LITERATURE REVIEW / REVUE DE LA LITTÉRATURE DOSSIER Placebos in Clinical Practice: an Ethical Overview Placebos dans la pratique clinique : un aperçu éthique M. Annoni · F.G. Miller Received: 13 June 2014; Accepted: 5 November 2014 © Lavoisier SAS 2014 Abstract The use of placebos in clinical settings raises a host of important ethical issues. On the one hand, ethical guidelines tend to categorically prohibit the clinical use of placebos because they require deception. On the other hand, a growing series of empirical studies has revealed that place- bos can be clinically effective and are still widely used by health professionals. In this article we provide a synthetic overview of the ethical debate discussing: 1) the ethics of deceptive placebos; 2) the ethics of placebos without decep- tion, and 3) the ethics of eliciting placebo responses without administering a traditional placebo. Keywords Ethics · Clinical medicine · Placebo · Deception · Open-label placebos Résumé L ’utilisation de placebos dans les milieux cliniques soulève plusieurs questions éthiques importantes. D’une part, les lignes directrices éthiques ont tendance à interdire catégoriquement l’utilisation clinique des placebos, car ils nécessitent la tromperie. D’autre part, de plus en plus d’études empiriques ont révélé que les placebos peuvent être cliniquement efficaces et qu’ils sont encore largement utilisés par les professionnels de la santé. Dans cet article, nous proposons un aperçu synthétique du débat éthique en abordant : 1) l’éthique de placebos avec tromperie ; 2) l’éthi- que de placebos sans tromperie et 3) l’éthique de déclencher des réponses placebo sans l’administration d’un placebo traditionnel. Mots clés Éthique · Médecine · Placebo · Tromperie · Étude ouverte avec placebos Introduction A placebo is a medical intervention believed to be inactive for the patient’ s condition but administered by a health pro- fessional as if it was an active treatment [1]. Depending on the circumstances and on the biomedical theory assumed, a placebo can be a pill, an injection, a diagnostic or even a surgical procedure [2]. Placebos are usually defined as “pure” if they are believed to lack therapeutic properties in general (e.g. lactose pills, saline injection, etc.), and “impure” if they are known to be effective for other condi- tions or under diverse modalities of administration (e.g. anti- biotics for viral infections, over-the-counter analgesics, vita- mins, etc.) (for a discussion of this distinction see [3,4]). Pure placebos are often described as “inert,” but this is mis- leading because lactose pills or saline injections contain ingredients with biochemical properties and these “inactive” interventions can be effective in promoting placebo responses. The use of placebos in clinical settings raises a host of important ethical questions, the most important of which regards the use of “benevolent”, “paternalistic” or “therapeutic” deception. Is it ever ethical to deceive patients for their own good? In this article we provide a synthetic overview of the ethical debate over the clinical use of place- bos, focusing on their use as interventions in clinical practice as distinct from their use as control interventions in random- ized, placebo-controlled trials. What follows is divided in four parts. First we reconstruct the historical debate over the use of placebos. Then, in section two, we review the main ethical arguments advanced to support or restrict the clinical use of deceptive placebos. Finally, we introduce the newer strands of the debate by discussing the ethics of placebos without deception and the ethics of eliciting pla- cebo effects without administering physical placebos. The origins of the placebo debate In contemporary medicine the practice of administering inactive interventions has been relatively common until the M. Annoni (*) Dipartimento di Scienze della Salute, University of Milan & Department of Experimental Oncology, IEO, Istituto Europeo di Oncologia Via Adamello 16, 20139, Milan, Italy e-mail : marco.annoni@ieo.eu F.G. Miller Department of Bioethics, National Institutes of Health, 10 Center Drive, Building 10, Room 1C118 Bethesda, MD 20892-1156 Douleur analg. DOI 10.1007/s11724-014-0400-1