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Commentary: Harm, Truth, and the Nocebo Effect

Published online by Cambridge University Press:  11 March 2020

DIEN HO
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Extract

Nocebo effects occur when an individual experiences undesirable physiological reactions caused by doxastic states that are not a treatment’s core or characteristic features.1 As Scott Gelfand2 points out, there are numerous studies that have shown that the disclosure of a treatment’s side effects to a patient increases the risk of the side effects. From an ethical point of view, nocebo effects caused by the disclosures of side effects present a challenging problem. On the one hand, clinicians’ duty to inform patients of the consequences (including possible side effects) of their treatments is critical in ensuring that patients’ autonomy is respected. Patients cannot act autonomously if relevant information is withheld from them (without their consent, perhaps). On the other hand, clinicians also ought to minimize harm to patients.

Type
Special Section: Causality and Moral Responsibility
Information
Cambridge Quarterly of Healthcare Ethics , Volume 29 , Issue 2 , April 2020 , pp. 236 - 245
Copyright
© Cambridge University Press 2020

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References

Notes

1. This is a rough sketch of what constitutes a nocebo. See Howick, J. The relativity of ‘placebos’: Defending a modified version of grünbaum’s definition. Synthese 2017;194(4):1363–96CrossRefGoogle Scholar for some of the philosophical challenges that confront attempts to define ‘placebo’ and ‘nocebo’ properly.

2. Gelfand, S. The nocebo effect and informed consent: Taking autonomy seriously. Cambridge Quarterly of Healthcare Ethics 2019 Google Scholar.

3. Colloca, L, Miller, FG. The nocebo effect and its relevance for clinical practice. Psychosomatic Medicine 2011;73(7):598–603 CrossRefGoogle ScholarPubMed.

4. Jensen, KB, Kaptchuk, TJ, Kirsch, I, Raicek, J, Lindstrom, KM, Berna, C, et al. Nonconscious activation of placebo and nocebo pain responses. Proceedings of the National Academy of Sciences of the United States of America 2012;109(39):15959–64CrossRefGoogle ScholarPubMed.

5. Pellegrino, ED. Is truth telling to the patient a cultural artifact? JAMA 1992;268(13):1734–5CrossRefGoogle Scholar, for example, mentions the example of disclosing poor prognoses that can cause a patient to become depressed. A negative emotional reaction to bad news is not typically thought of as a nocebic reaction.

6. Cohen, S. The nocebo effect of informed consent. Bioethics 2014;28(3):147–54CrossRefGoogle ScholarPubMed.

7. Fortunato, JT, Wasserman, JA, Menkes, DL. When respecting autonomy is harmful: A clinically useful approach to the nocebo effect. American Journal of Bioethics 2017;17(6):36–42 CrossRefGoogle ScholarPubMed.

8. See note 7, Fortunato, et al., 2017, at 41.

9. Wilson, L, Dworkin, SF, Whitney, C, LeResche, L. Somatization and pain dispersion in chronic temporomandibular disorder pain. Pain 1994;57(1):55–61 CrossRefGoogle ScholarPubMed.

10. See, for instance, Kaptchuk, TJ, Kelley, JM, Deykin, A, Wayne, PM, Lasagna, LC, Epstein, IO, et al. Do “placebo responders” exist? Contemporary Clinical Trials 2008;29(4):587–95CrossRefGoogle Scholar; Horing, B, Weimer, K, Muth, ER, Enck, P. Prediction of placebo responses: A systematic review of the literature. Frontiers in Psychology 2014;5(1079)CrossRefGoogle ScholarPubMed; and King, BH, Dukes, K, Donnelly, CL, Sikich, L, McCracken, JT, Scahill, L, et al. Baseline factors predicting placebo response to treatment in children and adolescents with autism spectrum disorders: A multisite randomized clinical trial. JAMA Pediatrics 2013;167(11):1045–52CrossRefGoogle ScholarPubMed.

11. Hanks, GW, Reid, C. Contribution to variability in response to opioids. Supportive Care in Cancer 2005;13(3):145–52CrossRefGoogle ScholarPubMed.

12. One might suggest that the institution of medicine is such that participants are largely aware of the implicit rules. As such, when a patient seeks help he assumes that his care-providers will behave (including the disclosure of risks) in a manner that is in his best interest while respecting his autonomy. Nondisclosure is not itself a sufficient reason to doubt clinicians’ fidelity.

13. The State of Queensland. Consent form for laparotomy. Quesland Health. Queensland, Australia; 2018; available at https://www.health.qld.gov.au/__data/assets/pdf_file/0034/149497/shared_file_47.pdf (last accessed 9 Sept 2019).

14. See note 3, Colloca, Miller 2011.

15. Wong, DL, Baker, CM. Pain in children: Comparison of assessment scales. Pediatric Nursing 1988;14(1):9–17 Google ScholarPubMed.

16. Miner, J, Biros, MH, Trainor, A, Hubbard, D, Beltram, M. Patient and physician perceptions as risk factors for oligoanalgesia: A prospective observational study of the relief of pain in the emergency department. Society for Academic Emergency Medicine 2006;13(2):140–6CrossRefGoogle ScholarPubMed.