OB-GYN-L Messages for December, 1996: Ethics and placebos (was IMB and IUD)

Ethics and placebos (was IMB and IUD)

From:

Arthurfree@aol.com

Thu Dec 12 12:09:03 1996

>
>Well, this dregs up the muck of purity of purpose. Dr. Freeland is to be
>saluted in his purpose of perceived non-intervention in a patient's
>complaint of a likely innocuous symptom that will spontaneously resolve
>in time. Persistence of the symptom will yield to the imperative of
>clinical intervention. At the outset with no indication of underlying
>pathology, the "placebo" approach fits well with the model of medical
>practice characterized as the era of authoritarianism. In the days of
>current enlightenment, we have gotten down to calling a spade, a spade.
>
>I fear that Dr. Freeland's well-intentioned approach plays directly into
>the hands of the arch-enemy of the non-scientific practice of medicine.
>If science be the temple of truth, physicians, as medical scientists,
>can not walk down both sides of the street. To direct a patient to the
>health food store to purchase a bottle of ascorbic acid with the idea of
>buying time simply sustains the myth. It is painfully remindful of my
>intern-days of ordering two c.c.s of sterile saline for a patient in
>pain or hysteria at the direction of an attending.
>

Your points are well taken, and I attempt to never "sell" a placebo (though my impression is that the more they cost, the better they work!). However, evidence has not been developed well for over ninety percent of what we do and treat. "Customary treatment" is no better in my opinion, if not supported by evidence, than alternative practices. I often preface a suggestion with "there is no medical evidence to support, but some patients have had relief with" (just as often with some customary interventions like a "complete physical" in a healthy adult, or a multiple vitamin) as with other interventions.

The flip side is the patient who comes in using an alternative treatment and claiming it has relieved their symptoms. My response in that situation is: "There is no medical evidence that this treatment helps your condition, but I have learned not to argue with success" (note: only of use in situations where an effective treatment has been tried and failed, or does not exist). I avoid endorsing the treatment in question, but do not further denigrate it.

Unfortunately, the squishy stuff above the tentorium often has more to do with a patient's symptoms than their anatomy or physiology (doesn't apply to original string about spotting with IUD!). There are many patients who respond only to what they think they will respond to, and my responsibility then becomes much more involved with: a)maintaining the therapeutic relationship, (you can be honest with a somatisizing patient without telling them "it's all in your head" which effectively chases them away), and b)protecting the patient from harmful adventures (as often at the hands of medical doctors as alternative practitioners), c)continuing to work with the patient on symptom relief while also working at discovering underlying psychological issues.

Ethical principles involved include (feel free to add to the list, or argue with it if desired!): 1)HONESTY is paramount. I cannot endorse a treatment that has not been demonstrated to work in good studies. 2)Non maleficience: I will not stand by while a patient is harmed or fleeced by a treatment which has been demonstrated to be ineffective (hence the support of cheap harmless treatments in self limited conditions if honesty is served). How many prescribe antibiotics for upper respiratory infections? This is an ineffective therapy with demonstrated ill effects and costs.

The second is a little tough, especially in oncology. Though the oncologists couch their recommendations as prolonging life in many cases. Some treatments are more effective at keeping patients in the system and away from trips to out of country clinics for unproven therapies that are more effective at removing family savings than they are at prolonging life or improving quality of life. I've never seen this as an explicit goal, but I have to assume that "maintaining hope" is the major goal in some treatments I've seen.

Arthur Freeland, MD Warrensburg, Missouri

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