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Clinical and Ethical Aspects of Placebos in Clinical Practice—Reply

Clinical and Ethical Aspects of Placebos in Clinical Practice—Reply In reply I appreciate Dr Marcus's comments and thank him for the opportunity to clarify any misunderstandings associated with my Editorial.1 In response, I agree that placebo is not the only intervention for which we have an incomplete understanding of the mechanism of action. But few such interventions provoke as much controversy or debate as placebos. Second, while considerable literature exists on the placebo effect, our understanding of its fundamental nature, mechanism, and effects is still far from complete, a situation common to numerous other physiologic and pathologic processes. Indeed, if, as the writer appears to claim, we have a robust understanding of placebo physiology, how could the clinical use of placebo be viewed as “deceptive” if prescribing a placebo results in a benefit for patients through a well-characterized physiologic mechanism? I confess that I am unable to see how the Editorial asserts that, “caregivers who do not prescribe placebos lack sensitivity and compassion for patients.” I certainly did not intend to imply any such viewpoint. The passage cited was meant to highlight the fact that there are other therapeutic approaches for which we also have limited understanding of underlying mechanisms but that do not seem to provoke the same passion as placebo effects. The example cited was that of practicing compassionate and empathic medical care, which appears to be associated with improved outcomes. Just like placebo effects, we have a limited understanding of the biologic mechanism underlying the putative salutary effects of compassionate care. Unlike placebo, however, there seems to be little controversy over using compassionate care to effect better clinical outcomes for patients. If and how placebos work and the biologic mechanisms of their potential effects are enormously complex issues, and much legitimate debate remains about their proper role in clinical medicine. It was never my intent to declare an “unqualified endorsement of placebos”; my goal was to stimulate further discussion about this controversial topic and present a perspective that I believe is often lost in this controversy. Finally, I do not believe the Editorial advocated abandoning evidence-based care in any way. Back to top Article Information Correspondence: Dr Avins, Division of Research, Kaiser Permanent Northern California, 2000 Broadway, Oakland, CA 94612 (andrew.avins@ucsf.edu). Conflict of Interest Disclosures: None reported. References 1. Avins AL. Needling the status quo. Arch Intern Med. 2012;172(19):1454-145522965282PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

Clinical and Ethical Aspects of Placebos in Clinical Practice—Reply

JAMA Internal Medicine , Volume 173 (8) – Apr 22, 2013

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Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6106
eISSN
2168-6114
DOI
10.1001/jamainternmed.2013.90
Publisher site
See Article on Publisher Site

Abstract

In reply I appreciate Dr Marcus's comments and thank him for the opportunity to clarify any misunderstandings associated with my Editorial.1 In response, I agree that placebo is not the only intervention for which we have an incomplete understanding of the mechanism of action. But few such interventions provoke as much controversy or debate as placebos. Second, while considerable literature exists on the placebo effect, our understanding of its fundamental nature, mechanism, and effects is still far from complete, a situation common to numerous other physiologic and pathologic processes. Indeed, if, as the writer appears to claim, we have a robust understanding of placebo physiology, how could the clinical use of placebo be viewed as “deceptive” if prescribing a placebo results in a benefit for patients through a well-characterized physiologic mechanism? I confess that I am unable to see how the Editorial asserts that, “caregivers who do not prescribe placebos lack sensitivity and compassion for patients.” I certainly did not intend to imply any such viewpoint. The passage cited was meant to highlight the fact that there are other therapeutic approaches for which we also have limited understanding of underlying mechanisms but that do not seem to provoke the same passion as placebo effects. The example cited was that of practicing compassionate and empathic medical care, which appears to be associated with improved outcomes. Just like placebo effects, we have a limited understanding of the biologic mechanism underlying the putative salutary effects of compassionate care. Unlike placebo, however, there seems to be little controversy over using compassionate care to effect better clinical outcomes for patients. If and how placebos work and the biologic mechanisms of their potential effects are enormously complex issues, and much legitimate debate remains about their proper role in clinical medicine. It was never my intent to declare an “unqualified endorsement of placebos”; my goal was to stimulate further discussion about this controversial topic and present a perspective that I believe is often lost in this controversy. Finally, I do not believe the Editorial advocated abandoning evidence-based care in any way. Back to top Article Information Correspondence: Dr Avins, Division of Research, Kaiser Permanent Northern California, 2000 Broadway, Oakland, CA 94612 (andrew.avins@ucsf.edu). Conflict of Interest Disclosures: None reported. References 1. Avins AL. Needling the status quo. Arch Intern Med. 2012;172(19):1454-145522965282PubMedGoogle ScholarCrossref

Journal

JAMA Internal MedicineAmerican Medical Association

Published: Apr 22, 2013

Keywords: ethics

References