ฝัง
- เผยแพร่เมื่อ 20 ก.ย. 2024
- "Good" medical trials are placebo-controlled, but when might it be immoral to even perform such an experiment?
Links for the Curious
The Ethics of Placebo-controlled Trials: Methodological Justifications (Millum & Grady, 2013) _ www.ncbi.nlm.n...
The ethics of the placebo in clinical practice (Lichtenberg et al, 2002) - jme.bmj.com/co...
The ethics of using placebo in randomised controlled trials: a case study of a Plasmodium vivax antirelapse trial - bmcmedethics.b...
"The Morality of A/B Testing" - techcrunch.com...
"What really helps the poor?" - aeon.co/essays...
![วันเกิดเธอ (TO YOU) - PHUWIN [ OFFICIAL MV ]](http://i.ytimg.com/vi/_ROx1Bj3T0Y/mqdefault.jpg)
'first, do no harm'. then second, realize just how wrong the first rule is.
The greater good is bigger than any individual. I believe we should seek to empower everyone to the fullest extent possible. But we are laden with the curse of uncertainty, ignorance, and imperfection. We can only hope to do the best we can with what we know.
People are systematically harmed to various degrees in our society every day regardless if you allow yourself to perceive it. The government you support and depend on is doing extreme harm to individuals. Sometimes for the better, and sometimes not. But often times, it is merely a matter of perspective and allegiance.
There are a lot of things to be said about inaction. If you could prevent harm, shouldnt you? I say absolutely. But some others often seem to twist things into it not being their problem... or worse, deluding themselves into ignoring and disbelieving the harm. And perhaps the worst of all, are those whom havent even thought through even the most basic principles of morality.
As terrible as it may seem, risks must be taken to advance. Indeed, a static steady state of society in which nothing changes (in the guise of protecting what we already have) is an end state to society... it is an existential threat every bit as great as nuclear war. I think it comes down to that some people dont recognize just how good things could be. Risk aversion is healthy to some extent, but it seems IMO that there is definitely a line that leads to disaster which stems from cowardice.
There are control groups - other than placebo controls. You can do a RCT, where one group receives "Current Standard of Medical Care" and the other group receives the new intervention. As long as you have good reason to believe in the new intervention, I don't see an ethical issue here. I think the actual issue is that people are needlessly obsessed with placebo-controlled trials, and aren't willing to use other types of control groups. "Is this better than literally nothing?" isn't the only relevant medical question. "Is this better than what we are currently doing?" also has value - and in this case, helps us avoid an ethical problem.
The Heparin problem in the video is not a good example of this, where we have only one treatment for this emergency situation and the suggestion is that it might actually be worse than doing nothing. You can't test the current standard against itself. This is what happens when new treatments for previously untreatable conditions are implemented before they're tested in a placebo trial.
This also creates a problem for all later RCT tests conducted in the way you describe. Pretend for instance that the treatment in question is blood letting for curing the plague. Blood letting does more harm than good, but it is the standard of care, it's what you were taught, so it's what you provide for all your patients. A new treatment comes around - mercury tonic. Compared to blood letting mercury tonic is great! Far fewer patients die of the plague, but latter on some people die of mercury poisoning. The gain in the apparent success of the treatment cannot actually be attributed to the mercury, it is the absence of blood letting that improved the survival rate, but an evidence based assessment of the situation would still suggest mercury tonic every time, even considering the possible long term side effects. Absent an initial placebo RCT, nothing can actually be determined about the effectiveness of a first of it's kind medicine, and thus nothing can be determined about a new medicine tested against the original. Sure if you constantly improve upon the standard of care, you will probably get an effective treatment eventually, but you could do a lot of unnecessary harm along the way. A placebo guarantees beyond a shadow of a doubt that a treatment has positive effects, which cannot be done through comparative trails.
Once you have a drug which beats placebo - subsequent drugs don't need placebo testing anymore. A >0, B>A, C>B - logically already implies C >0. My main point, is that we don't need to placebo test ALL DRUGS - we only need to placebo test 1st generation drugs. Once there is something which is already known to be better than placebo - and then a new competitor comes along - the question of "is new thing better than placebo" is not relevant, the question of "is this new thing better than the best current alternative" is relevant - and is not answered by placebo-testing.
My objection, is that as a culture, we only accept drugs which have passed placebo-controlled trials - when really that isn't the best test - such as when the current standard of care is already demonstrably better than placebo.
As for the Heparin case specifically - I would argue Heparin OUGHT to qualify under the 1st allowed use of a (placebo-controlled) RCT. In the absence of an RCT proving that Heparin or anything else, is definitely better than doing nothing - than that is ignorance. A suspicion that it might possibly help - is not evidence - it is ignorance - and therefore would fall under the 1st allowable use of an RCT as outlined in this video.
@@knights4159I do agree that this type of testing is worth using in certain circumstances. But it's still not better than placebo. It may seem harmless to do it like that, but comparing against a known treatment *compounds* all the error rates, variables, and just everything potentially bad, or potentially interfering with the results. You are testing "off of another test". Your "control" is now only as good as the clinical trials for drug A (or w.e it is).
This is why placebo is the gold standard, and will always be. Comparing it to placebo doesn't compound any errors. If you did do the type of test you are talking about, especially for something that has NO double blind placebo trials before this, you may very likely end up with results that have such big errors that they are essentially meaningless, or contradictory. That's the issue with this, and why it's not done as much as you think it should be.
quite informing video, thank you! could you talk more about the ethics of placebo on psychological experiments?
7:35 you've just described what TH-cam inflicts upon its members.
I spent the last 5 minutes looking for the placebo version of this video :)
When you utterly ignore opportunity cost, of course it's debatable.
What if you asked the patient for permission for him to be studied on. Is telling him that there may be a probabilty he'll take a placebo diminishing the placebo effect?
No, that's how most studies are done. Placebos can even work if the subject knows its a placebo.
But do they work as efficiently as when they don't know?
@@Macieks300 Would highly recommend you read this paper.
journals.plos.org/plosone/article?id=10.1371/journal.pone.0015591
@@Vulume That makes no sense
"You might discover something better than the current best option"--um, BALD is BEAUTIFUL!! In all seriousness though, this topic reminds me of the recent documentary "Three Identical Strangers", which tells the story of SPOILERS triplets separated at birth and placed in three different economic stratas, in families with distinct parenting styles, and then developmentally monitored long-term. Grossly unethical as the film demonstrates, but the research findings would have been in theory monumental... If the study had come to any formal conclusions and wasn't under seal. An incredible film and an incredible episode of THUNK, as always