U.S. Doctors Routinely Prescribe Placebos

Placebo is described in Hooper’s medical dictionary of 1811 as “an epithet given to any medicine adapted more to please than benefit the patient.” Thus, any therapeutic effect was thought to be based on the patient’s faith in his doctor and hence his belief in the treatment. A familiar example is when a parent places a band-aid on their child’s boo-boo. It can make the child feel better though there is no medical reason why. Placebos are often used as a control in studies where a new drug or treatment is being evaluated. If patients taking the new drug fare significantly better than those taking the placebo, the study supports the efficacy of the medicine. However, treatment with placebos may be far more common than you might think. A new national survey shows that over the past year, more than half of American doctors routinely prescribed placebos, rarely disclosing to their patients that they were doing so.

To investigate the “attitudes and behaviors regarding placebo treatments, defined as a treatment whose benefits derive from positive patient expectations and not from the physiological mechanism of the treatment itself,” Jon Tilburt and colleagues from the National Institutes of Health (NIH) and scientists from Harvard Medical School and the University of Chicago surveyed 1,200 U.S. internists and rheumatologists chosen randomly from a national list of such doctors; 679 responded. Of the respondents, 58 percent said they prescribed placebo treatments regularly, and 62 percent believe it is ethically acceptable.

Only 5 percent said they tell their patients explicitly that they are doing so. Rather than “placebos,” some 68 percent told patients they were a “potentially beneficial medicine or treatment not typically used for their condition,” 18 percent just called it “medicine” and 9 percent referred to it as “medicine with no known effects for your condition.” Surveys in Denmark, Israel, Britain, Sweden and New Zealand have found similar results. “Frankly, I was astonished,” said Dr. Ezekiel Emanuel, director of the NIH department of bioethics and a co-author of the report.

The most commonly prescribed placebos were over-the-counter pain relievers (41 percent) or vitamins (38 percent). Some physicians reported using antibiotics (13 percent) and sedatives (13 percent) as placebos, while 3 percent reported using saline solutions and 2 percent reported using sugar pills. “Most say they would prescribe a sugar pill for patients with a chronic painful condition if there were evidence of placebo efficacy,” Tilburt said in the study. “Nearly half say they have used treatments primarily to promote positive patient expectations more than once in a month.”

Though the study did not explore the physicians’ “complex beliefs and motives” for prescribing placebos, Tilburt speculates that they may believe that therapy such as pain relievers or vitamins may have some chance of a benefit, or that placebos may at least help the patients feel like they are being taken care of. “Prescribing harmless treatments like vitamins or over-the-counter painkillers to promote positive expectations without full disclosure or motivations might not raise alarm bells,” he said. “But prescribing antibiotics and sedatives when there is no clear medical indication could have serious adverse consequences for both patients and public health.”

Other experts say the practice raises serious ethical questions, such as how much a doctor should lie to their patient in order for the placebo to have the desired effect. “This is the doctor-patient relationship, and our expectations about being truthful about what’s going on and about getting informed consent should give us pause about deception,” said Franklin G. Miller, one of the study authors and director of the research ethics program in the department of bioethics at the NIH.

The American Medical Association (AMA) discourages the use of placebos by doctors when represented as helpful. Their policy states: “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.”

On the flipside, research has confirmed that fake treatment can have a ‘placebo effect,’ improving a patient’s condition simply because the person has the expectation that it will be helpful. In controlled clinical trials, 30 to 40 percent of depressed patients improve; an effect slightly less than antidepressants achieve. Placebos have also proven effective in treating pain and hypertension. “Expectation is a powerful thing,” said Robert DeLap, M.D., of the Food and Drug Administration. “The more you believe you’re going to benefit from a treatment, the more likely it is that you will experience a benefit.”

Placebo researcher Michael Jospe says that some circumstances justify “benevolent deception,” such as when a patient insists on a medicine that is unnecessary and carries needless risks. “You’ve got to be there on the oncology ward and see how suffering people get so demanding of drugs that might be extremely harmful to them,” Jospe said. “If you look at sugar pills in the broader context of a supportive doctor-patient relationship rather than just as ripping off the patient, you may come to a different conclusion” about the ethics of placebos. 

Many patients also suffer from conditions for which there are no scientifically proven treatment. “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,” Dr. Tilburt said.

Researchers have been studying the placebo effect for over 50 years. In 1955, anesthesiologist Henry K. Beecher published a groundbreaking paper called “The Powerful Placebo,” in which he concluded that, across the 26 studies he analyzed, an average of 32 percent of patients responded to placebo. In the 1960’s, breakthrough studies showed that ‘dummy pills’ produced physiological effects. For example, when participants were told they had taken a stimulant, their pulse rate sped up, their blood pressure increased and their reaction speed improved. The opposite effect was achieved then the participants were told they had taken a sleep-producing drug. But the power of positive thinking is not a new revelation. The Talmud, an ancient compendium of rabbinical though, states that: “Where there is hope, there is life.” And hope is just another name for positive expectation.