Questionnaire survey on use of placebo Uriel Nitzan, Pesach Lichtenberg Abstract Recruitment
We approached three groups of physicians and nurses,
Objectives To gauge the frequency and circumstances
who might be expected to differ in their attitudes
of use of placebo in clinical practice and the attitudes
towards the use of a placebo and its legitimacy as a
towards its use among those who administer it.
therapeutic tool. Of around 110 physicians and nurses
Design Retrospective questionnaire.
approached, 89 agreed to participate in the survey, all of
Setting Two large hospitals and various community
whom received and returned completed questionnaires. Senior physicians working in hospital inpatient and out-Participants 31 physicians working in hospital patient departments in medical and surgical specialties and
inpatient and outpatient departments, 31 head nurses
subspecialties—The bulk of the work of these respond-
working in hospital inpatient departments, and 27
ents was with inpatients, with one or two half days a
family physicians working in community clinics.
week spent in the associated hospital based outpatient
Main outcome measures Self report of frequency and
clinic. So as not to collect duplicate data for the same
circumstances of, and attitudes towards, use of placebo.
inpatient department, we included only one physician
Results Among the 89 respondents, 53 (60%) used
from each department. We covered all 31 inpatient
placebos (95% confidence interval 49% to 70%).
departments at two major hospitals in Jerusalem and
Among users, 33 (62%) prescribed a placebo as often
therefore included 31 respondents in this category. Ten
as once a month or more; 36 (68%) told patients they
physicians declined to receive the questionnaire.
were receiving actual medication; 15 (28%) considered
Head nurses working in the same hospital inpatient
that placebos were a diagnostic tool; and 48/51 (94%)
departments as senior physicians—Here too we had 31
reported that they found placebos generally or
respondents, one per department. As the nurses are
responsible for dispensing medications on inpatient
Conclusion Most practitioners questioned in this
wards, we included them to get a picture of what actu-
study continue to use placebos. Used wisely, placebos
ally takes place in the hospital services. All nurses
might have a legitimate place in therapeutics. Wider
approached agreed to participate in the survey.
recognition of the practice and debate about its
Family physicians working in community clinics—These
respondents were recruited from a weekly gathering ofabout 40 family physicians working in Jerusalem. Of
Introduction
these, 27 agreed to receive the questionnaire and allcompleted it. As we expected physicians working in the
How common is the use of placebos in clinical
same clinic to display independent prescribing habits,
practice? From the dearth of discussion in the medical
we allowed more than one physician from a single
literature—almost all references to placebo from a
Medline search refer to a research context—one mightsurmise that the clinical use of placebos is exceedingly
Statistical methods
rare. The deception involved in administering a
To assess the precision of the estimated proportion of
placebo certainly raises ethical questions, and some
placebo use in clinical practice, we calculated 95% con-
institutions have banned its use. Yet informal
fidence intervals. We used Pearson 2 test and Fisher’s
discussions with colleagues, as well as first hand obser-
exact test to test the significance of the association
vation of clinical activity in various medical depart-
between two qualitative parameters. P ≤ 5 was consid-
ments, suggest the practice still occurs. The only other
report that we could locate of placebo use in a clinicalcontext goes back a quarter of a century.1 The authorsfound that the placebo was rarely (about once a year
per physician) and inappropriately used.
Table 1 shows the composition of the group. We have
We reappraised how frequently and in what
summarised the data from the questionnaire under six
circumstances physicians and hospital nurses use
placebos in a clinical setting, how they understand the
Frequency—When we planned the study we assumed
mechanisms of actions, their views on ethics, and
that the use of placebo was not widespread and would
not exceed 10%. Among our 89 respondents, however,53 (60%) admitted using a placebo (95% confidence
interval 49% to 70%). The age and sex of respondent didnot affect results. In total, 53% of doctors and 71% of
Questionnaire
nurses reported using a placebo. Among users, 33 (62%;
We developed a questionnaire on attitudes and experi-
37% of the total sample) used a placebo as often as once
ence with placebos. We sought information on basicdemographics, the frequency of placebo use, thecircumstances of its administration, accompanying
An English translation of the questionnaire can be found on
beliefs about mechanisms of action, and ethical
positions. The questionnaire was administered in
This article was posted on bmj.com on 17 September 2004:
Hebrew (see bmj.com for an English translation). http://bmj.com/cgi/doi/10.1136/bmj.38236.646678.55BMJ VOLUME 329 23 OCTOBER 2004
action for placebos. Of 83 responses, most (62, or 75%)
Table 1 Demographic and professional data for respondents to
mechanisms. An additional nine (11%) respondents
suggested a combination of psychological and
Discussion Principal findings
We attempted to gauge the extent of placebo use in
Mean (SD) professional experience (years)
clinical work. Despite general disapproval in the medi-
cal literature,2 3 such use continues among 60% of our
respondents. The circumstances varied but included a
wide variety of clinical situations. Indeed, as only one in
20 would prohibit the placebo in all circumstances thepotential for placebo prescriptions is even greater than
a month or more. Differences between physicians and
the actual extent of use. We also found that most prac-
nurses in reported use and frequency of use of placebo
titioners who use placebos claim effectiveness for the
treatment in some or most cases. In light of this
Perceived therapeutic value—Of those who used a pla-
finding, it seems likely that the many such practitioners
cebo, most (48 of 51 who answered the question, or
will continue to prescribe placebos.
94%) found that it was either generally (17, or 33%) or
Many physicians relate to the placebo as a diagnostic
occasionally (31, or 61%) effective.
tool. This indicates a persistence of long discredited
Information given to patients—Of those using the pla-
notions of a separation between mind and body. A
cebo, 36 (68%) tell the patient that he or she is receiv-
placebo can assuage pain. Even in a meta-analysis that
ing a real medicine, and nine (17%) say nothing at all.
raised questions about the actual existence of a placebo
The rest either identify the placebo as such (two, or 4%)
effect the authors concurred that placebos can have
or tell the patient that he or she is receiving a
analgesic potency.4 The physician who nevertheless uses
non-specific medicine (six, or 11%).
a placebo diagnostically is at risk of reaching unfounded
Circumstances of use—We found a wide range of
conclusions, to the detriment of his or her patients.
applications for placebo (table 2). Placebos were givenin the form of saline infusions or intramuscular
Strengths and weaknesses of study
injections; paracetamol or vitamin C tablets instead of
Because we investigated all medical and surgical inpa-
the ordinarily prescribed medication; sugar or artificial
tient departments at two hospitals and chose only one
sweetener pills; or prepared placebo tablets. The medi-
senior physician and nurse from each, our findings are
cal conditions for which the placebos were used
quite comprehensive. A weakness of our paper,
included anxiety, pain (including abdominal), agitation,
however, is that we rely on self reports made retrospec-
vertigo, sleep problems, asthma, contractions in labour,
tively. This can be a problem when respondents are
withdrawal from recreational drugs, and angina
asked to look back and estimate the frequency of a par-
pectoris (when the blood pressure was too low to allow
ticular behaviour. The fact that a particular respondent
for vasodilators). The stated value as a diagnostic tool,
uses a placebo in a clinical context is not likely to be
referred to in table 2, was to distinguish organic from
misremembered, however, even if the frequency is mis-
psychogenic or simulated arthralgia, seizure disorder,
judged. Moreover, in light of the suspect moral validity
of such treatment, we would anticipate that placebo use
Ethical stance—Of 79 responses on ethics, only four
would be understated in the responses to the question-
(5%) thought that the use of placebos should be
naire. If so, our finding that placebo prescribing is a
categorically prohibited. Most of the others considered
widespread practice cannot be doubted.
placebo use conditional on certain circumstances, suchas prior experience (26, or 33%), notifying patients of
Previous study
receipt of a placebo (23, or 29%), or evidence from
In a previous study, the extent of placebo use was
research that the placebo was effective (19, or 24%).
found to be considerably less, about one prescription a
Perceived mechanism of action—Respondents were
year per physician.1 In our study over a third of the
permitted to propose more than one mechanism of
respondents reported using a placebo once a month or
Table 2 Circumstances in which placebo was administered. Figures are number (percentage of those who reported use) of respondents* Hospital based physicians Family physicians
After “unjustified” demand for medication
To buy time before next regular dosage of medication
*53 respondents reported that they use placebo (19 hospital based physicians, 22 nurses, and 12 family physicians). Each respondent was permitted to cite morethan one circumstance in which he or she used placebo. BMJ VOLUME 329 23 OCTOBER 2004
more, and nearly 60% at least once a year. Though the
What is already known on this topic
differing methods of the data collection rendercomparisons across these studies difficult, our findings
No study has recently attempted to assess the use
suggest that the use of the placebo is increasing. The
former study recorded actual prescriptions and waslimited to actual placebo pills or saline, while we stud-
Placebos may be effective in some areas, but their
ied the self reports of healthcare providers, and, in cer-
tain circumstances, paracetamol and vitamin pills were
What this study adds Implications
Three in five clinicians continue to use placebos
Some have advocated banning the clinical use of
Clinicians believe that some patients benefit from
placebos because of the deception involved in
administration and the possible harm to the doctor-patient relationship.2 3 Others have suggested guide-
The role of placebo treatment, its mechanisms,
lines for the proper use of placebos without violating
and its ethics need to be the subject of wider
the patient’s trust and autonomy.5–7 Our study shows
that administration of placebos for clinical purposescontinues. Clearly, wider recognition of the practice,and debate about its implications, are needed. Further
Goodwin JS, Goodwin JM, Vogel AV. Knowledge and use of placebos by
investigations into the extent and nature of use should
house officers and nurses. Ann Intern Med 1979;91:106-10.
be conducted, particularly in a clinical context where
De Deyn PP, d’Hooge R. Placebos in clinical practice and research. J MedEthics 1996;22:140-6.
the placebo’s effect may differ from that found in ran-
Hill J. Placebos in clinical care: for whose pleasure? Lancet 2003;362:254.
domised controlled trials.8 9 Moreover, though Israeli
Hrobjartsson A, Gotzsche PC. Is the placebo powerless? An analysis ofclinical trials comparing placebo with no treatment. N Engl J Med
medicine is taught and practised as elsewhere in the
Western world, similar surveys in other geographical
Brown WA. Placebo as a treatment for depression. Neuropsychopharmacol-ogy 1994;10:265-9.
areas may reveal cross cultural differences.
Lione A. Ethics of placebo use in clinical care. Lancet 2003;362:999.
Lichtenberg P, Heresco-Levy U, Nitzan U. The ethics of the placebo in
Contributors: UN had the original idea for the study and com-
clinical practice. J Med Ethics (in press).
piled the data. Both authors jointly developed the questionnaire.
Vase L, Riley JL, Price DD. A comparison of placebo effects in clinical
PL wrote most of the article and is guarantor.
analgesic trials versus studies of placebo analgesia. Pain 2002; 99:443-52.
Hyland ME. Using the placebo response in clinical practice. Clin MedAre written responses to some referrals to a general haematology clinic acceptable? Allison Tso, Lucy Harris, Tim Littlewood
Each year about 1000 patients are referred to the
department of haematology in Oxford. Excluded from
Questionnaire
this number are referrals for problems related to
coagulation, which are seen at the Oxford Haemo-
Was a written reply offering advice rather than an
outpatient appointment acceptable to you? Yes/No
philia Centre. We wondered whether a written reply to
Was the advice given helpful to you? Yes/No
the general practitioner would provide the same qual-
Would you be satisfied with a written response in the
ity of healthcare advice more quickly, and with less
inconvenience to the patients, than seeing patients in a
Do you know if the patient was satisfied with a written
Methods and results
One consultant (TL) received 274 letters of referral
example, a mild macrocytosis (mean cellular volume less
between 1 November 2001 and 1 January 2003 and
than 105 fl) without accompanying cytopenia was the
wrote a response to 121 (table). We subsequently sent
commonest referral for which TL sent a written
each of the general practitioners who had received a
response. In all patients, the blood film had been exam-
written response a questionnaire (box) with a copy of
ined (and was normal apart from the mild macrocytosis)
their original referral letter and a copy of the written
and advice was offered about checking for possible
causes of macrocytosis (including vitamin B-12 or folate
TL sent written responses if the patient neither
deficiency, liver disease, hypothyroidism, drug related
required further investigation (such as a bone marrow
causes, and excess alcohol consumption), if these factors
biopsy) nor treatment that would better be done in thehaematology department and if no evidence indicated a
This article was posted on bmj.com on 1 October 2004: http://bmj.com/
serious underlying illness, such as malignancy. For
cgi/doi/10.1136/bmj.38253.703553.F7BMJ VOLUME 329 23 OCTOBER 2004
GEORGIA, PETITIONER v. THOMAS McCOLLUM, WILLIAM JOSEPH McCOLLUM AND ELLA HAMPTON MCCOLLUM No. 91-372 SUPREME COURT OF THE UNITED STATES 505 U.S. 42 ; 112 S. Ct. 2348 February 26, 1992, Argued June 18, 1992, Decided SYLLABUS Respondents, who are white, were charged with assaulting two African-Americans. Before jury selection began, the trial judge denied the
AMITY GLOBAL BUSINESS SCHOOL Module Syllabus Tourism is often claimed to be the biggest industry in the world, yet tourism is not really an industry, more a gathering together of disparate forms of production and consumptive activities. The distribution of this tourism is highly unequal geographically in terms of where tourists come from and where they travel to, though this is changing w