The American Society of Pain Management Nurses (ASPMN) position is that placebos should not be used by any route of administration in the assessment and management of pain in any patient regardless of age or diagnosis.

Definition:

Placebos may be defined as any medication or procedure that produces an effect in patients resulting from its implicit or explicit intent and not from its specific physical or chemical properties (Bok, 1974). In the clinical practice of assessing and treating pain, placebos may be inactive substances (e.g. normal saline injections), subtherapeutic doses of active substances (e.g. injection of 0.5 mg morphine in 1 ml of saline for an adult), or a sham procedure (electrodes with no therapeutic value).

Background:

Pain is recognized as being completely subjective and not measurable by objective means. Self-report of pain is considered the most reliable indicator of pain. People in pain are vulnerable and dependent on healthcare providers for pain management. When patients with pain seek care they have a right to expect that their physicians and nurses will provide therapy that is based on rational, scientifically validated evidence (Wall, 1993). It is widely acknowledged that pain is frequently undertreated. Inappropriate placebo use is one of many ways that pain may be undertreated as well as erroneously assessed. Clinicians may administer a placebo, not out of maleficience, but rather in good faith, based on erroneous beliefs that use of the placebo will provide valuable information or help patients by relieving pain without harmful side effects. In addition, clinicians may use placebos in a punitive sense for patients who have exhibited manipulative or demanding behaviors or for patients in whom diagnosis of the cause of the pain or methods to relieve pain have failed.

Ethical tenets:

Central ethical tenets of the American Nurses Association Code for Nurses (1995) include truth telling, fidelity, trust, and respectful care. The use of placebos necessarily involves deception, which automatically raises serious ethical concerns. Use of placebos threatens the inherent ethical values and norms of healthcare professionals. Informed consent, which is most often absent in the use of placebos, is a necessary requirement for promoting the autonomy and well-being of patients. The use of placebos may ultimately compromise the therapeutic relationship between patients and healthcare providers by eroding the necessary environment of trust.

Recommendations:

Healthcare providers have an ethical obligation to ensure that policies are present within the institution to prohibit the use of placebos for assessment or management of pain in all patients with pain. Institutions should develop educational programs to inform professionals about pain management, including the inappropriate use of placebos. Ethics committees should be consulted for assistance in formulating institutional policies and procedures regarding the use of placebos.

Summary:

The American Society of Pain Management Nurses adamantly opposes
the use of placebos in the assessment and treatment of pain in all patients.

References:

Bok, S. (1974) The ethics of giving placebos. Scientific American, 231(5), 17-23

Wall, P.D. (1993) Reply to E. Leskowitz. Pain, 53(1), 115.

American Nurses Association (1995). Code for nurses with interpretive statements. Kansas City, MO: American Nurses Association.

Suggested Readings:

• Ferrell, B.R., and McCaffery, M. (1996). Current placebo practice and policy. ASPMN Pathways, 5(1), 12-14.

• Fox, A.E. (1994). Confronting the use of placebos for pain. American Journal of Nursing, 9, 42-46.

• Goodwin, J.S., Goodwin, J.M., and Vogel, A.A. (1979). Knowledge and use of placebos by house officers and nurses. Annals of Internal Medicine, 91, 106-110.

• Hinnant, D.C. (1995). Institutional policy prevents misuse of placebos. ASPMN Pathways, 4(1), 1, 7.

• McCaffery, M., Ferrell, B.F., and Turner, M.T. (1996). Ethical issues in the use of placebos in cancer pain management. Oncology Nursing Forum, 23, 1587-1593.

• Rothman, K.J., and Michels, K.B. (1994). The continuing unethical use of placebo controls. New England Journal of Medicine, 331, 394-397.

• Turner, J.A., Deyo, R.A., Loeser, J.D., VonKorff, M., and Fordyce, W.E. (1994). The importance of placebo effects in pain treatment and research. Journal of the American Medical Association, 217, 1609-1614.

American Society of Pain Management Nurses
7794 Grow Drive · Pensacola, FL 32514
850-473-0233 · 888-342-7766
ASPMN@aol.com

* Permission to print/download granted to Mayday PainLink at EDC, by Robert Rupp, ASPMN. March 4, 1998.