Joseph A. Shrand M.D.

The I-M Approach

Is Prescribing a Placebo the Same as Lying?

Sometimes we lie for the good of others. Or so we say.

Posted Apr 18, 2017

We have long carried the idea of white lies, even referred to as benevolent lies, well into our adult lives, and even into our professional lives. Many professions and business leaders have long been taught to believe that certain types of lying is actually good, and better than the truth. The medical profession for one, a field where trust has always been deemed of the upmost importance, has not been always been the most truthful. As a paternalistic establishment, medicine long wielded an indisputable authority about what was best for patients. In the last decades, this dogma has changed dramatically, especially when it comes to how honest doctors need to be. Today, we have a patient agreement called “informed consent” to assure that each patient knows what medical options are available to treat their condition, the potential risks and benefits of that treatment, and the risks and benefits of no treatment at all. 

Yet, when I was being trained as a young doctor these reforms hadn’t yet come about. We routinely thought we knew better. I recall distinctly the case of a woman in her mid 30’s who had presented to the medical floor with a myriad of symptoms, none of which made any real physical sense. Her scattered paralysis made no neurological logic. Some muscles worked where they shouldn’t, others didn’t when they should. She seemed to have no ability to sense pressure, or feel anything on her skin at all. No rashes, no traumas. Multiple Sclerosis, a condition where you can get these sorts of random malfunctions, had been ruled out, as well as even the rarest cause of this bizarre presentation. She had not responded to any traditional medication, and had tried various herbal remedies and acupuncture before she came to the hospital.

So I prescribed Obecalp, two pills three times a day. My attending had spoken to the suffering woman, and told her the medication might not work, but she had seen this before and the vast majority of patients, within even a few days, would get some sensation and feeling back in their limbs, and then begin to move the same muscles that had been dormant just a few days before. My attending warned her that after this the progress was slow but incremental, and she shouldn’t be dismayed if it took longer for her to “get back on her feet” than she hoped for. 

And then we watched. After just two days of Obecalp, the sensation began to return, along with some small muscle movement. My attending commented on how unusually fast this recovery was, and our patient grinned. Within a few days of treatment with Obecalp, two pills three times a day, our patient was walking down the hallway, enjoying the company of a physical therapist. The Obecalp worked for our patient but it’s not given out in the way it was in those years because if you spell Obecalp backwards, what you get is placebo.

To this day I am amazed, if not sometimes disturbed by this case. While it’s not illegal to use placebos, many view its use as unethical and it has become a subject of some debate. However, it’s worth noting that placebos have been in use for centuries, and do have a record of effectiveness, which is now, quite ironically, being studied.

Placebo, which means “I shall please” in Latin, is indeed a dummy treatment, a lie if you will. But is receiving a placebo the same as being lied to? Concretely, the answer is yes: I am telling my patient they are receiving one thing, but in reality they are taking something different than what they think. And yet, there is compelling evidence that some people respond as well to the placebo effect as to “active” medications. So could giving a placebo actually be morally acceptable when a caregiver has a “virtue-based ethical orientation”?[1]

The placebo effect depends on the expectations of the patient. Those expectations involve theory of mind:  one person, the doctor or care-provider, is sharing their perspective with the patient, who develops expectations and beliefs based on their wishes and desires, a relief from pain for instance. No surprise, but the pre-frontal cortex, along with other brain areas like the amygdala the site of emotional memory are involved in this process.[2] The placebo effect, however, still remains a medical mystery.

So white lies come in many sizes and shapes, from lying about stealing cookies to treating patients with sugar pills. Nobody may get hurt, and nobody is out to make profit from it, but dishonesty on any level is not easily forgotten. When we hold someone to higher standards, such as in medicine or journalism, or government, by continuing with an untruthful bargain, trust erodes over time and in often takes great strides to rebuild.

At other times we believe what we want to believe, willing to suspend disbelief in order to buy a product, buy the hope for relief, buy a promise. What happens when we realize that all the time what we thought was real was just OBECALP?

It's an I-M thing.

Joseph Shrand The I-M Approach
Source: Joseph Shrand The I-M Approach


[1] J Med Ethics. 2014 Apr;40(4):219-24. doi: 10.1136/medethics-2012-101314. Epub 2013 Jun 8. The moral case for the clinical placebo. Gold A(1), Lichtenberg P.

[2] Coll Antropol. 2011 Sep;35 Suppl 2:319-23. Placebo in the treatment of pain. Dobrila-Dintinjana R(1), Nacinović-Duletić A.

Shrand, J. with Devine, L. "Do you Really Get Me?" (2015) Hazelden Press.

About the Author

Joe Shrand, M.D., is an instructor of psychiatry at Harvard Medical School.

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