Placebo surgery is effective, but is it an ethical treatment?

The latest research suggests that placebo surgery is sometimes more effective than real surgery.

　　Usually when we think of a placebo, we think of it as a body-free sugar pill that is used as an alternative to experimental drugs, a common medical method that allows researchers to compare the results of two groups of volunteers to determine whether the new treatment regimen is effective. In contrast, placebo or sham surgery is uncommon, involving the administration of sedatives, scalpels, and stitches, but are not truly interventional treatments, which, although relatively rare, are sometimes used in medical studies to determine the effectiveness of "real surgeries."

　　For example, a 2013 Finnish medical study looked at the results of 146 patients, some of whom underwent arthroscopic partial meniscalectomy (a common knee surgery), and some patients had only made an incision and did not actually repair it.

　　In 2014, a study by the University of Oxford in the United Kingdom found that there was basically no difference between patients who underwent surgery for real shoulder pinch squeeze and those who only "drilled" holes in the affected area, and in any case, everyone involved in the study knew that patients may end up undergoing fake surgery, real surgery, or no surgery at all.

　　In 2018, Finnish researchers again studied shoulder pinch squeeze surgery and came to a similar conclusion – both groups of patients had similar levels of shoulder pain for two years after surgery, whether they underwent real or fake surgery. Simo Termeira, adjunct associate professor at the Finnish Centre for Evidence-Based Orthopaedic Corrections (FICEBO) at the University of Helsinki, said: "Around 21,000 decompression procedures are performed in the UK each year, which is 10 times greater than that of decompression in the US, and the results show that patients receive placebo therapy with significant results. ”

　　Professor Tep Jarwinn, Chief Surgeon at the University of Helsinki School of Medicine, a leading figure in the field of surgery and a member of the 2018 research project, said: "The placebo-treated patient group received the same treatment as other patient groups, but also underwent special treatment – in addition to the acromial process bone, which is the hook-like bone of the scapula extension, which is said to reduce the pressure on the rotating tendon of the shoulder. "According to the study, it was a randomized trial in which patients were told in advance to be divided into two groups and if their symptoms did not improve within 6 months, crossover treatment was available, meaning that if placebo therapy did not work, they could undergo real surgery."

　　Jarvin believes that placebo therapy has important implications for patient treatment. But some patients say that because patients undergoing real surgery is very painful and expensive, and it takes a certain amount of time for the body to recover after surgery, it is easy to understand why many people think that placebo surgery is unethical.

　　Dr Lewis Flint, editor-in-chief of the American College of Surgeons, said: "This kind of surgery is morally unacceptable, but this is only my personal opinion and does not necessarily reflect any policy of the American College of Surgeons, and when we conduct medical research, we perform in accordance with the first principle of 'no harm', which is also the ethical basis for avoiding placebo surgery." ”

　　Flint and other medical researchers believe that placebo surgery exposes patients to a risk of complications, and while the corresponding risk is small, it is not worth the risk in comparison.

　　Risk level for placebo surgery

　　In 2014, a study published in the British Medical Journal reported that researchers' analysis of 53 trials involving placebo surgery showed that placebo surgery had a better effect in 74% of trials, placebo surgery was no different from ordinary surgery in 51% of trials, and real surgery was more effective than placebo surgery in 49% of trials, but the surgical intervention was weaker than placebo therapy, in other words, in about half of the trials. The population that received placebo surgery had a similar effect to those who underwent real surgery, while in the other half of the trials, the population who underwent real surgery was only slightly better than placebo surgery.

　　The authors did note that, overall, placebo patients had fewer serious complications than those who underwent real surgery because the former did not perform the main surgical procedure, but they found that there was a potential "harm" to placebo surgery in only two trials, both of which were stopped early for patient safety reasons.

　　Flint noted that most of the surgeries described in the 2014 study were done using mild sedatives rather than general anesthesia, and the complication rates of these procedures were very low, so it was not surprising that patients had a low risk of receiving placebo surgery, however, there are still a small percentage of patients with serious complications, should patients currently be exposed to unnecessary surgical risks, although the associated risks are low?

　　Professor Jalwyn in Finland strongly rejects those who consider placebo surgery unethical, pointing out that you would find which treatment option is more unethical: Option A is based on less or no medical evidence, to study the safety and efficacy of treatment, and only to adopt some common surgical practice to get patients to undergo repeated surgical treatment; Scheme B is to involve a limited number of patients in placebo surgery, in more than 50% of post-treatment surveys, It was confirmed that the treatment regimen was not inferior to that of surgery (at least the same effect).

　　Other types of "sham surgery"

　　Less controversial than placebo surgery is "sham therapy", which does not alleviate the patient's condition and does not reduce the patient's real risk, Flint explained that there are some specific placebo treatment procedures in medical research, you can accept a certain treatment plan, let the patient think that they are being treated, but in fact they are not accepting, which is ethically acceptable, for example: the impact of acupuncture therapy on the treatment of low back pain. In the test, one group of patients received acupuncture treatment, while the placebo group only "stuck" a toothpick on the patient's skin, Flint said: "When the toothpick pierces the skin, the patient will have a 'acupuncture' feeling, but there is actually no needle into their skin, we have also tried blunt-tipped retractable needles before, and the results show that the patients in the placebo group are as effective as the acupuncture group." ”

　　Placebo surgery may have a positive effect for the same reasons as placebo drugs, which can lead patients to believe that the drug or "sham surgery" they are currently taking will make them healthier and have a strong supportive effect on the mind, while placebo surgery may increase the placebo effect compared to non-invasive treatments (taking sugar pills), and placebo drugs may activate the human biochemical pathways affected by actual surgical interventions. (Ye Qingcheng)