the observation that physicians opt for impure placebos rather than pure placebos is disconcerting because most ethical debates and professional policies focus squarely on pure placebos . clearly , deliberately prescribing inert tablets differs in many ways from prescribing active treatments , which may benefit the patient despite a lack of supporting evidence . however , because physicians accept the benefit of placebo - like interventions,2 
 6 
 7 these two examples share much in common . moreover , unless fully disclosed to the patient , prescriptions for unproven active interventions infringe on patient autonomy and informed consent in the same way that pure placebos do , yet the active nature of these medicines also carries the risk of adverse effects . whereas physician surveys identify global patterns in the clinical use of placebos , interpretation of regional differences  conceptually and practically  must consider relevant sociocultural and political environments . despite the dominance of modern biomedicine in all recently surveyed countries , alternative medical systems integrate alongside , or otherwise coexist with , conventional medicine to varying degrees . national healthcare models also differ , for example , publicly versus privately funded systems , as do legal and regulatory frameworks , professional codes and the social values in which they evolved . placebo effects vary as a function of country and culture.8 perhaps such cultural variations lend colour to physician perceptions and the use of different types of placebos  for example , contributing to the tendency of american physicians to prescribe antibiotics as placebos , while their colleagues in canada and denmark tend to prescribe vitamins.2 
 3 
 5 qualitative methods , to complement our quantitative approaches , are necessary to better capture the nuanced views of practicing physicians . and yet , we continue to turn to quantitative studies in order to identify new and pressing directions for future research . for example , canadian psychiatrists are six times more likely than non - psychiatrist physicians to prescribe sub - therapeutic doses of drugs to patients . in light of the incremental dosing practices associated with antidepressants , and the continuing controversy over their clinical efficacy for mild - to - moderate depression , our team interviewed psychiatrists to explore notions of sub - therapeutic doses and to shed light on their role  as well as that of placebo effects  in the clinical treatment of depression . briefly , none of the interviewed psychiatrists equated sub - therapeutic doses with placebos , but several acknowledged that placebo effects likely contribute to positive patient responses following ingestion of very low doses . furthermore , physicians appear to promote placebo effects through their interactions with patients , consciously crafting language around the topic of dose to shape expectancies of both improvement and adverse effects.9 whereas psychiatrists may shy away from explicitly invoking placebo effects , elements of placebo medicine retain an essential place in modern psychiatry . physician surveys from europe , north america and the middle east consistently report the clinical use of placebos  predominantly impure and active placebos . regardless of methodological discrepancies , these studies underscore the need to expand ethical debates on the clinical use of placebos beyond inert treatments . with conceptual inconsistencies leaving many physicians unaware of the fact that they prescribe impure placebos,2 
 9 
 10 educating medical students about the science of placebos  a topic rarely taught  is a fundamental step towards clarifying misconceptions , aligning terminologies and making ethical and judicious use of placebos in clinical practice.11 from the american medical association 's restrictive position to the german medical association 's permissive stance , policies regulating the use of placebos are nascent and controversial when they are not entirely absent , as is the case in canada . this may , stakeholders ranging from physicians and scholars to policy makers and lawyers will convene in montreal to seek consensus and to forward canadian policy recommendations . only through such opportunities to share knowledge and exchange perspectives can we tackle the complex nature and far - reaching implications of the use of placebos in the clinic . do media headlines oversimplify the nature and prevalence of the use of placebos in modern medicine ? without question . do existing survey data , with their inclusion of both pure and impure placebos , inflate the perceived use of inert treatments ? most likely . do methodological differences between studies obscure direct comparison of results ? to some extent .
increasingly a focus of research as well as media reports and online forums , the use of placebos in clinical medicine extends beyond sugar pills and saline injections . 
 physician surveys conducted in various countries invariably report that placebos are routinely used clinically , impure placebos more frequently than the pure ones , and that physicians consider them to be of legitimate therapeutic value . 
 inconsistent study methodologies and physician conceptualisations of placebos may complicate the interpretation of survey data , but hardly negate the valuable insights these research findings provide . because impure placebos are often not recognised as such by practitioners , they remain at the fringe of many placebo - related debates , hence quietly absent from discussions concerning policy and regulation . 
 the apparent popularity of impure placebos used in clinical practice thus presents unresolved ethical concerns and should direct future discussion and research .