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THE online discussion between proponents of conventional medical science and those who see the scientific method as too “closed-minded” can become frustratingly repetitious. When evidence is shown of a therapy being ineffective beyond placebo, this question is frequently posed: “If it makes the person feel better, where’s the harm?” Having had this discussion many times myself, I’ll share with you what I think the answer is.
There are multiple harms. The harms are both direct and indirect, and both physical and ethical.
First, medicine has spent decades adapting to the societal call to drop the paternalistic role, where The Expert was not to be questioned. Instead, we are encouraged to be skilled advisors, using our knowledge and experience to assist patients in medical decision making. Our expertise lies in understanding how the body works in health and disease, how to identify what is going wrong, and how to approach fixing it. Our more subtle skills include gaining an understanding of what the patient needs from us and how this is most effectively communicated and delivered. What is needed can be as simple as an explanation or reassurance, or as complex as an intensive care unit admission on inotropes and a ventilator, or major invasive surgery. If the treatment we offer is a sham “therapy” for its placebo effect, we are not honouring our professional training or our patients’ rights to evidence-based care.
Next, if the patient does feel some symptomatic relief from a placebo, they may be falsely reassured about the original condition, and not seek a review of diagnosis. This is particularly dangerous if the placebo is delivered by a provider other than a medical practitioner, who has not made a competent diagnostic evaluation first. We know that the placebo effect can only improve a sense of wellbeing, but not bring about healing of tissue (although spontaneous healing of self-limited conditions may occur).
Third, the provision of a “remedy” for every symptom encourages patients to have a dependence on the health care provider, rather than to take responsibility for their own health and wellbeing. If we are always recommending “medicine”, we are teaching patients that every symptom reflects a “disease”, or that their body is somehow “damaged”. On the other hand, we know that watchful waiting can safely monitor self-limited conditions. The ability to do this, however, requires a long term doctor–patient relationship, with the ability to recheck and review symptoms and progress. The current tendency of many emergency department staff to do a “full work-up” on patients presenting with likely benign conditions works against the ability to educate patients about review and reassessment, and, frequently, the tests become the placebo.
In moving away from authority figures towards the role of consultants in health assessment and disease management, we can regain wonder and pride in our mastery of medical science. We understand metabolic pathways and cell membrane structures in intimate detail. We can distinguish dietary ketosis from diabetic keto-acidosis, glucose metabolism from fructose, understand the risks of thromboembolism and of its prevention and treatment. We can explain about acid-base balance and why “alkaline water” isn’t therapeutic. We can keep in touch with newer areas of physiology and therapeutics through reading, journal clubs and clinical meetings, and use what we learn to educate and benefit our patients.
When patients ask us about the advice they got from their naturopath, the product they bought from the homeopath or the supplements they are taking, we can explain how the placebo effect works and refer them to the evidence. The time taken in explanation and reassurance provides a placebo effect in itself – without any deception.
Dr Sue Ieraci is a specialist emergency physician with 35 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She is an executive member of Friends of Science in Medicine.
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This is an excellent article Sue. I have also seen your considered posts online and thank you for your ongoing contribution to public health.
While remembering that only doctors are trained in scientific diagnosis and others often make wrong diagnoses, and no-one knows everything, and that diagnosis is built on the premise that science identifies he correct answer for the majority and that no unscientific studies are done scientifically, non-scientific methodologies and practitioners should acknowledge themselves as such.
Thank you, David. It’s important that those of us with expertise in science and medicine continue to help others find their way through the many sources of misinformation that abound, generally wanting to sell some useless product.
Well said Sue.
I have seen your well written replies on various social media, trying to persuade the illogical, misinformed, ignorant and in some cases deliberately mischievous.
Among them, some may be receptive and appreciate your efforts.
Silence is compliance and like you, I don’t tolerate quackery and woo quietly.
Please continue to fight the good fight.
I have no issue with the placebo benefit of a sympathetic provider (as I said in the article) – it is deceptive use of placebo “remedies” that is ethically suspect. Complementary practices that assist well-being – such as massage or meditation – are also ethical if no claims are made for specific therapeutic benefit. The oft-repeated argument that “science doesn’t know everything”, however, is no excuse for making false or exaggerated claims. The example of glucosamine is an illustrative one – it is our responsibility to explain to patients what the best available evidence shows at any particular time.
A medical practitioner should not be “loath to present myself as an expert on everything” – patients come to us on the basis that we have the training and experience that DOES amount to expertise – just as we consult architects or lawyers because they are experts in their respective areas. Palliative care is also science-based medicine – it does not rely on belief, but on evidence.
Medicine is based on a scientific model, and the evidence continually accumulates and gets refined – just as it does in astronomy or oceanography. Our role is to interpret the science and the accumulating evidence for our patients in a way that leads to the best available solution to their issues. Of course this includes the need for perception, emotional intelligence and good communication skills to understand and meet those needs. All of this can be done without resorting to deception.
I lean towards the gentler approach. Mindful of the incompleteness of our knowledge about disease and the body system I am loath to present myself as an expert on everything. I am also loath to rebuke or condemn the beliefs and wishes of my patients. Far better to explain what we know to them, educate them than seem to rebuke them for opting for alternative treatments. While agreeing with the general text of the article, I feel it is still one sided.
The psychological benefits of a placebo have been documented. Fine, it may be only psychological but if it passes the HARM test, which is to say it does no harm physically, psychologically or economically – which includes providing false confidence (eg: leading to the abandonment of scientifically valid treatments, or ignoring worsening signs of other disease), and contributes to the patient feeling better, then is it not producing a benefit to that patient.
In the same way we provide palliative care not expecting a cure, should we not accept the benefits of a placebo.
Provided we can satisfy the HARM test, we should accept also that we do not know everything. Many diagnoses in psychiatry rely not on chemical or electrical measurements, or imaging techniques but on distinct criteria, as in DSMIV (which I still use), which are nonetheless open to interpretation. They have been refined to exclude operator error, but are still not as absolute as say, a Full Blood Count.
I am wary of false hope, and dangerous claims (like Cancer Therapy Quacks and Chiropractors claiming to massage away diabetes) and have no doubt of their danger. That said, lavender based aromatherapy can help some patients with sleep and relaxation and poses a much lesser risk then a benzodiazepine. Where it works, placebo or not, is this not an ethically and functionally better option. More to the point, seeing it work with some, have we proof that iot does not have any scientific basis for effect. If we apply Poppers falsifiabiliity test, then condemning it as a placebo and finding it works with some patients satisfies the falsifiability test of our argument. A better explanation is that we don’t know why it works in some patients.
Remember also that when quack medicine is shown to work (eg: Glucosamine) it is rapidly adopted into mainstream medicine, and when accepted medicine is shown to be ineffectice it is rapidly out of favour (again eg: glucosamine).
My advice is to not be too scientific in our practice of medicine, accept our knowledge limitations, before condemning alternative or placebo therapy, consider the HARM factors, and above all remember that the patient before us is not the same as every other patient, for a wide range of psychological, cultural and social reasons.
Remember also that the drug “Doctor” has proven placebo benefits when applied (Michael Balint) before we get too conceited.
While remembering that doctors do make wrong diagnoses, and don’t know everything, and that not everything that may work for some people has been proved ‘scientifically’, and that not all scientific studies are properly done.