Placebo Heals, ‘Nocebo’ Kills
“Finish last in your league and they call you idiot. Finish last in medical school and they call you doctor.” — Abe Lemons
The placebo effect has been known to at least some lay people, but few, if any, know of the powerful ‘nocebo’ effect on human health and illness. Nocebo is a detrimental effect on health produced by psychological or psychosomatic factors, such as negative expectations of treatment or prognosis. While the placebo effect can have a powerful healing capacity, as shown in elegant studies in medical and surgical situations where placebo has proven better than drugs or surgery, there has been no study done on the dangerous effects of the nocebo on patients’ life and illness.
When I wrote in the British Medical Journal (BMJ) that “In the company of specialists life becomes miserable on earth,” there was a spate of rapid responses. 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?”
One doctor Herbert Nehrlich from Australia wrote a response which reads, “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 would surely collapse if the truth were told. From the chaos sprang a new order: Always tell the truth, 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 of one drop of dandelion milk during a full moon I became a believer in the power of the placebo… 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) Thinkers like Herbert are rare these days.
The stimulus for this piece was a visit to my neighbour, who had just died from fibro sarcoma of the vertebral canal area. The death warrant given by his cancer specialist almost killed him a couple of years ago. He was told that he would not last more than three months, at the most. After many hours of psychotherapy and symptomatic Ayurvedic treatment at a good centre, the man lived with his family for a good two years.
In cardiology, thanks to monetary fascism, we are in a terrible position. 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 him!
Cancer is equally bad, if not worse. Specialists are sure about the life span of a patient just looking at the biopsy report, as if it gives them a holistic picture of the disease. These nocebo specialists, who abound in many other fields, deliberately generate fear to capture their prey in their web of disease-mongering.
“Some doctor told me I had six months to live and I went to his funeral.” — Keith Richards
Sundaram S
4 years ago
There have been no more articles from Prof Dr. Hegde in a long time. Hope all ok with him
Ramesh Poapt
4 years ago
perfect, sir!
Simple Indian
4 years ago
Another fine article by Dr. Hegde. In all human civilizations, doctors always commanded the highest respect due to their skills and 'power' to cure diseases. Some civilizations even equated doctors (semi-religious quacks, actually) with their deities. But, over time doctors have become so business-like and greedy, even a simple child-delivery by natural means is advised against, in favor of C-section - simply because the doctor and his/her clinic gain lot more from the latter. The same goes for myriad tests and scans patients are advised to take, mainly for financial gains to the doctor. Like teachers, doctors have lost much of their respect due to such malpractices. Wish their governing body MCI in India were more conscientious and honest in regulating this important profession. Long live honest medical practice !
4 years ago
I would like to compare your story to a Weatherman. For instance, imagine that you are watching TV and the weatherman tells you that there is a 60% probability of rain in your area the next day, and let us assume it actually DOES rain. Do you really think that the Weatherman was correct?
(I took this example from one of Taleb's books and I strongly recommend you read it.)

So as per your example that the Cardiologist tells the patient that "I am not even sure you will make it back home alive", the Cardiologist is just telling the patient a PROBABILITY of the event (Sudden Cardiac Death) happening. Similarly, if a patient is diagnosed with Stage 4 CA lung, the Doctor usually tells him " The 5 year survival is roughly 5 - 10%."

Kindly note that the Doctor is NOT predicting the future. he is only telling the patient the Probability of survival.

Taking another example, lets the MEDIAN survival of a patient with Fibrosarcoma is roughly 6 months. What this means is that when you plot the survival vs time curve for fibrosarcoma patients, 50% of the population lies below the 6 months line. Now, STATISTICALLY speaking, the right hand side of the curve can basically extend till infinity. Mind you, the Doctor is NOT telling the patient he has 6months to live, he is only telling aPROBABILITY of the event happening. Whether or not it DOES happen is altogether different.

Coming to the question of whether it is better to paint a rosy picture VS a grim picture to a patient of lets say Fibrosarcoma, I would suggest you try to answer that question using Game Theory. The first rule in Game Theory is that you should NEVER play a DOMINAT-ED strategy. Kindly build a 2 X 2 matrix writing the rewards of the players(Doctor and the patient in this case), and see which strategy wins. It turns out that it is ALWAYS Better to give a Poor prognosis rather than a very good prognosis.

As per your quote of Keith richards, I strongly believe that if 1 billion people drive in a car from Mumbai to Pune at 200 kilometer per hour, there would be some who would definitely reach Pune in 40 minutes. But, just the fact that SOME people do make it to Pune, does it mean that THEY were right ?

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