ETHICS IN ACTION
The Placebo Effect By Gerald Maloney, DO, on behalf of the SAEM Ethics Committee
SAEM PULSE | NOVEMBER-DECEMBER 2020
The Case
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You are managing a 48-year-old male patient with a history of chronic pancreatitis due to longstanding alcohol abuse who presented to the emergency department (ED) for vomiting and abdominal pain. He visits the ED fairly frequently (once a month) for similar complaints. He rarely has any acute lab abnormalities, and his labs tonight are unremarkable. He usually presents with pain out of proportion to his physical exam and lab findings. The nursing staff believes his complaints are “drugseeking” and he is requesting IV opiates on this visit. The nursing staff is asking you to let them give a saline flush in the IV and tell him he is getting a powerful new opiate called “normalsaline.” You think they are correct and believe he may have an addiction issue and may
be exaggerating his symptoms in an attempt to get opiates. He also has a history of being belligerent; however, you’re unsure if this is the right way to approach this patient. Should you give him the saline placebo, or is there a better way to handle this patient? One of the most difficult and commonly encountered scenarios in clinical ethics is dealing with difficult patients and balancing aspects of justice, beneficence, autonomy, respect for persons, and non-maleficence. This balance can become even harder to achieve when the patient is challenging to deal with due to mental health issues, intoxication, or other personality issues (e.g. overt sexism or racism). When the patient has characteristics that we perceive as difficult or undesirable, we may find ourselves conflicted in our approach to the patient; subsequently, our view of as to what should constitute
ethical behavior in regard to the patient may be unclear. Respect for persons underlies all other precepts of clinical ethics. It is a fundamental precept that we should view all patients with respect, irrespective of their circumstances or status. By approaching every patient from the same ethical level playing field, we start off treating everyone with the same level of respect. The other ethical precepts: autonomy, beneficence, nonmaleficence, and justice all flow from our basic concept of respect for persons. Getting back to our scenario, there appears to be a lack of respect for the patient. The patient visits the ED frequently for chronic pain with an underlying disease process that may not be easily quantifiable with our usual diagnostic testing. He is also reported to be belligerent, loudly requests opiates, and has a history of substance use
