stringent revisions to better compel doctors to ethically prescribe placebos.
Despite convincing and compelling arguments against placebo administration in clinical practices, it has been claimed to be ethical and sometimes essential to the well being of the patient as some ethicists have argued that the benefit the placebo produces outweighs its flaws. At times, placebo prescription can be the best form of treatment to a patient in cases in which active medication provides no benefit or alleviation for the patient’s symptoms and/ or condition or in other circumstances. “…placebos are the best available treatment in the case of the patient who has refused the available treatments for personal or financial reasons” (Foddy 5). For example, patients may refuse antidepressants to treat their depression due to the side effects it induces; in this instance, placebos may be administered. In an interview with Anne Barnhill, she shows her approval that placebos can be prescribed under deception when the patient has made it clear that he/she is open to alternative treatments. Also, she explained a situation in which she wanted her doctor to deceptively prescribe a placebo to end her suffering from insomnia during her pregnancy (Barnhill). This shows that there may be patients who do need and wish to have placebos deceptively prescribed to finally be relieved of their suffering from their condition or illness. Sometimes, it is better to prescribe a placebo to a patient rather than leaving him/her empty handed because effective medications may be unavailable for patients who live during a time of an epidemic, in remote areas, in impoverished areas, or in war zones (Foddy 6). Under these circumstances, placebo administrations are not only ethical but seem necessary for the patient; however, these arguments will later be refuted, revealing why placebo administration will never be ethical under the AMA’s current guidelines.
One of the biggest arguments against placebo administration has been the fact that it requires deception and the fact that it violates patient autonomy; however, it has been argued that the placebo can be prescribed to a patient without using deception or infringing patient autonomy. In Ted Kaptchuk’s randomized controlled Irritable Bowel Syndrome (IBS) experiment, he proves how placebos may be administered without deception as he openly discloses to the subjects in his trial that they will be receiving placebos in a form of a pill by caring, concerned doctors. Although the patients are fully aware that they are receiving placebos, they still experience a great a relief in their symptoms of IBS compared to the control group that received no treatment at all (Kaptchuk et al.). This demonstrates concrete proof that placebos do not have to be prescribed deceptively in order for the patient to experience the placebo effect and to be relieved of their suffering. Furthermore, deception is a big part of the argument against the usage of placebos in clinical practices because it infringes and limits patient autonomy, but it has been argued that placebos can be administered deceptively without doing so. In certain cases where there is no treatment available for the patient’s condition, placebos can be prescribed under deception by the doctor because there is no better treatment for the patient to choose from; hence, patient autonomy is not infringed upon because there is no better treatment to offer to the patient than placebo administration (Foddy 9). Hence, the arguments in favor of placebo administrations have negated claims against it as research and ethicists have proven or agreed that placebo prescriptions can be ethical when it is not performed under deception or with infringement upon patient autonomy.
In examination of both arguments for the ethics of prescribing placebos in clinical practices, it appears to be only impractical and idealistic to propose the ethical prescription of placebos in the clinical contexts. There is insubstantial evidence to prove that doctors can administer placebos without the use of deception. In an interview, Dr. Howard Brody has stated that although there may be research that asserts the possibility of placebo administration without deception, he declares that “…those data are based on relatively small studies…” (Brody). The research that is done to prove that placebos can be administered without deception is insufficient and inconclusive. Also, there are insubstantial supports that bolster the beneficial impacts placebos are alleged to have on patients. In a clinical trial done by Dr. Asbjorn Hrobjarsson and Dr. Peter Gotzche, patients were randomly put into a placebo or no treatment group. In the placebo group, the subject was either given a pharmacological, physical, or psychological placebo. At the end of their trial, they “…found little evidence in general that placebos have powerful clinical effects,” and concluded that “…there is no justification for the use of placebos” (Hrobjarsson and Gotzche). Near the conclusion of the interview with Howard Brody, he believes that the “…best answer to [whether placebos can be administered without deception] is that we really don’t know” (Brody). Therefore, this shows that there is not much evidence and support to prove that placebos can be prescribed without deceiving the patient and are effective. More research needs to be completed before it can truly be said that placebo prescriptions do not require deception.
Action must be taken to make the guidelines for placebo administration more definite by revising the AMA’s policy. If the usage of placebos in clinical practices is to continue, the AMA must alter its guidelines to confine placebo usage under ethical circumstances. The guidelines should ban placebo administrations and should only allow physicians to prescribe placebos when there is no treatment available to the patient, whether it is due to regional circumstances or financial problems (Foddy 5). Furthermore, in order for physicians to optimally prescribe placebos and avoid harmful placebo administrations to their patients, the AMA should require that doctors be educated on how the placebo effect can be induced and of the harmful impacts the placebo can produce upon a patient to give doctors incentives to avoid careless and convenient placebos prescriptions (Colloca). Instead of allowing placebo prescriptions, the AMA should encourage physicians to display exceptional bedside manners to all patients as it is proven to affect and benefit the patient’s health. As a professional who is knowledgeable about the placebo effect, Dr. Brody himself believes that the “….best thing for doctors to do if they want their patients to feel better is to try to get a good relationship and not to give placebos” (Brody). These steps should be taken by the AMA for doctors to better ethically prescribe placebos and prevent dangerous and harmful placebo prescriptions that may be detrimental to the patient.
Some alternate methods can be used to replace placebo prescription in clinical practices in order to alleviate patient discomfort. For instance, doctors should be motivated to exhibit exceptional bedside manners to the patient instead of prescribing placebos because Dr. Andrew Klein and Pier Forni have “…found that when doctors were more courteous…, their patients were more likely to survive and avoid complications than the patients of docs who were…boors” (Park). This gives doctors great incentives to treat their patients with care and show empathy to them as it has been proven that patients will feel better without even administering a placebo. Dr. Hrobjarsson also agrees that the best alternative for placebo prescription “…is a consultation strategy involving dialogue, empathy, information about relevant facts, and joint decisions about diagnosis and treatments.” (Hrobjarsson 68). Dr. Brody believes that “…we get more placebo effect total for more patients if we simply try to build good relationships than if we try to figure out a way to ethically give placebos” (Brody). As these professionals all seemed to accept and encourage excellent patient care as an alternative to placebo administration, the AMA should not permit placebos but rather encourage physicians to improve their bedside manners and show more care for their patients.
Although the AMA provides guidelines for the ethical prescription of placebos in clinical practices, these protocols are convoluted and must be revised to end the controversial issue of placebo administration in clinical practices. Instead of allowing the “ethical” prescription of placebos by American physicians, the AMA should ban placebo administration to protect unsuspecting patients who will suffer from the careless administrations of doctors and only allow special cases of placebo prescription in which the prescription is dire to the patient’s improvement in health (Brody). Doctors should be required to divulge the medical community’s perspective on whether a form of treatment is considered a placebo or not in order to prevent a controversy of what deems as a placebo (Barnhill). Before doctors go out in the field, they should be educated in the serious and dangerous effects from placebo administrations under deception and those prescribed as active medication (e.g. antibiotics) to discourage placebo usage under conditions that may potentially put the patient’s health at risk (Colloca). More importantly, the AMA should encourage doctors to possess exceptional bedside manner and to demonstrate concern and empathy for the patients because all treatments can potentially be enhanced to the maximum benefit for the patients if doctors engage with their patients and develop a good doctor-patient relationship.