The Placebo:Lying to the Patient-A Skillful Use of Reassurance and Encouragement?
The American Medical Association (AMA) has a policy regarding the use of placebos in clinical practice and here it is:
H-140.869 Placebo Use in Clinical Practice
A placebo is a substance provided to a patient that the physician believes has no specific pharmacological effect upon the condition being treated. 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.
Physicians may use placebos for diagnosis or treatment only if the patient is informed of and agrees to its use. A placebo may still be effective if the patient knows it will be used but cannot identify it and does not know the precise timing of its use. A physician should enlist the patient’s cooperation by explaining that a better understanding of the medical condition could be achieved by evaluating the effects of different medications, including the placebo. The physician need neither identify the placebo nor seek specific consent before its administration. In this way, the physician respects the patient’s autonomy and fosters a trusting relationship, while the patient still may benefit from the placebo effect.
A placebo must not be given merely to mollify a difficult patient, because doing so serves the convenience of the physician more than it promotes the patient’s welfare. Physicians can avoid using a placebo, yet produce a placebo-like effect through the skillful use of reassurance and encouragement. In this way, the physician builds respect and trust, promotes the patient-physician relationship, and improves health outcomes. (CEJA Rep. 2, I-06)
Thoughtful and empathetic communication from the physician to the ill patient is a therapeutic tool. In fact from the above AMA policy: "Physicians can avoid using a placebo, yet produce a placebo-like effect through the skillful use of reassurance and encouragement. In this way, the physician builds respect and trust, promotes the patient-physician relationship, and improves health outcomes."
My question: What if the reassurance and encouragement is to the physician clinically unrealistic? However this is unknown to the patient. Nevertheless, to the physician, at this point, such reassurance would be considered as theraputic and beneficent. Would that misrepresenation to the patient of the patient's clinical condition be considered "a placebo of a 'placebo-like' effect"? A placebo of a placebo? Does lying to the patient represent "skillful use" of reassurance and encouragement? And is that consistent with AMA's ethics policies? ..Maurice.
posted by Maurice Bernstein, M.D. @ 4:15:00 PM
7 comments
7 Comments:
You ask: "Does lying to the patient represent "skillful use" of reassurance and encouragement? And is that consistent with AMA's ethics policies?"
That's really a mixed bag, Dr. Bernstein. The physician who is trying to encourage a patient who really has no hope is actually giving them moments of peace ... however, he is not promoting "respect and trust," when doing so.
Then again, there's the realization that if he is giving hope to a hopeless case, that eventually, the patient will realize that he's been lied to ... and this will happen when he's at his sickest, and least able to emotionally cope with the realization of having been betrayed by a trusted medical professional.
False hope is really far crueler than a grim, but honest, assessment. Being told that each person is different, that unexpected positive things can still happen, and that whether things improve or worsen, that the physician will be there with the patient, helping in whatever way possible, would probably be more helpful in the long run.
I believe that any encouragement should be tempered by reality for the sake of the patient.
It's my opinion that the "spirit" of the AMA's position comes down to the idea that placebos must only be used honestly, and never as a tool that will give a physician a handle on a difficult patient, or on a patient with a difficult diagnosis.
If used, it should be used to benefit the patient - not the physician.
As a patient, I find that line of thinking really scary. Physicians cannot have it both ways. You can't say "Your access to certain kinds of information should be restricted because you should be getting the information you need from your doctor, not from other sources" and at the same time say "Oh, and by the way, the doctor could be lying to you, but that's OK." Lying has NO place in the therapeutic relationship, regardless of how "skillful" the doctor thinks they're being when they do it.
"What if the reassurance and encouragement is to the physician clinically unrealistic?"
I don't understand the question. How often does a doctor encounter a situation where there is genuinely no hope at all?
People who are ill can almost always be helped to live better, whether through psychotherapy, social services or ergotherapy (or whatever the word is in English).
Even they dying can have hope. My sister is an internist and is particularly proud of the ways she brings different interpretations of "hope" to patients and family. She will commonly face a family in distress because Granny, who has not been well for a long time, is now very unwell with kidney failure. My sister will make explicit different outcomes that might be hoped for. That Granny will stay like she is now, but for longer? That she will be cured and go live in an apartment by herself? That she will die comfortably surrounded by the family who love her? Helping a patient and family reconcile reality and hope is one of the most rewarding parts of her profession.
There are apparent exceptions. ALS, for instance. Quick deterioration, never knowing how you're going to wake up in the morning, never being able to adapt to new circumstances. That's a tough one. But listening to and believing a patient can relieve discomfort and anxiety all by itself. This is a reassuring technique used all the time by all good and ethical doctors. No lying required.
Intractable depression is possibly the worst, because depression is by definition the loss of hope. Most depression is amenable to some kind of intervention, but if it is not, then it would not be amenable to encouragement, and so is clearly not the subject of the article.
I really don't understand why reassurance and encouragement are being equated with lying - especially not by a bioethicist, who should know better.
Alison, realistic reassurance and encouragement by the physician is what we physicians should all be doing. We understand the medical prognosis, we listen to what the patient says and how the patient feels about the illness, quality of life and the future based on the prognosis that the physician is aware. The physician then talks with the patient regarding the patient's views about the illness,quality of life and future which are unduly pessimisitic, based on misunderstood information. This would be the realistic reassurance and encourgment that should be provided to the patient.
Offering reassurance and encouragment which is not based on facts or accepted prognosis and about which the doctor is aware but not the patient, is essentially lying to the patient. But this may not be unacceptable therapy if one considers that such "good news" might indeed have a placebo effect and actually do good to the patient.
If the physician and nobody else has any idea of the prognosis and hope is the only way of anticipating the end results, then hope is what should be provided by the physician. ..Maurice.
My father had cancer of the lining of his lungs and his doctor told him he would be back to work by a specific day signed paper and all... so my parents didnt worry as my dad got sicker and sicker, then his doctor went on vacation and the head oncologist took on his case for the time she was on vacation. One of the first things he asked my parents was "Why don't you have hospice" they replied that hospice was for terminal patients and his doctor had signed a paper stating he would be back to work by a specific date, the head oncologist had to give my parents the grim news that my dad now only had about 2 months to live and he needed to get hospice. My parents because of my dads orignal doctor kept going on with life as usual mom worked and dad was working in the yard and keeping busy cause he was out on disability or something like that. Because of his doctor we never were able to spend that extra family time that we would have if we knew that my dad was dieing, this is not right how doctors can straight up lie to patients like that, my mom tried to sue but she had no case because lieing is morally wrong? I think that deliberatly lying to a FAMILY not just a patient and giving fals hope is illegal and should be persued. Yes his doctor knew he was dieing but her reason for not telling the truth......"I didn't want to take the fight out of him" That is bull, when someone can't fight why tell them they can, it destroyed not only what time we all could have had left as a family but also our belief in medicine its self, none of us trust doctors now, and for good reason.
Do clinical patients usually agree, by signing all of the 'first time patient' forms, to unknowingly take placebo in the event that the doctor thinks it might be beneficial? I suspect that my doctor gave me a prescription for placebo, and i don't know if i ever agreed to it or not.
I doubt any patient is given a document to sign that says that "therapy might include a placebo"... except, of course, if the patient was enrolling into a research project where one arm of the experiment would be the use of a placebo, the other arm a drug to be tested for efficacy. In this regard, the subject, as part of informed consent, must be made aware that instead of the drug, a placebo may be randomly assigned to the subject. ..Maurice.
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