Original Articles
 

By Mr. Ahmed AL_Jumaih , Dr. Ibrahim Al Kadhim , Dr. Amjad AL-Seraya , Ms. Audrey Nicholls , Prof. Abdulla AL SAYYARI
Corresponding Author Prof. Abdulla AL SAYYARI
King Saud Bin Abdulaziz University for Health Sciences Riyadh, - Saudi Arabia
Submitting Author Prof. Abdulla Al Sayyari
Other Authors Mr. Ahmed AL_Jumaih
King Saud Bin Abdulaziz University for Health Sciences Riyadh, - Saudi Arabia

Dr. Ibrahim Al Kadhim
King Abdulaziz Medical City, - Saudi Arabia

Dr. Amjad AL-Seraya
King Abdulaziz Medical City, - Saudi Arabia

Ms. Audrey Nicholls
Cardiac Center King Abdulaziz Medical city, Riyadh, - Saudi Arabia

BIOETHICS

Placebo Prescribing; Saudi Arabia,, Nursing, placebo Effectiveness, Placebo Action.

AL_Jumaih A, Al Kadhim I, AL-Seraya A, Nicholls A, AL SAYYARI A. Placebo Prescribing Habits And Views In A University Hospital. WebmedCentral BIOETHICS 2010;1(9):WMC00587
doi: 10.9754/journal.wmc.2010.00587
No
Submitted on: 10 Sep 2010 10:08:16 AM GMT
Published on: 10 Sep 2010 11:07:39 AM GMT

Abstract


Background and Objective There are no reports about Placebo Prescribing Habits among Saudi health care providers. This study aims addressing this question.
Methods This is a cross-sectional self administered survey-based study about frequency, views and indications, of placebo prescribing/dispensing practices and analyzing these in relation to demographic data.
Results Fifty-five surveys were completed by physicians and 27 by nurses. 67.9% have been in the profession for > 3 years. Only 27.8 % of the doctors said that they ever prescribed a placebo. Of the prescribers, only 2% of the doctors and 42% of the nurses told the patients that they are actually prescribed a placebo (p=0.07.)
83% of doctors and 62% of nurses thought that placebos are usually or sometimes effective (p=0.01). Five times as many nurses (30%) as doctors (6.6%) believed that placebo prescription should always be prohibited (p=0.007).
The majority of respondents believed that the mode of action of a placebo is though psychological mechanism.
The commonest indication for prescribing a placebo by doctors was as a” supplement to a medication” (86.1%) and for nurses was to “calm the patients” ( 43 %)
The responses by medical staff and medical residents were not significantly different
Conclusions
The frequency of the Saudi doctors prescribing a placebo is lower than reported elsewhere. Of the doctors who prescribed a placebo only 2% told the patients that it is actually placebos. Near to two-third of the respondents believed that the placebo mode of action is through a psychological mechanism and the vast majority felt that placebos are at least “sometimes effective” and very small percentage believed that placebo prescription should be prohibited


Introduction


Placebo treatment is defined as an active or inert treatment whose impact is anticipated to come about by positive expectations on the part of the patient’s and not from any known physiological mechanism of the treatment per se. (1)
The ethics of the use of placebos as treatment in clinical medicine is controversial. A major ethical objection frequently put forward by ethicists against its use is that it involves deception, and as such it goes contrary to the fundamental bioethical concepts of patients’ autonomy and informed consent. On the other hand, another view expounded holds that since placebo treatment promotes positive expectations on the part of patients that this by itself is a justification to consider placebo use as ethically acceptable (2-6)
In a recent review article (7) it was reported that between 41% and 99% of doctors prescribe placebos. Up to 50% of physicians and nurses (range 16% to 50%) believed that placebo treatments are either always, often, or generally effective (7)
The indications invoked for placebo prescribing are many and include using it to relieve presumed “unreal “pain” This was reported to be the indication by 84% (8), to reduce the as diagnostic tool and to appease a persistently demanding or complaining patient (9)
In a recent lecture at the annual Residents’ Day celebration, in our institution, by a well known Saudi personality, he advocated that healthcare providers, should not tell the patient that there is no treatment for their condition: instead he suggested that even an inert substance should be given to them without their being told that it is inert. There is a general feeling among the Saudi public that this should be the case.
Therefore, this study was designed to find out if placebo prescribing by Saudi doctors reflect this societal view and to delineate and compare the prescribing practices and the views on placebo among Saudi doctors to those by expatriate nurses working in the same institution and to assess the factors affecting their prescribing habits.

Methods


This is a cross-sectional self administered survey among physicians and nurses working at King Abdulaziz Medical City, The physicians were from 3 specialties- Medicine, Family & Community Medicine and Psychiatry. The nurses were sampled from an advanced cardiac center in the same institution.
Besides questions on demography, questions were asked about the prescribing frequency, perceived mode of action and effect of placebos and indications for its use.
Descriptive statistics were used to examine the physicians’ characteristics as well as frequencies of prescribing habits and attitudes; we used multivariate logistic regression to determine if any characteristics of the respondents were independently associated with regularly prescribing placebo treatments.

Results


Fifty-five surveys were completed by physicians (34.0 % from medicine, 38.3 % from family and community medicine and 27.7 % from psychiatry) and by 27 by nurses.59.6% of the respondents were males and 53.3 % were medical residents. The mean age was 29.1 years (4.5); 32.1% have been doctors or nurses for < 3 years and 67.9% for > 3 years.
Only 27.8 % of the doctors said that they ever prescribed a placebo. Of the doctors who prescribed a placebo, 70 % told the patients that it is an actual medication and 27.2% told them “nothing” and only 2% told the patients that it is actually a placebo. Among the nurses who dispensed or used placebos, the corresponding figures were 29%, 28.9% and 42% respectively (p=0.07)
Of all the nurses surveyed, 77.8% said they would never dispense a placebo. This compares to 72.2% of doctors. (p=0.86) (Table 1). 83% of the doctors who prescribe placebos, thought that they are usually or sometimes effective. The corresponding figure for the nurses was 62% (p=0.01) (table 1)

Discussion


The frequency of Saudi doctors prescribing a placebo (27.8 %)is lower than reported elsewhere. This compares to 86 % among Danish general practitioners (10), 72% among Swiss general practitioners (11).and 45 % among academic doctors in the Chicago area (12). In a recent study among internists and rheumatologist in USA, half reported often recommending placebo treatments (13). This reported high prevalence rate of placebo use has not changed over the last 3 decades among hospital doctors (14) or general practitioners (15)
Almost two-thirds of the respondents in our survey believed that the placebo mode of action is through a psychological mechanism. However, fewer psychiatrists than that thought so. This could be explained on the basis that psychiatrists are expected to know more about placebo actions and as such would be aware that studies have shown that there might be other elements involved besides the purely psychological effect (16). Another studies reported that 75% of doctors believed that the placebo mode of action is through a psychological mechanism also (17)
Of the doctors in our survey who prescribed a placebo, 55.5 % told the patients that it is an actual medication and 22.2% told them “nothing” and only 2% told the patients that it is actually a placebo . The nurses were more truthful and fewer of them claimed that the placebo is a medication. Our findings among , however, are similar to other reports which showed that 68% of the doctors prescribing a placebo, tell the patients that he or she is receiving a real medicine, and 17% say nothing at all and only 4% told the patients they are actually prescribing placebo(17). Among Swiss primary care physicals, 64 %those prescribing a placebo told the patient that it was a drug or a therapy (11)
Only 21.5% of all the doctors we surveyed believed that placebos are effective. This belief drops with duration of being a doctor. However of those who prescribed placebos 84% thought it was effective or somewhat effective . These findings are similar reported previously (17 )
Five times as many nurses (30%) as doctors (6.6%) believed that placebo prescription should always be prohibited. Much of the call for the prohibition of placebo prescribing is based on the belief that this is unethical practice invading the patients’ autonomy and is loaded with deception (4). 73% of nurses surveyed thought that it is deceptive to use placebo as treatment (6). This might related to the fact that Saudi doctors have a tendency towards paternalism whereas expatriate nurses in general have a tendency towards more respect for patients’ autonomy.
Nurses and doctors also differ significantly with regards to what they thought was the main indication for placebo prescribing. The commonest indication for prescribing a placebo by doctors was as a” supplement to a medication” (86.1%) and for nurses was to “calm the patients” ( 43 %) (p=0.01)
60% of nurses and 31 .1% of doctors intimated that placebos should be permitted if research or experience support its efficacy

Conclusion(s)


The frequency of the Saudi doctors prescribing a placebo is lower than reported elsewhere. Of the doctors who prescribed a placebo  only 2% told the patients that it is actually placebos. Near to two-third of the respondents believed that the placebo mode of action is through a psychological mechanism and the vast majority felt that placebos are at least “sometimes effective” and very small percentage believed  that placebo prescription should be prohibited

 

Reference(s)


1. Macedo A, Farré M, Banos JE: Placebo effect and placebos: what are we talking about? Some conceptual and historical considerations.Eur J Clin Pharmacol 2003, 59:337-342
2. Biller-Andorno N: The use of the placebo effect in clinical medicine - ethical blunder or ethical imperative? Sci Eng Ethics 2004, 10:43-50
3. Lynöe N: Ethical and professional aspects of the practice of alternative medicine. Scand J Soc Med 1992, 20:217-225.
4. Lione A. Ethics of placebo use in clinical care. Lancet 2003;362:999
5. Rich BA: A placebo for the pain: a medico-legal case analysis. Pain Med 2003, 4:366-372
6. Ernst E, Abbot NC: Placebos in clinical practice: Results of a survey of nurses. Perfusion 1997, 10:128-130.
7.  Fässler M,   Meissner K,   Schneider A and   Lind K Frequency and circumstances of placebo use in clinical practice - a systematic review of empirical studies BMC Medicine 2010, 8:15
8. Goodwin JS, Goodwin JM, Vogel AV: Knowledge and use of placebos by house officers and nurses. Ann Intern Med 1979, 91:106-110
9. Saupe R: The use of placebo as seen by nursing staff.Pharmacopsychiat 1986, 19:347-348
10. Hrobjartsson A, NorupM. The use of placebo interventions inmedical practice—a national questionnaire survey of Danish clinicians. Eval Health Prof 2003;26:153-65.
11. Fässler M, Gnädinger M, Rosemann T, Biller-Andorno NUse of placebo interventions among Swiss primary care providers. BMC Health Serv Res. 2009 Aug 10;9:144.
12. Sherman R, Hickner J. Academic physicians use placebos in clinical practice and believe in the mind-body connection.J Gen InenMed 2008;23:7-10.
13. Tilburt JC ,   Emanuel EJ   Kaptchuk TJ,   Curlin FA  and   Miller FGPrescribing "placebo treatments": results of national survey of US internists and rheumatologistsBMJ 2008;337;
14. Gray G, Flynn P. A survey of placebo use in a general hospital. Gen Hosp Psychiatry 1981;3:199-203
15. Thomson RJ, Buchanan WJ. Placebos and general practice: attitudes to, and use of the placebo effect. NZM dJ1982;95:49
16. Hrobjartsson A, Gotzsche PC. Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment. N Engl J Med 2001;344:1594-602.
17. Nitzan U, Lichtenberg P. Questionnaire survey on use of placebo.BMJ 2004;329:944-6.

Source(s) of Funding


No funds were recived

 

Competing Interests


No competing interes to be declared

Disclaimer


This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.

Reviews
3 reviews posted so far

Placebo Prescribing Habits in a University Hospital
Posted by Dr. William J Maloney on 16 Feb 2014 12:07:42 AM GMT Reviewed by Interested Peers

http://www.webmedcentral.com/article_view/587
Posted by Dr. Fissal A Shaheen on 25 Oct 2010 11:09:09 PM GMT

Comments
0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.

 

Author Comments
0 comments posted so far

 

What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
Where
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)