Placebo paradox: Descartes dilemma
Your intern in ED has just seen a 25 yo. woman who has presented with 30 minute history of SOB, tachycardia and feeling like she is going to faint. Her obs at triage are normal other than tachypnea @ 30/min. To examine her chest is clear. She is sating at 100% on 6 l/m HM. The super keen intern has stabbed her in the radial artery and come up with the following gas: pH = 7.45, pO2 = 350, pCO2 = 26, HCO3- = 16 SpO2 = 100%. You go to the bedside and ask the usual questions: She tells you she also has asthma, but has not really had an “attack” since she was a kid, today she felt SOB and ‘weird’ after an argument with her supervisor at work….she is demanding a “neb” for her asthma attack…. but you know she is suffering “acute hyperventilation syndrome”.
OK, this is bread and butter to all of us. I would like to use this case to discuss a recent New England Journal study by Wechsler et al which compared albuterol, placebo “albuterol”, sham acupuncture and “no treatment / watchful waiting”. They then measured FEV1 change and also subjective patient symptom improvement. You can read the study, but here are the two telling graphs:
For a great dissection of this study, discussion of the Placebo Effect and a lambasting of the author’s conclusions check out David Newman of Smart EM’s podcast on this paper.
To me this is a fascinating study as it illustrates perfectly the folly of mind-body dualism (Descartes’ dilemma) – the doctrine that separates the human mind and body. In modern medicine this is pervasive, however I find it absurd. The reason so many sham therapies have proven so popular is the direct result of modern medicine’s inability to deal with the ‘whole patient’. For many patients – this is paramount – they don’t see the divide, they just know that they feel unwell. The “placebo effect” is real and the alternative-medicine practitioners have been utilising / exploiting it with great success.
So, now back to our 25 yo in the ED. We know she has hyperventilation syndrome. She is currently feeling pretty anxious, subjectively dyspnoeic and might be at risk of unpleasant symptoms such as carpo-pedal spasm etc. She is however very unlikely to have any serious complications. She as a history of asthma, but giving her a dose of salbutamol is unlikely to help, and will very likely make her panic / anxiety worse. Doing nothing is an option, I think most of us try a bit of acute cognitive therapy in this scenario with mixed results.
So what to do? Is it ethical to use a “placebo neb” – this would violate her autonomy, but if effective would relieve her symptoms? Like it or not – we do this every day, we delude ourselves into believing we are using effective treatments, when the evidence shows no benefit – but the patient’s get the benefit of the placebo effect and symptoms are relieved.
This goes to the core of our oath. Is our job to relieve symptoms and suffering or to follow the book and treat disease, are we treating the tumour or the patient, the FEV1 or the dyspnoea?
What would you do? Love to hear your comments
Dear Doctor, you are cordially invited to the GP FOAM party…
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About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
never mind descartes, let’s just blame plato… and maybe the stoics… the mind-body thing is a huge contemporary problem me thinks and i agree totally.
as for the patient I think I’d just tell them what I think to be true
– i think the problem with her breathing isn’t her asthma
– i rarely use the term “panic attack” as it seems to me that lots of patients having hyperventilation attacks aren’t chronically anxious or panicked. sometimes even acutely they aren’t panicked they’re just hyperventilating
– she doesn’t need the medicine
– it’s unlikely to do her harm but might make her a bit more jittery
and then if she still wanted it i’d give her the medicine anyhow
i do the same thing with antibiotics for URTI – i tell them it’s all nonsense (but in a better worded way than that) and then if they still want it i give it to them. i’m not sure we should be fighting with our patients over such things, but we should at least be honest.
now if they really want their appendix out when i know it’s not appendicitis then that’s a different story…
Andy
What no D-dimer? Huh Just stirring the pot!!!
Time to treat the whole patient, not just treating symptoms -treat the mind as well. Difficult in the short term -beneficial in the long term.
Just my 5cents worth.
Kane
OK Andy
Is it OK to say: I believe that a saline neb will help alleviate your breathlessness and not cause “jitteriness” then give her a saline neb? Or does that destroy the placebo effect and result in no effect? It is an ethical Catch-22. Honesty might be doing her a disservice by removing the benefit of the meaningful (to her) placebo effect?
Casey
That said, there is some – admittedly weak – evidence (http://www.ncbi.nlm.nih.gov/pubmed/21203519) that suggests that even telling her it’s a placebo won’t dispel the placebo effect. I think though if you say ‘I’m going to give you a saline nebuliser (I wonder if the more syllables you can fit in there the better the effect…) because I think it will help you feel better then that’s fine because you’re being honest about what your giving and why, even if you’re being deceptive about the mechanism of action.
I’m not sure I agree with the antibiotic thing though – for a viral infection they will provide no benefit, so simply have the risk of side effects to the patient and drug resistance to the community.
OK. What about prescribing SSRI etc for mild, transient low mood. This is ubiquitous in GP land – I am sure there is a major placebo effect in this area. This is the area where a doctor can be holistic and treat the patient in their social context. I reckon the pills sometimes get in the way of good doctoring, placebo helps, but a strong therapeutic relationship helps more.
Unfortunately you could never study the doctor vs. SSRI vs placebo for depression – unless you used robot doctors maybe?
C
Jake got in before me there with the comment about placebos still being effective even if the patient is told. And i agree that the evidence for that is fairly weak.
That being said i think it’s a little bit beside the point as i think honesty trumps pragmatism. There’s an awful lot in that phrase and i’m not sure I possess the philosophical language as yet to flesh it out but i think there’s something in it
Doctors themselves are one big placebo effect some of the time and i think we engage in almost as much pseudo science as the Supplements, Complementary and Alternative Medicine (SCAM – mark crislip’s not mine….) brigade do.
I would venture that no one in modern western society holds the position of trust that the medical profession does and this makes honesty (within the very limits of what we actually know; admitting that we don’t know is also key!) a governing telos over pragmatism.
The thing about giving antibiotics is a slightly different question I admit but i still think letting the patient decide to have an antibiotic after an informed decision (including lack of effect and things like side effects and resistance and all that) is still a perfectly reasonable thing to do.
Great questions though Casey
And Kane I’d have the D-dimer, serum rhubarb and CT head to toe already ordered!
Andy, the way things are going, helped along by some doctor/patient collusion, antibiotics will soon be placebo effect anyway
great discussion folks
I qualified in medical acupuncture through Monash Uni and found treating patients with chronic pain was a whole lot easier afterwards. It gave me a greater understanding of mind/body dualism ..can pain exist without the mind and how does the mind influence the pain?
Andy about who holds greatest trust in western society , the annual polls are unanimous. Its the nursing profession not doctors. At least in Australia..lol.
PLacebo effect is real and we should use it therapeutically. But I agree..be honest about it. Thats why acupuncture is effective. its accessing a mind/body mechanism ( one teacher of mine called it the spinocutaneous reflex) that we don’t well understand but have observed an effect that is beneficial. If you want to call it placebo, thats fine. The Chinese, Japanese and Koreans explain it another way. Either way the effect is there.
Remarkably at times I have used acupuncture in emergencies ( it generally does not work that rapidly in the main) and have been surprised by the results. One night a nurse I was in the aircraft with developed vomiting and refused to have any medications. I treated with standard acupuncture with relief. It can work well in migraines.
I agree give the saline neb but tell her that it is saline.
thanks for the pointer about nurses being more trustworthy! perhaps trustworthy wasn’t the best term to use.
i was talking about it to my wife (a non-medic) and she thought people trusted doctors because they possessed knowledge about things that were foreign to most people
I think the authority of knowledge we have along with a high rating of trust/honesty (though not the highest) makes us hugely powerful and influential
To pinpoint the dilemma: Medicine is there to help the patient with minimal harm. The obvious solution is placebo in most cases, as Salbutamol can produce some unwanted side effects. This gets reduced to a philosophical and ethical dilemma, rather than medical. Can one lie to a patient to make her/him better? I would opt for a half-lie (mainly to assuage the MD’s conscience). Tell your patient: “It’s most probably nothing to worry about and will go away by itself. Some MDs suggest inhalation of saline. It either works as wetting agent, or as placebo, I’m not sure. If it does not help, we can always switch to Salbutamol. Meanwhile we’ll watch you closely to make sure you get better fast.”