I specialize in internal medicine and serve as primary care physician for most of my patients. Since I really do believe in informed consent, in general I make a genuine effort to tell my patients about their condition and prospects, explain their options, and encourage them to make decisions about their care. However, I confess that sometimes in unusual cases I compromise my general principle. This seems justifiable, but I am open to being shown otherwise.
Here is an example. An elderly woman recently moved here to live with her daughter and son-in-law, who have been my patients for years. She was running low on several prescription drugs and wanted me to write prescriptions for refills. I prescribed only enough to last her six weeks and persuaded her to come in for a thorough general physical. At my request, she had her records sent me by her previous physicians—a general practitioner and three specialists. I also had her bring in all the drugs she has been using, prescription and over-the-counter. Reviewing this patient’s history and the results of the physical, I concluded that she definitely would be better off with an alternative to one prescription drug she has been taking, with a reduced dosage of another, and entirely without two others; and that she probably would be better off without most of the other things she has been using.
When I talked the matter over with her, she was open to my recommendations to reduce the dosage of one of her medications and to replace another with a different drug. However, she was reluctant entirely to give up anything she has been taking, although I explained the reasons, and her daughter joined me in promising we would keep an eye out for any problems. Finally, she consented, but two days later her son-in-law called and said his mother-in-law had become so anxious she could hardly sleep or eat. Since the anxiety could not have resulted directly from any of the changes in medication, I decided it was merely psychological and prescribed a placebo, instructing him to tell his mother-in-law that I was giving her this prescription as a “replacement” for the discontinued drugs.
That was a month ago. Last week I saw this patient again. She says she has been feeling better than she had in years, and her daughter says she has become far more alert and outgoing. Their impressions were confirmed by my examination and the results of tests, which came back today.
Do you agree that it was appropriate to make this exception to the norm requiring informed consent?
This question involves two distinct moral issues: about deception and about informed consent. One can prescribe placebos without lying. The questioner, however, intended to lead the patient to believe the placebo replaced other medications in the precise sense in which it did not. Like any lie, this one was unjustifiable. Granting for the sake of a more complete reply that the questioner did not lie, one can consider the justifiability of making an exception to the norm requiring informed consent. That norm is not absolute; in some cases, proceeding without a patient’s informed consent might be justified.
Before addressing your specific question, I wish to make two preliminary, general points.
One concerns our relationships with elderly persons. They generally are less able physically than they once were, and often are more distracted, confused, and anxious than younger people. As a result, others, including their own children and physicians, are tempted to treat them as if they were hardly more able than small children to make decisions about important matters. This temptation should be resisted lest elderly people be treated unjustly, and their personal dignity thereby violated, on the basis of disabilities that, though significant, are compatible with continuing competence to shape their own lives. Of course, many elderly people do gradually become less competent, and as this occurs they may be competent with respect to some matters but not others, as is the case with children. Still, with respect to any particular matter, every elderly person should be presumed competent unless and until the contrary becomes obvious to those helping care for him or her.
Your question also points up the widespread failure to coordinate the treatment of patients and the tendency to overmedicate many of them, not least the elderly. Your review of a new patient’s medications is wisely calculated to deal with this shortcoming. But the problem you encountered with this patient makes it clear that her previous physicians fell short quite seriously in the matter.
Your explicit question about informed consent is distinct from a closely related issue regarding deception, which I shall consider first. In prescribing the placebo, did you tell the women’s son-in-law to lie to her?
One can use a placebo without lying. Consider situations in which people care for themselves and their children. When experiencing minor health problems, such as colds, many sophisticated people resort to traditional home remedies, saying something like: “Plain tap water undoubtedly would be just as good for me, but my mother always gave us hot tea when we caught a cold, and it does make me feel better.” The tea is consciously used as a placebo, and yet it works. Again, many parents care for a small child’s minor scrape or bruise by kissing it “to make it better,” and some administer a pink soothing syrup made of sugar water and red food coloring as a remedy for minor complaints. The kiss or the spoonful of syrup does make the child feel better. Because they manifest love and offer reassurance, such placebos work; and provided parents make no other, false claim (“This syrup will kill the nasty bug that is making your nose run”), no deception need be involved. Similarly, when patients ask for futile and possibly harmful medication—say, powerful antibiotics for a common cold—a physician, while refusing, can offer a placebo: “I cannot prescribe that, because it would not help, and unnecessarily using it has long-term disadvantages; but, if you insist, I can give you something I am sure won’t do any harm that you can take while the ailment runs its course.” The physician leaves the placebo’s mode of action unstated, and the patient may be deceived by drawing an unwarranted conclusion. But the physician says nothing false; the patient need not be deceived; and, even for the sophisticated patient who realizes that the remedy may be a placebo, it can have its psychologically beneficial effect, just as the hot tea and soothing syrup do.214
You might say you proceeded in exactly the same way in communicating to your elderly patient that the placebo was a “replacement” for all the discontinued drugs. The placebo did psychologically replace them, and you could argue that you asserted nothing more. That argument, however, seems to me unsound. While in other contexts replacement might ambiguously signify either a placebo or an effective medication, and while the placebo might work even if the patient were not deceived, your elderly patient had become anxious precisely because she was giving up what seemed to her effective medications. In this context, you must have realized that you could not alleviate her anxiety unless she accepted the placebo, just as she previously accepted the substitute you recommended for one of her drugs, as an effective drug replacing those you considered unnecessary.
If this analysis is correct, you deceived your elderly patient into continuing to get along without the discontinued drugs by telling her son-in-law to lie to her. That was unjustifiable despite the fact that the placebo worked, since lying is wrong and telling others to lie is doubly wrong. Someone might argue that, even if you lied, the lie was justified inasmuch as it benefited the patient and was necessary. But good ends never justify bad means, and lying always is wrong (see LCL, 405–12). Moreover, the lie was not “necessary” since there was an alternative. You could have dealt straightforwardly with the patient’s anxiety, perhaps by offering her a mild tranquilizer for a few days but if necessary by referring her to a specialist for counseling to help her overcome her unreasonable emotional dependency on the drugs she had been taking. That would have enhanced her self-control and so made her more able to make necessary decisions and live her own life.
Still, you might say your elderly patient was seeking only reassurance rather than effective medication, consider my analysis unsound, and deny that what you said was a lie. Though not conceding that, I turn to your original question: Was using a placebo to quiet your elderly patient’s anxiety a justifiable exception to your general policy of obtaining patients’ informed consent?
Someone might argue that you made no exception because the patient did in fact consent to taking the placebo you prescribed, and her consent was sufficiently informed. When did she consent? Proponents of this view could answer that she consented implicitly by seeking your services as her physician, agreeing, albeit reluctantly, to follow your advice with regard to her medications, and accepting the placebo as a “replacement” for the discontinued drugs. Her consent was informed, the argument would go, not by any one thing you told her, but by your entire effort to communicate with her so that she could willingly cooperate in carrying out your decisions about changes in her medications. Since the placebo was not an effective medication with potentially serious side effects, it might be argued that the consent you received was sufficiently, even if not fully, informed.
In my judgment, however, that argument is not sound. A placebo has no potentially serious side effects, of course, but the patient’s need to take side effects into consideration is only one reason for the requirement of informed consent. While your patient no doubt gave informed consent to changing her medications, she took the placebo under the illusion it was an effective drug. So, even if what you said, to make her think that, was not a lie, her consent to taking the placebo was not informed. While she willingly cooperated in carrying out your decisions, she did not, with regard to the placebo, make her own decision or understand yours. To that extent, you did make an exception to your general policy, and the question remains as to that exception’s justifiability.
One argument that the exception could not be justified is based on the concept of patient autonomy, namely, the view that, provided a patient is competent, his or her decisions by themselves determine what health care providers may do to and for him or her. In making the exception, the argument would go, you tried to determine what was good for the patient, despite her contrary view of the matter.
Against this argument, one way of trying to justify the exception would be to say that, while this patient is competent in general, her competence did not extend to deciding how to deal with her anxiety. The treatment of choice, the placebo, could relieve her anxiety only by providing the illusion that the discontinued medications were being replaced by another effective drug. So, someone might conclude, your elderly patient was not competent to decide about the placebo, and you rightly decided on her behalf, just as you rightly decide on behalf of unconscious accident victims to take the steps appropriate to save their lives.
This attempted justification, however, is unsound. True, people competent in general can lack competence about alternatives that transcend their comprehension and ability to evaluate. Competence, however, is an individual’s moral capacity to shape his or her own life, and this capacity is not limited by the fact that, when one cannot allay inappropriate feelings by knowingly using a placebo, only deception by another will make it effective.
In sum, your elderly patient was competent and you did make an exception to your general policy on informed consent. However, assuming you did not lie to or wrongly deceive her—which I do not concede—giving her the placebo without her informed consent might be justified on the grounds that it benefited her and was not unfair to her. That line of argument is possible, it seems to me, because—in reply to the question with which you began—the informed consent requirement is not a moral absolute, but only a general duty open to exceptions. Its ethical basis is not that patient autonomy, understood as a patient’s capacity to determine what is good for himself or herself, is an overriding value; in fact, autonomy, so understood, is an instance of the error of subjectivism.215 In truth, the duty to obtain the informed consent of competent patients is grounded in the facts that only they can mediate among their own interests, integrate medical treatment with other aspects of their lives, limit it in accord with their other responsibilities, and effectively carry out their own part in it. Whenever proceeding without informed consent may adversely affect these purposes, making an exception is likely to be unfair, and so unjustifiable. But making an exception is fair if that surely will not adversely affect these purposes or otherwise harm the patient and if it seems likely to benefit him or her in some way.
Still, this incident must not establish a pattern in which this elderly patient’s own decisions will be replaced by your judgments made in cooperation with her daughter and son-in-law. For that reason it seems to me that you should frankly tell her you gave her a placebo, and promise you will never prescribe one for her again. In this way, she will learn from the experience and be better able in the future to shape her own care and deal with any anxieties related to it.
214. See Mary Crenshaw Rawlinson, “Truth-Telling and Paternalism in the Clinic: Philosophical Reflections on the Use of Placebos in Medical Practice,” in Placebo: Theory, Research, and Mechanisms, ed. Leonard White et al. (New York: Guilford Press, 1985), 410–11, and studies cited. In Rawlinson’s article as a whole (403–418), however, she attempts to justify deception.
215. Edmund D. Pellegrino and David C. Thomasma, The Christian Virtues in Medical Practice (Washington, D.C.: Georgetown University Press, 1996), 117–25, provide a fuller criticism of the exaggerated notion of patient autonomy.