FEATURE

The oft forgotten Nocebo effect

Prof. B. M. Hegde,
hegdebm@gmail.com

“Finish last in your league and they call you idiot. Finish last in medical school and they call you doctor.”

 Abe Lemons

The placebo (I please) effect has been at least known to some lay people but very few, if any, know the effect the most powerful nocebo effect in human health and illness. While placebo effect can have such powerful healing capacity as shown both in elegant studies in medical and surgical situations were placebo has proven better than the drug or surgery (Sc. Transl. Med 2011; 3: 70 and J. Amer coll cardiol 2005;) there has been no study done on the far more dangerous nocebo effect on the patients’ life and illness. When I wrote in the BMJ on “In the company of specialists life becomes miserable on earth,” there was a spate of rapid responses to my above rapid response. In my response I had said: “In view of the new scientific wisdom on the Placebo effect in human illnesses, are we right in giving cancer patients a deterministic predictability prognosis about their future? Does that not further deplete their immune guard? Doctors have been predicting the unpredictable future (BMJ 1991; 303: 1565) of cancer sufferers. Why are we Nocebo cancer doctors? ...and many more imponderables in the cancer arena where ignorance abounds!

One doctor Herbert Nehrlich from Australia wrote a response which reads like this: “Professor Hegde strikes again.And he rarely misses the target. I remember the time, back in the Fatherland, when doctors were fibbers. Not only did they talk in Latin with an occasional Greek twist thrown in for difficult patients; they actually painted rosy pictures of the future for doomed patients. There were far too many experts in medicine in post-WW II Germany and most were taken seriously, which was probably due to the need for paternal guidance that was felt by nearly all survivors of a lost war. So, some preached that lying to a patient was a strict no, no. Others maintained that a patient's immunity card house would surely collapse if the truth were told. From the chaos sprang a new order: Always tell the truth. The consequences be damned.Hope cannot be taken away, my father used to say, and many were doing just that in a slipshod, hurried manner.When I saw my first wart fade within days after the application ofone drop of dandelion milk during a full moon I became a believer in the power of the Placebo. And how right Professor Hegde is when he points his finger (bone?) at the monster that is so alive and well, the Nocebo.We have a choice:We can tell a patient that their test results are very bad and to go home and get their affairs in order. And, even if not asked,to give them so many months to live as if we were handing out a prescription. Or, we can tell them that their illness is very, very serious BUT wewill, with their help throw everything that has ever shown results, anywhere in the world, at the problem. Faith in the doctor, like faith in general, is all about things hoped for. Take this hope away and you may be politically correct. But so are those physicians who believe in euthanasia." (BMJ 2011; 342:d20530) Herbert like thinkers are rare these days.

I wonder if there are people out there having more experience than I have about the gravity of the nocebo effect as my main job in the last quarter century has been to cater to patient’s fear of being given a deadly prognosis by their specialists in two areas, cardiology, my special interest and, cancer, the inevitable curse on mankind. This piece was stimulated after I came back from my neighbour’s house that just died from a fibro sarcoma of the vertebral canal area. The definite death warrant given by his cancer specialist almost killed him about a couple of years ago. He was told that he will not last more than three months at the most! After lots of hours of psychotherapy and symptomatic Ayurvedic treatment at a good centre the man lived with his people for a good two years pain free and doing most of what he wanted to do including his family’s cloth business. What worries me even now is how on earth did his learned cancer specialist realise that he will live only for three months? There is no way scientifically. Quantum physics shows the futility of future predictions as the future is yet to be born; human system does not follow the linear laws anyway. We are warned by physicists not to predict the unpredictable future of patients but, who listens? (BMJ 1991; 303: 1565)

In cardiology, thanks to the monetary fascism, we are deadly. The way our young catheter pushers predict the hapless victims’ future is something that has to be seen to be believed. They show the patient their gadget, the angiogram of the epicardial coronary vessels and tell the patient and his relatives that “this vessel is 100% blocked. If you do not have it angioplastied right away I cannot even guarantee that you will reach home alive!” I would be happy to angiogram the doctor himself and give him that kind of prognosis what would happen to him? The fear thus generated (nocebo effect) could really kill that patient. Cancer is equally bad if not worse. They are dead sure about the life span of each patient looking at their biopsy report as if the latter gives them a holistic picture of their disease. These nocebo specialists who abound in many other fields deliberately generate fear to catch their prey into their web-disease mongering. One could fool some people for sometime and many  people for a while but the truth will emerge sooner than later to tell you that you cannot fool all people for all times. Before that happens and patients leave us like rats leaving a sinking ship we better be warned. While money is your good friend make truth your better friend to be a healer first and businessman next.  Doctor has a great responsibility to his patients. Of course, medical ethics is long forgotten. The components of doctoring that are lost these days are common sense and logic.We better learn from history as otherwise we will be condemned to relive history.

“I mean some doctor told me I had six months to live and I went to his funeral.”

                            Keith Richards.

***********************