182 Isr J Psychiatry Relat Sci - Vol. 51 - No 3 (2014) ABSTRACT Prior to the development of the pharmaceutical industry and the advocacy of evidence based medicine in the late 20th century, placebo treatments were commonly used by physicians. In current clinical practice, neither a physician’s confdence in the efcacy of a specifc treatment nor his personal ethical norms are any longer sufcient to initiate a given therapy. We will discuss whether placebo treatments can be ethically used in clinical practice as an alternative to standard therapy, and propose an innovative conceptualization of the factors involved in the exclusion of placebo treatments from the clinical seting. Patient-related ethical and interpersonal arguments and physician-related legal and ideological arguments concerning placebo usage are presented. We describe current use of placebo treatments in the healthcare system and suggest that placebo therapy thrives and that its therapeutic efcacy is widely acknowledged. There is currently “underground” use of placebo medication, open label placebo trials, and innovative approaches to informed consent to facilitate ethical prescription of placebo therapy. Finally, using the specifc example of treatment for depression, we demonstrate how the arguments against placebo use might be undermined, to retrieve the legitimacy of placebo therapy. Address for Correspondence: Uri Nitzan, MD, 15 Hatet-Zain St., Ramat Hachayal, Tel Aviv 69276, Israel. urini@clalit.org.il “And the Lord said unto Moses, Make thee a fery serpent, and set it upon a pole: and it shall come to pass, that every one that is bitten, when he looketh upon it, shall live.” Subsequently, and until the 20 th century, placebo continued to be an essential component in the treatment of patients. In 1807 Tomas Jeferson wrote in a letter to Dr. Casper Wistar: “One of the most successful physi- cians I have ever known, has assured me, that he used more bread pills, drops of colored water, and powders of hickory ashes, than of all other medicines put together. It was certainly a pious fraud” (1). Te frst clinical trial using a placebo arm took place in 1931 (2). Since then, and following the development of efective and specifc interventions, and the intensifying implementation of the principle of informed consent, placebo usage was gradually eliminated from the clinical setting. Nonetheless, in many randomized controlled trials a placebo arm is still considered the gold standard control method. An active control arm is another option, depend- ing on the efcacy of standard treatment. Nussinovitch et al. (3) discuss in detail the ethical dilemma involved, and the essential question is: are we allowed to administer an inert pill to a sick patient when an efcient and approved drug already exists? Substantial literature addresses this dilemma. Emanuel and Miller (2) delineate strict guidelines for the use of placebos in clinical trials in their seminal paper in the New England Journal of Medicine. Additional guidelines were published by the European Agency for the Evaluation of Medicinal Products, as part of the International Ethical Guidelines for Biomedical Research involving Human Subjects, and a position paper regard- ing the matter was also published by the Israel Medical Association in 2004 (3). Discussing the interesting and complex role of placebo in clinical trial deserves a separate paper and is beyond the scope of the present manuscript. In a sense, medical science defnes evidence-based efcacy of drugs by “excluding the placebo efect.” However, INTRODUCTION Since ancient times, physicians have commonly used non-specifc placebo treatments. An early example is the story of the Nehushtan in the Book of Numbers [21:8]; Using Placebo Medications in the Clinical Seting – An Intellectual Game or a Possible Reality? Uri Nitzan, MD, 1,2 Yuval Bloch, MD, 1,2 and Shmuel Fennig, MD 1,2 1 Shalvata Mental Health Care Center, Hod Hasharon, Israel 2 Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.