The Ethics of Prescribing Worthless Treatments

Dec 10, 2015

Is it ever ethical for a physician to prescribe a treatment to a patient that they know to be entirely without efficacy? Is it ever possible to do this without deceiving the patient to some degree? I think the answer to both questions is a clear “no.”

Within the flipped reality of “alternative medicine,” however, it suddenly becomes acceptable to deceive patients and sell them worthless treatments, as long as the deception was minimally successful.

A recent editorial in Scientific American by Allison Bond addresses this question. She manages to hit upon many of the reasons placebo medicine is inappropriate, but her reasoning is a bit muddled and she comes, in my opinion, to the wrong conclusion. She wraps her commentary in an anecdote of a terminal patient for whom she cared who found relief from Reiki. She concludes:

Of course, when it comes to treating patients with painful, life-threatening diseases, the goal of our care should be to lessen suffering, regardless of where such relief originates. A few months after Ms. W left the hospital, I learned that she had died, and the news hit me hard. I thought back to her treatment under our care and hoped that even among the misery, we had eased her suffering through our therapies—“alternative” or not.

I think that Bond goes through the same thought process that many physicians go through. She has some understanding of the trade-offs, but in the end as long as their patients say they feel better, they are OK with using placebos. This position, however, is misguided.

Continue reading the entire article by clicking the name of the source below.

25 comments on “The Ethics of Prescribing Worthless Treatments

  • I read this article yesterday on SBM as well as the entire (now rather large) comment section. Much to your point, some of the comments and back and forth between some of the established skeptical posters and the author were of particular interest. The author was very dogmatic with the poster, which I found a bit odd. Of course there’s a line between doing no harm and fraudulently charging a lot of money for something peddled as a cure that might also do no harm, but in the absence of (and often in the presence of) profit the placebo effect in all of its complexities can sometimes result in positive outcomes. Not at all a black and white subject, which is where I think the author went a bit astray (more with his comments than his actual post).



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  • I think a lot of the grey can be taken out if we listen to the fact that a good ‘bedside manner’, as I have mentioned elsewhere, is the most effective placebo effect of all. At out local GPs, we had doctors forced to write everything on computers. In order to save a lot of work, they would input the computer as you spoke. Depending on the typing ability of the doctor and pauses whilst they thought about the correct medical term to input from your garbled description of what was wrong, the surgery went in fits and starts with either or both of you losing your train of thought. It was very stressful and you always came away thinking you had not been treated properly. A few years of this and a little word in the ear of one of the kindest doctors I have ever been seen by, they have stopped the practice and now give you full attention only looking at the computer to look up records if you are not sure what to say yourself. The difference is amazing and being sent home with no medicines seems an ok thing now. ‘Come back and see me in a couple of weeks or if it gets worse’ while actually
    Looking at you and making you feel part of the community does the trick.



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  • But then if the placebo effect works reliably, is than not equivalent to prescribing a medicine that works equally effectively?

    What is really crooked is prescribing very expensive placebos.



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  • Roedy

    What is really crooked is prescribing very expensive placebos.

    It’s all crooked right from the get go.

    Since the title of our article is:

    The Ethics of Prescribing Worthless Treatments

    We should keep in mind the ten Ethical Obligations that can be found in any introductory text. They are:

    1.Justice, 2.Non-Injury, 3. Fidelity 4.Veracity 5. Reparation 6. Beneficence 7. Self-Improvement 8. Gratitude 9.Liberty 10. Respectfulness.

    So right away, number 4 is violated and also violation of 2 is likely. Some others are on shaky ground.

    These ethical obligations are a framework that I bring right to the front of my mind when I realize that I am in a situation where I need to judge anything to be good/bad, right/wrong and valuable/not valuable. The framework shouldn’t be seen as “commandments” that are written in stone. They are all given different weights of importance depending on the situation at hand. It’s up to the individual to run the question through an analysis where they decide which obligation takes priority and which must be deemphasized. This takes some practice because the various obligations can be in conflict with each other depending on the context. While it is possible that we can accept some amount of harm in certain situations, in this case, I just don’t see my way clear to excusing what is clearly a lie that could lead the patient to some future medical harm, especially when there are easy alternatives that are well within the realm of good ethical behavior.



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  • I think there should be some protection for people suffering from cancer and other serious conditions. When I was ill 9 years ago I was aware that some people found it hard to know the right thing to say. I didn’t know how to reassure them. I do know the wrong thing to say though, and that is:

    ‘I’ve come across this miracle herb/natural cure. A friend had what you’ve got, they took it and now they’re in remission.’ Is the worst but there is also the insidious:

    ‘My group will pray for you every week’ (from my mum) and ‘Do you mind if I practice ‘Reiki from a Distance’ as I need to do that to complete the course,’ (from a teaching assistant at my school).
    Initially, and because my mind had other priorities, I considered it harmless and actually rather nice that they were thinking of me. However, as treatment moved forward and I realised what an array of effective methods of curing cancer have been developed by the slow march of science and the hard work of many dedicated researchers I became resentful and offended by their actions. After all if I recovered (spoiler alert: I did!) they could claim credit for my recovery. Thinking of ways to neutralise this, and knowing that if I later countered their claims by putting the credit where it trusty belongs, they would just smile knowingly, I phoned my friend Martin and called in a favour.
    Now when they make these claims I can point out that Martin has an equal claim on the credit for my recovery because he sacrificed a chicken. (The fact that it was a frozen one from Tesco’s is neither here nor there).

    In medicine let’s just be honest with people. If the placebo effect even works when the patient knows it’s not real medicine, then give them the choice but don’t dress it up in magic. I’m not much into locking people up, but those who exploit the dying by offering fake and harmful ‘cures’ and discourage patients from taking medical treatment seriously deserve it. We should throw away the key, but not before giving them a potion that ‘Will let them walk throug walls’.

    Apologies for rambling off topic, long day!



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  • I agree entirely, Roedy. The trick is avoiding unwanted deceit, which I think entirely possible.

    Placebos should only be used by conventional doctors integrated with all choices of appropriate treatment so that they only are used when other techniques fail or their possible supplementary effect can do no harm. Given freedom of access to their own medical notes, patients so wishing can see exactly what treatment they have received. Patients often don’t wish to know the details. Any doctor asked for details or challenged directly over placebo must, of course, report clearly at once. Doctor reports to patients are often partial and it may be that a code of practise that you select years before need can guide consulting room behaviour selecting either, always maximum detail over treatments or appropriate disclosure.

    Placebos, though, don’t depend critically on the deceit. There remains efficacy even with the full knowledge of the fact of it being a placebo. Reporting it to be nevertheless effective, then giving the honest level of effectiveness when prescribed open-handedly, may recoup much efficacy loss.

    Currently half of all antibiotics are given by doctors for viral complaints. This is described as prophylaxis against possible bacterial infections in the weakened patient.

    This is entirely disingenuous and is pulling the same trick but with substantial risks.

    Doctors who prescribe more ethically, witholding spurious antibiotics, are judged as unsatisfactory more often by their patients.



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  • Currently half of all antibiotics are given by doctors for viral
    complaints. This is described as prophylaxis against possible
    bacterial infections in the weakened patient.

    MRSA and most of the other superbugs were born of this strategy.



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  • Not all “alternative medicine” is flipped reality!!
    That’s just sheer arrogance and stupidity. Who wrote that? Steven Novella.
    Okay, here goes, Steve: are probiotics helpful for, say, gas, or is that a placebo?
    My mother, who was a nurse and knows a lot about the body, said I should take them. Is she “prescribing” a placebo?
    Btw, my mother’s now taking Chinese herbs for her asthma and it’s fucking working, and she ain’t no dummy; believe me. (She’s been suffering for years, is tired of prednizone. )



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  • My dad died of cancer last year. I assisted in his care until the very end. No placebo will work when you’re in the final stages. It’s sheer hell. When you’re in rapid decline, at the end, nothing will do anything. When you’re too weak to get up or talk or go to the bathroom no placebo is going to do anything. In fact, placebos and cancer don’t mix at all, in my opinion. Cancer is an ugly, powerful disease.
    I would be in favor of giving placebos to patients who suffer from chronic psychosomatic pain.
    Question for you above. Hope you find it.



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  • P.S. That question I asked was for the erudite and witty Steve007, not for the opinionated and narrow-minded Steven Novella.
    P.P.S. I am sure many treatments now regarded as traditional were considered “alternative” when they were first introduced. I do not like most alternative medicine, but to reject all of it in its entirety is lunacy.



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  • Long day. I thought someone was advocating placebos for cancer patients, and I was just saying how absurd and wrong that is. As it turns out, that is not what the fellow said.
    And I got him mixed up with someone else to boot.
    I heard that Viagra is a placebo. It’s all over the news.



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  • When I was aged about ten or eleven I spent an entire night being violently sick, and eventually bringing up blood.

    The elder of the two Doctors at the local practice diagnosed that I’d been eating green apples.

    My mother did not accept that, and called his junior partner.

    I can remember hearing him bounding up the stairs; he stuck his head round the door, took a quick look, and ran downstairs again.

    Next thing, I was in an ambulance having white socks and a white gown put on me; when asked the name of my school, I passed out before I could complete the answer.

    My Appendectomy scar is large and crooked; there had been no time for niceties; I’d been within minutes of death.

    Thank goodness Charlie “the Prince of piffle”, or one of his ilk, hadn’t been in charge.

    But most of all, thank goodness for my mum!



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  • Thanks for the kind words, Dan. Steven Novella is a smart guy but he’s too dogmatic IMO. He’s like the Sam Harris of SBM. There is zero room for nuance in his view, and you know, the world is full of nuance. He’s like one of those slippery slopers who think that any gun control legislation, however logical, ultimately leads to no guns. And that’s just silly. But I see I’m all over the map here.

    Your mother sounds wise. I think probiotics are useful, but not for gas per se. However it’s a well regarded strategy for IBS (irritable bowel) and a host of other conditions. Instead of loading you up with info here I’ll ask you to visit the wiki, which is well done for this entry:

    https://en.wikipedia.org/wiki/Probiotic

    I have to ask, is the Chinese herb your mother is taking Ma Huang (ephedrine hydrochloride in its standardized form)? If so, that’s a well know bronchodilator. I’ve taken it in the past, though it needs to be closely monitored as it can have adverse cardiac effects:

    https://en.wikipedia.org/wiki/Ephedra#Safety_and_regulatory_actions_in_the_United_States

    Prednisone is no fun but it is effective and for some asthmatic crises is the only thing that works well. I think you’re accurate with your PPS. As I’ve stated elsewhere I take a few supplements to round out my diet and for additional benefit (vit D, fish oil, and niacin among others). We must educate ourselves and not rely on others.



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  • So sorry to hear about your dad, Dan. You’re right, it is an ugly, powerful and destructive disease. It has rampaged, in various forms, through my family It’s also very variable and some kinds are treatable. We need researchers to be properly funded and respected and charlatans to be punished. Let’s stay angry and change the world! These days I challenge idiots and profiteers wherever I see them. They should not get an easy life. Have a good weekend!
    Steve



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  • Hi Steven.
    I’ll get back to you (if I can) about the herb. As for prednisone, she usually ends up going back on it, but doesn’t like it – and probably for good reason.
    She insists that she can find other ways of finding relief, although she seems to have tried everything. I haven’t asked her lately if the herbs are still working. I hope it wasn’t a brief placebo effect that she described!
    She may be wrong. Although she is wise (How could my mother not be?) she might not find anything that works as well as that infernal steroid. (Bad for the bones, bad for a lot of things.)
    Asthma is a hard problem – like consciousness.
    I’m sure Steve N. is “smart” in a quantitative sense, but that kind of un-nuanced attitude is not a sign of a good mind, a good thinker. “Smart” people are a dime a dozen. Cheney is smart too. An un-nuanced smart guy is virtually an oxymoron.
    I like Harris, up to a point. Now Mailer
    What is SBM? I know what SM is (and don’t approve of it), but all these acronyms are killing me.



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  • Thank you so much. Have a good week-end, Steve.
    I like what you said about challenging people and staying angry.
    And many forms of cancer are highly treatable.
    My father’s prostate cancer had already spread to the bones when he was diagnosed. If his urologist had given him a simple DRE a year before it might have saved his life although that doctor (and he is a good surgeon; I’ll give him that) claimed otherwise. BS. Fast growing or not, if he had caught it before it had metastasized I don’t see how that would not have been advantageous. Not reasonable to think otherwise, as far as I can see.
    Another related problem, Steve, is care for the elderly. My father’s late wife (my stepmother) started a Home Care agency for the elderly, with my father’s help.
    My father ended up using them himself. They were not equipped to handle it. It’s damned hard to lift a 170 pound man from a chair to a bed for example. The aides were not trained to deal with an elderly cancer patient. And it got more and more difficult. (Homecare for the elderly in the U.K. and elsewhere might be better. In fact, my stepmother’s agency was based in theory on a system of cooperativism that she had observed in Bologna, Italy.)
    The good news is that he had a good, long, productive life, died at home, left a legacy (a great body of work) and was prepared.—He was a life-long atheist too. Go figure.
    Thanks for letting me get this off my chest, as it were.
    All the Best, Steve (Headswapboy). —DR



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  • I would take out respectfulness. Respectful of what? of whom? If you’re a doctor and you have to treat someone you don’t respect, you treat him and that’s that. You don’t have to like him or respect him. I don’t know about your list there, Laurie. What’s the context? Those words are too airy, arbitrary, and abstract. Is this normative ethics in a general sense that we’re talking about, or medical legal ethics in the real world?
    There’s no list out there, and if there is, no one is being forced to follow it in its entirety. The entire medical profession violates half of those principles on a continuous basis every day, every hour.
    Liberty, to use another example. “Hi, I’m Dan, and I am going to make sure that I don’t violate your liberty.” What’s that? Sometimes people need to be restrained.
    I don’t like rules, formulas, lists.
    Apart from that I like your comments, as always. I can see that you explained that we need to adapt to each situation but that list was annoying; you can add six or seven more words, heap them on top of each other. What text is that from? Reparation? Beneficence? Self-improvement?



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  • If you’re a doctor and you have to treat someone you don’t respect…

    If you’re a doctor and you follow LaurieB’s Ethical Obligations, you won’t disrespect someone.

    Sometimes people need to be restrained.

    Sometimes people need to be unrestrained. People need to restrain themselves most of the time – notable exceptions being the items on LaurieB’s list, with which we all can be as unrestrained as we like.

    I don’t like rules, formulas, lists.

    That doesn’t mean you don’t need them or that they aren’t good for you or the community.



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