Ethics

Antidepressants and Doctor Deception

By Adam Kolber

A recent analysis of modern antidepressants has found that they are little better than placebos in treating most cases of depression.  If true, this is disappointing news for the multibillion dollar industry that markets these drugs.  On the brighter side, though antidepressants are may be little better than placebos, placebos can be surprisingly effective.  Patients successfully using antidepressants should not stop using them simply because of these findings. 

Placebos are widely thought to be effective in treating pain, anxiety, and depression. Recent brain imaging studies show that placebos can relieve pain in much the same way as conventional medicines.  Placebos can also help in diagnosis to distinguish epilepsy, a neurological disorder, from pseudoseizures, a psychological disorder. 

While many people are aware that placebos are openly used in double-blind medical experiments, far fewer know that doctors sometimes surreptitiously give patients placebos in hospitals and medical offices.  Doctors may use pure placebos, like sugar pills and saline injections, as well as so-called impure placebos, conventional medications used in situations just to generate a placebo effect (e.g., antibiotics to treat viral infections or multivitamins to treat conditions that do not involve vitamin deficiencies).  So if a doctor prescribes an antidepressant just to generate a placebo effect, then the doctor has prescribed an impure placebo.

A recent survey of faculty physicians at Chicago-area medical schools found that almost half had used a placebo of one form or another in clinical practice and almost all believed that placebos can be therapeutic.  Only 12% believed that placebos should be categorically prohibited. 

Should a doctor stop prescribing antidepressants to a particular patient when the doctor believes that antidepressants will be no better for the patient than placebos?  After recent changes in the American Medical Association?s Code of Medical Ethics, the doctor may have little choice but to stop. In November 2006, the AMA prohibited doctors from intentionally administering substances that they believe will only have placebo effects, unless they disclose to patients that they are doing so. 

To most effectively use placebos in clinical practice, however, doctors cannot reveal their placebo nature.  While placebo deception is a gray area of the law, the AMA?s prohibition makes it increasingly likely that doctors risk professional sanctions and legal liability when they use placebos without obtaining informed consent to do so.

Given our limited knowledge of placebo effects and patient preferences, the AMA prohibition is premature.  While placebo deception should be rare, it sometimes promotes patients? best interests.  A rational patient might very well prefer to be deceived in some cases, if it means receiving a cheap and effective therapy with little risk of side effects.  Even if a doctor believes that antidepressants will have no more than a placebo effect on a patient, we ought to allow the doctor to continue the therapy as before.

The AMA?s placebo prohibition, while seemingly opposed to the wishes of most physicians, is nevertheless understandable.  Placebo deception may damage doctor-patient trust.  Moreover, patients who receive traditional therapies but incorrectly believe that they are receiving placebos may have lowered expectations of treatment efficacy and thereby do worse than they would have otherwise.  Placebo deception should be treated like a scarce medical resource, used sparingly but not categorically prohibited.  If placebo deception is used too frequently, patients will have reason to doubt the efficacy of whatever treatments they receive. 

Placebo deception raises challenging questions about how we ought to trade off seemingly incommensurable values such as honesty and pain relief, truth and comfort.  While the trend in medical ethics toward increased disclosure to patients has generally improved medical care, it can be taken too far.  The AMA?s categorical prohibition of placebo deception does just that.

I discuss these issues in more detail in a recently published article in the Yale Law & Policy Review, available here.

Full post as published by Neuroethics and Law on April 09, 2008 (boomark / email).