Editorials

Placebo by proxy

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d4345 (Published 11 August 2011) Cite this as: BMJ 2011;343:d4345
  1. David J Grelotti, child and adolescent psychiatry fellow 1,
  2. Ted J Kaptchuk, associate professor of medicine2
  1. 1Department of Psychiatry, Massachusetts General Hospital and McLean Hospital, Harvard Medical School, Boston, MA 02114, USA
  2. 2Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
  1. david_grelotti{at}hms.harvard.edu

Clinicians’ and family members’ feelings and perceptions about a treatment may influence their judgments about its effectiveness

The effect of placebo on the patient and the patient’s environment is often debated, but people other than the patient may also feel better when a patient receives placebo treatment. The anthropologist Claude Lévi-Strauss alluded to this when he described how medical treatments, including those where ritual alone provides the cure, occur in a social context and convey a “sense of security” to the social group.1

Clinicians and family members may have an emotional response to a patient’s treatment and think that the treatment is helping the patient even in the absence of any direct physiological benefit to the patient or indication from the patient that the treatment is working. These feelings and perceptions may arise when placebos, including “impure” placebos, such as active drugs or operations that have no effect on the disease process, are used in clinical practice and research settings. Because these feelings and perceptions are not accounted for in descriptions of the placebo effect and can exist independently of any placebo effect on the patient, they can be described as placebo effects by proxy, or placebo by proxy for short. Although placebo by proxy has important implications, the phenomenon is underappreciated and rarely discussed.

Placebo by proxy could be as ubiquitous as the placebo effect, and in some situations placebo by proxy can dominate clinical decision making. For example, the parents of …

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