SciMoms Chats: placebos and compassion

SciMoms Chats are a series of articles based on our SciMoms chat. Yesterday, we discussed placebos after reading a new study about the efficacy of acupuncture for pain relief in cancer patients. The original conversation has been edited for clarity and references added where needed.

Alison: This study is interesting: (Acupuncture in cancer study reignites debate about controversial technique). I have a hard time with the hardcore skeptic viewpoint on placebos. It seems so heartless. At some point, if something relieves something as subjective as pain and helps people stay on their treatment regimen for cancer, who cares if it is an elaborate placebo. Something that is happening is helping. And if that something keeps people in care and receiving effective treatment, isn’t that a good thing?

This issue makes me think of this Science-Based Medicine article about placebo effects (Placebo, Are You There?). There is something going on here, even it is not the acupuncture itself. (This is one of the best articles on placebos I have read, by the way!)

Anastasia: I’m all for placebos for adult humans, and maybe older children who are susceptible to placebo. Just not for young children or animals who can’t consent!

Alison: It does change the ethics when the subject is someone who cannot give consent. I agree that informed consent is key. Using a placebo that you know is a placebo without telling people is a violation of that cornerstone of our medical system. I am concerned about the erosion of informed consent if we regularly use placebos without it. History shows that without informed consent, there are huge problems.

Layla: I think a case can be made for it when it comes to managing pain.

Alison: Pain is so subjective. It seems inherently different to me than placebo for curing cancer or something like that. A placebo is not going to reverse runaway cell division, but if it helps someone’s subjective experience? I have a hard time with the strict skeptical stance here.

Anastasia: Alison, you are right. The strict skeptic stance doesn’t work here – it needs to be tempered with compassion.

If you tell someone a medication or treatment is a placebo, will it still work?

Layla: It can. There are studies where they tested this and people still benefit from a sugar pill even when they know it is a sugar pill! (A placebo can work even when you know it’s a placebo)

I’d love a placebo that would work for my headache right now…

Anastasia: So sorry you have a headache! If placebos can still work even if the doctor discloses that it’s a placebo, then why lie?

It seems that the ethics are evolving. Have you seen these dueling articles from 2013 and 2015? The first (“Comparable Placebo Treatment” and the Ethics of Deception) argued that using placebos “does not amount to deception; that it can preserve patient autonomy; and that it is therefore morally legitimate.” While the second (Placebo and Deception: A Commentary) argued “undisclosed placebos is not a “lie” but is a straightforward case of deceptive misleading the patient.”

I wonder if there’s a % of patients that lose efficacy if you tell them. Placebos are such a strange subject! Reminds me of this study that found more expensive placebos are more effective (Commercial Features of Placebo and Therapeutic Efficacy).

Layla: HA! It’s like that prank where they took chicken nuggets and told people it was organic and it suddenly tasted better! At the heart of it, we’re all snobs (Could You Tell the Difference Between Organic and Fast Food? A New Viral Prank Vid Says Probably Not).

Alison: There is so much important research being done on placebos. Sorting out what make one person a placebo responder and another a placebo non-responder (Is the Placebo Effect in Your DNA?), understanding why the placebo effect in clinical trials has been increasing in the US (The Rising Placebo Effect), and, in my field in particular, why Parkinson’s patients seem particularly susceptible to placebo effects (The Placebo Effect in Clinical Trials in Parkinson’s Disease). I really do think that understanding placebo effects and incorporating whatever it is that makes placebos work into medicine will be better for patients.