Honesty is harder when the truth risks harm.
People taking sugar pills and other faux medications with
inert ingredients for such symptoms as pain, dizziness, headache, and depressed
mood often experience relief. The placebo effect is well known. The placebo’s
evil twin is the nocebo—it comes from a Latin word
meaning I will harm—and it has recently gotten more attention from researchers.
The Harvard Mental Health Letter
reports 20 percent of patients taking sugar pills in clinical drug trials
spontaneously report unpleasant side effects—and even more describe unpleasant
effects if they are asked.
Expectations matter. If we expect help, we may feel better. If
we expect distress we may feel it. And these physical manifestations are real,
not imaginary. The Harvard letter reports on an experiment in which volunteers
were told a mild electric current would be passed through their heads and that
they might experience headaches. There was no current, but two thirds of the
volunteers got headaches.
A New Yorker story by Gareth Cook reports that people
involved in clinical drug trials often experience the symptoms they are warned
about even when they are taking placebos.
In research on fibromyalgia treatments, the story says, eleven percent
of the people taking sugar pills dropped out of the trial because of debilitating
People also experience the nocebo effect as a result of
disasters and scary information, alarming news and rumor. After the 1995 saran gas attack in a Tokyo subway,
many people who had actually not been exposed to the nerve gas suffered the
highly publicized symptoms of dizziness and nausea. A New York Times story by Paul Enck and Winifred Hauser
tells of a participant in a clinical trial for an antidepressant drug who
attempted suicide by swallowing 26 pills. The person’s blood pressure plunged
dangerously even though the pills swallowed were harmless.
Sometimes the same treatment can be both placebo and nocebo.
The Harvard letter tells of volunteers
who experienced discomfort when told an injection contained an allergen, and relief
when told an injection would neutralize the symptom. In both cases the
injection contained only salt water.
Informed consent is a powerful doctrine that obligates
physicians to tell patients all the risks of treatments. But what if all that
information is detrimental to the patient? A Boston Globe story by Chris Berdik reports some
reflections by doctors, all of whom urge honesty combined with the kind of thoughtful
and skilled communication that takes some time with the patient. Dr. Luana Colloca, a researcher at
NIH who studies placebos and nocebos, describes positive framing—you can say that
two percent of the people on this treatment had nasty side effects, or that 98
percent did not. The Times story emphasizes
that a doctor’s choice of words is important. The story quotes the cardiologist Dr. Bernard Lown who once said,
"Words are the most powerful tool a doctor possesses, but words, like a
two-edged sword, can maim as well as heal.”