In the context of a serious illness, some participants also used a speech of desperation to justify prescribing placebos: provided that the patient could benefit from them and that certain other conditions were met, they felt that it was “worthwhile” to try placebos as a last resort. Additional conditions necessary for the acceptance of placebos included the lack of a proven effective treatment, placebo that does not harm, and the person who suffers or otherwise suffers. Although the WADA`s Code of Medical Ethics itself does not have the force of law, the courts generally give it weight in resolving issues in the area of informed consent. In Culbertson v. Mernitz, the Indiana Supreme Court, said, “The 1992 Code of Medical Ethics, as drafted by the American Medical Association`s Council for Ethical and Judicial Affairs, sets the standard for the medical profession for informed consent.” 26 In November 2006, following a proposal by the Ethical and Judicial Affairs Council to prohibit placebo deception, WADA adopted its current position on the use of placebos. The report, published in June 2007, notes that the use of misleading placebos is ethically inappropriate. WADA recommends that detected placebos can still be effective and allow the use of placebo “for diagnosis or treatment only if the patient is aware of it and agrees to its use.” 27 However, it is widely accepted that misleading placebos provide greater benefits. In fact, the placebos revealed can lead to side effects, skepticism about the medical system, and a loss of trust in doctors, which could make placebos more harmful than no treatment at all. A final reason is the difficulty of proving that the doctor caused the patient`s harm by not disclosing the use of a placebo. In a traditional case of informed consent, a lawyer can prove that a physician negligently failed to share important information with the patient.
Cases with placebos are difficult for lawyers because the whole basis of the placebo effect is a lack of disclosure to the patient. “Pure” placebos are, in fact, sugar pills or saline injections with no therapeutic value (apart from the fact that this is due to the psychological effects – we will come back to this later). This “pure” strain has been used by about 12% of GPs at some point in their careers. Among these doctors, there were various motivations, including the desire to create psychological treatment effects, reassure patients, soothe patients` desire for treatment, and treat “non-specific conditions.” Half of the doctors only told their patients something vaguely promising, such as “this therapy has helped many other patients.” About 25 percent told their patients that the treatment “promoted self-healing,” and less than 10 percent showed that the treatment was actually a placebo. Some focus groups suggested that careful use of language could solve the dilemma: if doctors are vague or cautious about how they describe placebos, they could use them to induce placebo effects without lying directly to patients. In other words, some participants suggested that careful wording (or “falsifying” the truth) could be a way to avoid “blatant” lies and thus make prescribing placebos acceptable. This resolution was not satisfactory to all participants and there were significant differences in the interpretation of some words. For example, some viewed “treatment” as a cure, while others viewed it as a simple implication that the substance could help the patient in some way. Other terminologies and formulations were also interpreted in different ways and the term “placebo” itself was problematic. For some, the “placebo” should be avoided at all costs; For others, avoiding the word “placebo” was an unacceptable deception.
Many participants believed that using the term “placebo” would render placebos powerless. Is it true that doctors prescribe treatments that they do not think are biochemically effective? The WADA guideline states that doctors must explain to patients that they can better understand their condition if they try different medications, including a placebo. If the patient agrees, the doctor does not have to determine which drug is counterfeit, nor does it have to obtain the patient`s specific consent before giving the falsified treatment. When participants looked at both the process and outcomes of prescribing placebo, they tried to weigh the pros and cons that were interpreted broadly in terms of individual patient, family, patient-doctor relationship, and society as a whole. When evaluating the benefits and harms, some groups and individual participants are guided by a tension between (a) physicians` desire to be honest (respecting patient autonomy) and (b) physicians` desire to do everything they can to help their patients. Participants recognized the potential for positive health outcomes from taking placebos and harm caused by the misleading prescribing process. Table 2 summarizes the multiple advantages and disadvantages of prescribing a placebo discussed in the focus groups. The following excerpt from Focus Group 5 shows how these advantages and disadvantages were discussed in interaction.
What did the doctors actually tell their patients? More than two-thirds of those who prescribed placebos told patients they had “received medications that are not normally used for your condition, but from which you could benefit.” To capture the range of public perspectives, we were guided by the concept of maximum variation sampling, an approach to sampling accepted in qualitative research […].