From the Mouths of Babes

We take a lot for granted, don’t we? As parents we assume responsibility both for the wellbeing of our children and also their voice. Somebody has to, and obviously we, as their adult guardians, are better able to decide what’s best for them than they are –especially when they are young and inexperienced. It’s hard to argue with that, of course… At least I thought so until I happened upon an article in The Guardian newspaper that started me wondering whether the arrogance of age blinds us to a conceit that should be re-examined. https://www.theguardian.com/lifeandstyle/2016/sep/26/should-children-be-able-to-give-consent-for-medical-treatment?CMP=share_btn_link

I’m not advocating the abrogation of our responsibility to make the decisions –especially in the very young- nor to neglect to act in what we consider to be their best interests. I think it’s more about soliciting their opinions and perhaps incorporating these, where feasible, in the ultimate decision. Clearly, age is a major factor in how engaged the child will be –in the UK, at least, ‘Anyone over the age of 16 can consent to treatment, but so can younger children if doctors think they can understand and are competent to make medical decisions. Neurobiological research shows that the prefrontal cortex, home of balancing risks and rewards, is the last area of the brain to mature. So can adolescents – who are often impulsive risk-takers – be trusted to make decisions about their health?’

There was an interesting 1982 study that addressed the issue of the competency of children and adolescents to make informed treatment decisions: https://www.ncbi.nlm.nih.gov/pubmed/7172783?dopt=Abstract   In it, ‘9-year-olds appeared less competent than adults with respect to their ability to reason about and understand the treatment information provided in the dilemmas. However, they did not differ from older subjects in their expression of reasonable preferences regarding treatment.’

And indeed, there has been some effort to accommodate the child’s wishes in the latest policy statement on Informed Consent of the American Academy of Pediatrics: http://pediatrics.aappublications.org/content/pediatrics/early/2016/07/21/peds.2016-1484.full.pdf  For example: ‘When defined as agreement with proposed interventions, assent from children even as young as 7 years can foster the moral growth and development of autonomy in young patients. This consideration is based on an understanding that, starting around 7 years of age, children enter the concrete operations stage of development, allowing for limited logical thought processes and the ability to develop a reasoned decision.’

Of course, I am a gynaecologist with an adult practice, so I rarely have occasion to delve into the ethical minefield of paediatric consent, but occasionally I am exposed to its intricacies vicariously. These are frequently related to childhood vaccinations. In my Canadian province of British Columbia, vaccinations for hepatitis B and chickenpox as well as HPV (to females only –at the time of this writing) are offered to all children in grade 6 –in other words, to 11 year olds. https://www.healthlinkbc.ca/healthlinkbc-files/grade-6-immunizations Of course, ‘It is recommended that parents or guardians and their children discuss consent for immunization.’ But under some circumstances, even an eleven-year old might be considered a ‘mature minor’ and could potentially consent to the vaccination on her own: ‘In B.C., immunizations for school aged children are given in grade 6 and grade 9. Most of the time, the vaccines are given by nurses at immunization clinics held at schools. Children may also get vaccines at a health unit, youth clinic, doctor’s office, or pharmacy. In all of these settings, a child can consent to the vaccine on their own behalf if the health care provider has determined that the child is capable of making this decision.’

Ruth, a thirty-six-year-old woman whose daughter I had delivered eleven years ago, returned faithfully to my office each year for a pap smear. She had a history of several increasingly abnormal smears, eventually necessitating a minor excision procedure three or four years ago for an HPV-related pre-cancerous lesion on her cervix. Fortunately there had been no evidence of recurrence since then.

She’d always been a nervous woman -her pregnancy no exception- and the subsequent abnormality on her cervix had done nothing to alleviate her anxiety. Even her clothes seemed adjectival to the noun of her angst. Exquisitely ironed white cotton sweatshirts and similarly fussed black jeans over highly polished black leather pumps were her inviolable uniform on each visit. She wore her long blond hair tied in a pony-tail so tightly pulled from her forehead, I imagined I could see tiny fissures opening up on her scalp where it was tearing. And she constantly clenched and unclenched her fists as if she were training for some hand-shaking marathon.

Everything about her usually screamed stress. And yet, when I saw her recently, she had relaxed her hair so it danced freely on her shoulders, and was actually wearing a pale blue silk blouse and a pretty black skirt. At first I didn’t recognize the smiling woman who seemed so comfortable as she sat chatting with one of my young pregnant patients. But as soon as she saw me, she stood and grinned at me as if I were a cherished friend. I suppose I was…

“Doctor,” she said, even before she sat down as I closed the door to my office. “Remember Trish?” she pronounced the name slowly, in case I didn’t remember delivering her.

I nodded and tried not to roll my eyes. She was always telling me about Trish –every visit she had something new to report –and A in spelling, or a Silver in some race she’d entered.

“Well, she’s in Grade 6 in school now…” She stopped and scanned my face to see if I could guess what she was about to tell me. She often played this game and, sadly, I never succeeded.

This time, however, she prolonged it sufficiently long that I began to wonder if she’d forgotten what she was going to tell me. “…And you’ll never guess what happened,” she finally added -probably to tease me.

I knew it would continue like this until I said something. “What?” It wasn’t a very profound response, and I think she was a little disappointed –especially in my evident lack of excitement.

“My little Trish has grown up,” she bubbled with obvious pride. And then, when I didn’t say anything, she continued. “This is the year they all get their vaccinations…” She fixed me with a suspicious stare as she tried to decide whether or not I knew that.

I held my expression to an anticipatory smile and a nod.

“Well, she decided to have the vaccination, doctor!” I could hear the exclamation mark as it rebounded off the walls. “I mean, I’d discussed it with her beforehand and everything, but it was her decision!”

I took a deep, but silent breath. “Was there ever any question about it, Ruth?”

I could see her withdrawing into her face as her eyes took turns jousting with mine.

“She had a lot of questions at first.”

“Questions…?”

She nodded –warily, I thought. Carefully. “Mainly about the HPV one, though.”

“What did she want to know?”

I felt another probing jab with from her eyes before she called them off and sighed. “It was about the boys.” I waited patiently. “She wanted to know why they didn’t have to get the HPV vaccination.”

It was a common complaint, and one that I shared. Although several weak arguments have been made for male exclusion, none of them are convincing.

“She thought boys would have the same risk as girls, and it was so unfair she wondered whether she should refuse to be vaccinated as a protest,” Ruth said proudly.

I wondered where that idea had come from –Ruth was a zealous supporter of HPV vaccinations, I knew. “So you convinced her to change her mind?”

She shook her head. “I tried, believe me. I even phoned the school to make sure they knew I wanted her to have the vaccination.” But I could tell she was pleased that her daughter had evaluated the matter so carefully. I was certainly impressed.

“So what changed things?”

She rolled her eyes and smiled. “One of the boys in the class made a face at her.” Then she sighed. “Perhaps not the most persuasive of arguments…”

All I could do was nod. If someone makes the right decision for the wrong reasons, it’s not really a teaching moment, I suppose…

 

 

 

 

 

 

 

 

 

Rethinking Placebos

Placebo. I love the word; it comes from the Latin verb placere: to please, and in the first person future indicative –placebo– translates as ‘I will please’. Wonderful.

I’ve been thinking about it a lot lately, probably since rereading a Dec. 31/14 article in Medscape entitled ‘Should Doctors Use More Placebos?’ http://www.medscape.com/viewarticle/835197 The answer, of course, is ambiguous –no one seems to want to commit to the use of a technique favoured in the days when there were few other options; times when there were no antibiotics, no condition-specific medications –no detailed knowledge of the physiology of the body, let alone diseases. Those were times when naming the problem and being able to give a likely prognosis was an important part of Medicine. I suppose it still is. But the other, equally important component nowadays, of course, is solving the problem so named –solving, as well as hopefully curing it with specifically targeted medications or therapies.

Placebos have usually been construed as inert, essentially harmless substances with little or no known properties that might otherwise be helpful in restoring bodily health. No pharmacological effect… So why would anyone wish to use them anymore? Or do we?

In this informed era of medical ethics –and of course, social media- would it even be possible to use placebo treatment, except, maybe, in a study where a treatment is being compared to no -or likely ineffective- treatment (placebo treatment) and where the participants are unaware which substance they are receiving (so as not to bias the results) and have understood and accepted this? Not something likely to occur in the average visit to a doctor’s office for an illness.

And the ethics that need to be considered? Well, amongst others, the concept of autonomy –the right of an individual to make both their own treatment decision and an informed choice. And then, of course, there is the ethical requirement for Informed Consent. How can you give someone a treatment without telling her that you may well end up using something that is pharmacologically inert? A non-medication, as it were.

A placebo is usually a trick –you think you have been given something specifically designed to help; you take it on trust; you have faith in the doctor… If you found out that what you had been given –lied to about, in fact- was inert, wouldn’t that undermine your confidence, and especially your trust, in that doctor? Even if it worked? Or maybe especially if it worked –it would mean he thought your condition was more psychological than physiological –i.e. ‘all in your head’. Not very likely to foster a continuing relationship.

But what if the doctor told you he was going to use a placebo for your condition? Would it work if you knew? Well, here’s where it can get interesting; there is a difference between using a placebo and using the placebo effect: the approach to the patient matters as well as what is given to attack the problem. Such things as actually hearing the patient –listening to what they have to say- rather than immediately reaching for the prescription pad; being reassuring and sympathetic. Friendly. Understanding. The demeanour and hope with which any treatment is administered has been shown to effect the results –the art of Medicine.

But nowadays, we all know about this. The fact that there is some theatre to medicine, and a play of characters is not a secret –although I suspect that most of us prefer not to think about it when we ourselves have an illness. The play within the play…

It got me thinking about placebos in my specialty, though. Are there any placebos in gynaecology, for instance, and do we ever use them? We certainly use the placebo effect in obstetrics –we are constantly reassuring our patients about the never-ending and always-changing symptoms occasioned by their growing bodies. Most of them don’t need investigations or tests- nor do they need any specific medication -just an acknowledgment by the doctor that whatever the patient has noticed is not something to be worried about. It is not something malevolent, nor likely to affect the baby, but merely something that happens in pregnancy –part of the spectrum. Something to be expected. It’s a trust issue. That’s why they came to you after all.

And what about gynaecology? All medicine involves placebo effects –we’ve just discussed that- but what about placebos? Are we kidding ourselves to think that gyaecology is exempt from their use? I suppose it depends on how you define a placebo. As we’ve already seen, a placebo is classically defined as a substance that is not likely to have any measurable pharmacological effects and so is considered inert. But what about a substance that is not yet proven by scientists to have an effect –for example by well-designed studies that compare various treatments? Of course, it may simply be that no one has actually studied the substance so far; there are many complementary and alternative medicines that Western Medicine has not subjected to analysis. So their use by the doctor would not necessarily be as a therapy, but maybe as an acquiescence to a patient’s request, in the absence, perhaps, of any other recognized treatment options.

How about a substance that has some effects, and yet likely not enough, nor sufficiently consistently to be considered a mainstay treatment, but which might be sold, say, in a health food store? Some of the phytoestrogens found in materials like clover or soy have estrogenic effects, but may attach weakly or ineffectively to certain estrogen receptors -and in some organs but not others…

And then there are medications that are useful for other conditions –perhaps related, but not necessarily so- but are re-packaged for a new life. The use of ovulation inducers in infertility treatment, even when the patient is known to be ovulating –a just-in-case therapy. Or an antibiotic for a new-onset, ultrasound negative –but as yet undiagnosed- pelvic pain in a woman when she shows up in a busy emergency department. Maybe it’s an infection… Or vitamin pill use for the busy woman who doesn’t have time for a healthy diet every day. It can’t hurt and it may help… Surely these are placebos.

Or substances that have switched their roles over the years –were they inadvertent placebos that have been since promoted? Acetylsalicylic acid (ASA) was once only considered a pain reliever and was used for menstrual cramps. It seemed to help patients cope with the period but this was assumed to be only because of the pain relief. So it was a placebo for coping, a therapy for pain. Then, because it was later discovered to be an anti-prostaglandin –which is a chemical mediator of inflammation and has a direct effect on the flow through blood vessels (and hence one cause for increased bleeding and cramping with periods because of dilated blood vessels in the area)- ASA, or at least more modern analogues of antiprostaglandins such as ibuprofen, was reassigned to a new function. A new, non-placebo job, as it were. So, although it did one job at first, was it an unsuspecting placebo that actually did two jobs? Is that a temporal placebo? An interesting philosophical conundrum –but I suspect I am stretching the concept beyond any useful application.

Maybe we’re looking at the whole idea of placebos the wrong way. In our data-glutted age where information is conflated with knowledge perhaps we need a concept that defies mere illumination and transcends erudition. Something that is so embedded in the weft of context that it disappears in the very act of searching for it –an unsolvable Where’s Waldo. Sometimes our need for elucidation of every aspect of the world we live in is self-defeating. Maybe –just maybe- we don’t need to know where the geese go when they disappear through clouds that gird the mountain tops. Just that they come back every year. ..Somehow.