Why You Should Sometimes Prescribe a Placebo

Hi. I'm Art Caplan, from the NYU Langone Medical Center Division of Medical Ethics in New York City. Today I want to talk about a tough moral challenge that many physicians face: Should I ever prescribe a placebo to somebody, knowing that it is a placebo? Should I ever give something to a patient just because I want to give them something, even though I know that it is ineffective?

There are 2 types of placebos that we will be talking about. One is literally a sugar pill, something that is absolutely inert and is not expected to do anything. The other is sometimes aspirin or maybe a pill that has a mild effect, but is more or less still irrelevant as any type of treatment that one would seriously give. Interestingly, Medscape conducted a survey in which roughly 50% of doctors said that they would never do this; about one quarter said that they would; and the remainder, nearly 20%, said that it depends.

I faced this issue myself. A few years ago, we had people coming into the hospital from different cultures who expected to get some kind of a pill. If they went to the doctor and they didn't get something, they thought it was a sign of disrespect, and they would absolutely go to somebody else. Even though we thought that their anxiety was not particularly related to any underlying disease or that they had some type of a cold and didn't need further follow-up, our doctors were giving aspirin to these people just as a way to make sure that they maintained a relationship with them and that they would come back for future care, instead of turning to alternative medicine or just not returning because they thought they were not being taken seriously.

Sometimes, culturally, the use of placebo is something that you have to really consider. It is part of what patient expectations are. You can certainly try to talk them out of that expectation, but in my experience with this particular population in New York City, that wasn't going to happen. I can at least think of some areas where a placebo is justified.

I also believe that sometimes there is such a thing as a placebo effect. You can make people feel better sometimes just because they took a pill. An enormous number of people actually respond to pain medication in part due to the placebo effect, so I can imagine situations where a doctor might say, "I don't want to give you a dangerous drug. Let's see if this helps your chronic pain or your complaint about feeling anxious," and then give a placebo and see if it goes away.

What becomes ethically challenging about that behavior is whether you then debrief the patient later. And I think you have to. I think you have to say, "I gave you a placebo. It did help and you did feel better. Maybe that's the placebo effect, but I don't think you have an underlying disease and there isn't something here to treat." You don't want to leave the patient feeling that they have a pill and there is a real disease if they are responding to the placebo. Part of placebo use, if you are going to do it, is debriefing the patient or coming clean later about what is going on and what was done. They might get angry and say that you deceived them or tricked them. You may say, "No, I just wanted to see whether there was a placebo effect. It is real, and I wanted to see if you responded to it, because that is part of what I need to know in order to treat you better."

In general, I don't think placebo should be off-limits. What I think is off-limits is not telling the truth in the long run to your patient. If you are going to try placebo approaches with particular patients, I think you should have a strategy for debriefing them and for letting them know what was done, so that trust can still be maintained between you and your patient.

I'm Art Caplan, at the NYU Langone Medical Center in New York City. Thanks for watching.