Do no harm – but a white lie couldn’t hurt, could it?

Placebos have been a well-known and effective tool for medical trials and professionals, but how ethical is it for doctors to use them on patients? Nathan Rockley argues they could be a slippery slope that is best left untouched.

Ask yourself a question: should doctors be allowed to lie to elicit the placebo effect?

Some of them do.

A 2013 paper found that 12% of GPs had prescribed a “pure” placebo (eg. a sugar pill or saline solution) at least once in their career, and 97% admitted to prescribing an “impure” placebo (real treatments but effective for other conditions, eg. antibiotics for a viral infection) at least once.

While beginning to write this article, I posed the question to some friends, and their responses included “no, it’s crossing a line,” and “nah, it just feels wrong.”

Spoiler alert: I agree. But it was tricky to pin down why.

After some thinking, it came down to three issues: it robs patients of agency, erodes trust, and could lead to more mistakes.

Paternalistic Approach

While placebo treatment is effective in treating conditions such as depression, chronic pain, and even Parkinson’s, it is a textbook example of a paternalistic approach to doctor-patient interactions.

By allowing doctors to lie, even for the sole benefit of the patient, we remove the patient from the centre of their care. You force the patient to give up their position of expertise in the interaction. For example, if I have a psychosomatic condition (one which is caused or aggravated by a mental factor such as stress), the only way treatment will work is if I don’t know it is a placebo and therefore don’t know what the root of my condition is.

Slippery Slope

Furthermore, if we weaken our stance from “doctors should never lie” to “doctors shouldn’t lie to patients except when they think it is in their best interest”, what is to stop this from slipping down the slope to “doctors decide what to do and aren’t accountable to patients”?

As a patient, my ability to choose what happens to my body goes from complete control to blind trust.

Doctors Make Mistakes

As an aspiring doctor, the possibility that I could lie to a patient terrifies me. It seems that we are all for safeguarding the patient from others but forget that, to a degree, we must also protect the patient from ourselves.

Take the case of wrong-site surgeries: one in five hand surgeons has operated on the wrong hand at some point in their career. To prevent this kind of thing, every surgical team in the UK goes through a pre-surgery checklist together which includes checking the right patient is in surgery, and that the right area of the body is labelled.

Why? Because humans are flawed. Increasing the number of situations that a doctor makes decisions alone (by allowing them to lie to elicit the placebo effect) will surely increase the number of mistakes.

This is not to say that we shouldn’t trust doctors. The patient-doctor trust relationship is a crucial part of a positive and healing medical experience. The issue is that if both parties aren’t open and equal in the interaction, the ability to establish trust is weakened.

The effectiveness of a placebo lies in the power of psychology, and the same effect could be accessed by referral to counselling or therapy alongside treatment. This is an upgrade on a placebo, as not only are the same beneficial effects achieved, but the patient also remains at the centre of their care. Furthermore, they are empowered by the therapist to work through it themselves. 

Another option is meta-placebo treatment, in which the patient is informed that they are receiving a placebo and thus the ethical dilemma is somewhat avoided. Research is needed to assess the effectiveness and practicalities of meta-placebo treatment.

In the meantime, white lies should stay within the realm of phrases like “I’ll be there in 5 minutes” and be kept far away from medicine.

Nathan Rockley (he/him) is a third-year medical sciences student. (Instagram: @nathanrockley)

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