‘The use of a harmless alternative therapy is not necessarily wrong. Even if the treatment itself is just a placebo, it can help many patients. Some patients feel better with it, and it would be arrogant, high-handed and less than compassionate to reject such therapies simply because they are not supported by sufficient scientific evidence’.
How often have I heard this notion in one or another form?
I hear such words almost every day.
Arguments along these lines are difficult to counter. Any attempt to do so is likely to make us look blinkered, high-handed and less than compassionate.
Yet we all – well almost all – know that the notion is wrong. Not only that, it can be dangerous.
I will try to explain this with a concrete example of a patient employing a harmless alternative remedy with great success… until… well, you’ll see.
The patient is a married women with two kids. She is well known to her doctor because she has suffered from a range of symptoms for years, and the doctor – despite extensive tests – could never find anything really wrong with her. He knows about his patient’s significant psychological problems and has, on occasion, been tempted to prescribe tranquilizers or anti-depressants. Before he does so, however, he tells her to try Rescue Remedies@ (homeopathically diluted placebos from the range of Bach Flower Remedies). The patient is generally ‘alternatively inclined’, seems delighted with this suggestion and only too keen to give it a try.
After a couple of weeks, she reports that the Rescue Remedies (RR) are helping her. She says she can cope much better with stressful situations and has less severe and less frequent headaches or other symptoms. As she embarks on a long period of taking RR more or less regularly, she becomes convinced that the RR are highly effective and uses them whenever needed with apparent success. This goes on for months, and everyone is happy: the patient feels she has finally found a ‘medication that works’, and the doctor (who knows only too well that RR are placebos) is pleased that his patient is suffering less without needing real medication.
Then, a few months later, the patient notices that the RR are becoming less and less effective. Not only that, she also thinks that her headaches have changed and are becoming more intense. As she has been conditioned to believe that the RR are highly effective, she continues to take them. Her doctor too agrees and encourages her to carry on as before. But the pain gets worse and worse. When she develops other symptoms, her doctor initially tries to trivialise them, until they cannot be trivialised any longer. He eventually sends her to a specialist.
The patient has to wait a couple of weeks until an appointment can be arranged. The specialist orders a few tests which take a further two weeks. Finally, he diagnoses a malignant, possibly fast growing brain tumour. The patient has a poor prognosis but nevertheless agrees to an operation. Thereafter, she is paralysed on one side, needs 24-hour care, and dies 4 weeks post-operatively.
The surgeon is certain that, had he seen the patient several months earlier, the prognosis would have been incomparably better and her life could have been saved.
I suspect that most seasoned physicians have encountered stories which are not dissimilar. Fortunately they often do not end as tragically as this one. We tend to put them aside, and the next time the situation arises where a patient reports benefit from a bogus treatment we think: ‘Even if the treatment itself is just a placebo, it might help. Some patients feel better with it, and it would be arrogant, high-handed and less than compassionate to reject this ‘feel-good factor’.
I hope my story might persuade you that this notion is not necessarily correct.
If you are unable to make your patient feel better without resorting to quackery, my advice is to become a pathologist!!!
I am unclear – is this a ‘story’ (as stated), or an account of a genuine patient (and how is the case history known)?
And it would appear the patient was not told told she was receiving a placebo. She did not give fully informed consent. That is unethical.
And an anecdote about one patient and a GP who fails to refer her to a specialist when he should have done is not evidence of anything. See Ernst here, in numerous entries!
Using placebos is not quackery if patients are fully informed. And placebos do work (up to a point), even if patients are fully informed by their placebist (one who practices and studies the use of placebos).
it’s not evidence !!!
it’s a story to explain how patients can get harmed by a prevalent attitude of clinicians towards ‘harmless’ alternative treatments [sorry, but I thought that was quite clear].
“and the doctor – despite extensive tests – could never find anything really wrong with her.”
it seems that the extensive tests undertaken is what failed her! Given a proper diagnosis she would have received different advice which would probably have caused her to go into shock, which is when RR could be helpful.
“concrete example” suggests it’s an actual case history that’s been anonymized for privacy. “hypothetical example” would be clear.
OTOH, there must be concrete cases you could cite of patients/doctors who tragically delay effective diagnosis and/or treatment in the belief that their magical/”go away” pills are good for getting rid of annoying ailments/patients. Why use hypotheticals if you can draw on the real thing?
Isn’t the whole point of a placebo is that the patient is not told it it a placebo? “Here, take this. It contains no ingredients, whatsoever, that will cure your illness,” versus, “Here, take this. It might be helpful.”
Colin seems to be attempting to live like a real-life Homer Simpson.Homer’s personality is complex mix., according to the joke required in any given situation. So at one time he and the kids are sitting in front of a pile of empty pizza boxes, and Homer declares, in cod- Classical style, ‘We have eaten and we have eaten well’, like a kind of ‘idiot savant’. But then he becomes the genuine idiot when he earnestly defends his candy- eating to Liza by declaring ‘ Purple is a fruit’.
As a pathologist I would like to state that we are not in favour of using quackery to make patients feel better (At least no more than other doctors).
Empathy and compassion is also an important part of being a pathologist. It may not look that way just by reading the pathology reports. It rarely happens that we are in direct contact with patients. But when we are, I can assure you that we do not come across as coldhearted academics or fans of quackery.
We are vey much aware that specimens/biopsies we recieve are from real living patients with real problems that we should do our part in helping to resolve.
And when we on our own initiative contact surgeons friday afternoon to explain to them, that they should not wait for the written report on monday to tell a patient (before the weekend) that a sigmoid colon resected on suspicion of cancer was in fact diverticular disease – would that not qualify as compassionate behaviour?
In short: Doctors who find quackery acceptable are not suitable as pathologists either!!
But using placebos is not quackery if fully informed consent is obtained.
Placebos can be an adjunct to TLC.
in my story, informed consent was not obtained
THAT’S ONE OF ITS MAIN POINTS
and there were no actions to identify a cancer when it develop during seemingly effective placebo therapy
THE SECOND MAIN POINT
OVERALL, MY POINT IS THAT THERE IS A RISK IN USING ‘HARMLESS’ PLACEBOS
I have no objections to the points. In fact I totally agree. What I object to is shaming of pathologists (and other medical specialties for that matter). It is unfounded and unnecessary. To apply science as well as compassion is important for all of us.
A recent newspaper article reporting on a women that died after foregoing cancer treatment and deciding to take an ‘alternative’ path. – many similarities with your blog post
But isn’t it illegal to offer cancer patients ‘treatments’ that is known not to work? Surely those practitioners are breaking the law?