Placebo effects and mechanisms in clinical research

Placebos

Nursing: Ethical Implications for Giving Placebos

When it comes to nursing, giving medications is one of the primary functions. However, whether it is acceptable to give placebos without the patient's knowledge - on the advice of the doctor - is something that presents an ethical dilemma. Currently, it is not acceptable for a nurse to give a patient a placebo unless the patient is aware of it. Some nurses, though, wonder whether this practice makes sense. It would seem that telling the patient that the pill is a placebo would nullify the idea of giving the patient a placebo to see if he or she had the same reaction that would be seen with the 'real' medication. It would make more sense, it would appear, if a nurse were allowed to give the patient a placebo on the advice of the doctor without the prior knowledge of the patient. That would allow a determination to be made as to the true effects of the placebo, and that is the issue that will be addressed here.

Placebos are similar in category, in the opinions of many people, to holistic medicine, herbal treatments, and energy work in that many individuals in the medical field believe that these treatments really do not medically do anything, and the only way that they 'work' is because the patient's mind believes that they will (Connelly, 1991). If a patient is told that he or she is receiving a placebo, however, what then? Would the 'treatment' fail to work? Studies have not really shown whether this is or is not the case, but common logic would suggest it would be so. When a person believes strongly enough in a pill or some other type of therapy that it actually works for them, there is no valid medical reason to take that hope from them (Power, n.d.). If they know they are getting a placebo they will not expect it to work, and therefore it will not. It could harm the welfare and faith of patients who could otherwise be helped (Power, n.d.). Some say this is lying to the patient and unethical, but how can helping a patient to feel better - and in many cases actually improve from a health standpoint - ever be unethical?

Description of the Ethical Problem for Nurses Who Give Placebos

Right now, nurses have to tell patients that they are being given a placebo and not an actual drug, therapy, or treatment, even though the doctor has authorized the placebo. There is concern that this takes away from the way that a placebo works (Power, n.d.). It mitigates the chance of a placebo effect, whereby the person taking the pill or receiving the treatment believes that it will work, so the person perceives themselves to feel better. This has been seen most commonly with pain management, but it is also seen with other types of medications and treatments for other diseases and conditions. The placebo effect is well-noted in a great deal of medical literature, and is being likened more and more to an alternative or holistic form of medicine, since people who receive a placebo are not getting any 'real' medication (Power, n.d.; Ambrose, 2007).

Many countries use alternative medicine, especially where access to good traditional medical care is scarce or non-existent (Connelly, 1991). In places like that, people have to make do with what they have, but they have had a long time to experiment. he alternative medicines being used now have been used for a long time, so they are no longer the mysteries they once were. Much is known about them and how they work. Many people are still skeptical that any alternative treatments can work at all (Connelly, 1991). While that is understandable, there is evidence that alternative remedies do work, sometimes, for some people. Others do not seem to be helped by them at all. It is not clear whether this has to do with a person's belief as to whether the treatment will work, or if different people's bodies just react to these treatments in different ways, producing the variation in results.

Most people think of alternative medicine as being only herbal remedies like Ginseng or Ginkgo Biloba that can be bought at any health food store and most major retailers (Power, n.d.). While over-the-counter herbs are certainly part of alternative medicine, they are most definitely not all of it. The placebo effect is part of that alternative idea from the standpoint of traditional medicine. From the standpoint of alternative medicine practitioners, though, what they do is not the same as a placebo. They believe in the herbs that they use, and they believe in energy healing and other natural remedies (Power, n.d.). However, from a strictly Western medicine standpoint, most of these people are thought of to be selling false hope and placebos, which is why it is important to discuss how the two issues tie in together.

Alternative medicine can also include acupuncture, acupressure, massage, experimental herbal drugs, chiropractics, and naturopathics, among other things (Moerman, 2002). Naturopathics, which is still an unfamiliar term to many people, are doctors who use natural remedies of all kinds to treat or cure many diseases. They use these remedies instead of conventional treatments and synthetic drugs (Moerman, 2002). So far, around 10% of Canadians see a natural health or alternative medicine practitioner on a regular basis and 42% of Canadians turn to alternative medicine first to meet their health needs (Jones, 2002). In the United States the numbers are not as high, but they are growing all the time as these people move away from what is not working for them in Western medicine and toward a more Eastern style of medicine - which Western doctors still generally insist are nothing but placebos that are packaged in such a way that causes people to buy into them and believe that they work - and they often do (Moerman, 2002).

This may seem surprising to many people, to find that almost half of the people in a country are trying to treat health problems with something other than conventional medicine before seeing what many would call a 'real' doctor. It is not all that shocking, really. Alternative medicine has been used for thousands of years by people like the Chinese and the Native Americans (Moerman, 2002). It is only natural that eventually it would begin to interact with traditional Western medicine. Only time will tell, however, how the interaction will really go and whether the Western culture will be able to accept the ideas of the alternative practitioners (Moerman, 2002). It is a game of 'wait and see' and whether nurses can give patients placebos without their knowledge may end up being that type of game, as well.

Some people are also really afraid of doctors and they do not want to take medication or go through some type of treatment for something. They have what is called the 'white coat syndrome.' Going to a chiropractor or acupuncturist does not always feel to these people like going to an actual doctor, but it does not feel like a placebo, either, and like they are just doing something for nothing (Moerman, 2002). Often the offices are decorated in a much more relaxed way, and the stark white walls and plastic chairs seen in many doctor's waiting rooms are replaced by comfortable sofas and beautiful paintings. While not everyone responds well to these changes, people who are afraid of 'real' doctors are often much more comfortable in a place that does not have the feel or smell of a traditional doctor's office (Moerman, 2002).

Impact of the Nurse-Placebo Ethics Debate on Heath Care

How this issue impacts health care is more important than ever because of all of the holistic and alternative approaches that are being seen today (Ambrose, 2007). Individuals who are told that they are being given a placebo often will not see any benefit from it. This may also turn them to Eastern medicine where they feel that something will actually be done for them, instead of giving Western medicine a chance. If they are not told that they are receiving a placebo they may feel that the 'medication' they received was adequate and that will keep them on the side of Western medicine. Western medicine and health care wants and needs this so that doctors and hospitals can continue to make money (Ambrose, 2007). However, some of them are coming around to the idea that Western medicine and Eastern medicine must work together to have the largest benefit for patients (Ambrose, 2007). There are many reasons why alternative medicine is becoming so important to the health care system. Money, of course, is one of the reasons. Money is always one of the reasons. But it is not the only one.

Other than bringing in money, there are several reasons that alternative medicine and the health care system should work together. First, many good doctors and respected community members in the medical field are seeing a bond between traditional and alternative medicine as being of great importance for the future of health care (Ambrose, 2007). Whether someone views something as a placebo or not from a medical standpoint, if it improves the health and well-being of a patient then it is good for that patient, and good for the medical community as a whole (Ambrose, 2007).

The second reason for the health care system to allow alternative medicine is that people believe in it in the same way that they believe in placebo pills if they are not told that they are placebos (Ambrose, 2007). There will always be some people who do not think that these things work, and they might not work for them, but there are many people who have been helped by non-traditional medical practices, just as there are many people who have been helped by more traditional means (Ambrose, 2007). People should be allowed to choose which one they want without fear of getting in trouble with the law, getting someone else in trouble for practicing medicine without a license, or going to someone who is not reliable and safe. When Western medicine begins to take on more 'placebo' treatments, doctors and nurses will find that they are able to do more for their patients by saying that they are going to help them, instead of by saying that they are going to give them something that they know is not real medicine to see what happens (Ambrose, 2007).