Abstract
A deeply bad idea
And so another trend begins in America. This time it is placebo pills for kids.
On 1 June a company called Efficacy Brands (I’m not making this up) put cherry flavoured sugar tablets on sale on the web. The company was started by a mother with three young children, who has appeared on the morning television shows in the US to publicise her inspiration. For just under $6.00 you can order a bottle of these pills to “treat” children when real medicine isn’t appropriate and a hug and a kiss aren’t enough. The pill is called Obecalp—placebo spelt backwards. How clever is that?
I first became aware of the power of placebos 30 years ago when I was an intern in a large US urban hospital. Our pharmacy stocked two “special” painkilling drugs, available by a doctor’s prescription only. One came in a brilliant red capsule and the other was deep purple. The interns were instructed that these pills were for people who abused pain medications and were to be dispensed with care—and with a good story. It turned out that the red one was aspirin and the purple one was Tylenol [paracetamol], although you couldn’t find those exact words anywhere on the labels, which had (in very small print) the generic constituents of the medications. And sure enough, I had a number of patients who said to me that they simply had to have that red pill, or that purple one, insisting that it was the only thing that took their pain away.
If it is ever ethical to use a placebo—and I’m not sure that it is—this is an example of when it might be appropriate: helping someone with a chronic problem, using medicine with proved efficacy, one that is not too dangerous. And without completely lying about what’s in it. This meets many, but not all, of the criteria set out in a recent BMJ article offering guidance for prescribing placebos (3 May, p 1020; doi: 10.1136/bmj.39564.454502.C2).
In a randomised controlled trial in the same issue, Ted Kaptchuk and colleagues cleverly deconstructed the components of the placebo effect (3 May, p 999; doi: 10.1136/bmj.39524.439618.25). They showed that an important part of how placebos work is the patient-practitioner relationship. In their study, the response rate went from 44% to 62% when the clinician added “warmth, attention, and confidence” when delivering placebo acupuncture to treat the symptoms of irritable bowel syndrome. It’s a great demonstration of what psychiatrist and GP trainer Michael Balint called the effect of the “doctor as drug.”
Doctors know that we have this drug available, and good doctors dispense it wisely and effectively. The power of reassurance, empathy, and confidence can go a long way towards helping patients with any number of complaints, and of course parents have a similar power to comfort and even heal their children.
While I can think of situations in which it might be appropriate for doctors to administer a placebo pill, I can’t say the same for parents. The problems are numerous. Firstly, whom are we treating here, children or their parents? If placebos are to work, the patients need to believe in them. Are doctors thus going to dispense these pills to the parents for their children, without telling them it is an inactive substance? Or is it left to the parents to determine that it is appropriate to trick their children into believing they are getting real medicine to help them?
Secondly, what will happen when the children become adolescents and find out that they were being sold a pill of goods, so to speak? Such a discovery can’t be good for their trust in their parents, which is often at a nadir at that age anyway.
Thirdly, if parents use placebos to comfort their children, what are they teaching them? That tablets are the answer for all our aches and pains? And perhaps all our other problems too? Not advisable.
Finally, what makes us think that kids actually want medicine? If all children are like my three, who are now all teenagers, they won’t take medicine when they are little, and they don’t want it when they are big either.
And I don’t buy the argument that giving a child a placebo pill is just like putting a plaster on a scratch: we know it doesn’t make any difference, but we tell the kids that it does. Sure, there are kids who end up wanting a colourful plaster for every possible ache and injury, but I have never seen an adult addicted to plasters. I have seen very many adults who want a pill for every ill.
All in all, a placebo pill for children seems like a deeply bad idea, however well intentioned. Kids who are in pain, or sick, but don’t require real medicine need someone to give them a hug or a kiss or, if a treat is indicated, maybe a sweet. But they don’t need a sugar pill, and they certainly don’t need to be deceived into thinking that it’s the pill’s magic, not Mum’s or Dad’s, that helped them feel better.