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Surgical Placebo in Jewish Law
Placebos have been used in one orm or another or atleast two centuries.
Researchers in the late eighteenth century,in an attempt to establish science as a sound discipline separaterom unorthodox and unconventional felds o treatment andtherapy, recognized the idea o conounding environmentaland psychological actors and attempted to mitigate them asbest possible. For most o its history, however, placebo use waslimited to medical treatments, and not initially applied to sur-gical procedures.In 1959, a landmark trial o internal mammary artery ligation was conducted, introducing the concept o surgicalplacebo and exposing the practice to ethical scrutiny.
It wasthought that the chest pain associated with heart attacks andangina was caused by decreased blood ow to the chest wall.By ligating the blood supply to the chest wall, the pain wouldbe preemptively mitigated. Patients enrolled in the control arm
I would like to extend my appreciation to R. Dr. Edward Reichman or hishelpul comments during the preparation o this article.1 .J. Kaptchuk, “Intentional ignorance: A history o blind assessment andplacebo controls in medicine,
Bulletin of the History of Medicine 
72:3 (Fall1998):389-433.2 L.A. Cobb, G.I. Tomas, D.H. Dillard, K.A. Merendino, R.A. Bruce,“An evaluation o internal-mammary-artery ligation by a double-blindtechnique,”
New England Journal of Medicine 
260 (1959): 1115-8.Dr. Yehuda Salamon is a frst year resident in anesthesiology at MonteforeMedical Center
Surgical Placebo in Jewish Law 
o the study had their chest cavity opened without any proce-dure actually perormed. Questions concerning the ethics o perorming such an invasive surgery without perorming thebenefcial technique arose as a result o this attempt to producea scientifcally sound experiment.Nearly our decades later, another surgical placebo trial was conducted using etal niagrostriatal dopaminergic neuronsgrated into the brains o patients suering rom Parkinson’sdisease.
Similar to the dramatic and invasive nature o thearterial ligation, the placebo-controlled patients were anesthe-tized and a burr-hole procedure
was perormed, without any additional invasive technique. In ollow-up, these placebo pa-tients were given the same medical treatments that their treatedcounterparts received, including a dose o Cyclosporin. A surgical placebo trial in 2002 ollowed a less severeprotocol. Arthroscopy and debridement had become the stan-dard treatment or osteoarthritis in the knees.
Moseley et alconducted a randomized double-blinded case-controlled study, with the placebo patients receiving modifed sedation and ew incisions and closures in the knee. A unique eature o thistrial was the inormed consent process, wherein the patient wasasked to write a description o the placebo arm o the trial,indicating their explicit consent to that possibility.
 In the latter two cases, controversy was sparked anew or a number o reasons, primarily because in the last two de-
3 O. Lindvall, G. Sawle, H. Widner, et al., “Evidence or long term survivaland unction o dopaminergic grats in progressive Parkinson’s disease,”
 An-nals of Neurology 
35 (1994): 172-80.4 Essentially, a small hole was drilled into a bone in the skull, without pen-etrating entirely through.5 Osteoarthritis occurs due to the breakdown o cartilage in, and subsequentnarrowing o, joint spaces, producing pain on movement. Te standard o treatment is orally administered pain medications, specifcally NSAIDs, orsurgical arthroscopy o the knee, which entails debridement o the jointspace.6 J.B. Moseley, K. O’Malley, N.J. Petersen, et al, “A controlled trial o ar-throscopic surgery or osteoarthritis o the knee,”
New England Journal of   Medicine 
347 (2002): 81-8.
Verapo Yerape 
cades, ewer and milder morbidities are attributed to surgicalinterventions than in the mid-twentieth century. Te debate,in large part, revolved around defning and determining theappropriate risk-beneft ratio that could justiy these invasiveand potentially harmul procedures.
Secular Ethical Concerns
Although the goal o this paper is to discuss Jewishethical considerations as they pertain to surgical placebo, a dis-cussion o the major ethical arguments outside o a religiouscontext in avor o and opposed to the conduction o such tri-als will serve well to introduce the religious concerns.Ruth Macklin is the major opponent o these so-calledsham” procedures (her coinage), and she oers a series o argu-ments that seek to undermine the legitimacy o the use o thesehazardous placebos.
She frst argues that the use o placeboshould be limited to situations in which there is no alterna-tive standard o care available. She defnes placebo very strictly,however, limiting its justifable property to benignity, such thatany negative eect whatsoever renders it unethical to adminis-ter. One must always minimize the risk o harm to the subjects,Macklin opines, which surgical placebos ail to do.Focusing on the risk-beneft ratio, Macklin believesthat any risk greater than that which is engendered by a medi-cal placebo would preclude entirely any ethical allowances. Sherecognizes the therapeutic potential o these surgical placebosand its equivalence to that o medicinal placebos, but she doesnot see this equivalence as justifcation or the risk that patientsencounter in their treatment. Additionally, she fnds that theinormed consent procedure is not eective enough in dispel-ling common misconceptions regarding the interests o thetrial, the patients, and the doctors.Macklin’s criticisms came in response to the argumentsand justifcations o Tomas Freeman et al, who elaborate on
7 R. Macklin, “Te ethical problems with sham surgery in clinical research,”
New England Journal of Medicine 
341 (1999): 992-5.

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