Medicine's inconvenient truth: the placebo and nocebo effect

Abstract

Placebo and nocebo effects are often regarded by clinicians as either a quaint reminiscence from the pre-therapeutic era, or simply as a technique for establishing the efficacy of therapeutic interventions within the locus of evidence-based practice. However, neither of these explanations sufficiently account for their complexity or their persistence and impact in clinical medicine. Placebo and nocebo effects are embedded in the very fabric of therapeutic relationships and are both a manifestation and outcome of the rituals that characterise clinical practice. They are also a stark reminder of the many personal and environmental factors, including the attitudes, beliefs and expectations of both doctor and patient, that shape the outcomes of health professional-patient interactions. We describe how recent biological and neuropsychiatric data have clarified the operation of placebo and nocebo effects in clinical practice - demonstrating the ability of the therapeutic context to modulate endogenous biological processes in a targeted manner. This, in turn, illustrates the potent philosophical and sociocultural aspects of medical praxis.

The application of Signalling Theory to health-related trust problems: The example of herbal clinics in Ghana and Tanzania

“…It is notoriously difficult to establish clear causal relationships between treatment and clinical outcome, making it difficult for patients to accumulate accurate knowledge about signal reliability. Powerful positive and negative feedback loops between trust and clinical outcome operate via the placebo and nocebo effects ( Arnold et al., 2014 ). Moreover, many conditions resolve themselves regardless of (or despite) medical intervention, and the widespread practice of polypharmacy (attempting several treatments simultaneously) makes it difficult to distinguish the effect of each, while widespread beliefs that divine intervention plays a strong part in healing further complicate the business of ascertaining which herbalists – and therefore what kinds of signals – were in fact trustworthy.…”

Placebos in Australian general practice: A national survey of physician use, beliefs and attitudes

“…29,35 Finally, most GPs surveyed believed that medical students could benefit from education about the placebo effect and how to harness it, supporting assertions that the inclusion of evidence-based education about placebo effects in medical curricula could be valuable. 36,37 The study was strengthened by recruitment from a large national database of GPs. However, the study was limited by a relatively low overall response rate, with 42% of GPs opening the email and 18% of these completing the survey.…”

Understanding empathy: why phenomenology and hermeneutics can help medical education and practice

“…Such a hermeneutic approach to empathy fits well with works that show how the medical encounter is an interpretive event in any case (Svenaeus 2001(Svenaeus , 2014Usherwood 1999). Indeed we may speculate that it is precisely in its interpretive aspects that empathy exerts so much power, for example, via context effects (Arnold et al 2014). It also suggests other potentials for practice: for how doctors can co-construct multivalent 'understandings' of illness and diseases, connected with personhood and with a more broadly interpretable embodied experience than is typically available in biomedicine.…”