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German doctors are told to have an open attitude to placebos

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d1535 (Published 08 March 2011) Cite this as: BMJ 2011;342:d1535
  1. Ned Stafford
  1. 1Hamburg

After more than three years assessing the scientific literature on the clinical use of placebos, the German Medical Association (Bundesärztekammer) has concluded that they can be effective and is encouraging doctors to have a more open attitude towards their use in some cases.

The assessment, conducted by the association’s scientific advisory board, urges doctors to receive training in the use of placebos and for medical schools to include instruction on placebo use in the curriculum. It notes that placebos can sometimes be more effective than standard drug treatments, can reduce unpleasant side effects, and can result in lower health costs.

“Placebos have a stronger effect and are much more complex than previously realised,” said Christoph Fuchs, the association’s managing director, at a press conference on 2 March announcing publication of the scientific advisory board’s 200 page report, Placebos in Medicine. He added, “The use of placebos is of enormous importance in the practice of medicine.”

The report also covers the history of placebos, their mechanics, and the ethical issues doctors face when using them. It estimates that around half of German doctors sometimes use placebo treatments in the form of pure placebos with no active ingredients, such as sugar pills, or so called pseudo-placebos, which contain an active ingredient that is either in a much reduced dosage or that has no proved effect on the ailment being treated.

Peter Scriba, the advisory board’s chairman, told the BMJ that the board supports use of placebos only when no approved drug is available, the patient has a minor illness or condition, placebo treatment does not raise the risk of harm to the patient, and when placebo treatment seems likely to succeed.

Studies reviewed by the board indicate that doctors most often use placebo treatments for pain, sleeplessness, mild depression, and digestive ailments, said Professor Scriba, the retired former director of the Innenstadt Medical Clinic of the University of Munich.

Professor Scriba said that early in his medical career he was sceptical of placebo treatments, believing that they should be used only for patients who seem to exaggerate or invent ailments. But he said that during the past 20 years of his career he has “become convinced” that placebo treatments can be effective and should be used routinely in medical practice.

Although the mechanics of placebo treatment were still far from being understood, he noted that studies using brain scans have shown that placebo treatments affect the same areas of the frontal lobe as standard drug treatments. “You can see it in the brain, the effect of placebos,” he said. “There is obviously something going on there, undoubtedly something that is having an effect.”

As to the legal and ethical aspects of placebo treatment, this is “a grey area,” Professor Scriba said. Doctors must be certain that no evidence based medicines are available before trying a placebo treatment, he said. “Patients deserve the best available medicine,” he added. “It would be unlawful if you don’t do that.”

In most cases doctors would not use a placebo until they had tried evidence based drugs, he said. When finally prescribing a placebo, doctors must not imply to patients that the placebo has an active ingredient but should say instead that it has been successful with other patients and is worth a try, he said.

A study done at the University of Hanover Medical School noted that 25% of doctors who had prescribed a placebo told the patient that it was a medicine, while 50% said vaguely that “this will help you,” 12% gave no explanation, 7% said that “this is a medicine with no specific effect,” and 5% said that it was a placebo. Some 50% of nurses in the same study told the patients that the placebo was a medicine, while 42% said that “this will help you.”

Notes

Cite this as: BMJ 2011;342:d1535