For German patients plagued with problems like chronic pain and mild depression, doctors may soon be trying something a little different: a placebo.
After completing a major study on the use of placebos, the German Medical Association recently concluded the fake pills sometimes work better than real medicines and recommended that doctors give them out more often — even without explicitly telling their patients.
That is in stark contrast to guidance from American and British authorities, who say using placebos without the patient's consent is unethical. Placebo pills are often made from things like sugar, flour or dust, though doctors also use other things like vitamins, herbal supplements or drugs with very little active ingredient.
'A lot of doctors will say it's easier to write a prescription but we're not giving patients the best treatment possible when we rely on drugs.'— Ted Kaptchuk
According to the German group, placebos don't come with any nasty side-effects and could be the last hope for patients with hard-to-treat ailments where no good medicines exist.
"You shouldn't give placebos for anything, but there are certain situations where they can be quite helpful," said Dr. Peter Scriba, chairman of the German Medical Association's advisory board.
He said placebos could help patients with mild anxiety, depression, chronic inflammatory problems, pain and asthma.
Experts have long recognized that placebos can sometimes cause physiological changes in patients who expect to get better and brain scans have shown that the brain reacts to placebos in the same way it does to actual drugs. They say placebos work best for diseases where there is a subjective component like perceptions of pain — and that they wouldn't work for other problems like broken bones or cancer.
Scriba said placebos shouldn't be used for conditions where an effective therapy exists and that doctors must tell patients they're getting something unusual. But Scriba said doctors aren't obliged to actually use the word 'placebo.' Instead doctors could tell the patient it has helped others with their condition and it might help.
Lying to patients?
Some experts were horrified by the less-than-forthright approach.
"That's what I call lying," said Ted Kaptchuk, an associate professor of medicine at Harvard University. "I'm not saying it's wrong, but it would be unacceptable in the U.S."
The American Medical Association warns that doctors who use placebos without telling their patients may undermine their trust and cause harm.
Kaptchuk thought there might be a role for placebos, but said doctors haven't yet figured out how to harness their potential. "In the U.S., we have a commitment to transparency," he said. "The Germans seem to be saying that it's OK to lie a little bit."
Still, he said using more placebos might wean people off drugs that haven't proven to be very helpful and could also save health care systems millions of dollars.
"The amount of drugs people are taking to really only get a [minor] benefit is astronomical," Kaptchuk said. "A lot of doctors will say it's easier to write a prescription but we're not giving patients the best treatment possible when we rely on drugs."
Last year, Kaptchuk and colleagues published a study that found people with irritable bowel syndrome who knowingly took a placebo still got better, providing some proof that doctors don't always have to deceive patients when giving them dummy pills.
Previous surveys have found up to half of the doctors in Denmark, Britain and the U.S. regularly give their patients placebos without telling them.
In Britain, medical authorities completely reject the idea that placebos might be valuable.
"We don't agree with the use of placebos at all because by definition, they're a medication that has no value," said Tony Calland, chairman of the British Medical Association Medical Ethics Committee. "Using placebos isn't scientific. It sends medicine back into the 19th-century."
Other experts said some patients might get better simply by spending more time with their doctors.
"The doctor-patient relationship is critical to the placebo effect," said Irving Kirsch, a professor emeritus at the University of Hull in Britain who has studied placebos. He said for some people, placebos are a case of mind over matter.
"Patients who trust their doctors and have a psychological expectation of getting better could trigger a reaction in their body," Kirsch said.