How Much Truth Should the Doctor Tell the Patient in View of the NOCEBO EFFECT?
The "Nocebo Effect" is described in the Wikipedia article by the name Nocebo and begins as follows:
"In medicine, a nocebo reaction or response refers to harmful, unpleasant, or undesirable effects a subject manifests after receiving an inert dummy drug or placebo. Nocebo responses are not chemically generated and are due only to the subject's pessimistic belief and expectation that the inert drug will produce negative consequences."
It has been through research using placebos to establish that such a negative reaction exists. The real clinical and ethical importance of such a concept is with regard to informed patient consent with regard to potential medicine side-effects or in presenting to the patient a full description of the complications of any form of treatment.
The Nocebo Effect as discussed in an article titled "To Tell the Truth: The Whole Truth, May Do Patient Harm: The Problem of the Nocebo Effect for Informed Consent written by Rebecca Erwin Wells and Ted J. Kaptchuk in the American Journal of Bioethics March 2012. The Abstract of the article follows:
The principle of informed consent obligates physicians to explain possible side effects when prescribing medications. This disclosure may itself induce adverse effects through expectancy mechanisms known as nocebo effects, contradicting the principle of nonmaleficence. Rigorous research suggests that providing patients with a detailed enumeration of every possible adverse event—especially subjective self-appraised symptoms—can actually increase side effects. Describing one version of what might happen (clinical “facts”) may actually create outcomes that are different from what would have happened without this information (another version of “facts”). This essay argues that the perceived tension between balancing informed consent with nonmaleficence might be resolved by recognizing that adverse effects have no clear black or white “truth.” This essay suggests a pragmatic approach for providers to minimize nocebo responses while still maintaining patient autonomy through “contextualized informed consent,” which takes into account possible side effects, the patient being treated, and the particular diagnosis involved.
How much of the "good news" of a drug or other treatment or disease prognosis and how much of the "bad news", that is, side-effects of the drug, complications of the surgery or other procedures or disease outcomes (in view of the documented "nocebo effect" ) would you want to know from your doctor?
For those who want to read more on the issue "Is It OK for the Doctors to Lie?" go to my earlier thread on the topic and take a quiz about lying if you were the doctor in various situations. ..Maurice.
Graphic: From the Wikipedia article.
posted by Maurice Bernstein, M.D. @ 10:27:00 PM
4 comments
4 Comments:
The moment I read "How much of the truth..." my teeth clench.
We are adults. If you don't tell ALL of the truth, you're not really telling the truth at all.
Just because there may be some unfortunate consequence of telling the truth does not justify withholding the truth (unless perhaps, the husband is asked if a dress makes her butt look fat).
Withholding (some of) the truth to "protect" the patient smacks of the paternalistic medicine that I personally find very offensive, and not appropriate these days. I wonder if it's even technically ethical.
Of course, what I've seen in practice is, physicians just about never mention any downside or side effect, unti/if directly asked. Then, they waffle. Then, the patient goes and reads it on the internet. Does anyone really think that is better?
TAM
TAM, if you did some of your own research on the matter of the NOCEBO effect and found that there appeared to be validity in the concern regarding how this would affect the symptoms and perhaps the outcome of a therapy, wouldn't you agree that withholding "some facts" or expressing the facts in a more careful and nuanced way, based on the patient's underlying disease and physician understanding of some of the psycho-social issues of this specific patient be a more beneficent way to inform?
I agree that getting the "facts" from the internet just primes the patient to develop the nocebo effect. The internet knows nothing about the patient. ..Maurice.
I'm not saying the NOCEBO effect isn't valid, I believe you that it is. I'm just saying that the solution to it isn't to withhold the truth.
Discussing it carefully, but truthfully, seems appropriate to me.
An older lady I was close to was prescribed all sorts of medications. No one would ever mention side effects when they were prescribed. Then, she'd fill the prescription, read the package insert and/or look on the internet, and refuse to take the medication. Or, if she did, and got any hint of a side effect, stop taking it.
I learned to be very determined about "making" the doctors discuss side effects, AND how often they occurred, and what to do if they did. For ex. - only 1 out of 100 people get this side effect. If you do get it, we can try splitting up the dose. We'll make sure the medication doesn't bother you too much. Then, she would actually try the medication, and work with the doctor instead of just refusing.
If a physician isn't fully truthful with patients, and they figure that out (easy to do with the internet) or even the package insert from the pharmacy, then they feel they have been lied to, and distrust the physician. That's how my friend felt - that they didn't care if she got side effects and was miserable. That they'd just write scripts, and not bother to discuss it with her.
In the past, where people just blindly trusted the doctor and did what they said, not discussing side effects might have worked to some extent. But there's too much information out there now.
I personally find the amount of medical information on the internet wonderful. Unfortunately, there are a lot of unreliable sites also. I think physicians would make out better by recommending reliable sites, then hoping people won't read it at all (if you can't beat 'em, join 'em)
TAM
The doctor patient relationship has to be based on trust.
Along the lines of what TAM said, if a patient discovers that a physician has withheld information from them, regardless of the reason, the patient is likely to interpret this as the doctor not being completely truthful or "lying" to them. Further, they may perceive it as a sign of disrespect or even an insult - that the physician doesn't trust them enough to use the information correctly or thinks they aren't "smart enough" to understand the information. Does wonders for that whole "relationship based on trust" thing, doesn't it?
So my position would be, that unless the patient requests otherwise, tell them the truth, the whole truth and nothing but the truth.
Personally, if I ever caught a doctor lying to me or deliberately withholding information, I would immediately terminate the relationship, and follow up with an ethics complaint to the state medical board.
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