CAN A PLACEBO BE THE PREFERRED FORM OF TREATMENT?

Until now we have considered the circumstances in which placebo treatment could be a legitimate therapeutic option. Could a situation arise wherein the placebo is the required form of treatment?

Case 3

A 32 year old mother of three is being treated for an agitated depression by means of hypnotherapy. In the course of one of the hypnosis sessions, the client envisions a bloody scene whose meaning is uncertain but which alarms her terribly. Refusing to continue with the therapy, she demands medication. The treating psychiatrist, seeing no alternative, prescribes imipramine at a starting dose of 25 mg, explaining to the patient that effectiveness generally requires two to four weeks at a dose of 200–300 mg. The day after taking her first 25 mg dose, she reports that a remarkable improvement has taken place and virtually all symptoms have subsided. She continues, diffidently, her psychotherapy. Attempts to discontinue the medication meet with immediate failure. Explanations by the suspicious psychiatrist that the medication requires higher dosage and longer duration are shrugged off by the client.

This vignette demonstrates several features of interest to our discussion. First of all, though imipramine, a tricyclic antidepressant, is a medication with established efficacy, it was used here as a placebo. Certainly, it was not the established noradrenergic action of the medication which, after one day and at a minuscule dose, brought about the clinical improvement. To quote our earlier discussion of the placebo, this treatment was being offered “as an alternative to … a standard, proven therapy [that is, a full therapeutic dose of imipramine] when the effect, if any, of that pill is expected to be mediated by psychophysiological mechanisms, such as expectation, relaxation, or conditioned response”. The client appeared to have been so unnerved by the images which arose in the course of hypnosis that she unconsciously exploited the first opportunity to produce a flight to health. Of course further psychotherapy was required to understand the source of the client’s anxieties. What, however, is relevant for our discussion is that, firstly, she was receiving a placebo, even though that had not been the initial intention of the treating physician; secondly, she was being helped by the placebo, and thirdly, deception was not involved. In these circumstances, not only was the placebo ethically justified, but to have discontinued the placebo would have been unethical, in so far as it would have deprived the client of effective treatment.