Jeremy Howick’s (2009) article is a welcome contribution to ethical debate surrounding the use of placebo-controlled clinical trials, because it approaches the issue from an unusual angle. Historically, the assumption that placebocontrolled trials (PCTs) are methodologically superior to active controlled trials (ACTs) has shaped the ethical debate by pitting those concerned about scientific rigor and benefits for future patients against those concerned about the welfare of current research participants. Howick’s article opens new areas of inquiry in an old discussion by questioning this fundamental assumption. Here we seek to refine some of Howick’s methodological arguments and expand on some of its possible ethical implications, particularly in regard to the use of PCTs in developing countries.