How Health Professionals Conceptualize and Represent Placebo Treatment in Clinical Trials and How Their Patients Understand It: Impact on Validity of Informed Consent.

CONTEXT: Previous studies suggested that many patients, who have given their informed consent to participate in randomized controlled trials (RCT), have somewhat limited understanding of what a placebo treatment is. We hypothesized that the relationship between patients and their health professionals plays a central role in this understanding. METHODS: We interviewed 12 patients included in RCTs (nine suffering from Parkinson's disease and three from Huntington's disease) and 18 health professionals involved with RCTs (eight principal investigators, four associated physicians and six clinical research associates). Semi-structured interviews were conducted after the RCTs had ended but before the treatment allocation was revealed. RESULTS: Only two patients clearly understood the aim of placebo-controlled RCTs. Only one principal investigator said she asks all her patients whether they agree to participate in RCTs. The seven others said they only ask patients who seem more likely to be compliant. Their selection criteria included docility and personality traits associated in other studies with enhanced placebo responses. According to 13 of the 18 health professionals, their relationship with patients may influence the amplitude of the placebo response. All but one clinical research associates added that the placebo response could result from a "maternal" type of care. All principal investigators said they have a strong influence on their patient's decision to participate. Finally, when interviewees were asked to narrate a memory of a medically unexplained healing, in eight of 11 physicians' narratives the beneficiary was a child while in 10 of 12 patients' narratives it was an adult. CONCLUSION: Our observations suggest that the interrelationship between health professionals and patients involved in RCTs could be compared to that between parents and children. Therefore, adherence to formal rules regarding informed consent does not ensure a balanced relationship between patients and health professionals.

An event in medical life, or the advent of a belief?

Freud's ambivalent relations with medicine are well known. Based on his relatively unknown text, A religious experience, published in 1928, the authors present an analysis of the internal reasons for this conflict. Responding to a letter from an American doctor, who tells him about his reactions to an autopsy and the influence it had on his religious faith, Freud suggests an analysis that leads him to make a surprising slip. This slip reveals the conflicts inherent in the practice of autopsy, considered as a peculiar event in medical training that puts a strain on the future medical practitioner's subjectivity. Based on the analysis of unconscious impulses and fantasmatic activity, the authors demonstrate that Freud's theory is still surprisingly relevant today in the light of testimonies from contemporary doctors confronted with autopsy during their training or daily practice.

L'analogie et le vrai en psychosomatique / Analogy and truth in psychosomatics

As teorias em psicossomática foram elaboradas a partir da confrontação entre medicina e psicanálise. Apesar dos progressos da medicina tecnocientífica, os estudos atuais da psicanálise efetivados no contexto dessa confrontação fecunda oferece regularmente elementos novos para a reflexão. A pesquisa apresentada aqui propõe acrescentar a o instante de dizer noção desenvolvida por M.-J. Del Volgo, a noção de analogização baseada sobre essa figura do discurso que constitui a analogia. A apresentação do caso de uma paciente sofrendo de eczema permite dar a sua plena consistência para essa noção, cujos efeitos podem, no final, renovar a visão defectologista própria à corrente psicossomática (AU)