From: mdkline@rodan.acs.syr.edu (Mark D. Kline)
Subject: Re: How Often Are Placebo's Prescribed?
Organization: Syracuse University, Syracuse, NY
Date: Wed, 11 Nov 92 12:57:05 EST

In article <17420@pitt.UUCP> geb@cs.pitt.edu (Gordon Banks) writes:
>In article <1992Nov2.210203.14827@newstand.syr.edu> mdkline@rodan.acs.syr.edu (Mark D. Kline) writes:
>>I believe it is unethical to lie to patients.  If you prescribe an
>>inert placebo to the hysteric, and tell the pt, "don't take too many of
>>these pills, they're really potent" the patient might have lots of side
>>effects - and might benefit.  But in the lie (the unstated violation of
>>the presumption that the potency is due to biological effect) the
>>doctor patient relationship - always an imbalanced one, from the power
>>standpoint - becomes a manipulative con.  
>>
>
>Well, tell me what you think of this:  we take patients with
>suspected pseudoseizures, and while hooked up to the EEG,
>say "we are now going to inject you with a medication that
>will probably cause you to have a seizure, so we can record
>it.  In this other syringe, we have another medicine that
>will instantly stop the seizure."  We then procede, and
>quite often (usually, in fact), the patient will oblige
>by going into their seizure (which the EEG records as
>not being a real seizure) on injection of the first, and
>quiets quickly on injection of the second.  This is a pretty
>certain way of telling if people have pseudoseizures.  Without
>it, we would have to leave them hooked up for hours and maybe
>days, costing thousands of dollars (often at taxpayer's expense)
>waiting for them to have one on their own.  Of course, some
>of them are so suggestible, that you can say "look, I think
>he's about to seize" and they will oblige, but the "medication"
>(both syringes are saline solutions) works a lot more often.
>Is this lying?  True it isn't medicine in the strict sense,
>but it does do what I said it would.  What would your do, Mark?

IMHO, the practice of saline injections as described above is ethically
questionable, and I am not sure of its diagnostic value; it might
induce psuedoseizures in patients who also have bona fide neurogenic
seizures (most pseudoseizure patients I've seen have both).  Some
studies of hysterics have shown that about 25% will be found to have a
"real" neurologic disorder over five year followup (I believe this is
ited in MR Trimble's book on Pseudoseizures).   Some of the
pseudoseizure cases you're diagnosing with saline might also have
neurogenic seizures apparent on monitoring with more adequate time
sampling.  I'm not sure what I would do, but I think I might try to
obtain the patients' consent to a single blind bedside investigation.
It might be ethically preferrable to explain "I will give you either an
active compound which might induce seizures or just sterile water" then
infuse water with full seizure precautions and an expectant attitude.

>Also, when I have a hysteric, I often prescribe physical 
>therapy, telling them, if you really work hard, you will 
>get better in a week or two.  With the right encouragement 
>from the therapist, this works quite often.  Is that lying?  
>They do often get better.

No - this is not lying, its doctoring.  The potential benefits of
physical therapy are real even though nonspecific.  I often recommend
PT  (or yoga, T'ai Chi, or massage if the patient would prefer
something exotic) to people with psychosomatic illnesses and I exhort
them to get well, partly by suggesting to them that they will get
well.  Creating an expectation of benefit is important, and I think
we "allopaths" are derelect if don't do what we can do bolster the
placebo effect - while keeping the patient's expectations realistic.