ABSTRACT
In medicine, placebos are used both in scientific studies and for practical therapeutic purposes. In evidence-based medicine, the efficacy of treatment may be determined as the difference between the effects of the verum (the active study drug) and the placebo, the latter being a substance lacking specific action on the disease under consideration. However, the improvements in patients' conditions under placebo treatment may be substantial and comparable to those with verum. Genuine placebos predominate in clinical studies, while pseudoplacebos prevail in practical therapy. The term pseudoplacebo can also be applied to many procedures in complementary medicine, including homeopathic medicine (Büchel et al., Placebo in der Medizin, 2011). The comprehensive definition of placebo, as used in a report by the German Medical Association (Büchel et al., Placebo in der Medizin, 2011), states that a placebo effect may occur even when treating with verum. The placebo effect is modulated by the context of the treatment, by the expectations of the patients and the doctors, and by the success of the relationship between doctors and patients. A number of unspecific effects, e.g., spontaneous alleviation, statistical effects, variance with time, methodological errors, in addition to the placebo effect make up the total response that is called"placebo reaction." A complete list of the effectiveness of placebo for all important diseases is still lacking. Further, it is not possible to predict which patients will respond to placebo. Which characteristics of doctors are important (competence, empathy, communicative ability and partnership, trust) in order to achieve a placebo effect, particularly in addition to the verum effect measures of evidence-based medicine? Are there doctors who are better in this than others? Could the nocebo effect weaken the efficacy of treatment in evidence-based medicine? Since a placebo effect may occur in almost any standard therapy, information about placebos should be provided during medical education and continuing medical education (CME). The use of placebo in clinical studies is ethically justified and lawful in consenting patients if there is no other effective treatment available with which the test substance could be compared. For daily practical therapeutic purposes, placebos may be ethically acceptable and lawful if there is no effective therapy available, if the complaints are minor, if the patient expressly wishes treatment, and if there is a reasonable likelihood of success. However, an explanation of the expected benefits and risks must be provided to the patients. At present, there are two explanatory theories for the mechanism of action of placebo, namely, the associative and the mentalistic explanation (Büchel et al., Placebo in der Medizin, 2011). Interestingly, effects of placebo and of verum can be localized in the brain by physiological and anatomical techniques. With many open questions remaining, research on placebo is currently very active. These aspect and neurobiological findings in particular may facilitate for "scientifically" educated doctors to accept that ineffective materials, i.e., placebos, are in fact effective.
Subject(s)
Clinical Trials as Topic/ethics , Informed Consent/ethics , Patient Participation/trends , Patient-Centered Care/ethics , Physician's Role , Physician-Patient Relations/ethics , Placebo Effect , GermanySubject(s)
Acupuncture Therapy , Deception , Placebo Effect , Placebos/therapeutic use , Practice Patterns, Physicians'/standards , Acupuncture Therapy/ethics , Ethics, Clinical , Ethics, Medical , Evidence-Based Medicine , Humans , Materia Medica/therapeutic use , Physician-Patient Relations/ethics , Practice Patterns, Physicians'/ethicsSubject(s)
Materia Medica , Patients/psychology , Physician-Patient Relations/ethics , Placebo Effect , Placebos , Clinical Trials as Topic/ethics , Deception , Europe , Evidence-Based Medicine , France , Humans , Informed Consent , Materia Medica/administration & dosage , Materia Medica/economics , Personal Autonomy , Placebos/administration & dosage , Placebos/economics , Practice Patterns, Physicians'/ethics , Safety , Suggestion , Treatment Outcome , United Kingdom , United StatesABSTRACT
BACKGROUND: The increasing demand for complementary and alternative medicine (CAM) raises ethical questions about specific aspects of both CAM and conventional medicine (COM). METHODS: The present article provides a critical survey of the most important ethical aspects in the current debate about CAM. RESULTS: The relevant ethical issues arise mainly in 4 main areas: 1) patient information, 2) research ethics, 3) cost, and 4) education. Most of the contributions used for our purpose are based upon the implicit assumption that, in principle, the ethics of CAM and COM have to be identical because of the same underlying doctor-patient relationship. This premise is shared by the author. CONCLUSIONS: Substantial efforts on various levels will have to be made in order to create the conditions necessary for CAM to be ethically justified. But the ethical implications for COM also have to be considered.
Subject(s)
Complementary Therapies/ethics , Complementary Therapies/statistics & numerical data , Ethics, Medical , Beneficence , Clinical Competence , Complementary Therapies/economics , Cost-Benefit Analysis/economics , Drug Approval , Education, Medical , Germany , Homeopathy/economics , Homeopathy/ethics , Humans , National Health Programs/economics , National Health Programs/ethics , Patient Education as Topic/economics , Patient Education as Topic/ethics , Physician-Patient Relations/ethics , Phytotherapy/economics , Phytotherapy/ethics , Treatment OutcomeABSTRACT
Los llamados efecto placebo y nocebo son efectos reales que resultan de la interacción entre la actividad mental y el estado funcional del organismo. Esta interacción se puede describir hoy en términos precisos a través de la influencia que las estructuras del sistema límbico ejercen sobre el hipotálamo y las regiones del tallo cerebral que controlan las funciones endocrina, motora y vegetativa. El conocimiento de estos mecanismos pone de relieve la importancia de factores sugestivos, como la confianza en el terapeuta o en el tratamiento indicado, en la curación de enfermedades o de sus secuelas. Existen evidencias de que algunas terapias sin una base científica sólida como la acupuntura, la homeopatía o la terapia floral, logran sus resultados a través de estos mecanismos. Incorporar los principios psicobiológicos que origina el efecto placebo a la relación médico paciente, puede resultar una contribución positiva para una medicina más efectiva y humana, pero siempre dentro de los límites que imponen la ética de no mentir y el respeto a la integridad e inteligencia de los pacientes
The so called placebo and nocebo effects are real, and result from the interaction between the mental activity and the functioning of the body. This interaction is presently described in precise terms as the influence exerted by limbic structures on the hypothalamus and on the brain stem's nuclei that control the endocrine, motor and vegetative functions. Understanding of these mechanisms discloses the important role played by suggestion, like trusting your therapist or trusting the treatment, in the cure of diseases and their sequels. There is also evidence that therapies without a strong scientific foundation, like acupuncture, homeopathy or flower therapy, can achieve some results based on these mechanisms. The introduction of the psychobiological principles governing the effect of placebo into the medical practice could contribute to a more effective and human medicine, provided that the ethical limits imposed by the truth and the respect to the patient´s integrity and intelligence are observed
Subject(s)
Limbic System , Placebo Effect , Physician-Patient Relations/ethicsABSTRACT
Esta tese é fruto de um trabalho de pesquisa de campo desenvolvido ao longo de uma década. Insere-se no campo das Ciências Humanas e da Saúde através da linha de pesquisa Racionalidades Médicas e Práticas de Saúde, coordenada por Madel T. Luz. A partir de um enfoque sócio-antropológico, realiza-se um estudo comparativo entre a prática clínica da racionalidade médica homeopática e da psicanálise. Buscamos compreender os sentidos e significados atribuídos aos processos de adoecimento erecuperação da saúde; bem como os valores culturais, subjacentes a estas práticas, presentes em segmentos da classe média carioca, que levam determinados sujeitos a procurarem estas formas terapêuticas, para aplacarem seus sofrimentos. Para tanto criamos a categoria sociológica: sujeitos em terapia, que inclui a percepção de estados positivos, que chamamos de saúde e seu estado ideal denominado cura; a percepção de estados indicativos de um movimento desestabilizador, nomeado adoecimento; uma perspectiva terapêutica de respeito às singularidades e à pertinência temporal das intervenções possíveis, de acordo com as circunstâncias globais de cada paciente; e, o que ao nosso ver é a maior distinção destas propostas terapêuticas, uma relação terapeuta-paciente única, desafiadora, instigante, onde a sintonia se faz necessária para que o processo caminhe, numa direção que não se sabe a priori qual é, mas que é fruto desta interação. Trabalhamos com a análise das representações sociais dos homeopatas e psicanalistas acerca do sujeito (ou quem se trata), da saúde (ou o sujeito saudável), da cura(ou momento da alta) e da doença (ou o sujeito doente); agregando a esta análise a percepção da dinâmica das consultas homeopáticas e das sessões psicanalíticas referidas por estes profissionais, bem como aquilo que eles valorizam no processo terapêutico que desenvolvem com seus pacientes...
This thesis results from fieldwork research developed along one decade. It belongs to the domain of Humanities and Health Sciences in the line of research Medical Rationalities and Health Practices, coordinated by Madel T. Luz.From a social-anthropological perpective, a comparative study is carried out involving the clinical practice of the homeopathic medical rationality and psychoanalysis. The aim of the study is to understand the meaning and sense attributed to the processes ofsickening and recovery as well as the cultural values underlying the aforementioned practices, present in segments of Rio de Janeiros middle class, which lead certain subjectsto seek these therapeutic modes to ease their suffering. In order to develop such a study, a sociological category was created people in therapy , which includes the perception of positive states, which we deem health and its ideal state called cure; the perception ofstates indicative of a destabilizing movement, named sickening; a therapeutic perspective respectful of singularities and of the temporal adequacy of the possible interventions,according to the global circumstances of each patient; and, what in our opinion is the main distinction between these therapeutic proposals, namely, a unique, challenging and instigating therapist-patient rapport, in which being in tune with one another is necessaryfor the process to take place, albeit in a direction which no one knows beforehand which will be, but which depends on this interaction.We have worked with the analysis of social representations of homeopaths and psychoanalysts of the subject (or the one in treatment), of health (or the healthy subject), of healing (or the moment of release) and of sickness (or the sick subject); adding to theseanalyses the observations around the dynamics of homeopathic and psychoanalytic sessions as related by...