PLACEBO EFFECT

More than half of doctors offer fake prescriptions to make patients feel better -- and that's OK, most doctors say.
The findings come from a survey of 679 internists and rheumatologists. Doctors in these specialties often see patients with chronic illnesses or chronic pains that are difficult, if not impossible, to cure. Sometimes fake medicine -- placebos -- make such patients feel better.
Fake drugs can have very real benefits. It's called the placebo effect. In clinical trials, many patients who receive placebos do better than real-world patients who get no treatment at all, notes study researcher Jon C. Tilburt, MD.
"Twenty to thirty percent of the benefit seen in rheumatism drug studies are due to the placebo effect. Real changes in health go along with the belief that patients will get better," Tilburt tells WebMD.
Tilburt and colleagues asked the doctors a series of questions, each a bit more blunt than the last:
If a clinical trial showed a sugar pill was better than no treatment for fibromyalgia, would you recommend sugar pills to fibromyalgia patients? Yes, 58% of the doctors said.
Do you ever actually recommend treatments primarily to enhance a patient's expectations? Yes, 80% of the doctors said.
In the last year, did you recommend a placebo treatment to a patient? Yes, 55% of the doctors said.
What did the doctors actually tell their patients? Over two-thirds of those who prescribed placebos told patients they were getting "medicine not typically used for your condition but which might benefit you."
Is it "appropriate" to fool patients this way? Yes, 62% of the doctors said.
"I don't think doctors have anything but the patients' best interest in mind when they give a placebo prescription," says Tilburt. "They are thinking about both the physical and psychological well-being of the patient."
The hard-to-accept truth is that doctors don't have proven treatments for many of the ills that plague their patients.
"With untreatable conditions or chronic conditions when we have run out of treatments, doctors are willing to try virtually anything -- if they are convinced it is safe -- to make the patient feel better, even if the mechanism is a psychological mechanism," Tilburt says.
Placebo Prescriptions: Right or Wrong?
Is it right for doctors to prescribe treatments they believe are not biochemically effective?
Here's the official policy of the American Medical Association:
Use of a placebo without the patient's knowledge may undermine trust, compromise the patient-physician relationship, and result in medical harm to the patient.
A placebo must not be given merely to mollify a difficult patient, because doing so serves the convenience of the physician more than it promotes the patient's welfare.
Physicians may use placebos for diagnosis or treatment only if the patient is informed of and agrees to its use.
Placebo Prescriptions: Right or Wrong?
That last point seems tricky. How can a fake drug work if a patient knows it is fake?
The AMA policy says doctors should explain to patients that they can better understand their condition if they try different medicines, including a placebo. If the patient agrees to this, the doctor does not have to identify which medicine is fake, nor does the doctor have to get the patient's specific consent before giving the patient the fake treatment.
There's nothing wrong with this approach, says medical ethicist Arthur Caplan, PhD, professor of bioethics at the University of Pennsylvania, Philadelphia.
"It is ethical to use treatments that are low risk and have few side effects if you can relieve people's symptoms," Caplan tells WebMD. "Placebos are especially useful in the treatment of the psychological aspects of disease. Most doctors will tell you they have used placebos."
But doctors do often prescribe placebos the wrong way. In today's world, a doctor can't write a prescription for a sugar pill. The doctor has to prescribe something -- and every active medicine carries some risk of side effects.
"What you can use as a placebo is complicated. I have seen people dispensing antibiotics as placebo for mothers who want something for their kids' flu," Caplan says. "Not only does this not help, but it does build up drug resistance and may have some serious side effects for the child."
Most doctors use relatively harmless drugs, such as baby aspirin, as placebos. Clearly, great care must be taken to ensure that the placebo drug's risk is less than the benefit of the hoped-for placebo effect.
"We know it is wrong when doctors give potentially harmful medicines in a manner that may not be warranted," Tilburt says. "If I think it will actually have only a placebo effect, I should not give a patient a sedative. The compulsion by doctors to benevolently promote patient expectations can play out in a way harmful to patients."
In the end, Tilburt suggests, the effectiveness of a placebo treatment may well hinge on the trust patients have in their doctors.
"Maybe it isn't about taking a pill at all," he says. "Maybe it is the relationship between the doctor and the patient that makes the real difference."
Tilburt, formerly with the bioethics department of the National Institutes of Health, is now assistant professor of medicine at the Mayo Clinic, Rochester, Minn. The study appears in the Oct. 24 online first edition of the journal BMJ.