UK placebos

The study - conducted by researchers at the universities of Oxford and Southampton and published in PLOS One - found that the overwhelming majority of 783 GPs had prescribed a placebo to at least one of their patients. The Royal College of General Practitioners (GPs) says placebos have their value in medicine. But Dr Margaret McCartney, a GP in Glasgow, Scotland, disagrees. She says she has never knowingly prescribed a placebo, and insists more time should be spent on improving doctors' consultations with their patients, rather than basing healthcare on lies and deception.

DW: Is there an element of self-deception on the part of patients - that they want to be made to feel like they are being treated the way the want to be treated and the way they feel is the right way to be treated?

Dr Margaret McCartney: I would argue that we don't need placebos to get these caring effects from consultations and it's very clear from research that when patients have time to talk about the things that matter to them and feel like they're being listened to by a doctor who has concerns for them, and wants to explain things in ways that are understandable and useful, those kinds of consultations tend to make people better, compared with cold, brusque consultations where you don't see the same person twice and you're not quite sure what's going on. So, why would you want to use a deceptive placebo pill when we can be much more honest, spend the time that we'd like to spend with patients - having good consultations as opposed to consultations that result in a medicine substitute - and have a higher quality of consultation with a patient who's not being lied to and who has been given better information about their health.

So, for you this is an issue of having the time to deal with patients properly and fairly. But that is an issue that practices around Europe are having to face - that there is less time to spend with patients. Here in Germany, doctors allow themselves about five minutes with a patient. It doesn't matter what you come to them with, most doctors will want you out the door again in five minutes. Is that something that needs to be addressed more urgently than whether placebos work, because that surely is part of the underlying feeling of this study, that some placebos work.

Yes… I don't think that the result from this study should be, "Oh, GPs are busy and stressed, therefore give more placebos" - [as if] that would be better for people! I think that would be the worst possible result. I don't know about the situation in Germany. But certainly in the UK we work to a contract, which means that my time is meant to be spent looking at a computer screen, ticking boxes to say that I've asked someone to stop smoking or checked someone's weight, or filled in a risk analysis or questionnaire for them. I'm not really given the ability to free myself of these things that are not important to the patient and not that important to me as a doctor.

What is more important to that person is why they are here, what they're concerned about, what their worries are and what I can try to do to help with that. And sometimes the patient's priorities have got lost in terms of what the government [sees as] priorities as to what I should do as a doctor. And this is wrong for many reasons, but fundamentally because it's taking away the centre of the consultation from the patient, and moving it onto the doctor and even worse onto the doctor's computer. So in many ways I think we have to liberate ourselves from the shackles of industrial medicine and get back to what we can do that is good for patients without deception, and treating people as human beings, as adults who are perfectly able to make informed decisions, whom we can work with, without a futile lie creeping in that is a placebo, and instead focusing on having human dialogue.

There is also the issue that some placebos have their risks. It may be the case that there's no active ingredient in, say, a vitamin pill that a doctor might prescribe to a patient, but there are risks in taking too many non-working drugs… what sort of risks are we talking about?

The first risk is people taking placebos, thinking they'll do them good when actually they won't. For example, we've had a survey done in the UK a couple of years ago, where people got treatments for malaria and were recommended homeopathy as an ideal preventative for malaria, which clearly is dangerous advice because homeopathy is a placebo, it's not going to have any affect at all in preventing malaria. Then you've got the ability for people to make a lot of money through offering placebos to people, who are not going to benefit from the biological affects of the placebos that are being given, but who invest a huge amount of time and effort, money and hope in things that are never going to work for them. Do we want to be lied to or deceived, or do we want to be properly informed patients, able to have a grown-up conversation with a doctor? Shouldn't we want doctors to be honest about the limitations of medicine, but still offer humanity and still offer compassion, time, and care to keep someone well or help them through an episode of illness?

I imagine there is also a lot of pressure - whether it's placebos or real drugs - from the pharmaceutical industry that does work very closely, it would seem, with a lot of doctors to have certain drugs used in certain circumstances. And then it rubs off on the patients - they believe that these drugs that they've heard about are going to help.

Absolutely, and I think that the whole problem of over-diagnosis and over-treatment is one that patients and doctors should be working together on, and that involves being honest, sometimes painfully honest, about how useless an awful lot of medicine is. A lot of screening doesn't work, a lot of antibiotics don't work, and a lot of anti-depressants for people with mild depression don't really work. So, it's kind of painful, I think, for doctors to stand up and say, "A lot of these things aren't very good." But this protects patients. And it doesn't mean to say that because a tablet doesn't work that a doctor should lose interest or not still want to help someone. It's just that we should be more honest about what is useful and what is not. And of course there are lots of evidence-based things that are not necessarily placebos that can help. So, for example, exercise can be a good treatment for many conditions, social interaction can be very useful to protect people who are at risk of other conditions. So, there are other things that can be done that are evidence-based and are not necessarily a prescription, or a tablet, that we should be thinking about. I certainly don't think we should be using unproven, non-evidence-based complimentary medicine… that's just as bad as using orthodox medicine that doesn't work. We have to apply the same standard of evidence to everything. And if we do this right, and are brave enough to be honest and bring that information to patients, we will end up with better informed patients and happier doctors.

Dr Margaret McCartney is the author of the book, The Patient Paradox - Why Sexed Up Medicine is Bad for Your Health.