Journal ol Abnormal Psychology 1975, Vol. 84, No. 2, 172-174
Was Deception Justified—And Was It Necessary? Comments on "Self-Control Techniques as an Alternative to Pain Medication" Herbert C. Kelman Harvard University Ethical issues raised by the use of placebos in clinical practice are discussed in connection with the case of a patient undergoing self-control training, who was withdrawn from antipain medication without his knowledge by substitution of a placebo. Ethical problems resulting from the use of deception in this case center on the patient's right to informed consent, on the quality of the patient-therapist relationship, and on potential damages to the patient's selfconcept. On the other hand, a number of mitigating factors may well have justified the use of deception in this particular case. Nevertheless, the question is raised whether deception was really necessary and might have been avoided by a therapeutic model that goes beyond the control of specific behaviors and views the treatment as part of a larger process designed to enhance the patient's capacity to cope with his life situation. The case report by Levendusky and Pankratz (1975) provides a good starting point for considering some of the subtler ethical issues raised by the use of placebos in clinical practice.1 The authors describe the case of a patient who underwent a training program in self-control of severe pain through the use of relaxation, visual imagery, and cognitive labeling. He was highly resistant, however, to giving up his antipain medication, on which he had come to rely. The authors decided to withdraw him from the medication without his knowledge by substituting increasing proportions of a placebo for the medication. The deception involved was clearly designed to benefit the patient, and it apparently did contribute to a successful treatment program. Moreover, the indications are that the decision to use deception was taken responsibly, rather than casually. Thus we are obviously dealing with a benign deception, which makes it easier to focus on the ethical implications of deception as such, even where it does not cause any readily apparent harm to the patient. The use of deception in the case reported here raises several ethical questions: 1. Does the therapist have a right to decide what treatment is ih the patient's best interest without obtaining the patient's informed consent? Requests for reprints should be sent to Herbert C. Kelman, Harvard University, Department of Psychology and Social Relations, William James Hall, Cambridge, Massachusetts 02138. 1 My own thinking about these issues was greatly stimulated by Sissela Bok's recent paper (Bok, 1974). I am very grateful to Dr. Bok for showing me the manuscript and discussing some of the issues with me.
It is apparent from the report that Mr. X was a competent individual, who had voluntarily admitted himself to the hospital and who was well aware of the fact that the medication was an unsatisfactory solution to his chronic pain and was having a debilitating effect on him. By tricking him into a course of treatment that they could not persuade him to follow, the therapists deprived him of the freedom of choice to which he was entitled. Even though the patient's resistance may have been based on irrational fears, and even though the treatment may have been not only medically indicated but also consistent with the patient's own goals, there is much potential for abuse in the view that the therapist is better able to decide what is good for the patient than the patient himself. Thus, the sidestepping of informed consent represents a dangerous practice, although, alas, not an unprecedented one in hospital settings. 2. Does the use of deception undermine the quality of the relationship between therapist and patient? Clearly, there is the danger that a patient, once deceived, even though it may have been "for his own good," will no longer be able to fully trust the therapist, and that the therapist's future effectiveness may thereby suffer. The authors report that Mr. X, when informed of the deception, responded with some incredulity and anger, but there are no indications that the experience undermined the future course of treatment. Nevertheless, the possibility of such an effect cannot be discounted, particularly when we keep in mind that deception has a tendency to escalate and to spread into different areas of the relationship. The difficulty in containing decep-
172
COMMENTS tion is illustrated in the present case by the fact that the introduction of the placebo was accompanied by a second deception. As the dilution of the patient's medication began, a second drug was prescribed to ease his withdrawal symptoms (which, incidentally, seemed to play an important part in the success of the procedure, because Mr. X attributed the withdrawal symptoms that he did experience to the effects of this drug). The authors do not say what they told Mr. X about the purpose of this drug, but they obviously did not reveal its true purpose—to ease withdrawal—since he had not been told that he was undergoing withdrawal. 3. Does the use of deception have potentially damaging consequences for the patient's selfconcept? For many patients, a central or at least a derivative concern engendered by their symptoms is their inability to control their own lives. The brief history presented in the report suggests that this was a major issue for Mr. X, a man of many professional, intellectual, and social accomplishments, who found himself unable to lead the kind of life he wanted because of his chronic pain and drug dependence. One of the great virtues of the self-control training he received was that it helped to restore the sense of personal efficacy that he had lost. There is, in my judgment, a real danger that the discovery that he has been tricked and manipulated might confirm the patient's sense of dependence and powerlessness and prove a setback in his efforts to regain control over his own life. There is no indication in the case report that this happened to Mr. X, but the possibility of such subtly damaging consequences must be considered before we conclude that a deception is entirely benign. On the other side of the ledger, one can cite a number of mitigating factors that might serve to justify the use of deception in the present case: 1. The therapists were confronted with an ethical dilemma. Though concerned with the ethical implications of deceiving the patient, they "felt most obliged to use a procedure designed to help the patient achieve a personally and medically desirable goal" (p. 168). Mr. X's dependence on his medication was clearly destructive, as the patient himself realized, yet his resistance to giving up the drug was apparently overwhelming. What was needed was a dramatic demonstration that he could, in fact, do without it. The therapists made the clinical judgment that the only way they could provide this demonstration was to withdraw him without his knowledge and then
to confront him with this fact. Their report suggests that this clinical judgment was validated by the success of the treatment and the apparent absence of psychologically damaging side effects. It might be argued that the deception in this case did not deprive the patient of the opportunity to choose between different forms of treatment, involving different arrays of costs and benefits, but merely helped to overcome a barrier to a form of treatment that the patient really wanted but was afraid to enter into. 2. In support of the last point, the authors could cite the fact that the patient admitted himself to a ward in which "adjustment of pain medication was an explicit expectation of the setting" (p. 166). The patient did know, for example, that the medication schedule and the interval between injections were being modified. Thus, it can be argued that the deception was only partial and involved only the details and the timing of the treatment rather than the fact that such a treatment would be undertaken. Although there is no question that the patient was deceived, the treatment did seem to be within the range of possibilities to which he had at least implicitly given his consent. 3. A further mitigating factor is the way in which the decision to use deception was reached in this case. Indications are that it was not a routine or casual decision, based on the therapists' interest in making the job easier for themselves. The authors report that the staff wrestled with the task of reducing the drug dosage in light of the patient's great apprehension, and that they reached the decision to proceed without the patient's knowledge only after much discussion. Such a careful and responsible approach counteracts the potentially damaging long-term effects that the use of deception might otherwise have on hospital practices. It communicates the principle that deception can be countenanced only under very special circumstances and makes it less likely that such procedures will be legitimized, routinized, and institutionalized. On balance, I find it difficult, despite my real misgivings, to take an absolute stand against the use of deception in the case reported here. And yet I wonder whether the deception was really necessary. The patient seems to be a man who was highly motivated, had considerable ego strength, and showed an ability to accept objective evidence. Moreover, he gradually developed skills in controlling his pain and recognized the effectiveness of these skills. Might it have been possible, as his confidence in these self-control efforts grew, to obtain his consent to a procedure
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whereby the pain medication would be gradually withdrawn, with the understanding that (in the interest of counteracting resistances) he would not be told the exact timing and amount of withdrawal and that he would be closely monitored to deal with possible side effects of the procedure? I do not know to what extent the therapists tried or considered such a procedure. They apparently concluded that, once they reached the 6-hour injection interval, they could not obtain the patient's consent for further adjustments in the medication, because of his acute anxiety about any change, his conviction that he needed the medication, and his overt resistance to efforts in this direction. It would be presumptuous of me to secondguess the authors' clinical judgment, since I was not there, I am not familiar with the techniques they used, and I am not even a clinician. All I can do, therefore, is to raise the question and to point out that it is precisely the role of the outsider to raise the kinds of questions that may not emerge from 'an insider's perspective. From my reading of the authors' own description of the patient and the treatment, I come away with the feeling that they may have underestimated Mr. X's coping abilities. They do so, perhaps, because they work within a model that emphasizes specific behaviors (self-controlled relaxation, covert imagery, cognitive relabeling, causal attribution) without sufficient attention to the person responsible for those behaviors. I do not wish to minimize the value of the training techniques they employ; in fact I am greatly impressed with
their apparent effectiveness. I do not dismiss them on the grounds that they "merely" deal with symptoms, nor do I regard them as incompatible with the personal dignity of the patient. But I think it is important to keep in mind that the training program, for the patient, is part of a larger process of coping with his life situation. Thus, while Mr. X was obviously concerned with controlling his pain, he was also concerned with regaining control over his life, with fulfilling his potential, and with repairing a damaged self-concept. It seems reasonable to assume that, as he learned to control his pain, his self-confidence and sense of efficacy also grew. Let me suggest—and I do so with no sense of certainty—that the course of treatment might have been different if the therapists had been prepared to work with the broader motives that the patient brought to the treatment and to draw on the increasing coping capacities that the patient developed as the treatment proceeded—in other words, to deal with him as a whole person. They might have found that deception was not necessary to initiate the withdrawal procedure. They might even have concluded that deception was more likely to retard than to advance the treatment process. REFERENCES Bok, S. The ethics of giving placebos. Scientific American, 1974, 231 (5), 17-23. Levendusky, P., & Pankratz, L. Self-control techniques as an alternative to pain medication. Journal of Abnormal Psychology, 1975, 84, 165-168. (Received October 23, 1974)
Was Deception Justified—And Was It Necessary? Comments on "Self-Control Techniques as an Alternative to Pain Medication" Herbert C. Kelman Harvard University Ethical issues raised by the use of placebos in clinical practice are discussed in connection with the case of a patient undergoing self-control training, who was withdrawn from antipain medication without his knowledge by substitution of a placebo. Ethical problems resulting from the use of deception in this case center on the patient's right to informed consent, on the quality of the patient-therapist relationship, and on potential damages to the patient's selfconcept. On the other hand, a number of mitigating factors may well have justified the use of deception in this particular case. Nevertheless, the question is raised whether deception was really necessary and might have been avoided by a therapeutic model that goes beyond the control of specific behaviors and views the treatment as part of a larger process designed to enhance the patient's capacity to cope with his life situation. The case report by Levendusky and Pankratz (1975) provides a good starting point for considering some of the subtler ethical issues raised by the use of placebos in clinical practice.1 The authors describe the case of a patient who underwent a training program in self-control of severe pain through the use of relaxation, visual imagery, and cognitive labeling. He was highly resistant, however, to giving up his antipain medication, on which he had come to rely. The authors decided to withdraw him from the medication without his knowledge by substituting increasing proportions of a placebo for the medication. The deception involved was clearly designed to benefit the patient, and it apparently did contribute to a successful treatment program. Moreover, the indications are that the decision to use deception was taken responsibly, rather than casually. Thus we are obviously dealing with a benign deception, which makes it easier to focus on the ethical implications of deception as such, even where it does not cause any readily apparent harm to the patient. The use of deception in the case reported here raises several ethical questions: 1. Does the therapist have a right to decide what treatment is ih the patient's best interest without obtaining the patient's informed consent? Requests for reprints should be sent to Herbert C. Kelman, Harvard University, Department of Psychology and Social Relations, William James Hall, Cambridge, Massachusetts 02138. 1 My own thinking about these issues was greatly stimulated by Sissela Bok's recent paper (Bok, 1974). I am very grateful to Dr. Bok for showing me the manuscript and discussing some of the issues with me.
It is apparent from the report that Mr. X was a competent individual, who had voluntarily admitted himself to the hospital and who was well aware of the fact that the medication was an unsatisfactory solution to his chronic pain and was having a debilitating effect on him. By tricking him into a course of treatment that they could not persuade him to follow, the therapists deprived him of the freedom of choice to which he was entitled. Even though the patient's resistance may have been based on irrational fears, and even though the treatment may have been not only medically indicated but also consistent with the patient's own goals, there is much potential for abuse in the view that the therapist is better able to decide what is good for the patient than the patient himself. Thus, the sidestepping of informed consent represents a dangerous practice, although, alas, not an unprecedented one in hospital settings. 2. Does the use of deception undermine the quality of the relationship between therapist and patient? Clearly, there is the danger that a patient, once deceived, even though it may have been "for his own good," will no longer be able to fully trust the therapist, and that the therapist's future effectiveness may thereby suffer. The authors report that Mr. X, when informed of the deception, responded with some incredulity and anger, but there are no indications that the experience undermined the future course of treatment. Nevertheless, the possibility of such an effect cannot be discounted, particularly when we keep in mind that deception has a tendency to escalate and to spread into different areas of the relationship. The difficulty in containing decep-
172
COMMENTS tion is illustrated in the present case by the fact that the introduction of the placebo was accompanied by a second deception. As the dilution of the patient's medication began, a second drug was prescribed to ease his withdrawal symptoms (which, incidentally, seemed to play an important part in the success of the procedure, because Mr. X attributed the withdrawal symptoms that he did experience to the effects of this drug). The authors do not say what they told Mr. X about the purpose of this drug, but they obviously did not reveal its true purpose—to ease withdrawal—since he had not been told that he was undergoing withdrawal. 3. Does the use of deception have potentially damaging consequences for the patient's selfconcept? For many patients, a central or at least a derivative concern engendered by their symptoms is their inability to control their own lives. The brief history presented in the report suggests that this was a major issue for Mr. X, a man of many professional, intellectual, and social accomplishments, who found himself unable to lead the kind of life he wanted because of his chronic pain and drug dependence. One of the great virtues of the self-control training he received was that it helped to restore the sense of personal efficacy that he had lost. There is, in my judgment, a real danger that the discovery that he has been tricked and manipulated might confirm the patient's sense of dependence and powerlessness and prove a setback in his efforts to regain control over his own life. There is no indication in the case report that this happened to Mr. X, but the possibility of such subtly damaging consequences must be considered before we conclude that a deception is entirely benign. On the other side of the ledger, one can cite a number of mitigating factors that might serve to justify the use of deception in the present case: 1. The therapists were confronted with an ethical dilemma. Though concerned with the ethical implications of deceiving the patient, they "felt most obliged to use a procedure designed to help the patient achieve a personally and medically desirable goal" (p. 168). Mr. X's dependence on his medication was clearly destructive, as the patient himself realized, yet his resistance to giving up the drug was apparently overwhelming. What was needed was a dramatic demonstration that he could, in fact, do without it. The therapists made the clinical judgment that the only way they could provide this demonstration was to withdraw him without his knowledge and then
to confront him with this fact. Their report suggests that this clinical judgment was validated by the success of the treatment and the apparent absence of psychologically damaging side effects. It might be argued that the deception in this case did not deprive the patient of the opportunity to choose between different forms of treatment, involving different arrays of costs and benefits, but merely helped to overcome a barrier to a form of treatment that the patient really wanted but was afraid to enter into. 2. In support of the last point, the authors could cite the fact that the patient admitted himself to a ward in which "adjustment of pain medication was an explicit expectation of the setting" (p. 166). The patient did know, for example, that the medication schedule and the interval between injections were being modified. Thus, it can be argued that the deception was only partial and involved only the details and the timing of the treatment rather than the fact that such a treatment would be undertaken. Although there is no question that the patient was deceived, the treatment did seem to be within the range of possibilities to which he had at least implicitly given his consent. 3. A further mitigating factor is the way in which the decision to use deception was reached in this case. Indications are that it was not a routine or casual decision, based on the therapists' interest in making the job easier for themselves. The authors report that the staff wrestled with the task of reducing the drug dosage in light of the patient's great apprehension, and that they reached the decision to proceed without the patient's knowledge only after much discussion. Such a careful and responsible approach counteracts the potentially damaging long-term effects that the use of deception might otherwise have on hospital practices. It communicates the principle that deception can be countenanced only under very special circumstances and makes it less likely that such procedures will be legitimized, routinized, and institutionalized. On balance, I find it difficult, despite my real misgivings, to take an absolute stand against the use of deception in the case reported here. And yet I wonder whether the deception was really necessary. The patient seems to be a man who was highly motivated, had considerable ego strength, and showed an ability to accept objective evidence. Moreover, he gradually developed skills in controlling his pain and recognized the effectiveness of these skills. Might it have been possible, as his confidence in these self-control efforts grew, to obtain his consent to a procedure
174
COMMENTS
whereby the pain medication would be gradually withdrawn, with the understanding that (in the interest of counteracting resistances) he would not be told the exact timing and amount of withdrawal and that he would be closely monitored to deal with possible side effects of the procedure? I do not know to what extent the therapists tried or considered such a procedure. They apparently concluded that, once they reached the 6-hour injection interval, they could not obtain the patient's consent for further adjustments in the medication, because of his acute anxiety about any change, his conviction that he needed the medication, and his overt resistance to efforts in this direction. It would be presumptuous of me to secondguess the authors' clinical judgment, since I was not there, I am not familiar with the techniques they used, and I am not even a clinician. All I can do, therefore, is to raise the question and to point out that it is precisely the role of the outsider to raise the kinds of questions that may not emerge from 'an insider's perspective. From my reading of the authors' own description of the patient and the treatment, I come away with the feeling that they may have underestimated Mr. X's coping abilities. They do so, perhaps, because they work within a model that emphasizes specific behaviors (self-controlled relaxation, covert imagery, cognitive relabeling, causal attribution) without sufficient attention to the person responsible for those behaviors. I do not wish to minimize the value of the training techniques they employ; in fact I am greatly impressed with
their apparent effectiveness. I do not dismiss them on the grounds that they "merely" deal with symptoms, nor do I regard them as incompatible with the personal dignity of the patient. But I think it is important to keep in mind that the training program, for the patient, is part of a larger process of coping with his life situation. Thus, while Mr. X was obviously concerned with controlling his pain, he was also concerned with regaining control over his life, with fulfilling his potential, and with repairing a damaged self-concept. It seems reasonable to assume that, as he learned to control his pain, his self-confidence and sense of efficacy also grew. Let me suggest—and I do so with no sense of certainty—that the course of treatment might have been different if the therapists had been prepared to work with the broader motives that the patient brought to the treatment and to draw on the increasing coping capacities that the patient developed as the treatment proceeded—in other words, to deal with him as a whole person. They might have found that deception was not necessary to initiate the withdrawal procedure. They might even have concluded that deception was more likely to retard than to advance the treatment process. REFERENCES Bok, S. The ethics of giving placebos. Scientific American, 1974, 231 (5), 17-23. Levendusky, P., & Pankratz, L. Self-control techniques as an alternative to pain medication. Journal of Abnormal Psychology, 1975, 84, 165-168. (Received October 23, 1974)
