27 May 2008

Marketing placebo for use by the public

Today experts say placebo use by a parent is deceptive and unethical. Perhaps they have never practiced "medicine" or health care. Surely, they understand placebo has been used since antiquity, and continues in use. There are three issues: 1) does placebo work? 2) is placebo use in and of itself unethical, without consideration for who uses it, because it is deceptive? 3) is placebo use by parents unethical?

1) Placebo has been used by physicians and other health workers since antiquity, and continues in use today. There is a strong argument not using placebo is unethical. One expert says: “Each and every time you give a placebo you see a dramatic response among some people and no response in others.” Of course, that is well understood. In fact, it disguises by leaving unsaid one of the reasons placebo is justified. No medicine works 100% of the time. It may give some bodily reaction most of the time, but that is not the same as a curative action. Henry Beecher, whom we know as one of the initiators of research ethics, also gave us the medical short-hand that about 1/3 of patients get better by themselves, 1/3 by medicine, and 1/3 don't get better. That is based on his early 50's paper that said about 1/3rd of cures from any intervention are not due to verum, but to the placebo effect. The research about placebo ranges from 30-40% (or more) effectiveness to it is not effective at all. As a matter of professional judgment, in which "evidence" is primarily based on the physician's experience, placebo is a valuble tool in the arsenal of tools to help people feel better. As a general matter, in short, there is no pragmatic reason not to use it. It works.

2) The deception issue in medicine is problematic. But if placebo is treated llike any other intervention, then perhaps the problems disappear. Since no medicine works all the time, some more than others, when the physician tells the patient about any medicine it would be unethical to say it works all the time. So, what is the problem with treating placebo like any intervention, all of which have a potential not to work? That is, if use of placebo is unethical because of deception, then much use of medicine is deceptive for similar reasons. Any argument about placebo must be generalized to an argument about the use of deception in medicine and the uncertainty of medical knowledge in general. No physician knows with theoretical certainty whether any substance he or she gives will work.

3) Given the foregoing, the protestations against parents using placebo for their children sound more like the familiar refrain of "only physicians (MDs) know how to treat disease, and you parents should not be mucking about with the lives of your children." Defenses of this kind are dubious on many axes.

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