Placebo Effects and the Ethics of Therapeutic Communication: A Pragmatic Perspective

Abstract

In this article we explore the ethics of manipulating verbal information for the sake of influencing health outcomes through placebo and nocebo responses. Recent scientific research on placebo and nocebo effects has drawn attention to the ways in which communication by health professionals may modulate the symptoms of patients across an array of highly prevalent conditions such as pain, depression, anxiety, insomnia, irritable bowel syndrome, migraine, and Parkinson's disease. The positive and negative effects of clinicians' communication on patient outcomes pose important ethical issues, which we describe in this article under the label of "the ethics of therapeutic communication" (TC). We begin by reviewing available evidence supporting the claim that doctor-patient communication has therapeutic effects. We then identify in truthfulness, helpfulness, and pragmatism three morally relevant considerations that can guide clinicians in therapeutic communication with their patients. Finally, we examine the ethics of using TC to enhance the effectiveness of proven medical interventions and open-label placebos.

Implications of Placebo and Nocebo Effects for Clinical Practice: Expert Consensus

“…However, the experts also acknowledged the current lack of knowledge about how best to provide this information to patients to ensure that patients are optimally informed. For example, there is insufficient knowledge about the ways in which patients and health-care providers can maximize placebo effects and minimize nocebo effects over time during repeated interactions and treatments [25]. …”

Placebos Without Deception: Outcomes, Mechanisms, and Ethics

“…It is known that the expectation of pain relief has been found to modulate the central regulation of pain through, in particular, the dopamine reward system and the endogenous opioid system (Price, Finniss, & Benedetti, 2008). There is also a growing body of evidence that in addition to what practitioners say, the way in which they deliver these messages (for example, with more or less empathy) can also affect health outcomes (Annoni & Miller, 2016; Caspi & Bootzin, 2002; Friedman, Sedler, Myers, & Benson, 1997). …”

“…Third, the positive suggestions often delivered alongside open-label placebos could involve an element of deception, depending on their wording. This is, strictly speaking, a distinct issue and we leave a discussion of the ethics of therapeutic communication to another study (Annoni & Miller, 2016). In short, the research demonstrating the effects and mechanisms of open-label placebos demands a reanalysis of ethical strictures on placebo use, and further discussion on how open-label placebos might be implemented is warranted.…”

What influences placebo and nocebo responses in Parkinson's disease?

“…Doctor‐patient communication has therapeutic effects and holds power in promoting placebo responses or inhibiting nocebo responses . It has been shown that expectation plays a vital role in the placebo response, and medical providers serve as potent conditioning tools in guiding expectations .…”

“…It has been shown that expectation plays a vital role in the placebo response, and medical providers serve as potent conditioning tools in guiding expectations . Variables, such as the environment in which the interaction takes place, clinical routines performed, and the type of medical instruments used (eg, stethoscope) may all influence outcomes . Other factors influencing placebo‐related improvements include altruism, empathy, and compassion on the part of the physician, in addition to validation and invalidation of a patient's symptoms …”