The ethical use of placebos involves telling patients when this is in play. Here we discuss how to assess the need and the effect of prescribing one.

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Assessing placebo usage

A 2018 meta-analysis published in PLoS One indicates that general practitioners (GPs) and family physicians may be liberally using pure placebos, such as sugar pills, as well as non-specific therapies, such as prescribing antibiotics for a cold.

After identifying 16 studies from 13 countries for inclusion, researchers found that throughout a GP’s career, as many as 97% had prescribed a placebo at least once in their career. Up to 95% of GPs reported using a placebo in the last year, and up to 75% reported prescribing one every week.

GPs used non-specific therapies far more often than pure placebo: Up to 89% for monthly prescription of non-specific therapies, compared with up to 15% for pure placebos. If done correctly, there’s nothing wrong with this. The AMA offers a framework for prescribing placebos in its Code of Medical Ethics.

The AMA wrote:

“In the clinical setting, the 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.”

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AMA's advice for physicians

To prescribe a placebo ethically, the AMA advises that physicians:

1. Explain that exploring all medications, including placebo, could lead to a more comprehensive understanding of the condition.
2. Get informed consent before prescribing. However, the patient does not need to know when the placebo is used.
3. Avoid using placebos to placate patients. Doctors can achieve a placebo effect simply by encouraging and reassuring patients.

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Open-label placebo

According to Ted Jack Kaptchuk, professor of medicine, and of global health and social medicine, at Harvard Medical School, open-label placebo (OLP) studies have shown that some patients benefit from the placebo effect, even when they're told upfront about the placebo and give full informed consent.

Kaptchuk said:

“When we started this research trajectory, we would say that OLP had never been tried and we wanted to see what would happen if you took a placebo and knew it. We never lied about what to expect, never lied about what is in it, or exaggerated expectations.”

In a 2021 research paper published in Pain, Kaptchuk and a team of researchers compared the efficacy of OLP with no-pill control (NPC) and double-blind placebo (DBP) in IBS management. Over 6 weeks, 262 adults received OLP, DBP, or NPC interventions. Compared with NPC, participants who received OLP saw greater, statistically significant improvements in their IBS Severity Scores (90.6 vs 52.3, P=0.038). For OLP compared with DBP, IBS Severity Scores were similar (100.3 vs 90.6, P=0.485).

According to Kaptchuk, honesty and transparency are integral to the success of OLP. “We are meticulous in being honest,” Kaptchuk said. “In fact, patients can smell lies and, given the taint of deception that placebos have, any dishonesty would destroy the effect of OLP.”

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The placebo effect and empathy

Felicity Bishop, MSc, PhD, a placebo researcher based at the University of Southampton, said that when used properly, placebos should fall within the normal scope of patient-provider conversations.

“Having open discussions with patients about treatment options is vital for fostering trusting therapeutic relationships, involving patients in treatment decision-making, and respecting their right to autonomy,” she said.

In fact, Bishop’s latest research explores how physicians can harness the placebo effect that almost all medical treatments will have, without prescribing a placebo—all while respecting patient autonomy.

The protocol, called Empathico, is an evidence-based, theoretically grounded intervention that should “enable practitioners to better harness placebo effects of communication in consultations,” the researchers wrote. Specifically, the protocol trains clinicians to harness the placebo effect inherent in empathy and realistic optimism for osteoarthritis patients.

According to Bishop:

“By communicating realistically positive messages with clinical empathy, doctors may be able to enhance the effects of evidence-based treatments—strengthening placebo effects without prescribing placebos.”

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Putting placebos into practice

Regardless of whether you harness the placebo effect through a communication or more traditional means, the implications are the same: ethics and transparency are paramount. Kaptchuk offered the following guidance:

1. If applicable, voice your scepticism: If you’re sceptical about whether the placebo will work, the honest thing to do is tell the patient.
2. Cite the evidence: “We know that neurotransmitters are involved with placebo response and that specific, quantifiable, and relevant regions of the brain are engaged,” Kaptchuk said as an example.
3. Explain that results will vary: Some patients will see a benefit quickly, others gradually.
4. Be open to possibility: “Say something like ‘Let’s see what happens.’ Uncertainty is part of why OLP treatment can modify central sensitisation to provide relief.”

Above all else, Kaptchuk said, “Honesty is key. Using any kind of deception and positive-expectation manipulation is unethical.”

This article was originally published on 7th May 2022.

This story is contributed by Joe Hannan and is a part of our Global Content Initiative, where we feature selected stories from our Global network which we believe would be most useful and informative to our doctor members.