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Nowadays, medical treatment has become an advanced and complicated process that consists of many different steps and factors. One of the elements that can play a role in treatment is called the placebo effect, which is an interesting psychological phenomenon. Although the subject is not thoroughly researched, this effect is frequently used in clinical settings. However, over the years, this topic has raised a number of heated discussions and is still considered to be one of the controversial issues in the medical field. Some researchers indicate many advantages of the placebo effect, while others claim it to be damaging to patients health. According to several studies, despite the fact that in some cases, the placebo effect can trigger positive outcomes, it is still ethically questionable. Moreover, this phenomenon can also have a negative impact on a patient, which is why the use of the placebo effect is connected with many risks.
First of all, it is important to determine the definition of the placebo effect. According to Tavel, the placebo is defined as an inert medication used for its psychological effect, or for purposes of comparison in an experiment (490). Colaguiri presents a more broad definition, saying that the placebo effect is the product of a general expectancy learning mechanism in which verbal, conditioned and social cues are centrally integrated to change behaviors and outcomes (p. 171). In other words, it is a method where psychological manipulation is used in order to improve a patients condition. A considerable amount of research has been done over the last few years to understand and clarify how exactly the placebo effect works. Nevertheless, even though initially it was not considered as a serious element, nowadays, it is widely used as a part of the treatment.
At the same time, critics of using placebo argue that this method has many disadvantages, is ineffective and even dangerous. One of the first concerns that are raised during the debates is the question of ethics. Since most of the time, patients are unaware that they are being treated with inert medicine, the use of the placebo effect is considered to be deceptive. The issue of misleading patients, even for their own improvement, is a tough dilemma for doctors and nurses. There is a high risk that once patients find out about it, they can no longer trust healthcare professionals. For this reason, they can even refuse treatment, which may jeopardize further recovery. Unfortunately, it is difficult to determine the exact answer to such a dilemma, which is why the use of the placebo is debated.
Nevertheless, the American Medical Association (AMA) provides guidance and solutions to such a difficult problem. First and foremost, AMA implies that placebo treatment requires thoughtful, ethical justification since it deprives participants in the control arm of access to accepted therapy for some period of time ( Ethical Use of Placebo Controls in Clinical Practice ). In cases where the alternative treatment is available, the use of the placebo effect cannot be ethical. Moreover, it can be justified in situations where patients have given their consent to administer this method. It means that they must be fully aware of the fact that doctors are trying to treat them with an inert substance, which can interfere with the treatment.
Nevertheless, AMA clearly states that building a respectful relationship between a physician and a patient should be a priority ( Ethical Use of Placebo Controls in Clinical Practice ). Therefore, ethical constraints do not allow the use of placebo medication without the patients consent because it can upset a patient and negatively impact his or her trust in doctors. As a rule, before implementing a placebo in treatment, the doctor should notify patients about such plans, educate them by giving a brief description of the placebo and nocebo effect. Possible consequences should also be addressed because, for some people, the unawareness of the impacts can be an impediment to getting treatment. After a short personal session, a doctor must make sure that a patient accepted the suggestion and signed consent documents. In these circumstances, it is guaranteed that the use of placebo medicine is done in accordance with primary ethical principles.
Other researchers have also expressed their opinions on this issue. For instance, they discuss the importance of informing patients about possible placebo effects as failure to do so can cause distress. For example, Blease et al. conducted a qualitative study where they interviewed patients with irritable bowel syndrome (par. 2). The participants underwent a randomized trial, where they were informed about the placebo effect that was used on them. As a result, the patients demonstrated discontent with the situation, one of them even strongly protested that the person debriefing was mistaken because she felt she had benefited from the treatment (Blease et al. para 19). This outcome suggests that before trying to apply the placebo effect, whether in treatment or in trials, doctors should inform patients beforehand while also using accurate, evidence-based information. Otherwise, there is a risk that people would not understand or accept it, and in some cases, they can doubt the effectiveness of the treatment.
Besides, there are numerous doubts among scientists about the effectiveness of the placebo treatment since some studies demonstrated the inefficacy of this method. Locher et al. conducted an analysis and determined whether a placebo can be used in handling symptoms of an anxiety disorder (AD) and depressive disorder (DD) (p. 1011). The results were compared with the outcomes of treatment with prescribed medicine like serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). According to the research, SSRIs and SNRIs were significantly more beneficial compared with placebo (Locher et al, p. 1019). One of the reasons that were suggested by the scientists is that patients who have a major mental disorder may be more demoralized. For this reason, they may not fully believe in their recovery, hence reducing the placebo effect.
In addition, there are other concerns that are connected with the use of this phenomenon. One of them can be considered as a counterpart of the placebo since it produces negative effects on patients well-being. According to Tavel, it is called the nocebo effect, which is a harmful, unpleasant, or undesirable effect after receiving an inert treatment (p. 490). Such incidents happen when adverse symptoms occur not because of harmful components in the medicine but rather out of patients expectations or fears (Chavarria et al, p. 480). The critical factor of the nocebo effect is that this subject is much less studied, which is unfortunate, considering that it also can cause a damaging impact on a patients health.
Nevertheless, researchers also tried to understand the factors that contribute to this phenomenon. Kaptchuk et al. conducted a thorough study of how psychosocial factors that promote therapeutic placebo effects also have the potential to cause adverse consequences (p. 8). According to them, sometimes patients experience negative side effects of medications because they anticipate them and are extremely attentive to even slight discomfort, which they tend to interpret as a relapse of treatment. For example, researchers report that in trials of anticonvulsants for migraines, the participants who received placebos complained that the medication caused them to have memory problems and anorexia. The findings estimated that up to 26% of patients who are randomly assigned to placebos in trials discontinue their use because of perceived adverse effects (Katchuk, p. 9). Such a result suggests that trying to provide a positive outcome of the treatment with the help of the placebo effect may cause distress and recession.
Other studies indicate that the negative impacts of placebo treatment may vary. For instance, Colagiuiri et al. state that adverse effects include headaches, fatigue, and nausea (p. 174). Furthermore, they mention one of the earliest experiments, which was conducted in 1962, that demonstrated the nocebo effect. According to the study, Japanese men who were allergic to lacquer trees, were given resin and then were told that the resin was from lacquer trees (Colagiuri et al, p. 185). However, this was a lie as the resin was taken from other trees. Nevertheless, the participants reacted as if they touched the allergen, and the symptoms were severe. Colagiuri et al. note that participants developed skin irritation and rashes that lasted for up to 11 days (p. 185). This result displays the destructive potential of the nocebo effect. For this reason, it becomes evident that the use of the placebo is connected with high risks since there is no guarantee that it would enhance beneficial outcomes. In addition, it can also increase harmful effects and interfere with the treatment.
In addition, there are some studies that indicate how medical workers and patients perceive placebo therapy. For example, in the article by Baldwin et al., it is stated that the awareness about placebo use is increased among orthopedic surgeons. However, they do not understand or appreciate its mechanism of action; therefore, they are reluctant to use it. The researcher suggests providing trainees with a better education on the topic of using the placebo. The training should include the information on such topics as possible outcomes, the mechanisms behind the placebo effect, and how to employ it ethically and with respect to patients. In this case, doctors can better understand the advantages and limitations of this phenomenon and use it effectively in their profession, whether in clinical trials or in treatment.
Nevertheless, several arguments support the use of the placebo effect. In some cases, advocates favor possible benefits over other principles, with the reasoning that patients unawareness may bring positive outcomes. For example, in the study of Howe et al., participants with allergy underwent a trial, where they were forced to experience an allergic reaction (p. 1074). After that, a medical doctor prescribed a cream with no active ingredients but convinced patients that it would trigger a specific response. Moreover, a doctor delivered this information in different manners, for one group, a healthcare provider displayed confidence and compassion, whereas, in the other group, he demonstrated low competence and indifference. The results indicate that the allergic response was different, it enhanced when the provider acted both warmer and more competent and negated when the provider acted colder and less competent (Howe et al, p. 1074). Thus, this research presents evidence that the placebo effect helps patients to feel better, and for this reason, it can be used in treatment.
However, even though this study suggests that placebo effects can be used to improve treatment outcomes, it can also be applied to worsen patients condition. There are many factors that can contribute to the efficiency of such a method, including the approach to the delivery of the information and how a doctor displays his competence to a patient. Therefore, in cases where a doctor cannot provide reliable evidence that the placebo treatment will work, there is a high risk that the effect will not work in treatment. Moreover, in some cases, it can negatively affect a patient, causing unexplainable symptoms or pain. Therefore, the consequences of such a phenomenon are too unpredictable; that is why the use of placebo is restricted by ethical guidelines. The policy of asking for permission from a patient before implementing a placebo medicine seems completely reasonable. After all, in the scenario where a patient unknowingly received such treatment and got adverse effects or relapse, a doctor must be held fully accountable for such results.
One more fact that should also be taken into consideration in analyzing this topic is the fact that the placebo effect has no scientific basis. While some studies indicate that in certain instances, it improves patients condition, there is little evidence in general that it produces positive clinical outcomes. Moreover, there is no objective explanation that describes the mechanisms behind this phenomenon. The efficacy of this method is demonstrated only in critical trials with comparison groups. There are little evidence-based studies that provide scientific justification for the use of placebo, for example, what elements provide results in such a treatment. Medical professionals are yet to figure out how a body without any help produces chemicals that imitate the effect of medicine with active ingredients. For this reason, more research needs to be conducted on this subject before implementing a placebo on a regular basis in a clinical setting. Otherwise, the results of a treatment cannot be predicted or regulated, which may present a hazard for a patients condition.
In conclusion, it would appear that even though the placebo effect is present in medical practice, its efficiency is yet to be thoroughly examined. Although some studies and trials demonstrated that placebo could positively affect the process of treatment, there are many concerns regarding the validity and the ethical use of this method. In order to fully understand the complex mechanisms behind this phenomenon further research on this subject must be conducted. In this case, it would be easier to figure out how to guarantee that the placebo effect is maximized while the nocebo effect is minimized. Moreover, it is evident that ensuring the ethical ways to use this method should also be identified. In order to do this, efforts must be made to design precise guidelines. These instructions should promote honest delivery of the information to patients as well as getting their informed consent. In this case, the application of the placebo effect will be justified.
Works Cited
Baldwin, Mathew J., Karolina Wartolowska, and Andrew J. Carr. A survey on beliefs and attitudes of trainee surgeons towards placebo. BMC surgery, vol. 16, no.1, 2016, pp. 27.
Blease, Charlotte, et al. Informed Consent and Clinical Trials: Where is the Placebo Effect? British Medical Journal, vol. 356, 2017.
Chavarria, Victor, et al. The Placebo and Nocebo Phenomena: Their Clinical Management and Impact on Treatment Outcomes. Clinical Therapeutics, vol. 39, no. 3, 2017, pp. 477-486.
Colagiuri, Ben, et al. The placebo effect: from concepts to genes. Neuroscience, vol. 307, 2015, pp. 171-190.
Ethical Use of Placebo Controls in Clinical Practice. AMA Principles of Medical Ethics: I, V.
Howe, Lauren C et al. Harnessing the Placebo Effect: Exploring the Influence of Physician Characteristics on Placebo Response. Health Psychology, vol. 36, no.11, 2017, pp. 1074-1082.
Kaptchuk, Ted J., and Franklin G. Miller. Placebo Effects in Medicine. The New England Journal of Medicine, vol. 373, no. 1, 2015, p. 8-9.
Locher, Cosima, et al. Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders among Children and Adolescents: A Systematic Review and Meta-analysis. JAMA psychiatry, vol. 74, no.10, 2017, pp. 1011-1020.
Tavel, Morton E. The Placebo Effect: Mental or Physical? EC Psychology and Psychiatry, vol. 7, 2018, pp. 490-495.
Annotated Bibliography
Blease, Charlotte, et al. Informed Consent and Clinical Trials: Where is the Placebo Effect? British Medical Journal, vol. 356, 2017.
The article explores the issue of providing participants of the trial with accurate information about research. The researchers suggest that investigators often neglect their ethical responsibilities. Moreover, they explore the appropriate use of placebos in clinical trials and whether it is important to inform the participants. In conclusion, the researchers note that participants should be given the information about the role of placebos, even though in some cases, it may be necessary to conceal details of the trial.
This study is relevant to the topic since it provides knowledge on the ethical side of using the placebo effect. Several parts of the article include exploring the placebo responses, problems with the justification of misinforming the participants. Besides, the researchers provide sane advice on how to improve the disclosure.
Chavarria, Victor, et al. The Placebo and Nocebo Phenomena: Their Clinical Management and Impact on Treatment Outcomes. Clinical Therapeutics, vol. 39, no. 3, 2017, pp. 477-486.
This article focuses on exploring the use of placebo and nocebo effects in medical care. The researchers not only provide accurate information on the subject but also propose strategies to improve the outcomes of this phenomenon in treatment. This study could be appropriate in investigating the matter of the placebo effect since Chavarria et al. conducted thorough literature research.
Colagiuri, Ben, et al. The placebo effect: from concepts to genes. Neuroscience, vol. 307, 2015, pp. 171-190.
This article presents recent genetics studies on the placebo effect. The researchers investigated how various substances in medication (such as dopamine, opioid, serotonin) impact the placebo response. The study provides valuable information that can help doctors to personalize medical intervention that involves the placebo effect.
Ethical Use of Placebo Controls in Clinical Practice. AMA Principles of Medical Ethics: I, V.
This is a part of the Code of Medical Ethics Opinion 2.1.4, which provides guidelines for the ethical use of placebo. Since ethical issues and dilemmas are prevalent in the medical profession, these guidelines are useful for doctors who want to provide professional care while also taking ethical principals into account.
Howe, Lauren C et al. Harnessing the Placebo Effect: Exploring the Influence of Physician Characteristics on Placebo Response. Health Psychology, vol. 36, no.11, 2017, pp. 1074-1082.
The trial in this article displays how the behavior of the doctor can influence a patients expectations and even the effect of the treatment. Moreover, the researchers focus on the impact of the placebo response; therefore, the study may be useful in examining the subject of the placebo effect in clinical practice.
Kaptchuk, Ted J., and Franklin G. Miller. Placebo Effects in Medicine. The New England Journal of Medicine, vol. 373, no. 1, 2015, p. 8-9.
This study discusses if the placebo effect can be compared with the results of medication and surgery. Moreover, the researchers address the issue of the legitimacy of such a method. Although the article does not provide statistical evidence of the effectiveness of the placebo, it is still can be used for researching the subject.
Locher, Cosima, et al. Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders among Children and Adolescents: A Systematic Review and Meta-analysis. JAMA Psychiatry, vol. 74, no.10, 2017, pp. 1011-1020.
This study explores the efficiency of placebo in comparison with SSRIs and SNRIs for the treatment of mental disorders in children and adolescents. The researchers calculated and define the outcomes, which provided interesting information on whether the use of placebo is appropriate in treatment.
Tavel, Morton E. The Placebo Effect: Mental or Physical? EC Psychology and Psychiatry, vol. 7, 2018, pp. 490-495.
This study provides thorough literature research on the subject, including the information about the placebo and nocebo effect. Moreover, Tavel discusses the scientific rationale and ethical issues of using the placebo. For this reason, this study can be beneficial in examining the subject.
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