My three rules for placebo

Placebo or practices that are poorly or not based in evidence is an ethically questionable practice in medicine. Is it okay to prescribe medications for patients knowing that they will have limited or no benefit? Because of this I’ve established three rules for myself with regard to placebo. To some extent they are unattainable but I’ll keep trying.

  1. I have to tell the patient. I’ll be fully transparent that what I am doing for them or prescribing for them is placebo. I’ll tell them that it can have benefit but not beyond that effect. The placebo effect notably still has effect even when the patient is aware of it.
  2. I cannot benefit from it. No money should go into my pocket because of my prescribing placebo. This is easy in primary care because I get no kickbacks from drug companies. But I have to be careful with joint injections, ultrasound, or skin biopsies. This is more applicable to surgeons and alternative practitioners because they directly benefit from prescribing their treatments. I think that the prescriber and the practitioner should be separated in this case, such as how it takes a physician to write a referral to physical therapy. It prevents that conflict of interest. It could become quite contrived if this were implemented fully but I do believe every person claiming to be an advocate for the health of patients and populations should have some introspection about their profit off their therapies.
  3. It should cause little to no harm. Shoulder arthroscopy for example is largely placebo and it causes significant harm. Similarly, many people have been killed by vertebral artery dissections from chiropractors. Homeopathy and massage, docusate and mucinex, however are pretty much harmless placebo. I cannot prescribe placebo if I know it can cause significant harm to patients.

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