In October of 1973, Sam Shoeman was diagnosed with terminal cancer and given three months to live. Just after New Year’s, he passed away. However, an autopsy revealed that his original liver scan was faulty and his tumor was so small it couldn’t possibly have killed him. His doctor could not determine the cause of death stating “[Shoeman] didn’t die from cancer, but from believing he was dying of cancer” (Pilcher, 2009). Today, doctors routinely cite Shoeman as a victim of the nocebo effect.
We are all familiar with the placebo effect, as we discussed it in class today. A patient takes a pill — which could simply just be sugar — and somehow they feel better! However, Psychology Today describes the placebo’s equally powerful and far less understood evil twin: the nocebo effect, or the unintended consequences of negative thinking (Barber, 2012). The nocebo effect has the potential to disrupt how we communicate with our doctors while demonstrating the true power of the human mind.
In Latin, nocebo translates to “I will harm” (Merriam-Webster, 2017). But it’s true power doesn’t only lie in linguistics. A 2011 article in the journal of Neuropsychopharmacology defines the placebo effect as a positive reaction that stems from the suggestion of benefits. Conversely, the nocebo effect is a negative reaction that stems from the suggestion of harmful side effects (Benedetti, 2011). For example, at the University of California, participants had electrodes strapped onto their heads and were told that the electric current may cause severe headaches. Over 67% reported headaches; however, not a single volt of electricity was produced (Fox, 2012).
The fact that just mentioning negative symptoms can worsen a patient’s outcome challenges informed consent. Doctors are required to tell patients about all possible side effects of any treatment. But knowledge of the nocebo effect places physicians in an ethical dilemma, giving a whole new perspective to the old adage, “truth hurts.” In March of 2012, researchers at Harvard proposed a way to combat this ethical tug-of-war: contextualized informed consent (Wells, 2012). Dr. Colloca at the National Institutes of Health explains that when a doctor says “2% of subjects experienced this nasty side effect”, the patient will focus on the harm. But if the doctor says “98% of patients did not have that experience”, patients are less likely to experience the nocebo effect while still being informed (Berdik, 2012). In other words, the nocebo effect highlights the need for even more care when doctors and patients communicate.
While doctors may use their knowledge of the nocebo effect to alleviate pain, some may be more inclined to invoke the evil twin for less noble intentions. A 2011 article in Science Translational Medicine examines how the nocebo effect can intentionally induce pain. Participants were separated into 2 groups. Each was given a steady dosage of pain medication as heat was applied to their leg. Group 1 was told that the medication was starting. This knowledge doubled the positive effects of the medication. However, Group 2 was told mid-experiment that their medication had stopped and they may feel more pain (even though it didn’t actually stop). The nocebo effect was so strong that the group reported pain at the same level as a third group receiving no medication (Bingel, 2011). In other words, doctors used the nocebo effect to create pain that didn’t exist. Imagine this ability in the hands of interrogators bound by strict restrictions on physical harm. How might attitudes on torture shift if pain stems only from the mind of the victim?
In conclusion, the placebo effect (and now, the nocebo effect) present significant ethical questions surrounding the principles of respect for patient autonomy and nonmaleficence. Can we find a way to balance both of these principles? Comment with your thoughts!
REFERENCES
Pilcher, H. (2009). The science of voodoo: when mind attacks body. New Scientist.
Barber, N. (2012). Voodoo Death I. Psychology Today.
Merriam-Webster. (2017). Definition of nocebo. Merriam-Webster Dictionary.
Benedetti, F.; et al. (2011). How Placebos Change the Patient’s Brain.
Fox, E. (2012). Rainy Brain, Sunny Brain: How to Retrain Your Brain to Overcome Pessimism.
Berdik, C. (2012). The nocebo effect: how health warnings make you sick. Boston Globe.
Hi Julia!
This is a really interesting post! I have not previously heard of the nocebo effect, but I definitely see how it presents a problem. Although they may have the same underlying principles, I think that the idea of a placebo effect and nocebo effect should be examined separately. While patient autonomy is relevant in both cases, nonmaleficence is not. Considering the placebo effect is used “in the hope that it will produce a therapeutic effect” and relieve patients of unpleasant symptoms, I think it falls more under the principle of beneficence (Lichtenberg, Heresco-Levy, Nitzan). Based on the cases we looked at, it appears that placebos are usually used when traditional methods of pain relief are no longer working or if actual medication is not necessary for the patient, as seen in Case 2 from the Lichtenberg article. If a placebo effect is usually not harmful, produces less (if any) side effects and is prescribed with the principles of beneficence in mind, I think its use is justified.
However, as you mentioned in your post, it may be difficult to prevent a placebo effect from turning into a nocebo effect. Both of these effects are considered to be expectation effects, which means “the person taking the placebo may experience something along the lines of what he or she expects to happen” (“Placebo Effect”). If this is the case, it does seem rather easy for a patient to flip back and forth between experiencing a positive placebo effect to a negative nocebo effect simply based on a conversation with a physician or even a friend about the “treatment”. Is this enough of a reason to prevent the use of placebo effects? Does the risk of potentially becoming a nocebo effect and claiming to experience harms that are not there outweigh the benefits of potentially instilling a therapeutic placebo intervention?
I also wonder if it is possible to generalize these expectation effects to traditional medications. If there exists a correlation between believing you will get better and getting better as well as hearing potential side effects and then claiming to experience the side effects, should physicians limit the amount of information they give patients regarding potential side effects if they are not overly detrimental to the patient’s health? Most medications have a variety of side effects; however a majority of the potential side effects are fairly miniscule and will not cause any life-threatening consequences. In these cases should physicians consider only alerting the patients of the most severe side effects with the hope of preventing this nocebo effect in regards to the more minor side effects? Although this would be done with good intentions, does it overstep the boundaries with regards to patient autonomy?
Once again, I really liked this post! I think comparing the two opposing sides of expectation effects is important to consider when discussing whether or not the use of a placebo is ethical or safe in the first place.
References
Lichtenberg, P., U. Heresco-Levy, and U. Nitzan. “The Ethics of the Placebo in Clinical Practice.” Journal of Medical Ethics 30.6 (2004): 551-54. BMJ, Dec. 2004. Web.
“Placebo Effect.” American Cancer Society. N.p., 10 Apr. 2015. Web. 07 Feb. 2017.
Hi Julia!
Your post was very interesting; I didn’t realize a nocebo response could be so powerful. The placebo effect is known to affect patients suffering from serious ailments. As Kenquavius pointed out in his post, a placebo could be so strong it could rival the success of the actual medicine. With the possibility of a nocebo response being this strong, it truly does bring into question some ethical responsibilities at the hands of medical professionals. For instance, if a doctor may be harming a patient by informing them of possible side effects, is he acting in an ethical manner? Whether they know it or not, doctors have an incredible influence over their patients. “The verbal and nonverbal communications of physicians contain numerous unintentional negative suggestions that may trigger a nocebo response.” (Planès, et al.) When a simple notion of suggestive language may influence the way a patient perceives a treatment or procedure, does the patient really have full autonomy? The way I see it, there isn’t a way to obtain medical advice without bias. Doctors will always give their opinion on the best course of action. Therefore, patients should always obtain a second opinion. A way to reduce this unintentional bias may be to obtain the opinions of multiple doctors or medical professionals.
References
Planès, Sara, Céline Villier, and Michel Mallaret. “The Nocebo Effect of Drugs.” Pharmacology Research & Perspectives. John Wiley and Sons Inc., Apr. 2016. Web. 07 Feb. 2017.
“Unlocking the Healing Power of You.” National Geographic. National Geographic, 24 Jan. 2017. Web. 07 Feb. 2017.
Hey Julia
Awesome job on this post. This idea of the Nocebo is very interesting especially since it is the opposite spectrum of the placebo effect that we were discussing in class. The idea of the nocebo effect and the placebo effect are very similar to what sociologists call “A Self Fulfilling Prophecy”. A Self-Fulfilling Prophecy is basically a prediction that directly or indirectly causes itself to become true. In this sense, the patient’s mind is basically shaped by the idea of “prophecy”. This is actually very common amongst all people. For many people, their first instinct when they are sick with symptoms is to look up online what disease they could possibly have. And as you know, nothing is set in stone and the internet would probably tell you that you have something that you don’t. This ultimately leads to anxiety and distress, which are probably a branch of this Nocebo Effect.
What is also very interesting in terms of science is that we have yet to discover the full potential of our minds in connection to our bodies. You can see this as many cultures have adopted many different ways of treating patients because there are still many things unknown. E.g. Western medicine and Eastern medicine are very much different.
What I found really interesting is that you mentioned that the Nocebo Effect highlights the need for more care between doctor and patient communication. I agree with this statement because doctors need to be aware of how patients can respond to certain things that they tell them. We discussed this idea in class as well.
I also see how the Nocebo Effect could be an unintentional act of violating non-maleficence for the doctor. The facts, especially in healthcare setting, already have many negative connotations deemed societally. For example, if the doctor says the words “risk, indefinite, unsure, probability, possible could cause…” and though these are all facts, there is already a negative connotation instilled. Now a question comes up of how can we possible avoid this underlying implicative undertone?
Hi Julia,
Your post reminded me of a true story that I read in a book which I’m currently reading for another class, called The Cure Within. It’s about a patient named Mr. Wright that was diagnosed with a very aggressive cancer. It had completely invaded his body–he had tumors “the size of oranges” and was on oxygen and sedatives. He heard about this experimental drug, however, and insisted the doctors administer the drug to him. Even though he didn’t fit the criteria for the trial (because he had less than three-months to live) doctors gave him the medicine, and he improved drastically better than everyone else in the trial almost instantly. Shortly after, Mr. Wright read in the newspapers that the drug trial was actually failing, and this news caused him to relapse. Doctors decided to lie to him and told him not to believe in newspapers. They gave him another installment of the drug (which was actually just a saline shot). Again, he had a remarkable improvement and was even able to fly back home. For a while, he was completely fine, but then the American Medical Association announced that the medicine administered to Mr. Wright was a definite failure. Mr. Wright again relapsed and died from his cancer two days later.
I think this is a perfect example of the power of positive and negative thinking, while also describing the placebo effect. While this may be an extreme case, who’s to say that negative thoughts degrade health and positive thoughts improve health. I think in the long run, Mr. Wright’s cancer would have definitely killed him (I don’t think positive thinking or the placebo effect is the cure for diseases), but I do think positive thoughts improve the potential outcomes of situations. I agree with you in that doctors should be conscious with how they word situations when describing them to patients. If there is any way to improve the perspective that the patient has on their outcome, then I believe doctors should do anything that they can in order to help them, even if it’s as small as better word choice.
Work Cited
Harrington, Anne. The Cure Within: A History of Mind-Body Medicine. W.W. Norton
& Company, 2008.
Hey Julia,
Thank you so much for introducing the phenomenon of nocebo effect into our discussion. When I read some articles online pertaining to nocebo effect, I was baffled to see that not a lot of empirical studies have been conducted to better understand this effect. Which in turn hasn’t helped the medical community because there has not been sufficient discussion on how to potentially deal with it. One of the articles I read suggested a technique of “authorized concealment” to potentially reduce the nocebo effect in patients. In authorized concealment approach patients who have been prescribed drug are asked if they agree not to receive information about certain types of side effects. Obviously adverse side effects with the potential of serious harm have to be disclosed as it is important for the patients to make an informed consent. There are definitely some limitations to this approach such as patients rejecting the drug if they didn’t know all the side effects of the drug, patients finding out the side effects of the drug anyways through the internet. Another potential unethical objection to this technique may be that it seems that patient autonomy is compromised as they are not given all the information, but the article argues that it wouldn’t compromise patient autonomy because they willingly chose not to get information about the side effects.
I was very surprised during our class discussion about the angiogram case study when a lot of people sided with the opinion that the physician must disclose all the potential outcome of the procedure, even if it is practically impossible (less than 0.01% chance). I wonder if after knowing about the nocebo effect people would change their opinion on whether physicians should disclose every bit of information about the negative outcome of the procedure if it meant potentially increasing the chance of it happening in the first place. Talking to my father who practiced medicine for more than 25 years in India where the principles of patient autonomy are not upheld as much as it is in the west, I learned a lot about how doctors deal with this issue when their patients, in many cases illiterate and superstitious, may react more severely to information about minute negative outcomes. In balancing the principles of non-maleficence and patient autonomy, I have to admit that I do side with the former in lot of this cases.
Work cited:
Colloca, Luana, and Franklin G. Miller. “The Nocebo Effect and Its Relevance for Clinical Practice.” Psychosomatic medicine 73.7 (2011): 598–603. PMC. Web. 11 Feb. 2017.