Therapeutic deception

No matter how much we would like to distill medicine down to something explainable and predictable, we are always going to be confronted with phenomena which defy explanation and run contrary to conventional dogma. Enter again the placebo. There is a nice piece in the online version of the Boston Globe which I came upon through Arts and Letters Daily:
http://www.boston.com/bostonglobe/ideas/articles/2010/05/09/the_magic_cure/?page=full

The piece summarizes nicely some of the more contemporary work on placebos for the treatment of human diseases. It raises a number of particularly interesting questions regarding placebos and their deployment in medical practice. One particularly devilish issue is whether a physician is obligated to reveal they are using a placebo for treatment. The author actually suggests there is data that placebos may work even if the patient knows they are placebos. I wonder if we would be obligated to inform the patient that there are side effects associated with placebos (nocebo effect)?

I suspect this issue will gain even more attraction in the future for the simple reason that our therapeutic endpoints become more and more focused on patient reported outcomes. It is difficult to imagine that placebos will have much effect on a fractured femur, sepsis, or a DVT. However, as we become more focused on end points relating to patient perceptions and symptoms, and the active drugs deployed have more subtle effect sizes, I can imagine that the placebo may become a better, safer, and cheaper alternative. How can we use this approach without violating patient trust?

It may be we need to delude ourselves first in order to allay our guilt that we might be deceiving our patients. An exclusion from practice may be too accurate reality testing.  Perhaps we will need to develop medications which impair our reality testing?