Streams

Take Two of Nothing and Call Me In the Morning

Monday, October 27, 2008

Franklin Miller and Ezekiel Emanuel, chair and senior faculty at the National Institutes of Health Clinical Center discuss the medical ethics of prescribing placebos and withholding information from patients. The study appears in the current issue of BMJ.

Guests:

Ezekiel Emanuel and Franklin Miller

Comments [19]

Stephanie from Brooklyn

P.S. I agree with Laura [12], that the study [and the conversation] were unclear.

Use of "true placebos," (classically, inert benign sugar pills etc.) got confused with "prescribing things with intention of invoking a placebo effect -- or other curative result" and didn't quite get straightened out.

The guest/s on the show were not concerned about making these distinctions.

But the outrage expressed, it seems to me, is due to concern that this, in essence, "off label" use of medications as "true placebos" is easily sloppy or dangerous.

As well as the harmful impacts of antibiotics or sedatives as "off label placebos," their use as a "cure" could obscure a real problem, while throwing a monkey wrench into clear communication between patient and doctor.

[But I do not believe, [17], that the doctors would prescribe these drugs without telling the patients what they are. Ignorance can only go so far. What the doctors are playing to is that the patients will "hear what they want to hear" and think that the drug will do the trick.]

Kudos, [16] - good points!

The use of placebos is ages old. The current trends in off-label use of medications deserve more attention as a conceptual shift in how we view medicine and medicinal substances.

Oct. 28 2008 03:33 AM
Stephanie from Brooklyn

Antibiotics:

I could hardly believe my ears.

Please, Brian, do a show about antibiotics and the dangers of overuse.My biological gut flora and fauna will thank you.

It's taken a lot to forgive those doctors who have already prescribed antibiotics to me, in a range of arbitrarily strong doses for the same problem, (rosacea) even when I ask them to give me the minimum needed, as my body is sensitive and doesn't need much to get the job done.
I go home and note the prescription is twice as strong as a similar one years earlier, and call in with a question -- the doctor says, oh well, then just take one a day instead of two.

This felt callous to me. This was in a training clinic with a supervising doctor, most recently, and just as with the professor on your show, being a teacher seems not to add to the use of carefulness.

First, do no harm ...

As noted in NYTs Tara Parker Pope's columns, it's up to the patient to monitor everything in today's medical climate.

Make your own placebos!
Free yourself!

Oct. 28 2008 02:16 AM
Paula B from Chappaqua

I'm surprised no one has mentioned the fact that the doctor's use of a "placebo" that is in reality an antibiotic or a sedative, instead of a sugar pill, which is the traditional substance in a placebo, is guilty of deception! No doctor should allow a patient to take an active substance without their knowledge. Is is unethical for many reasons,including the facts mentioned above but also because it's dangerous to drive a car when under the influence of a sedative.

Oct. 27 2008 09:52 PM
Beth Lanes Battinelli, PhD from Central New Jesey

Is it a placebo or a problem?

It is not a placebo or a problem when prudently prescribed, a rest providing sedative allows the body to get the rest it needs to heal.

The real placebo effect and problem is when the physican uses of the prescription pad to make the physican feel like a better doctor.

Oct. 27 2008 01:44 PM
Amy from Manhattan

Hugo & Harry, I absolutely agree. A patient may have a subclinical bacterial infection--too low-level to be causing any symptoms--& an antibiotic could kill off all but the resistant bacteria, which could then reach levels that do cause disease. Especially since many patients, once they feel better, don't finish taking all their antibiotics, which makes development of resistance more likely. The possibility of a resistant infection spreading in the population is much more serious than the effects of a sedative. Besides, the MD could tell patients the drug supposedly for their symptoms has sedative side effects & give them the usual warnings against driving, etc.

(BTW, Hugo Furst? Looks more like Hugo Forth this time. You're not a parachute jumper, are you? ...sorry, folks, old joke)

Oct. 27 2008 11:11 AM
michael from brooklyn

The whole discussion about American doctors prescribing placebos negates the role energy and mind body interaction in a substantive way. As such it points to severe problems with the system. i happen to be a strong believer in the work of Dr. Sarno- and his understanding of Mind Body interaction. While the pain issues that he treats are often not structurally based there are real physical issues involved.

I had sever sciatic pain for the last year. I know that the pain was stress related and i worked hard to lessen my stress but wasn't fully successful in getting over the pain. Last week I went to an acupuncturist in the East Village. After three sessions my pain is gone. I believe that the energy flow in my body was aided which allowed me to get better. Was this a placebo? according to many yes- according to me....

Oct. 27 2008 11:09 AM
Pradeep from Atlanta, GA

Why does an ill person go to a Dr ?? To get better.. right??? so everything or anything a Dr does to make the ill person get better is always and will always be ethical.
BUT what is UN-ethical here could be:
1) Charging heavily for something which is just a sugar pill !!
2) Being careless about prescribing something which could have adverse affect on the patient.

And both these things have absolutely nothing to with "placebos".

So.. My conclusion is placebos are perfectly ethical.

-Pradeep GUPTA

Oct. 27 2008 10:53 AM
Lauren T from Brooklyn NY

I'm not sure that this study is really measuring the prescribing of (or recommendation of -- there is a difference) true placebos. I have had the experience of going in to my doctor with a bad cold and being told that there's nothing they can do to cure the illness, but that certain OTC medicines may help ease the symptoms. Should those truly be considered placebos? Also, valium isn't really a placebo (i.e. sugar pill) because it does affect the patient's body and state of mind. It could be good medicine to help a patient feel calmer so that natural healing can take place. So this conversation seems poorly defined to me, and the shock and outrage hard to understand.

Oct. 27 2008 10:49 AM
doctor david from manhattan

you are discounting death math. only a few percent of people with step throat go onto death if you do nothing. MOst get better on their own.

but a 5% death rate is not acceptable, so they ALL get penecillin to save the 5%

that is not a placebo effect.

dr david NYC

Oct. 27 2008 10:46 AM
hmm

Students, your professor has a very poor bedside manner.

Oct. 27 2008 10:45 AM
Harry Burger from Long Island

Prescribing antibiotics when the doctor's professional opinion is that the illness is a virus isn't just unethical, it is medically unsafe to the public health, as improper use of antibiotics contributes to the evolution of superbugs that are immune to normal antibiotics. Those doctors who have done so have violated their Hippocratic Oath by putting the public at greater risk. Doctors should know better - ignorance is not a valid excuse here.

Oct. 27 2008 10:44 AM
Lisa from Queens

All in your head:

Yes, that's what I got for a year before I finally got a diagnosis of ovarian cancer.

Oct. 27 2008 10:44 AM
concerned

Doesn't this delay and muddle the patient's own assessment of their treatment.

I've come across incompetent doctors that I only learned were so after visiting other doctors for second and third opinions.

Oct. 27 2008 10:43 AM
Lisa from Queens

[1] JT

Yes, how much do these placebos cost and who is paying the price for "nothing"? Is this pill ever set up to masquerade as an expensive pharmaceutical?

Oct. 27 2008 10:43 AM
levjosh

relation between age and willingness to proscribe or accept placebo?

Oct. 27 2008 10:40 AM
Hugo Furst from Manhattan

So this guy is disturbed by the use of sedatives as a placebo but using antibiotics doesn't bother him? Isn't the overuse of antibiotics a massive problem in world health right now, breeding horrific strains of antibiotic-resistant bacteria?

Oct. 27 2008 10:39 AM
levjosh

well, this would be a litmus test on whether americans blindly trust their doctors.

comparable to the way it is obvious to those who disregard the usda's "organic" label -- preferring oregon tithe or another standard, due to the lack of credibility that a segment of the population has for an entire licensed authority.

Oct. 27 2008 10:38 AM
Sue from Brooklyn

Aside from whatever impact this may have on someone's health, what does it do to the relationship of trust between a physician and patient? If a physician prescribes a placebo once, are they more likely to do so again -- to get impatient and not investigate symptoms that might have a real cause, however hard to detect? I worry that this will encourage doctors -- already time-constrained -- to not listen properly to a patient's symptoms. What is wrong with the doctor just saying, no, you don't need this?

Oct. 27 2008 10:36 AM
JT from Long Island

Do insurance companies pay for the placebos? If so, how much?

Oct. 27 2008 10:07 AM

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