The Placebo Effect

Survey: Half of US doctors use placebo treatments
By MARIA CHENG, AP Medical Writer

LONDON – About half of American doctors in a new survey say they regularly give patients placebo treatments — usually drugs or vitamins that won't really help their condition. And many of these doctors are not honest with their patients about what they are doing, the survey found.

That contradicts advice from the American Medical Association, which recommends doctors use treatments with the full knowledge of their patients.

"It's a disturbing finding," said Franklin G. Miller, director of the research ethics program at the U.S. National Institutes Health and one of the study authors. "There is an element of deception here which is contrary to the principle of informed consent."

The study was being published online in Friday's issue of BMJ, formerly the British Medical Journal.

Placebos as defined in the survey went beyond the typical sugar pill commonly used in medical studies. A placebo was any treatment that wouldn't necessarily help the patient.

Scientists have long known of the "placebo effect," in which patients given a fake or ineffective treatment often improve anyway, simply because they expected to get better.

"Doctors may be under a lot of pressure to help their patients, but this is not an acceptable shortcut," said Irving Kirsch, a professor of psychology at the University of Hull in Britain who has studied the use of placebos.

Researchers at the NIH sent surveys to a random sample of 1,200 internists and rheumatologists — doctors who treat arthritis and other joint problems. They received 679 responses. Of those doctors, 62 percent believed that using a placebo treatment was ethically acceptable.

Half the doctors reported using placebos several times a month, nearly 70 percent of those described the treatment to their patients as "a potentially beneficial medicine not typically used for your condition." Only 5 percent of doctors explicitly called it a placebo treatment.

Most doctors used actual medicines as a placebo treatment: 41 percent used painkillers, 38 percent used vitamins, 13 percent used antibiotics, 13 percent used sedatives, 3 percent used saline injections, and 2 percent used sugar pills.

In the survey, doctors were asked if they would recommend a sugar pill for patients with chronic pain if it had been shown to be more effective than no treatment. Nearly 60 percent said they would.

Smaller studies done elsewhere, including Britain, Denmark and Sweden, have found similar results.

Jon Tilburt, the lead author of the U.S. study, who is with NIH's bioethics department, said he believes the doctors surveyed were representative of internists and rheumatologists across the U.S. No statistical work was done to establish whether the survey results would apply to other medical specialists, such as pediatricians or surgeons.

The research was paid for by NIH's bioethics department and the National Center for Complementary and Alternative Medicine.

The authors said most doctors probably reasoned that doing something was better than doing nothing.

In some cases, placebos were given to patients with conditions such as chronic fatigue syndrome. Doctors also gave antibiotics to patients with viral bronchitis, knowing full well that a virus is impervious to antibiotics, which fight bacteria. Experts believe overuse of antibiotics promotes the development of drug-resistant strains of bacteria.

Some doctors believe placebos are a good treatment in certain situations, as long as patients are told what they are being given. Dr. Walter Brown, a professor of psychiatry at Brown and Tufts universities, said people with insomnia, depression or high blood pressure often respond well to placebo treatments.

"You could tell those patients that this is something that doesn't have any medicine in it but has been shown to work in people with your condition," he suggested.

However, experts don't know if the placebo effect would be undermined if patients were explicitly told they were getting a dummy pill.

Brown said that while he hasn't prescribed sugar pills, he has given people with anxiety problems pills that had extremely low doses of medication. "The dose was so low that whatever effect the patients were getting was probably a placebo effect," he said.

Kirsch, the psychologist, said it might be possible to get the psychological impact without using a fake pill. "If doctors just spent more time with their patients so they felt more reassured, that might help," he said.

Some patients who had just seen their doctors at a clinic in London said the truth was paramount.

"I would feel very cheated if I was given a placebo," said Ruth Schachter, an 86-year-old Londoner with skin cancer. "I like to have my eyes wide open, even if it's bad news," she said. "If I'm given something without being warned what it is, I certainly would not trust the doctor again."



The Pros vis-à-vis Cons notwithstanding; Let us just remember that the Doctor- Patient relationship is sacred. Honesty is always the best policy in dealing with patients especially with regards to their treatments.

On Organ Transplants and Medical Ethics

The issue of when to declare a person dead in order to harvest his/ her vital organs so that another person may live is a very delicate one no matter from which angle you look at it. An issue that's hard to ignore and poses a lot of questions and quite a dilemma to all the parties involved.

There’s an on- going debate as to when to declare potential organ donors dead. The old criterion of brain death as the sole determining factor is now being challenged by a lot of people in the medical field. Many of them are now advocating on a new protocol called Cardiocirculatory death as the new basis to declare a person dead.

The New England Journal of Medicine tackle this issue in its August edition and the Associated Press pick up the story. I copied the said article as the link to the NEJM website and posted them here.

So, read on…



Doctors debate when to declare organ donors dead

By STEPHANIE NANO, Associated Press Writer Thu Aug 14, 3:56 PM ET

NEW YORK - A report on three heart transplants involving babies is focusing attention on a touchy issue in the organ donation field: When and how can someone be declared dead?

For decades, organs have typically been removed only after doctors determine that a donor's brain has completely stopped working. In the case of the infants, all three were on life support and showed little brain function, but they didn't meet the criteria for brain death.

With their families' consent, the newborns were taken off ventilators and surgeons in Denver removed their hearts minutes after they stopped beating. The hearts were successfully transplanted, and the babies who got the hearts survived.

"It seemed like there was an unmet need in two situations," said Dr. Mark Boucek, who led the study at Children's Hospital in Denver. "Recipients were dying while awaiting donor organs. And we had children dying whose family wanted to donate, and we weren't able to do it."

The procedure — called donation after cardiac death — is being encouraged by the federal government, organ banks and others as a way to make more organs available and give more families the option to donate.

But the approach raises legal and ethical issues because it involves children and because, according to critics, it violates laws governing when organs may be removed.

As the method has gained acceptance, the number of cardiac-death donations has steadily increased. Last year, there were 793 cardiac-death donors, about 10 percent of all deceased donors, according to United Network for Organ Sharing. Most of those were adults donating kidneys or livers.

"It is a much more common scenario today that it would have been even five years ago," said Joel Newman, a spokesman for the network.

The heart is rarely removed after cardiac death because of worries it could be damaged from lack of oxygen. In brain-death donations, the donor is kept on a ventilator to keep oxygen-rich blood flowing to the organs until they are removed.

The Denver cases are detailed in Thursday's New England Journal of Medicine. The editors, noting the report is likely to be controversial, said they published it to promote discussion of cardiac-death donation, especially for infant heart transplants.

They also included three commentaries and assembled a panel discussion with doctors and ethicists. Many of the remarks related to the widely accepted "dead donor rule" and the waiting time between when the heart stops and when it is removed to make sure that it doesn't start again on its own.

In two of the Denver cases, doctors waited only 75 seconds; the Institute of Medicine has suggested five minutes, and other surgeons use two minutes.

State laws stipulate that donors must be declared dead before donation, based on either total loss of brain function or heart function that is irreversible. Some commentators contended that the Denver cases didn't meet the rule since it was possible to restart the transplanted hearts in the recipients.

"In my opinion, it's an open-and-shut case. They don't have irreversibility, and they don't have death," said Robert Veatch, a professor of medical ethics at Georgetown University.

But others argue the definition of death is flawed, and that more emphasis should be on informed consent and the chances of survival in cases of severe brain damage.

The Denver transplants were done over three years; one in 2004 and two last year. The three donor infants had all suffered brain damage from lack of oxygen when they were born. On average, they were about four days old when life support was ended.

In the first case, doctors waited for three minutes after the heart stopped before death was declared. Then the waiting time was reduced to 75 seconds on the recommendation of the ethics committee to reduce the chances of damage to the heart.

The authors said 75 seconds was chosen because there had been no known cases of hearts restarting after 60 seconds.

The hearts were given to three babies born with heart defects or heart disease. All three survived, and their outcomes were compared to 17 heart transplants done at the hospital during the same time but from pediatric donors declared brain dead.

"We couldn't tell the difference," said Boucek, who's now at Joe DiMaggio Children's Hospital in Hollywood, Fla.

There were nine other potential cardiac-death donors at the hospital during the same period, but there wasn't a suitable recipient in the area for their hearts, the report said.

The parents of one of the infants in the study, David Grooms and Jill Airington-Grooms, faced the devastating news on New Year's Day 2007 that their first child, Addison, had been born with little brain function and wouldn't survive.

After they decided to remove life support, they were asked about organ donation, and quickly agreed.

"The reality was Addison was not going to live," said Jill Airington-Grooms. "As difficult as that was to hear, this opportunity provided us with a ray of hope."

Three days later, Addison was taken off a ventilator and died. Her heart was given to another Denver-area baby, 2-month-old Zachary Apmann, who was born five weeks premature with an underdeveloped heart.

His parents, Rob and Mary Ann Apmann, said they were given several options and decided to wait for a transplant. They agreed they would accept a cardiac-death donation to increase Zachary's chances.

Mary Ann Apmann said she wasn't worried that the first available heart came from a cardiac-death donor.

"At that point, Zachary was so sick. We did have him at home. But we knew it wasn't much longer," she said.

After the transplant on Jan. 4, his condition quickly improved, and his blue lips disappeared.

Now, at 21 months: "He's just a crazy little kid who loves to play and swim and throw rocks," his mother said.

The two families haven't met yet but have been in touch through letters and calls. Coincidentally, David Grooms said he had an older brother who died three days after he was born in the 1970s with the same heart condition as Zachary's. The Grooms now have an 8-month-old daughter, Harper.

"Addison did only live three days in this world, but because of this, she lives on," her mother said.


Here's the link to--
The New England Journal of Medicine

Life & Death

The new United States guidelines on who should and should not get care in catastrophic events and disasters that was released yesterday by a multi- disciplinary task force whose members includes people from various medical groups, military, academe and government agencies such as the Centers for Disease Control and Prevention, the Department of Health and Human Services and the Department of Homeland Security will surely elicit a lot of criticisms from various sectors by citing that Doctors and Health Practitioners should not be given the God-like task to determine who should receive treatment or not or to put it more bluntly, who should live or die.

The said guidelines is an ethical nightmare anyway you look at it since it will affect a lot of people and it is quite understandable for some people to oppose the said recommendations.

And it is never easy for any person, more so to people who have sworn to save lives to the best of their abilities to be confronted with this kind of dilemma but we need to bite the bullet when the worst- case scenario occur to preserve vast needed resources both in manpower and supply.

Aside from the obvious that cover people with the highest risk of death or very slim chance of survival owing to the degree or severity of an injury or illness, the guidelines also include-

• People older than 85.
• Those with severe trauma, which could include critical injuries from car crashes and shootings.
• Severely burned patients older than 60.
• Those with severe mental impairment, which could include advanced Alzheimer's disease.
• Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.


In this age of terrorism and super- bugs, I deemed it as a wise move (although with reservations) from the authorities to come up with the guidelines to follow in the event of a massive catastrophe so as to avoid the same confusion that occurred in various hospitals following the 9-11 Terrorist attacks where medical personnel were overwhelmed by the sheer volume of casualties.

Let’s just hope that the medical personnel that will be manning the triage if ever the circumstance calls for it will be knowledgeable and competent enough to handle this life and death questions in their midst.

You can read the controversial guidelines from the May 2008 issue of Chest, the American College of Chest Physicians Journal entitled DEFINITIVE CARE FOR THE CRITICALLY ILL DURING A DISASTER

The Vicente Sotto Memorial Medical Center Scandal

Primum non nocere

This morning, I saw the so- called Vicente Sotto Memorial Medical Center Scandal on YouTube and I was appalled by the way those medical professionals handled the situation wherein some doctors and nurses of the said hospital were seen laughing, videotaping and boisterous while performing an operation on an unidentified patient to remove a canister of body spray stuck inside his rectal vault.

Copies of the said video is now roaming the world wide web as well as in the form of multimedia messages being passed around on cell phones of every Juan and Juana de la Cruzes both in the Philippines and abroad which will further damage the already soiled reputation of the medical profession that is under fire and scrutiny after the exposé regarding the cheating perpetrated by some unscrupulous individuals in collusion with some Review Centers during the Nursing Board Examinations two years ago.

Based on my experience a case like this in the Philippines is quite unusual and you can expect that word will certainly travel fast in the four walls of the hospital, a patient’s privacy and confidentiality be damned (which is never practiced or observed anyway).

Also given the penchant of Filipinos for gossips and making other people’s business theirs, it’s not surprising that what could have been a hush- hush affair has turned into a circus that one could only imagine in a carnival freak show.

I have encountered several cases in similar situation in the United States wherein a patient will come in with abdominal pain or rectal pain and after a thorough physical and medical examination, we discovered to our horrors, foreign objects (e.g. toothbrush cases, soda cans and bottles, umbrella handles, etc.) stuck in places wherein they should not even be present.

In an ideal world, this could have been dealt with without any incident but in the real world even among doctors and nurses and other members of the medical profession who are supposedly and should be well- versed on patient‘s right to privacy and confidentiality, cases like the one that was seen in that Cebu hospital will always elicit curiosity, laughter and even ridicule for after all, humans are not perfect and we are prone to succumb to its frailties.

And yes, even in a country like the United States of America where you are expected to be always politically correct in everything, people in the medical field would react the same way like their brothers and sisters in the profession in any part of the world when confronted with the same scenario. The difference though is people here usually talk and make light of the situation privately and amongst themselves without resorting to histrionics and more importantly no jerk will take a video or a picture and worst, post it in YouTube for the entire world to see.

I’ve been in a similar situation in the past but I can say that all the people who were involved in the procedure as well as the staff who were curious enough to drop by and see for themselves the “unusual case” conducted themselves in a more appropriate and professional manner.

Obviously there was a failure in discipline and ethics here since the head of the team that operated on the patient allowed the unthinkable to happen under his watch. Add to the fact that this incident occurred in the presence of both medical and nursing students make it even worse!

And then we ask ourselves--

Did the members of the Medical- Surgical Team of the Vicente Sotto Memorial Medical Center violate the rights of the said patient?

Definitely.

Did the members of the Medical- Surgical Team renege on their duties and responsibilities as medical professionals?

Certainly.

Did the members of the medical- surgical team break their oath as medical practitioners?

Without a doubt.

Those involve should be held accountable for their actions and be meted the necessary sanction that merit the gravity of their indiscretion.

Lest we forget, aside from the Hippocratic Oath, members of the Medical profession should always bear in mind this fundamental tenet of Medicine---

First, Do No Harm (Primum non nocere).


Here's the video of the said scandal and watch it at your own risk. Let me just reiterate that the posting of this video here is not meant to cast aspersion on the character of the patient who will remain unidentified but done so for educational purposes only so that people in the medical profession will not commit the same mistake again.






Here's the latest news from ABS- CBN--
3 doctors, nurse face raps over YouTube 'rectum scandal'