Case Description: Use of Placebo (Deceptive Treatment)
You are the primary treating psychiatrist for a 40-year- old man with schizophrenia which has proven difficult to control through ongoing treatment. Your patient has become convinced that he contracted syphilis through a recent sexual encounter, though he repeatedly tests negative for syphilis and other STDs. Confusingly, in other recent conversations he claimed not to have been sexually active in “a very long time.”
He is becoming volatile and untrusting because you have not given him medicine for the syphilis. You worry that this anger could adversely affect his willingness to take the psychiatric medicines you are carefully calibrating to stabilize him.
What should you do?
This hypothetical case is adapted from a real case study: https://doi.org/10.1136/bmj.38236.646678.55
Discussion of Case: Use of Placebo (Deceptive Treatment)
Get the facts.
- Might any questions help to clarify sexual history? How might you ask them?
- Autonomy v. stated choice?: you may wonder whether your patient’s clearly stated desire for strong antibiotics you consider unnecessary and thus harmful do or do not represent true inner autonomy, rational choice-making capacity.
- Autonomy v. beneficence: you may perceive the patient’s autonomously stated demand for STD treatment to be at odds with doing what is best for the patient.
- Beneficence v. truth telling: you may perceive the possibility of using deceptive practice such as a placebo as potentially advancing patient welfare but violating a rule of truth telling that is generally respectful and trust-building.
Identify tensions between ideals.
In this case you may feel acutely several kinds of tensions among ideals:
Identify possible courses of action:
- Continue to try to explain why it would not be medically appropriate to provide the syphilis medication, offering to re-test if changes develop either in sexual practice or symptoms.
- Offer to provide a pill that you explicitly say has no known active ingredient and that you don’t expect to have an effect, for his concern about syphilis.
- Provide the syphilis medication to show you are “on board.”
- Give the patient pills that you claim are for treating syphilis, but which are really placebos (sugar pills).
- Other?
Practice preventive ethics—avoid strict dilemmas:
- Consider encouraging patient to develop a psychiatric advance directive addressing patient care when the health team considers delusions to be operative, including questions of whether the stable patient thinks deception could ever be temporarily justified.
- Disclose the deception at a later point when you feel the patient is more stable.
- Ask if in retrospect, he thinks you did the right thing providing the placebo.
- If so, document conditions under which he thinks deception for his sake could be warranted; promise always to reveal the deception later.
- If not, commit to nondeceptive ways to try to help him in the future.
If you interpreted the case as a strict dilemma, how could you minimize infringement?
If you decided to provide a placebo, how might you minimize/repair infringement?
If you used a psychiatric advance directive to authorize temporary deception with placebo:
• Acknowledge that when you deem the patient more stable, and ask if, in retrospect, the patient thinks that interpretation accords with intent.