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Perhaps of more concern are the ethical implications involved in the use of placebos to treat pain syndromes. Several review articles describe the deception involved in most instances in which physicians have used placebos,3,4 as well as the ethical implications for the nursing staff involved in dispensing the medication.5 By giving the patient under discussion a dose of placebo under the guise of giving a medication with known pharmaceutical effect, the physicians violated his right to informed consent regarding medical therapy. In addition, they abused their patient's trust and, by publicizing their deception, they seemingly legitimize this questionable practice.
Laurent Adler, M.D.
David Muller, M.D.
Mount Sinai Medical Center
New York, NY 10029-6574
References
Before lead intoxication was suspected because of the abnormal urinary porphyrin findings and confirmed by the finding of a high urinary lead excretion, the patient underwent an extensive workup, including an array of biochemical blood tests, abdominal ultrasonography, upper gastrointestinal series, abdominal computed tomography, gastroscopy, and colonoscopy. After the diagnosis of lead intoxication was made biochemically, the blood smear was examined and found to show the hypochromia and basophilic stippling typical of this disorder.
Modern technology has revolutionized medical diagnosis, but 30 years ago a patient with anemia, acute abdominal pain of recent onset, hypertension, and a remarkable degree of reticulocytosis would have had a blood smear examined earlier — and this should still be the case.
Christine Lawrence, M.D.
Albert Einstein College of Medicine
Bronx, NY 10461
The discussant did not seem to notice the overkill associated with weak diagnostic skill. The excesses of contemporary medicine, the emotional burden, the pain, the discomfort, the anxiety, the time spent, and the cost are among the forces that drive people into the arms of alternative medicine.
Imre J.P. Loefler, F.R.C.S.
Nairobi Hospital
Nairobi, Kenya
Michel Abramowicz, M.D.
Institut Médical Edith Cavell
1180 Brussels, Belgium
To the Editor: The initial evaluation of our patient focused on the possibility of an event that required surgical treatment, and only after such a possibility was excluded was an investigation of other possible causes of the abdominal pain and the anemia started. As Dr. Lawrence and Dr. Loefler point out, earlier examination of a blood smear in our patient could have led to an earlier diagnosis, thereby averting part of the intensive workup.
The placebo effect is a poorly understood psychophysiologic response. In appropriate circumstances, doctors may consider giving a placebo for the benefit of their patient.1 In our patient, narcotics were used several times to relieve pain, and we believe that the use of a single saline injection was justified in our search for a less harmful therapy.
Our patient turned to alternative medicine, not for any of the reasons suggested by Dr. Loefler, but because of his misguided belief that it could provide a safe and harmless cure for his mild, well-controlled diabetes mellitus. Indeed, this case report is a good example of how dangerous, even life threatening, alternative medicine can be.
We regret the errors in the serum iron concentration, which was 150 µg per deciliter, and the reticulocyte count, which was 4.5 percent.
Yitzhak Beigel, M.D.
Rabin Medical Center
49100 Petah-Tikva, Israel
References
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