Oh, no. It’s much more complicated than that. The ethical principle you describe might more clearly be defined as beneficence: acting in best interest of the patient. But what about when it conflicts with another ethical principle,namely autonomy: the right to decide what happens to your own body and what treatments you don’t get.
To my mind, there isn’t an obvious answer, but the conflict between these two is why there is debate about “using” the placebo effect as a treatment.
A very interesting ethical discussion I had with a doctor friend recently is that in some cases where a doctor identifies that amputation is the right/only course of action, they will only present that as a soft option to the patient, if at all.
This is because studies have since found that amputations can cause a great deal of psychological harm and it can be better for the patient if they arrive at the conclusion to amputate of their own volition - even if that takes months of excrutiating agony spent realizing not having the limb is better than the pain.
It was an interesting additional dimension to consider - even if the doctor knows much better than the patient, sometimes the patient feeling a sense of autonomy could be important for their wellbeing, and that short term pain could be beneficial.
In some ways this applies to everything we do that we think might be helpful. Sure we could get patients to loose weight by locking them up and only feeding them 1300 calories of veggies, but for some obvious reasons that isn't really an option. We can encourage them to take medications, but they still have to take them.
Atul Gawande talks about how much we have discovered in medicine in the last century, but that the next century is going to be about how to effectively implement that knowledge to help people. This applies to both the first world and to the developing world, though the challenges in both are different.
(also we probably wont stop discovering new treatments that we will them have to deploy...)
> Sure we could get patients to loose weight by locking them up and only feeding them 1300 calories of veggies, but for some obvious reasons that isn't really an option.
Yeah, but a lot of patients would consent to an offered treatment plan where they're locked up (and unable to sign themselves out!) and fed only 1300 calories of veggies.
The weird thing is, there are private businesses willing to provide exactly that kind of service (see: de-tox centers.) But doctors and hospitals generally don't see this as a valid form of in-patient medical treatment. Why is that? Do doctors think that patients have an inalienable right to bodily autonomy? (If so, how would surgery ever work?)
(The annoying point about this difference, to me, is that if a doctor were to diagnose you with X thing that keeps you at the hospital for a month, unable to leave—then your insurance would likely pay for that, and your employer would likely consider you on sick leave. But if a private business like a detox center keeps you for a month, then you have to pay for that out-of-pocket and you're likely to be fired from your job if you don't have the requisite vacation days saved up. From what I can see, it is in the patient's long-term interest if doctors get into this business!)
I figure the ethical debate extends into our societal issue of greed as well. Certain institutions would love to be able to give you no medication/treatment, charge you as though you had received it and you're none the wiser.
I am in two minds about it. On the one hand it would appear pretty ridiculous and there is no way that it should be paid for. On the other hand if it works via the placebo effect in a cost effective manner, is that a bad thing?
The placebo effect isnt bad, lying about the effects (homeopathy) charging much more than the cure is worth (homeopathy), and outright selling poison to people (homeopathy) is not ok.
The weird thing about homeopathy is that it's advertised as selling poison, but actually isn't. One of the ridiculous premises is that "like cures like", so it should be poison, but then there's the other ridiculous premise of diluting it to make it more powerful.
What's interesting is that it seems to depend on which truth you tell. To oversimplify, "take this, it's not medicine" doesn't help. "Take this, it's not medicine but it will help you anyway" does.
Which is interesting because presumably if they didn't charge you it would shatter the placebo effect. I wonder if cost of the procedure actually impacts the efficacy of the placebo?
They are still providing a service and even pills with starch in them cost something to make. I don't see any reason the doctor and hospital shouldn't charge.
But then we go deeper into what placebo is. If the patient needs the psychological comfort of being seen and OK'd by real doctors, staying home mentalizing their own well-being won't do much. It's about taking responsibility for self-care--to the extent possible, of course--as opposed to externalizing any ill state to a sanctioned (sacred?) pill.
I think placebo can be self-administered. I can make many pains decrease in intensity (or sometimes go away) just by thinking about it.
Last year I fell while mountain skiing and was in great pain at first (could barely move, standing up from lying down was excruciating, etc.)
The first day I didn't take any pain killer; the second day I did but it didn't really help. The third day I stopped taking the pills and just kind of "decided" I wouldn't suffer that much.
The pain didn't disappear completely, and it still hurt too much to get back on skis, but it stopped being so intense. When I got back home I did an x-ray exam and MRI and found I had broken a vertebra in two, that had lost 25% of its height. The doctor was super surprised I could walk normally and said: "do you not feel pain". I said I did but it was very manageable. She didn't investigate and just said "ok then, good for you!"
Also, I used to get hiccups that lasted a long time (30 minutes); and then I discovered you can make them stop very fast by being super calm and concentrating. Not only that, but since I found this out, I barely get hiccups at all anymore.
I think we can consciously control much more of our own body than we think, and we're only scratching the surface.
IMO the power of the mind and attitude is really key to how people perceive and function with pain. I don't think that we adequately understand it.
We see that all of the time... I recall working in a bakery in the mall in high school and chatting with a Vietnam veteran with chronic pain from a lung issue and a missing leg who would walk 8-10 miles on crutches every day at 5AM and sometimes do push-ups in our cafe area. He was the most positive person that I have ever met, which was striking when you'd see other folks with very minor issues grouse and complain and be visibly ill.
My mom was taught "therapeutic touch" in the 1960s in nursing school, which I believe isn't considered pseudoscience today. For certain types of patients, it was helpful, but the technique was mostly placebo.
Fundamentally, changing how people think is ethically problematic if it becomes manipulative, but it's a key factor for our well being as well.
> We see that all of the time... I recall working in a bakery in the mall in high school and chatting with a Vietnam veteran with chronic pain from a lung issue and a missing leg who would walk 8-10 miles on crutches every day at 5AM and sometimes do push-ups in our cafe area. He was the most positive person that I have ever met, which was striking when you'd see other folks with very minor issues grouse and complain and be visibly ill.
This might simply be that the Vietnam veteran happens to have much better and more stable chemistry than people with, say, depression.
It seems one danger with this placebo discussion is that we may end up at square one, blaming depressed/anxious/ADHD/BPD people for their problems...
I suspect that much of this issue is resolved by looking at how they sought consent for their study, since they had to inform participants about what they were going to do to them (though they could have phrased it as, I may do A, or I may do B).
Now, they can say, "I may do A, and I may do B, and there is evidence that both are effective"
Autonomy isn't a meaningful principle when it comes to medicine. Even patients who are doctors can't really give informed consent since they won't necessarily be knowledgeable in the specialty relevant to their treatment. And the vast majority of patients aren't doctors.
Not to invoke a slippery slope argument, but there are a lot of really horrible things that have been done without giving patients autonomy. We as a society need to consider it extremely carefully before any instance of acting against a patient's bodily autonomy.
If horrible things are being done to people, I'd pick the ones those people are doing to themselves almost every time over the ones being done to others in violation of their bodily autonomy.
Yes. Obviously you'd narrow things down and compare like to like. Anti-vaxers being the hot example of the day. Sometimes it's so obvious that we act on it, like with secondhand smoking, but I bet there's a lot more to dig into.
Right, that's the problem. The fact that doctors must ask for the consent of people who don't understand what they are consenting to.
The idea itself isn't that controversial - age of majority laws for contracts, voting, and even medical treatment clearly acknowledge the idea that some people are too young to know what they are agreeing to, so the decision should be made by someone else who takes responsibility for them (most things), or there should be no decision because there doesn't need to be one (voting).
We just need to refine our understanding to reflect the reality that as old as you may get, you will never understand some things.
Autonomy is not a problem of medical treatment, it's a fundamental principle of an ethical society.
Without autonomy, the concepts of voluntary/involuntary lose meaning, which can enable some very nasty scenarios. Exceptions to autonomy are rare and come with stringent legal duties and obligations on the responsible party. Doctors are not responsible for their patients in that way; they are service providers.
Lack of understanding should not be sufficient to undercut an ethical principle like autonomy. Imagine if I had the power to decide that you don't sufficiently understand the concept of autonomy, and must be shipped off to a re-education center.
Talking about it outside of the specific conflict, is disingenuous. Everyone understands how important Autonomy is. That's part of the issue, not a supporting argument to value it over the health of a patient. If there's no patient, there's no Autonomy either.
The point of autonomy isn't to treat the patient as the most knowledgeable person in the room, but to present the options, all considerations and drawbacks that you're aware of, answer any questions, and then ask them to make a decision. If you think that patients aren't smart enough to understand the implications of drug side effects and weigh the costs and benefits of treatment versus the original disease, then I really hope you're not a doctor. And I really really hope you're not my doctor.
To my mind, there isn’t an obvious answer, but the conflict between these two is why there is debate about “using” the placebo effect as a treatment.