Ethics in Action

The Placebo Effect

By Gerald Maloney, DO, on behalf of the SAEM Ethics Committee The Case

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

“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.”

disorder. These factors can create a negative impression of the patient among the ED staff and lead to “compassion fatigue.” Over time this can even result in a shift in behavior that results in a loss of respect and with it the rest of the basic tenets of ethical behavior. This makes it easier to engage in behaviors that can become unethical.

The nurse’s request to administer a syringe of normal saline while telling the patient it is a powerful new painkiller called “normalsaline” is unethical for many reasons. First, it violates both the principles of beneficence (we only act in ways to benefit the patient) and nonmaleficence (we do not act in ways that are deliberately not in the patient’s best interest). By not giving the patient pain medication when he is stating he is in pain, we violate these principles. This does not mean we should give him opiates; there are alternative pain medications (NSAID, IV APAP, ketamine, IV Lidocaine) that are non-opiate and may be beneficial. By failing to administer an analgesic we are acting against his best interests. Further, we are denying him autonomy (ability to make a decision to accept or reject a proposed treatment) by being deceitful. While we may feel he is being deceitful in describing his pain and that we may not be acting in his best interest by administering opiates, by being deceitful ourselves and not treating his pain, we are failing to behave ethically and treat him with a basic level of respect as a human being.

How to proceed?

In this case the ethical way to manage this patient would be to inform him we will provide pain medication, but that we do not feel opiates are the best treatment for his pain and offer an alternative analgesic. If the patient becomes belligerent or wishes to refuse treatment because he is not receiving opiates, that is his prerogative. Behaving dishonestly cannot be considered ethical in interactions with patients.

ABOUT THE AUTHORS Gerald Maloney, DO, associate professor of emergency medicine, Case Western Reserve University and associate medical director, Louis Stokes Cleveland VA Medical Center.