Meaningful and sensible placebos

It is not only a piece of matter that moves but also a universe of meanings and contexts. For philosophers, the word Meaning is everything but trivial. In a crowded street, you may point the location of the closest train station by extending your arm at speed in the direction of someone else’s head – the head of a lost tourist asking for help. And the very same precise movement of hands, yet, may signal something completely different. In front of the scene, inside an office in the corner’s building, an arm extension mirroring the aforementioned action might be a crucial constituent of a field cranial osteopathy session. Meaning is central in how we meet and react to the world and lies deep in the philosophical dimension of the placebo effect. And it rests just next to an intricate ethical puzzle.

Biomedical, philosophical and ethical perspectives on the placebo effect bluntly prove how a single word can hold so disparate meanings. If knowledge is to be widened and enriched through such multiplicity of views, an effort to look beyond the frontiers of isolated disciplines is needed. The placebo response, philosophers think, is something else than an inert pill. The context where that pill is given to a patient matters.

Philosophers are convinced that decades of research with placebos hide some lessons that have not been properly assimilated. By analysing in detail placebo responses, instead of disregarding them we would be able to get important insights for clinical practice. “What would happen if we use science to augment the art of medicine?” asks Charlotte Blease, a philosopher and cognitive scientist at the University of Leeds (UK) who explores the ethics of placebos.

Placebo effects point to a role in the clinic for aspects that have more to do with subjective experiences. In essence, it is about parameters that define the quality of a human interaction: active listening, making small talks or putting the patient at ease, Blease thinks, are all aspects highlighted by research on placebos that represent clinically useful ingredients of healthcare.

Placebos´ reputation among clinicians is not at their best, even if they might easily agree with these conclusions. Healthcare systems persistently struggle to satisfy a rising demand for a growing or aged population with limited resources, and that poses pressures on clinicians´ working conditions – which might ultimately influence routine medical praxis.

“In the UK, patients spend today an average of 8 minutes with their doctor. Our pressurized healthcare systems place a colossal stress on our doctors,” says Blease. There may be sound reasons for claiming longer clinical encounters. “Longer visits are associated with higher numbers of preventive and educative activities and better exploration of psychosocial problems,” comments Jesús López Torres Hidalgo, research secretary of the Spanish Society for Family and Community Medicine. “On the contrary, shorter medical visits are linked to lower levels of patient satisfaction, higher prescription of medicaments, higher return rate of patients and higher stress of doctors,” he adds.

We saw in earlier posts that the clinical entity of the placebo effect has potentialities and limitations (Belief and physiology boundaries). Likewise, pros and cons do also exist with regard to medicaments, some of which are aimed at alleviating conditions in which placebo effects might be useful – mostly, in certain nervous system disorders (Learning to self-care). Together with an ongoing slowdown of the drug discovery enterprise in relation to these conditions, there would be reasons to encourage an opening up of health approaches to other perspectives.

So placebos point to human relations and trust, as it occurs in doctor-patient encounters, is a crucial aspect that links with the ethical debate surrounding placebos. In most placebo studies done to date, patients were made to believe they were receiving something they were not actually given. For example, a sugar pill was said to contain, while it really did not, a certain pharmaceutical agent. Would that be acceptable from an ethical point of view?

“There is a strong tradition of considering placebo interventions unethical because they normally involve the deception of the patient,” says Asbjørn Hrobjartsson, author of the amplest and current meta-analysis of placebo effects across conditions. For some clinicians and philosophers, the word placebo immediately arises hostility or disdain. “Some philosophers have argued that lying to patients is always wrong”, comments Blease.

This reaction has a likely historical root: the respect towards the protection of patient autonomy has been a standard reference in medical practice for decades – since its concretion in the Declaration of Helsinki, a manifest raising after the Nazi human experiments occurring during the Second World War.

Yet other views are out there in the philosophical arena. For some philosophers, deception in the context of placebos need not be a morally serious infringement. Patients want to get better and may not care about how pills work, argue proponents of this view. Still, for others, deceiving a patient would be acceptable under some limited circumstances, depending on the particulars of the case. “Of course, that is far short of saying that deception should be normalised or simply accepted as Ok,” says Phil Hutchinson, a philosopher at Manchester Metropolitan University (UK) who works on the philosophy of emotions and moral psychology.

“The ethical debate hinges on the tension between respect for patient autonomy (the patient’s right to an informed decision about treatment options), and the right of beneficence (the duty of the doctor to provide beneficial treatments),” explains Blease.

Blease and Hutchinson, among other philosophers, are trying to tease out the moral puzzle. In Blease’s view, harming patients´ trust in physicians is a risk not worth taking, so she would discard deceptive placebos as a convenient approach. Rather, she is exploring alternative delivery options to circumvent the problem of deception in a manner consistent with informed consent. Also, she thinks that actual people‘s opinions and attitudes should be surveyed in order to establish what is ethically acceptable. “Ethics is deeply entwined with epistemology (how we interpret evidence). So, empirical issues influence ethical debates,” says the philosopher.

To make steps forward, the problem needs a proper framing, philosophers think – and a good starting point would be finding unequivocal definitions. “How we understand ‘placebo’ and ‘placebo effect’ has repercussions for how we frame our ethical enquiry,” comments Blease.

“Is a placebo a thing (such as a sugar pill)?” she adds. “Are sugar pills necessary to elicit the placebo effect? We know that a range of contextual cues (colour of pills, frequency of taking pills, but also the attitude of the practitioner) can augment the placebo effect,” comments the philosopher.

According to Hutchinson‘s view, the traditional idea of placebos is somehow contaminated and spoils the debate. “We don’t give placebos, we elicit meaning responses through employment of symbols which have significance for our patients and which can bring about medically significant responses,” says the philosopher. He goes on to explain how a proper definition would make the problem ethically approachable; “when one understands that we are witnessing a meaning response then the ethical question is recast because deception is no longer inevitable. There are many ways of eliciting a medically beneficial meaning response without deception.”

Open-label placebos would be a way to do so. In this choice, patients (once they consent) are told with transparency about the placebo effect. They are explained that placebo effects are intended to be engaged and to do so the doctor would elevate her or his enthusiasm for the treatment. But any deception about the pharmacological constitution of pills is avoided. “Placebos activate specific brain circuitry that produces relief of symptoms,” Blease proposes as a possible statement patients would be given.

To date, an open-label placebo approach has been tested and proved successful at alleviating symptoms in a couple of conditions (migraine and irritable bowel syndrome ¹ – a condition with abdominal pain in the absence of organic disease). Also, preliminary research points that people may show positive attitudes towards them. In a US study with outpatients, 85% of 800 respondents considered them acceptable and 61% would be willing to try for abdominal pain ².

Further research will need to explore further the details. “We need to tread carefully here,” points Blease, “there is a lot of hidden issues that need to be unpacked before we can even open the debate about the ethics of placebos in health care encounters,” she adds.

Nevertheless, philosophers think the effort is worthwhile, as there may be substantial benefits once the obstacles surrounding placebos are teased out. “We might speculate that patients would adhere to medications better, but also, there is the possibility that they may require lower dosages of, for example, analgesics,” comments Blease. “Perhaps we might find lower costs and more satisfied patients,” she concludes.