Leicester (UK), Ten years ago, a scan revealed that I had a torn meniscus in my knee. The pain was severe and I was limping most of the time. My doctor recommended arthroscopic knee surgery to repair it.
Afraid of the scalpel, I asked if there were other options. He said I could try physiotherapy, but it was unlikely to work.I consulted a physio and did the suggested exercises diligently and my knee pain and function almost returned to normal. I also ran my first (and only) marathon a year later.
Physio is not the only thing that can work in the same way as arthroscopic knee surgery. In the 1990s, Dr. Bruce Moseley found 180 patients who had knee pain so severe that they had trouble getting up from their chairs. They were then given either real or sham (placebo) arthroscopy.The actual arthroscopy involves giving painkillers and inserting a small metal tube (an arthroscope) into the knee to repair damaged cartilage and remove loose bone fragments that are causing pain.
The sham (placebo) arthroscopy procedure involved painkillers and a small cut on their knees, but there was no arthroscope, no repair of damaged cartilage and no cleaning out of loose pieces of bone.
Patients receiving the sham procedure thought they were receiving the real procedure (this is called “blinding”). And doctors and nurses mimicked the sounds of real surgery. Blinding is considered important to prevent patients' expectations from influencing the results.All patients were monitored for two years to see how many stairs they could climb before the pain increased. The results were clear: The sham procedure was equally good for pain and function. Additionally, since cosmetic surgery is less invasive, it is less harmful. For example, the risk of infection is lower.
Moseley's results have been replicated several times.On this basis, we can expect that the less invasive sham procedure has replaced the more invasive – and more harmful – real version. Yet more than one million arthroscopies are performed each year in the US, each costing US$5,000 (GBP 3,935) or US$5 billion. And around 40,000 are carried out each year in the UK, each costing GBP 1,681 (a total of GBP 67 million).
A similar story can be told about sham surgeries for many other conditions. For example, sham vertebroplasty (inserting a needle into the spine where cement is usually injected) works the same as the real thing (injecting cement to fix a fractured vertebra).Unfortunately, the cement glue can leak, potentially leading to more fractures. More comprehensively, a review of 53 placebo-controlled surgery trials found that sham surgery was as good as the real thing in more than half of the studies. Sham knee and back surgery works in the same way as actual surgery for pain. A pretend brain implant works just as well as a real implant in reducing migraine attacks. Simulated laser surgery works just like real laser surgery to stop gastrointestinal bleeding.And the simulated surgery works in the same way as the real surgery to make the sphincters function more efficiently.
Three Reasons Ethicists (Wrongly) Reject It
There are three main reasons why sham surgeries have not replaced real versions despite their benefits. First, some ethicists claim that the sham procedure is too risky. But I would argue that the sham version is usually less risky than the real procedure, yet it can work just as well. Second, some people believe that sham surgery can be tricked into being effective. There is a need (to let people who have sham surgery know that it could be the real thing).While Moseley's patients were blinded, several trials have shown that sham interventions can be done "in good faith" (whereby patients are told that the placebo is a placebo) and still work.
Finally, the name. Sham surgery is not a sham or a placebo. Sham surgery activates the wound healing cascade.
All living organisms are very good at reviving themselves when cut. If you cut off the head of a planarian flatworm, it may still grow back.The human head cannot grow back, but many human organs repair themselves. Whether the cut is caused by a thorn or a surgeon's knife, the process of wound healing begins. This includes blood clots forming to stop bleeding, white blood cells phagocytosing (devouring) harmful bacteria and nourishing the tissue and healing the wound. This involves forming new tissue and blood vessels to close the wound. Eventually, scar tissue and skin cover the wound.
All this happens to any patient who undergoes sham surgery.So the healing process initiated after sham surgery may alter the function of the knees, shoulders and back in a way that reduces pain and improves function (research is needed to confirm this).
Additionally, placebo surgeries often involve painkillers. With less pain, people feel more free to move around, and moving around often can reduce pain and improve function. Hence so-called placebo or sham surgery is better named "minimally invasive surgery". Patients suffering from conditions where placebo surgery would have resulted in more invasive, expensive and risky surgery may be offered the option of minimally invasive surgery.They can be given honest instructions about what the process involves.
Given that doctors are bound by the Hippocratic Oath to help and avoid harm, and minimally invasive surgery helps just as much as more invasive surgery without causing as much harm, this is arguably an ethical requirement.(talk) PY
PY
Afraid of the scalpel, I asked if there were other options. He said I could try physiotherapy, but it was unlikely to work.I consulted a physio and did the suggested exercises diligently and my knee pain and function almost returned to normal. I also ran my first (and only) marathon a year later.
Physio is not the only thing that can work in the same way as arthroscopic knee surgery. In the 1990s, Dr. Bruce Moseley found 180 patients who had knee pain so severe that they had trouble getting up from their chairs. They were then given either real or sham (placebo) arthroscopy.The actual arthroscopy involves giving painkillers and inserting a small metal tube (an arthroscope) into the knee to repair damaged cartilage and remove loose bone fragments that are causing pain.
The sham (placebo) arthroscopy procedure involved painkillers and a small cut on their knees, but there was no arthroscope, no repair of damaged cartilage and no cleaning out of loose pieces of bone.
Patients receiving the sham procedure thought they were receiving the real procedure (this is called “blinding”). And doctors and nurses mimicked the sounds of real surgery. Blinding is considered important to prevent patients' expectations from influencing the results.All patients were monitored for two years to see how many stairs they could climb before the pain increased. The results were clear: The sham procedure was equally good for pain and function. Additionally, since cosmetic surgery is less invasive, it is less harmful. For example, the risk of infection is lower.
Moseley's results have been replicated several times.On this basis, we can expect that the less invasive sham procedure has replaced the more invasive – and more harmful – real version. Yet more than one million arthroscopies are performed each year in the US, each costing US$5,000 (GBP 3,935) or US$5 billion. And around 40,000 are carried out each year in the UK, each costing GBP 1,681 (a total of GBP 67 million).
A similar story can be told about sham surgeries for many other conditions. For example, sham vertebroplasty (inserting a needle into the spine where cement is usually injected) works the same as the real thing (injecting cement to fix a fractured vertebra).Unfortunately, the cement glue can leak, potentially leading to more fractures. More comprehensively, a review of 53 placebo-controlled surgery trials found that sham surgery was as good as the real thing in more than half of the studies. Sham knee and back surgery works in the same way as actual surgery for pain. A pretend brain implant works just as well as a real implant in reducing migraine attacks. Simulated laser surgery works just like real laser surgery to stop gastrointestinal bleeding.And the simulated surgery works in the same way as the real surgery to make the sphincters function more efficiently.
Three Reasons Ethicists (Wrongly) Reject It
There are three main reasons why sham surgeries have not replaced real versions despite their benefits. First, some ethicists claim that the sham procedure is too risky. But I would argue that the sham version is usually less risky than the real procedure, yet it can work just as well. Second, some people believe that sham surgery can be tricked into being effective. There is a need (to let people who have sham surgery know that it could be the real thing).While Moseley's patients were blinded, several trials have shown that sham interventions can be done "in good faith" (whereby patients are told that the placebo is a placebo) and still work.
Finally, the name. Sham surgery is not a sham or a placebo. Sham surgery activates the wound healing cascade.
All living organisms are very good at reviving themselves when cut. If you cut off the head of a planarian flatworm, it may still grow back.The human head cannot grow back, but many human organs repair themselves. Whether the cut is caused by a thorn or a surgeon's knife, the process of wound healing begins. This includes blood clots forming to stop bleeding, white blood cells phagocytosing (devouring) harmful bacteria and nourishing the tissue and healing the wound. This involves forming new tissue and blood vessels to close the wound. Eventually, scar tissue and skin cover the wound.
All this happens to any patient who undergoes sham surgery.So the healing process initiated after sham surgery may alter the function of the knees, shoulders and back in a way that reduces pain and improves function (research is needed to confirm this).
Additionally, placebo surgeries often involve painkillers. With less pain, people feel more free to move around, and moving around often can reduce pain and improve function. Hence so-called placebo or sham surgery is better named "minimally invasive surgery". Patients suffering from conditions where placebo surgery would have resulted in more invasive, expensive and risky surgery may be offered the option of minimally invasive surgery.They can be given honest instructions about what the process involves.
Given that doctors are bound by the Hippocratic Oath to help and avoid harm, and minimally invasive surgery helps just as much as more invasive surgery without causing as much harm, this is arguably an ethical requirement.(talk) PY
PY
