Abstract

Objective To examine the attitudes of US patients about the use of placebo treatments in medical care.

Design One time telephone surveys.

Setting Northern California.

Participants 853 members of Kaiser Permanente Northern California, aged 18-75, who had been seen by a primary care provider for a chronic health problem at least once in the prior six months.

Results The response rate was 53.4% (853/1598) of all members who were eligible to participate, and 73.2% (853/1165) of all who could be reached by telephone. Most respondents (50-84%) judged it acceptable for doctors to recommend placebo treatments under conditions that varied according to doctors’ level of certainty about the benefits and safety of the treatment, the purpose of the treatment, and the transparency with which the treatment was described to patients. Only 21.9% of respondents judged that it was never acceptable for doctors to recommend placebo treatments. Respondents valued honesty by physicians regarding the use of placebos and believed that non-transparent use could undermine the relationship between patients and physicians.

Conclusions Most patients in this survey seemed favorable to the idea of placebo treatments and valued honesty and transparency in this context, suggesting that physicians should consider engaging with patients to discuss their values and attitudes about the appropriateness of using treatments aimed at promoting placebo responses in the context of clinical decision making.

Discussion

The opinions of US patients have been missing from debates over the use of placebo treatments in clinical practice and deliberate efforts by physicians to enhance patient care by promoting placebo responses. Our data show that patients are open to the idea of placebo treatments. Most (50-84%) judged it acceptable for doctors to recommend placebo treatments under conditions that varied according to the doctor’s level of certainty about the benefits of the treatment, the purpose of the treatment (for example, to address a patient’s need to receive a treatment), and the transparency with which the treatment was described to patients. Fewer than a quarter stated that it was never acceptable for doctors to recommend placebo treatments. In addition, many respondents indicated a willingness to try placebo treatments in different scenarios. This is generally compatible with trends reported in previous patient surveys in other countries regarding willingness to try placebo treatments.^{16 17 18 20}

Our findings also underscore the importance of honesty and trust in the prescription of placebo treatments. Respondents indicated that the use of placebo treatments could have a negative impact on the doctor-patient relationship if patients learnt that a doctor had recommended a placebo to placate patient’s expectations for treatment–especially if it did not work. Respondents said that doctors should be honest about an intervention being a placebo treatment when patients ask specific questions about the treatment, and they disagreed about whether it is acceptable for physicians to call a placebo treatment “real medicine.” Interestingly, some respondents thought that doctors should not disclose that a treatment is a placebo if it is working, suggesting some support for the non-transparent use of placebo treatments, a finding not reported in previous surveys.

Although clinical practice guidelines recommend against the use of placebo treatments to mollify patients,¹⁰ most participants in this survey judged their use to be acceptable to address patients’ need to feel like they received some treatment. Patients did, however, specify limits on how far physicians should go to placate patients, with over 90% judging it inappropriate for doctors to prescribe antibiotics for a cold, even when patients ask for it. Yet recent surveys suggest that a small proportion of physicians would indeed prescribe antibiotics to some patients in this situation, and that they had done so at least once within the past year.^4 21 Taken together, these findings hint at a disconnect between clinical practice guidelines, patients’ opinions, and physicians’ practices that should be further explored.

Although our data indicate a general acceptance of placebo treatments by patients, responses to different questions about the effectiveness of such treatments varied. While most thought when asked directly that placebo treatments are only effective when patients do not know they are receiving them, the responses to the more nuanced scenarios indicated a general acceptance of transparently prescribed “open” placebo treatments—both a belief that they are effective (62%) and a willingness to take them (61-65%). This discrepancy prompts questions about how well patients understand the concept of placebo treatments in general and whether providing additional detail in the scenarios adds to their understanding such that their answers to the corresponding questions are more accurate.

The study sample was representative of the population of Northern California but may not be representative of US patients in general. Our sample was more highly educated (≥44% college graduates) than the general population, had health insurance coverage through Kaiser Permanente Northern California, and had seen a physician within the past six months for a chronic medical condition. Although we constructed our definition of placebo treatments based on feedback from focus groups and pretest interviews, respondents may none the less have variable or limited understandings of the concepts of the placebo effect and placebo treatments. This is perhaps not surprising, given the variable understandings of these concepts among the placebo research community.⁵In view of the widespread variability in definitions and conceptions of placebo in the literature, we endeavored to employ a pragmatic definition of the placebo effect in our questionnaire that would be useful in the context of a patient survey. While there may be some vagueness and ambiguity in the concept of placebo treatments, the pattern of survey responses and our experience in exploring placebo treatments with focus groups indicate that patients are able to understand the difference between treatments that work on the basis of their inherent pharmacologic properties and those that may produce benefit primarily by means of positive expectations. We observed some variability in answers to analogous questions that were asked in different ways (for example, directly versus in contextualized scenarios), and it is difficult to know which formulation of the questions is likely to reflect attitudes more accurately. Furthermore, the survey captures patients’ opinions about a series of plausible hypothetical scenarios rather than actual behaviors and experiences.

Researchers of one study have argued that models of shared decision making need to include conversations between physicians and patients about the role of the placebo effect in clinical care,²² and clinical practice guidelines leave the door open for the use of placebo treatments when presented to patients transparently.¹⁰ Researchers of another study further suggest that attitudinal data can help develop and foster the use of effective and non-deceptive placebo treatment techniques.²⁰ That many patients in this survey seem favorable to the idea of placebo treatments suggests that physicians should consider engaging with patients to discuss their values and attitudes concerning the appropriateness of using placebos in the context of clinical decision making. Such conversations could allow physicians to determine which patients might be open to the use of placebo treatments and could help physicians tailor their description of placebo treatments according to patients’ preferences and level of understanding. Further research is needed to determine how physicians can optimally promote placebo responses in clinical practice and to guide the appropriate use of placebo treatments.

What is already known on this topic

• The use of placebo treatments by physicians in clinical practice has been documented in recent surveys
• Attitudinal surveys in other countries suggest that patients are open to the use of placebo treatments in specific circumstances
• This study provides data on US patients’ attitudes about the use of placebo treatments in clinical practice
• These data suggest that many patients are favorable to the idea of placebo treatments

What this study adds

Source: BMJ