Thought Experiment – Honest Deception

I had this idea about a decade ago, and actually seriously considered it for a while. Even though I’ve long abandoned it, it is quite interesting as a thought experiment as it exists in a moral grey space.

Background

I have been fascinated with placebos. It is explicitly designed to be ineffectual for the condition in question, yet it often induces an effect psychologically. Although the “Placebo Effect” is likely really due to the medical intervention and interaction, “Intervention Effect” just doesn’t sound as good. It is by nature deceptive, which is usually acceptable in a controlled trial; but in a real life doctor-patient relationship, it is difficult to get informed consent without sounding like a quack (except perhaps in this weird study).

I will share an anecdote about an ENT physician I know well. He owns and operates a clinic in a relatively rural area in East Asia. The clinic is extremely popular, with 300+ patients per day during cold and flu “high season”. As your incredulity sets in, the clinic record is over 500 patients/day (yes, for a single physician). This was decades ago, when clinics had their own pharmacies. There were several keys to success. One was managing expectations. For patients that came in after other doctors “failed” to rid them of their cold, he would tell them they would get better in a few days, and sure enough they would (duh). If the person just caught the cold, he would say it was more serious and wouldn’t be over for 10-14 days. The important part is that he would always give the patients a good dose of pills and capsules, which turn out to be mostly vitamins. According to his “market research”, the locals perceived the efficacy of the pills based on size (larger is better), color (more colorful the better, bonus points for two-toned capsules), shape (round is boring), and quantity. The pharmacy would already have cartons of individual combo packages of many large, colorful, shaped pills, which would be conveniently prescribed as “A” or “B” to save time. Not all placebos are created equal; back in those days, placebo discrimination was rampant.

Nowadays it is ethically questionable for placebos to enter a doctor-patient relationship, for obvious reasons.

Thought Experiment

Here is the thought experiment. It is difficult for a physician to take advantage of the placebo effect. Is it possible for a company to ethically sell placebos to the general public?

Currently there are already companies that sell pills with no active ingredients, but those pills are actually marketed as medicine. I consider those to be double placebos, with the giver and taker of the pill both receiving the placebo effect.

Imagine a company Obecalp Inc. It makes its pills and capsules, which contain no active ingredients, at FDA-approved GMP facilities. Aside from providing the medical field with placebos, it also has a consumer arm that sells to the general public. The consumer market is mainly for relatives of terminally or chronically ill patients with subjective symptoms such as pain.

The company provides full disclosure on its ingredients (or lack thereof). It also provides relevant literature and a summary of the latest research. Customers are explicitly told to expect that the pill will likely do nothing, and the placebo effect, if any, are likely to be for subjective symptoms only.  They are told that it may be detrimental to relationships since deception is involved, and should be used in addition to, and never replacing, proven treatments. In short, it requires informed consent.

The customers, not the doctors, would provide these placebo pills to their terminally or chronically ill relatives. This address several problems. It takes away the deception between the doctor and patient, and the accompanying financial dilemma (placebos must be charged the same as regular pills to deceive properly, even though they cost significantly less). It is by definition compatible with the principle of non-maleficence (“Do No Harm”), and may offer subjective improvements even without objective changes in the underlying condition.

Although arguably unnecessary, the company can address ethical issues about the price of the placebo by operating on a voluntary pricing model. That is, the company provides the placebos free of charge initially, and rely on the customer to pay whatever they think it is worth based on the outcome, perhaps with a suggested amount and a maximum cap (personal anecdote: I once used a voluntary pricing model at a garage sale, and people were confused without a suggested price).

I read somewhere that for controlled studies, placebo composition is not regulated nor is disclosure required; some are simply sugar pills, while others are designed to have the same appearance and even mimic possible side effects. For the consumer market this is obviously unnecessary. However, the company is free to provide a wide range of completely inert placebos in different shapes, sizes, and colors. The consumer can be confident that the pills are safe. It would be considered a “dietary supplement”, of which government approval is not required. Even the standard disclaimer “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease” seems redundant but wouldn’t hurt.

What do you think? Could this Obecalp company ethically sell placebos to the general public?

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